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To kids discovering the joys of rock in the early 70s via the electric grooves of T.Rex, it was a rite of passage to track back to Marc Bolan’s earlier incarnations.
Experiencing Tyrannosaurus Rex albums for the first time was bewildering. They sounded utterly, uniquely berserk and, almost half a century on, still do. Bolan’s 1968s debut saw the ex-mod/ex-beatnik turning his back on the loud guitars of John’s Children to indulge his psychedelic-folk acoustic hippie side. With Steve Peregrin Took rattling away on percussion, he warbled weirdly juxtaposed words about goddesses, Narnia and laundromats as Tony Visconti, himself a fledgling producer, aimed for something “different and unusual”. They achieved that. Bolan’s tremulous tones blend beautifully with the Eastern-influenced, sparse yet flamboyant arrangements. It’s like a team of medieval pixies are crafting theme songs for a spaceship. Two John’s Children songs – Hot Rod Mama and Mustang Ford – were re-recorded, and are the closest relatives to ‘rock’ here, but otherwise it wanders through the alleys of Bolan’s psyche with louche abandon. The finale, Frowning Atahuallpa (My Inca Love), throws in Hare Krishna chants and one John Peel reading a Bolan-penned, Tolkien-esque children’s story. Child Star discloses an exquisite melody while Strange Orchestras is staccato but strident. Both stereo and mono mixes are included on this two-disc (or vinyl) deluxe edition: Bolan preferred the mono back then, though Visconti has now re-mastered both. There’s a fresh wealth of new-found treasures: 12 tracks recorded for Peel’s Top Gear, four Joe Boyd sessions, seven Visconti home demos and two Bolan BBC interviews. With Prophets, Seers & Sages and Unicorn also upgraded, it’s time to revisit a duo that were of their time but far out in space.


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I am currently reading a book a came across when searching through Amazon. It's called Leadership in Dangerous Situations edited by Patrick J Sweeney, Michael D. Matthews, and Paul B. Lester. The subtitle is A Handbook for the Armed Forces, Emergency Services, and First Responders.
The bookgathers much of the research into Leadership in life threatening context. The book is broken into three sections with 20 total chapters. Section One is Enhancing One's Psychological Body Armor. This section discuss the latest research in courage, stress, resilience, PTSD, and ethics. Influencing When People Are In Harm's Way is the name of Section. Subjects covered include trust, team building, morale, decision-making under stress. This section uses the Station Fire to apply the principles. The last section is Leveraging the Organization. Subject matter includes creating culture, recruitment, selection, and leader development.
Sections of the book may be somewhat dry at points as the author cite the psychological studies pertaining to each of the subject. As you can imagine this can be difficult reading. The authors then explain how the research can be used to assist the leader before, during and after life threatening situations. At the end of each chapter the authors have listed Key Take-Away Points that summarize the information in the chapter.
I have read about 25% of the book and have found something useful on just about every page. When I finish reading this book. I will post an complete review.
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domain: literature


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Robbery attempt at Jain temple foiled
CHANDRAPUR, July 10, 2015: A gang of unidentified robbers made a failed attempt at ancient Parshvanath Jain temple in Bhadrawati on last Friday night. The robbers overpowered three sentries and succeeded in breaking into the main temple, but buzzing alarm foiled their bid and they fled, empty handed.
Stolen 'ashtadhatu' idols of Mahavira recovered
June 27, 2015; The police today arrested one person and recovered three 'ashtadhatu' (made of eight metals) idols of Lord Mahavira stolen from a Jain temple in Kishanganj district of Bihar.
Jain temple adds to Kochi's iconic structures
KOCHI, June 16, 2015: A Jain temple, resembling the famous ones on Mount Abu in Rajasthan, is nearing completion in the heart of Kochi along the quiet Srinivasa Mallan Road, just 50m from MG Road.
Jain temple of Ganga period excavated
Bharathingar, (Mandya dist),June 5, 2015, DHNS: A Jain Basadi, built during Ganga dynasty in the sixth century, has been excavated near Arethippuru village, Maddur taluk, Mandya district.
Precious idols stolen from Jain temple in Bihar
Kishanganj, May 14, 2015: Three precious idols were stolen from a Jain temple near the Thakurganj block office in the district, a police officer said Wednesday.

domain: history


Speaking in an interview published by L’Alsace, Minister for Sports Roxana Maracineanu responded to Lyon President Aulas’ repeated attempts to get Ligue 1 2019/20 campaign action back underway.
As revealed in our French Football Farce piece earlier this week, Maracineanu made inaccurate private and public assertions that inadvertently or otherwise contributed to the premature termination of the 2019/20 season.
“What do you want me to say? Cinemas will reopen soon. If Mr Aulas has different scenarios to propose, I invite him to make a film and to screen it in a cinema as it will be open to the public.”
“I responded to one of the many letters that he sent to me where I re-explained to him how the State functions, as well as the FFF and the LFP, and the relationships between them all.”


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As the name suggests, a solar powered weighbridge will consist of solar panels to store power.
The stored energy can subsequently power the weighing device.
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Exelon Weighing System head quartered in Ahmedabad, Gujarat, India, is a well-known global manufacturer, exporter, and supplier of Multi Deck Weighbridges In Mumbai.
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Our Multideck weighbridge is intended to determine both the total gross mass of the vehicle and the mass of each individual group axle.
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The main advantage of a multideck is transaction speed. In a single step, it gives all masses required for regulatory compliance and lawful for trade weighing.
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Omaha, Agricultural Building
View of the Agricultural Building during the Trans-Mississippi and International Exposition in Omaha (Douglas County), Nebraska. The structure has a wood frame with plaster of Paris and staff overlay. Designed in the Renaissance Revival style, the main entrance has a portico and smaller entrances at both ends. Shows windows with arched niches and columns. The roof line has a balustrade, a cornice, and flag poles with flags. Shows the Grand Canal.

domain: artistic


text: I have had a lot of milestone sessions so far this year! Here’s little Harper, starting off the line-up. For her newborn photography session (HERE) we used a theme of peaches, creams and tans. Mom wanted to continue the theme for Harper’s “Smile” Session. I love how it turned out! “Smile” sessions take place when baby is about 4 months old, and full of smiles! At this age, baby can usually hold up her own head, as well as push herself up on her arms. You can learn more about my Smile Sessions, as well as other milestone sessions HERE. If you’re interested in hiring an experienced portrait photographer for your newborn or baby, please contact me at email@example.com or call me at 717-344-9577.


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New Delhi: India continues to lag behind in broadband adoption, according to the latest 'State of the Internet' quarterly report by content delivery network, Akamai.
According to the report, India has the slowest Internet speed in Asia and globally it ranks 118th, behind Thailand, Indonesia, Philippines and Vietnam.
The Akamai report states that the average internet connection speed in India is 1.7Mbps. Still the country witnessed 8.4% per cent quarter on quarter change and 34% year on year.
South Korea emerged as the leader in the Asia pacific region, with 23.6Mbps followed by Japan and Hong Kong with 14.6Mbps and 13.3Mbps Internet speeds respectively.
“The global average connection speed continued its gradual increase heading into 2014, growing 1.8% quarter over quarter to reach 3.9Mbps. Given the long-term trending seen for this metric, it is likely that the global average connection speed will finally reach, and hopefully surpass, the 4Mbps broadband threshold in the second quarter,” says the report.
The report follows the findings by the research firm eMarketer which stated that India has had the lowest Internet penetration growth in Asia Pacific (APAC) at 17.4 per cent so far this year.

domain: geography


text:
The Lionel Hampton Big Band made it big during the period covered by this CD. "Flying Home," which Hampton had recorded at least twice earlier with combos, became a sensation thanks to Illinois Jacquet's honking tenor (which largely launched R&B) and the excitement generated by Hampton and his band (including the screaming trumpet section). This disc covers most of the war years, has a few V-discs (including the hit version of "Flying Home" and a two-part remake), and such numbers as "Loose Wig," "Hamp's Boogie-Woogie," "Overtime," and "Tempo's Boogie." Jacquet was actually with Hampton for a relatively brief period of time, but Arnett Cobb proved to be a perfect replacement. Also quite notable in the band is pianist Milt Buckner (whose block chords became influential) and such high-note trumpeters as Ernie Royal, Cat Anderson, and Snooky Young.
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AllMusic Review by Scott Yanow


Published Apr 23, 2010Grabbed from the bottom of the discount comic bin, there are no surprises here. I read comics, and Watchmen or The Dark Knight Returns are rare pearls in an ocean of juvenile humour, vaguely racist stereotypes and tough-as-nails dudes with names like Roque, who don't take crap from anybody.
The Losers are a black ops organization cheated of their rightful place in the intelligence community by a comically evil Robert Patrick. An unlikely series of paramilitary exploits commences as these losers inexplicably access helicopters and many high-end gadgets while on the lam. A lot of things explode. They shoot bazookas. Twice there are jokes worth laughing at. There are over 10,000 jokes in all, so this is not an impressive ratio. At one point the line: "Payback's a bitch" is delivered with no sense of camp. I can hear them pitching this, "It's like Lethal Weapon on steroids and acid; it's a high octane thrill ride!"
Filmmaker Sylvain White shamelessly strives to invoke a Tarantino vibe, right down to a slow-motion strut nearly cut and pasted from Reservoir Dogs. It's a delightful come-uppance that the innovative Kick-Ass was released a week earlier, which actually earned Tarantino comparisons for bold ideas and genuine storytelling prowess rather than a script that could have been labelled Stylized Rehashing of Conventions Volume 86.
However, from the cries of jubilation coming from the audience at the public screening, one can only assume the end is nigh. (Warner)


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I have a new video project for you. I need an animated company logo using the enclosed vector image and sound file.
It's not the greatest logo in my opinion but it's what the client wants.
Obviously an animation of a signature signing is a good idea. Also check out his linkedin account for more idea of brand and what he does.
Skills: 3d, adobe after effects, animation


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So you can now buy modalert online. Modalert is further known to impact histamine levels in the cerebrum. This monoamine hormone is an imperative piece of the slumber wake cycle administrative framework that controls daytime readiness. Slumber is seen as a hormone-actuated state; by alarming characteristic levels of these hormones, Modalert can advance expanded attentiveness amid the day and fight off weakness when participating in amplified times of mental strain. This medication is additionally seen to have an impact on norepinephrine, serotonin, and orexin frameworks inside the cerebrum. Different studies have discovered it to have a very neuroprotective impact, and additionally being a huge hostile to oxidant that can help the soundness of neural
Modalert tablets are further noted to have a significant weight reduction sway. It is refered to as expanding the rate of fat blazing even in individuals who current keep up a sound weight. Various studies demonstrate that Modalert has a longing lessening impact. This impact additionally has all the earmarks of being more prominent when utilizing 400 mg every day, instead of a "typical" measurements of 200 mg every day. This impact is equivalent to what is experienced when utilizing customary stimulants like amphetamines, however Sun Modalert is not viewed as a conventional stimulant.
Modalert 200 mg has likewise been discovered useful in the treatment of sedative and cocaine addictions. It has been watched that the clinical impacts of Modalert are to a great extent inverse to the manifestations of cocaine withdrawal. There have been a couple of studies into this impact, yet they were generally uncertain. It will positively be intriguing to see where further research runs with this.

domain: medical


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Regardless of the origin of the name, the caveman diet has many of the same principles as the paleo diet. It’s focused primarily on the consumption of higher quantities of real, unprocessed, non-packaged food that cavemen could have eaten thousands of years ago, before Safeway, Walmart, and all of the other mega-super-duper-grocery stores we have available in today’s world came into being. Here are the basics:
Chicken parmesan is not something that you would typically be having on Paleo because it is coated in bread crumbs. But this chicken parm is coated with Parmesan cheese and almond flour, which replaces the bread crumbs. You’ll still get that classic crunchy outer covering on the chicken, and of course the Parmesan will be baked right onto the chicken, so it’s just a matter of getting the other ingredients right. For the tomato sauce they are using garlic, oregano, and olive oil, and you can top it off with basil leaves and optional mozzarella cheese.
This is the ultimate modern day caveman cookbook series that is going to rock your Paleolithic world! In this series you will find no-cook Paleo recipes that are low carb, grain free, gluten-free and processed sugar free. Also, be sure to know that these recipes can fit in to a detox routine perfectly! Inside this book, you will find 50 mouth-watering truly Paleo-friendly recipes. Enjoy the benefits of - Weight loss - Improved immunity - Increased energy - Overall iPaleo-friendly recipes. Enjoy the benefits of - Weight loss - Improved immunity - Increased energy - Overall improved wellness - Lowered blood pressure Check out the rest of the series on topics like: Paleo desserts Paleo snacks Paleo smoothies Paleo bread Paleo slow cooker Paleo for beginners Paleo crockpot Paleo comfort foods Paleo on the go Paleo kids Paleo lunches Paleo to go Paleo easy recipes Make sure to pick up both the Kindle and paperback copies!… read more
You might think that the best part of these brownies is that you don’t have to bake them, but the real wow factor is that they combine two of the most popular desserts into one. You’re getting chocolate chip cookies and brownies in one package, and they’re layered on top of each other, so your taste buds get the flavor from each one. There are actually three layers to this, one that is mostly brownie, one that is mostly chocolate chip, and a middle layer that is a sort of hybrid of the two. Have this with some Paleo ice cream to really send yourself to the limits of deliciousness.
Ham Hash with Fried Eggs Keto Leek And Bacon Omelet Breakfast for One in a Pan Mexican-Style Breakfast Lasagna Baked Eggs With Spinach And Smoked Salmon Jalapeño-Bacon Egg Cups Breakfast Casserole With Sausage And Hash Browns Breakfast Casserole With Sausages Breakfast Stuffed Peppers Twice Baked Sweet Potatoes With Eggs Eggs Benedict With Avocado Sauce Asparagus and Mushroom Spaghetti Squash Quiche Egg Salad Dip Baked Eggs with Pancetta And Mushrooms Guacamole Stuffed Eggs Baked Eggs With Asparagus and Leeks Mini Ham And Broccoli Frittatas Tomato Basil Frittata Oven Omelet Crab-Stuffed Deviled Eggs With Tarragon Egg and smoked salmon open-faced apple sandwich Egg in a jar Shakshuka Garlic and parsley deviled eggs Egg and pesto stuffed tomatoes Zucchini and Sweet Potato Frittata Breakfast Burrito Zucchini and Egg Breakfast
If you’re trying this eating approach, you’ll have to say goodbye not only to foods well known to be unhealthy — such as ice cream, potato chips, and soda — but also all grains (including whole grains), most dairy, legumes (beans), and starchy veggies, among other foods. The thinking goes that foods in these elimination groups are toxic to our bodies because of modern farming practices.
Lately, I've been seeing more and more people talking about the Paleo diet and the best paleo cookbooks - and for a good reason. Although a lot of diets can often get complicated and hard to understand, the Paleo diet is pretty simple: only eat what a caveman would eat. What's better than being able to eat as much as you want and not have to track anything? Nothing! That's what I thought.
But, that being said, the one book that we do strongly recommend is Practical Paleo. This book is particularly valuable because it offers so much information all in one place. As a result, it is a powerful guide to beginning paleo and being successful with the diet approach. At the same time, there is a decent number of recipes on offer as well, so you’re not missing out in that area.
What I love the most about this cookbook is that it is different. Most paleo cookbooks tend to follow the same general patterns and styles, often resulting in dishes that are fairly similar to one another. But, that’s not the case here. Instead, the recipes take their inspiration from southern cooking and give you the chance to still enjoy those flavors and styles of meals.
Introducing paleo food to a family can be tough, especially as many people are resistant to the idea. As a result, this cookbook offers one potential way around the problem, by focusing on recipes that aren’t obviously paleo. The meals would also work well for many families because they don’t use incredibly obscure ingredients and often don’t have as many steps as other paleo recipes.
Apples are one of the healthiest fruits you can have, and are something our ancestors would have eaten anytime they came upon an apple tree. Here they’re filled with tasty things like raisins, brandy, cinnamon, and nutmeg, all baked right inside a cored apple. This means that the flavor gets infused right into the apple, which softens up during the baking process. Giving up dessert is not necessary on Paleo, it’s simply a matter of changing your idea of what dessert has to be. You’re getting a healthy and satisfying dessert here with no added sugar.
Quiche is usually fair game on the Paleo diet because it’s primarily made with eggs, and eggs are definitely a Paleo approved food. This particular quiche recipe includes plenty of delicious ingredients, and she’s topped it off with a zucchini hash crust so it’s crunchy on the top, and full of eggs and yummy vegetables on the bottom. All of the ingredients that are not Paleo in a traditional quiche have been removed and replaced with Paleo perfect items. Flax meal is used as an optional ingredient, and we’d suggest it since it adds beneficial omega-3s to the mix.
You’d think vegan and paleo sort of cancel each other out, with paleo diet recipes emphasizing grass-fed meats and free-range eggs and vegans avoiding all animal products. But when you think about what our “ancestors” probably really ate, it must have been a very plant-based diet. So, what does an ancestral vegan diet look like? Abundant fruits and veggies are something both eating philosophies have in common. Grains and legumes — go-tos for many vegans — are out, but paleo-friendly starches like sweet potatoes, yams, cassava and plantains are in, and they’re both tasty and filling. So are all the good fats, like nuts, avocados and olive oil. And we can sweeten things up when we need to with fruit juices, honey, molasses, pure maple syrup and dried fruits. This is starting to sound not only healthy, but also deliciously doable. Here are 18 tempting recipes that’ll have you saying: “Let’s do this!”
If you like to start your day with granola, most other versions you see on store shelves will not be approved on the Paleo diet. You’ll need construct your own granola recipe using Paleo foods such as nuts, seeds, dried fruits, and spices like cinnamon, and pumpkin spice. This gives you the ability to customize the granola according to your own taste as well as make sure you are only using high quality ingredients. You’ll want to avoid eating it with yogurt as well, as that’s a dairy product. Try it with almond milk as a delicious and nutritious substitute that’s dairy free.
At first, the title may seem like a paradox – chocolate and Paleo don’t always go hand in hand, but this book is a compilation of 80 mostly-healthy dessert recipes that are grain and dairy free. Certainly, any kind of treat should not be a daily indulgence, but for special occasions and gatherings, the recipe in The Paleo Chocolate Lovers Cookbook look delicious. I made the chocolate cupcakes with cookie dough frosting for a party recently and they were definitely a hit. Other recipes include:
This beef recipe is simple, but comes out delicious because of the way it is prepared. You get plenty of beef in the form of chuck roast, and it is recommended to use grass-fed beef in this recipe as well as any other beef recipe you follow while eating Paleo. It’s also using a few glasses of red wine, and a good portion of tomato paste. If you are concerned about the red wine, don’t worry, the alcohol burn away during the cooking process, leaving just the flavor behind. Between the resveratrol in the red wine, and the lycopene in the tomatoes, you are getting a very healthy meal here.
These are sirloin rolls have brussel sprouts and fennel as sidekicks, but the sirloin is going to get top billing as the star of the show. Making sirloin rolls can be tricky unless you know how to do it, and they’ve provided helpful instructions here so yours will come out looking just like theirs. They have bacon rolled up with the sirloin, so you’re going to get plenty of flavor, and it’s nice that they have matched all of this meat with Brussels sprouts, one of the healthiest vegetables around.
Perhaps the most compelling part of this cookbook is the thousands of glowing reviews. People write that Meals Made Simple is the must-have for every paleo kitchen thanks to its delicious recipes and helpful shopping guides. One person even goes so far as to say this cookbook changed her life! If that doesn’t motivate you to check out this product, we don’t know what will.

domain: food


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- Research article
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Does a complex intervention increase patient knowledge about oral anticoagulation? - a cluster-randomised controlled trial
BMC Family Practice volume 18, Article number: 15 (2017)
Oral anticoagulation therapy (OAT) is a challenge in general practice, especially for high-risk groups such as the elderly. Insufficient patient knowledge about safety-relevant aspects of OAT is considered to be one of the main reasons for complications. The research question addressed in this manuscript is whether a complex intervention that includes practice-based case management, self-management of OAT and additional patient and practice team education improves patient knowledge about anticoagulation therapy compared to a control group of patients receiving usual care (as a secondary objective of the Primary Care Management for Optimised Antithrombotic Treatment (PICANT) trial).
The cluster-randomised controlled PICANT trial was conducted in 52 general practices in Germany, between 2012 and 2015. Trial participants were patients with a long-term indication for oral anticoagulation. A questionnaire was used to assess knowledge at baseline, after 12, and after 24 months. The questionnaire consists of 13 items (with a range of 0 to 13 sum-score points) covering topics related to intervention. Differences in the development of patient knowledge between intervention and control groups compared to baseline were assessed for each follow-up by means of linear mixed-effects models.
Seven hundred thirty-six patients were included at baseline, of whom 95.4% continued to participate after 12 months, and 89.3% after 24 months. The average age of patients was 73.5 years (SD 9.4), and they mainly suffered from atrial fibrillation (81.1%). Patients in the intervention and control groups had similar knowledge about oral anticoagulation at baseline (5.6 (SD 2.3) in both groups). After 12 months, the improvement in the level of knowledge (compared to baseline) was significantly larger in the intervention group than in the control group (0.78 (SD 2.5) vs. 0.04 (SD 2.3); p = 0.0009). After 24 months, the difference between both groups was still statistically significant (0.6 (SD 2.6) vs. -0.3 (SD 2.3); p = 0.0001).
Since this intervention was effective, it should be established in general practice as a means of improving patient knowledge about oral anticoagulation.
Current controlled trials ISRCTN41847489; Date of registration: 13/04/2012
The prevalence of patients receiving anticoagulants in Germany is high, with about 930,000 people taking coumarins daily . Adequate oral anticoagulation management is therefore a key challenge in the medical care of elderly patients in general practices . In the general adult population in Germany, the 1-year prevalence of atrial fibrillation (AF), the most common indication for long-term oral anticoagulation , has recently been estimated at 2.3%, and it rises considerably with age . Oral anticoagulation therapy (OAT) is also used for secondary prevention, e.g. in patients with recurrent thrombosis .
Vitamin K antagonists (VKA), which are still the oral anticoagulants that are most often prescribed in Germany , take fourth place in the List of High-Alert Medications consisting of drugs that are most likely to cause harm to patients . The management of coumarin therapy is often challenging because the narrow therapeutic index (for patients with AF a target Internationalised Normalised Ratio (INR) of 2.0 to 3.0 is recommended) makes it difficult to achieve optimal doses of the medication, and food-drug interactions are common . Improper handling can thus lead to dangerous bleeding complications or thromboembolic events. About 20% of hospitalisations in Europe as a result of acute stroke are related to atrial fibrillation .
The introduction of direct oral anticoagulants (DOACs) has had a considerable impact on the world of oral anticoagulation: In Germany, dabigatran, a direct thrombin inhibitor, and rivaroxaban, a factor Xa inhibitor, were the first DOACs to be approved for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and at risk of stroke . Since receiving approval in 2011, prescriptions of DOACs have risen strongly, with 38 million defined daily doses (DDDs) of DOACs prescribed in Germany in 2012 (vs. 389 mio. DDDs of VKAs), and 183 mio. DDDs prescribed in 2014 (vs. 364 mio. DDDs of VKAs) . According to the GARFIELD registry (Global Anticoagulant Registry in the FIELD), which includes patients with newly diagnosed atrial fibrillation and at least one additional risk factor, the proportion of patients on DOACs in Germany increased from 4.3% in 2011 to 24.8% in 2014 . Although DOACs are considered to be an effective treatment choice for long-term anticoagulation therapy, there have been a number of concerns . For instance, the lack of a readily available monitoring test and the absence of specific antidotes (apart from dabigatran, for which an antidote was approved in 2015 ) are a problem in the event of DOAC-associated bleedings . DOACs are not suitable for all patients: For instance, patients with mechanical heart valves should not use them . Moreover, DOACs cost significantly more than VKA : In Germany, the mean net cost of vitamin K antagonists is €0.18 per DDD, compared to €3.75 for dabigatran, and €3.45 for factor Xa antagonists.
Oral anticoagulation treatment by caregivers in clinical practice is often unsatisfactory. A systematic review indicates under-treatment of high-risk atrial fibrillation patients in two thirds of analysed studies . Despite the need to maintain the INR within the guideline-recommended therapeutic target range in accordance with the indication , INR monitoring and documentation quality in German general practices have often been reported to be inadequate . A cross-sectional survey by Chenot et al. indicates gaps in patient knowledge that reduce the safety and effectiveness of OAT. High age and low education levels are associated with lower overall safety-relevant knowledge about OAT [16, 17]. Insufficient patient knowledge about OAT is related to poorer anticoagulation control [18, 19]. An additional predictor of poor anticoagulation quality includes long intervals between measurements .
Patient education has been proposed as a means of improving adherence to oral anticoagulation [9, 21]. However, currently existing patient education strategies vary in terms of content, setting, duration, stated goal, structure and involved personnel . In Germany, where general practitioners (GPs) manage the majority of patients on OAT , large-scale RCTs to test the effectiveness of clearly defined patient education interventions in primary care settings are needed . To the best of our knowledge, no study has yet analysed the effectiveness of a complex intervention that includes major elements of well-established tools such as practice-based case management, self-management of OAT, and additional education for patients and practice teams to improve their knowledge about OAT. Previous education strategies that have successfully reduced thromboembolic complications and mortality rates have mostly been based on self-management of OAT [24–26]. Nonetheless, self-management may not be suitable for all patients . Apart from self-management, case management, which involves systematically monitoring patients, encouragement to continue the treatment and action in the case of non-adherence or no improvement , has been successful in patients with other chronic conditions such as chronic heart failure , osteoarthritis , and depression .
Between 2012 and 2015 the Institute of General Practice, Goethe-University Frankfurt, Germany, conducted the cluster-randomised PICANT trial (Primary Care Management for Optimised Antithrombotic Treatment) on patients with a long-term (i.e., lifelong) indication for oral anticoagulants in general practices in Germany, with the primary aim of improving antithrombotic management in primary healthcare by reducing major thromboembolic and bleeding events requiring hospitalisation .
In this paper we investigate whether the complex PICANT intervention that includes practice-based case management, self-management of OAT and additional patient and practice team education leads to an increase in patient knowledge about anticoagulation therapy after 12 and 24 months in intervention recipients, compared to patients receiving usual care (as one of the PICANT trial’s secondary objectives).
The cluster-randomised controlled PICANT trial on anticoagulation management was conducted between June 2012 and March 2015 in 52 general practices in the federal states of Hesse and Rhineland-Palatinate. The study was approved on June 26th, 2012, by the ethical review committee of the University Hospital, Goethe-University Frankfurt, Germany. The study is registered at www.controlled-trials.com (ISRCTN41847489). The study protocol, the presentation of the Coagulation-Monitoring-List (Co-MoL), the practice and patient recruitment process and data on screened patients have already been published elsewhere ([32–34]). Publications are currently being prepared on the primary and secondary objectives.
Patients of ≥ 18 years of age, with a long-term (lifelong) indication for oral anticoagulation (atrial fibrillation/flutter, recurrent venous thromboembolism or pulmonary embolism, mechanical heart prosthesis, and other conditions, such as hereditary coagulopathy, intracardial thrombosis) and who were taking any kind of OAT (coumarins, antiplatelet therapies, DOACs such as dabigatran) were recruited. Moreover, they had to regularly attend the GP’s practice and sign an information consent form. Exclusion criteria included dementia, a life expectancy of less than 6 months, drug or alcohol abuse, residence in a nursing home, or insufficient German language skills.
As described in the study protocol, the complex intervention included the provision of tools for study participants. These included information materials for patients, which depended on the type of oral anticoagulation they were taking, as well as information materials on oral anticoagulation and guidelines for GPs and healthcare assistants employed in their practices .
In Germany, GP practices generally employ one or more health care assistants (HCAs, ‘Medizinische Fachangestellte’). Their role is comparable to healthcare assistants in the UK or to medical assistants in the United States . They perform basic clinical tasks such as intramuscular injections, ECGs, spirometry, and taking blood samples.
At a 1-day workshop, health care assistants were trained to perform case management and educate patients (including an information brochure and a video developed by Hua et al., both of which contained safety-relevant information relating to OAT) .
HCAs were taught to tell patients about their disease and treatment conditions, to encourage them to perform self-management and to monitor them regularly using the Coagulation-Monitoring-List (Co-MoL) explained in detail elsewhere . The training also included DOAC-related topics (e.g. monitoring of renal function). HCAs conducted patient interviews following patients’ visits at the GP’s practice. In general, time intervals between monitoring visits depended on the stable adjustment of therapy. Most contacts took place in the practice, as the majority of anticoagulant patients visit the practice regularly anyway. If necessary, patients were contacted by telephone between the practice visits as well. The results of the interviews were reported to the GP who decided whether any further action was necessary. The aim was to assess symptoms and adherence to medication in patients, and to detect complications early and assess adverse effects.
GPs were provided with detailed explanations of what to expect from case management. Quality meetings were held three times during the course of the trial to discuss the newly approved DOACs, as well as practical problems involved in anticoagulation and individual case reports.
For patients, the complex intervention consisted of practice-based case management involving treatment monitoring, patient education, the provision of individual OAT-specific information, and encouragement to perform self-management where applicable. The control group received treatment as usual according to the current evidence-based guideline for oral anticoagulation therapy [37, 38].
Data collection and patient knowledge questionnaire
The assessments occurred at baseline, after 12 and after 24 months. Patients completed a knowledge questionnaire developed by Hua et al. for a previous trial on education for patients receiving OAT [36, 39]. The questionnaire contains 13 items covering safety-relevant knowledge about OAT. It aims to measure what patients learned from the intervention. Five questions relate to the patient’s individual OAT therapy, such as the indication for oral anticoagulation and the expected duration of treatment. Four questions relate to drug and other interactions. The remaining four questions are about safety precautions, such as the recognition of complications or emergencies. Open-ended questions allow free-text answers.
After extracting the main information from the free-text answers given by patients, categories were constructed manually, and answers with similar content summarised. Key facts emphasised in the intervention were used to build the categories. Following the evaluation scheme of Vormfelde at al., each of the thirteen questions included in the questionnaire was weighted with one point. Wrong answers, replies such as “I don’t know”, missing answers, or answers that were not evaluable within the context of the question, received 0 points. The sum-score therefore ranged from 0 to a maximum of 13 points, with higher scores indicating greater knowledge about OAT . The questionnaire was handed out to all patients (regardless of their OAT), because most questions were about general safety-relevant aspects of OAT. However, the evaluation scheme was modified to take into account particularities of DOACs, using current guidelines as a basis . For instance, when asked about their individual monitoring intervals, patients who had switched to DOACs and gave answers such as “I no longer need monthly monitoring of coagulation in the general practice” were given one point in the corresponding item, whereas patients taking vitamin K antagonists were expected to report their individual monitoring intervals.
Means and standard deviations of patients’ total sum-scores at baseline and at the two follow-ups were calculated for each group. Differences in the development of patient knowledge between the intervention and control groups compared to baseline were assessed separately for each follow-up assessment using linear mixed-effects models, and practices were included as random effects to account for the clustered structure of the data. A p-value of less than 5% was considered significant. SPSS version 19 and SAS version 9.4 were used for data analysis.
GP and patient characteristics at baseline
The average age of the 52 general practitioners recruited for the trial was 50.9 (SD 7.7) years, and nearly two thirds of them were male (65.4%). The majority of the physicians were general practitioners (84.6%). Fewer than half of them (42.3%) worked in solo practices. In the intervention group, an average of 3 health care assistants worked in each practice, compared with a mean of 3.6 HCAs per practice in the control group.
Of the 1469 eligible patients who were invited to participate in the trial, 736 patients (50.1%) provided written informed consent and were included in the study at baseline . Of these, 702 (95.4%) were still participating after 12 months, and 657 (89.3%) after 24 months. The remaining 733 patients (49.9%) did not participate. Participants and non-participants were comparable in age (73.5 (SD 9.4) vs. 75.0 years (SD 10.9)) and sex (male, 55.0% vs. 52.9%). A slightly higher percentage of participants performed self-management compared to non-participants (11.6% vs. 7.0%).
The median age of the participants was 73.5 (SD 9.4) and 55.0% were male (56.2% in the intervention group vs. 53.9% in the control group). Atrial fibrillation was the most common indication for anticoagulation (81.1%), followed by recurrent venous thrombosis (9.8%), other indications (9.1%) and recurrent pulmonary embolism (8.3%). At baseline, most patients received coumarins (94.3%), while 4.9% of all patients took DOACs. The last measured INR value lay within the therapeutic target range in approximately two thirds of patients (65.1%). A minority of patients (11.5%) performed self-management (self-testing and dose-adjusting). According to the GPs, most patients (80.0%) showed “very good compliance”. Baseline characteristics of the control and intervention arm are shown in detail in Table 1. Groups were comparable in terms of sex, age, indication for oral anticoagulation therapy, and type of medication.
Patient knowledge about oral anticoagulation at baseline
At baseline, intervention and control patients presented similar mean values for their knowledge about OAT (5.6 (SD 2.3) vs. 5.6 (SD 2.3)) (Fig. 1). The maximum number of points achieved at baseline was 10.5 in the intervention vs. 11.0 in the control group. About 60% knew their indication for OAT (question 1, see Table 2). At least 2/3 of all participants were aware of the goal of oral anticoagulation therapy (question 2) and their individual required treatment duration (question 3). Major knowledge gaps were observed in specific and detailed knowledge of OAT. About one third of patients knew their personal INR target range (VKA patients), or that they did not have an INR target range (DOAC patients) (question 5). 88.2% of all patients did not know about analgesics that are safe for orally anticoagulated patients and available without a prescription (question 8). 17.9% of participants were aware of the precautions that should be taken after forgetting to take a dose (question 9). 6.5% of participants were aware of emergency situations, such as melaena and impaired vision, that require a doctor’s visit the same day (question 12).
Patient knowledge after 12 months
After 12 months, participants in the intervention group showed higher knowledge values than those in the control group (6.5 (SD 2.8) vs. 5.7 (SD 2.5)) (Fig. 1). Compared to baseline, the number of correctly answered questions increased by 0.78 (SD 2.5) in the intervention group as compared to 0.04 (SD 2.3) in the control group (p = 0.0009). In general, scores on questions that were answered well before the intervention (see above) showed less improvement than scores on questions that were answered poorly (see Table 2). At 12 months, a greater percentage of intervention recipients than control recipients knew about the recommended non-prescription analgesic for patients with OAT (question 8) (25.1% vs. 15.4%). Members of the intervention group scored better than control group members with respect to measures to be taken after forgetting a dose (question 9) (28.6% vs. 19.9%). Intervention recipients had greater knowledge of emergency situations such as strokes and bleeding complications than members of the control group (question 12) (22.5% v. 5.9%).
Patient knowledge after 24 months
At 24 months, the intervention group still returned higher scores than the control group (6.4 (SD 2.9) vs. 5.5 (SD 2.5)) (Fig. 1). Overall, the average scores were slightly lower in both groups than 12 months before. Compared to baseline, the level of knowledge of intervention recipients remained high, whereas patients in the control group showed a slight decline (0.6 (SD 2.6) vs. -0.3 (SD 2.3); p = 0.0001). The positive effect of patient education had not increased further at 24 months but remained approximately the same.
We present the results of the cluster-randomised controlled Primary Care Management for Optimised Antithrombotic Treatment study assessing whether patients with a long-term indication for oral anticoagulation knew more about OAT following a structured complex intervention. The complex intervention included practice-based case management, self-management of OAT and additional education for patients and practice teams. Compared to baseline, intervention recipients achieved a greater improvement in knowledge than patients in the control group after both 12 and 24 months. On a single item level, intervention patients made particular progress on items relating to the INR target range, the knowledge of a safe over-the-counter analgesic, precautions to be taken after forgetting a dose and the recognition of emergency situations.
The meaning of the results in the context of the literature
Although a large number of patients are treated with oral anticoagulants in German general practices, no standardised patient education strategy exists . Patients at risk of poor anticoagulation control (among others, patients with long intervals between measurements) are more likely to need therapy support through additional training . Moreover, socio-demographic factors such as high age can negatively impact knowledge and understanding of oral anticoagulation, and this should be taken into consideration when developing education programmes . Previous studies have demonstrated the need for ongoing OAT education, and periodic “refreshers” have been recommended for patients in order to maintain a satisfactory level of patient knowledge . Strategies used to provide patient education on OAT cover a wide spectrum that includes the use of written information materials either alone or in addition to self-management interventions . Written information materials may be most effective when they include simple and easy-to-understand information that takes readability into account . Although self-management has proved to be successful in reducing thromboembolic complications and mortality rates by half , it is not feasible for all patients . To our knowledge this is the first randomised controlled trial that has tested whether a complex patient education intervention that consists of practice-based case management and additional patient education can effectively raise knowledge that is relevant to patient safety.
Our findings are similar to those found in other recently conducted prospective studies [42, 43] and RCTs [44, 45] that describe an increase in knowledge resulting from patient education delivered face-to-face and by means of written information materials on OAT (without self-management). Furthermore, one prospective study showed that education that is focused mainly on the self-management of OAT can lead to an increase in patient knowledge . However, most previous interventions were conducted in hospitals [42, 44, 45], teaching centres  and anticoagulation clinics , whereas our intervention took place in general practices, where the majority of patients on OAT are treated in Germany . Most previous studies were characterised by small sample populations of fewer than 100 patients [42, 44–46]. In contrast, our trial included 736 participants at baseline. Moreover, most trials only analysed the short-term effects of educational programmes by assessing knowledge directly after the intervention [43, 44], whereas we were able to show that a high knowledge level was maintained in the intervention group over a period of 2 years. After 24 months, the average measures of knowledge had declined slightly in both groups but still remained at a high level among intervention recipients. Similar developments were observed in other trials [42, 46].
Our results are consistent with the German RCT by Vormfelde et al. which used the same questionnaire to evaluate patient knowledge after a patient education intervention . However, the interventions were different. In Vormfelde’s trial, HCAs provided patients with verbal information during training sessions, as opposed to our case management with additional patient education . In both trials, substantial gaps in patients’ knowledge were revealed at baseline : It is worrying that less than half of the patients on VKA in both trials were aware of their personal INR target range. In both trials, fewer than 25% of patients knew the safest over-the-counter drug for patients on OAT. In both studies, knowledge of potential emergency situations was low. However, the results in our trial were even worse, since less than 10% of the baseline population were able to recognise symptoms of stroke or bleeding complications. Our results are similar to other studies that identified inadequate patient knowledge about oral anticoagulants [47, 48].
Higher test scores in the intervention group at both follow-up time points confirmed the effectiveness of the interventions in both trials. However, in comparison to Vormfelde et al. the study population in the PICANT trial was more than twice as large (736 patients vs. 319 patients) which implies greater power to detect differences between intervention and control groups .
This study took place against a background of increasing prescriptions of DOACs. Approved in 2011, dabigatran and rivaroxaban were the first DOACs to be approved for the prevention of stroke and systemic embolism. They were approved shortly before we submitted the study protocol to the ethics committee in November 2011. Nevertheless, we addressed DOAC-related issues in our intervention, e.g. by providing study participants with specific DOAC-related information materials. Our trial was representative for the uptake patterns of DOACs in Germany at the start of patient recruitment: According to the GARFIELD-AF registry, the proportion of patients on DOACs in Germany was 4.3% in 2011 . Similar results were observed for our study population at baseline (in 2012, 4.9% of patients were taking DOACs). The number of patients on DOACs has increased strongly during the last 5 years . This seems to be especially true for patients with newly diagnosed atrial fibrillation . The percentage of VKA patients switching to DOACs was 7.6% in this trial, slightly lower than the results of a study by Bleckwenn et al., which was also conducted in German primary care practices .
For decades, the traditional concept in Germany has been one of “the-doctor-does-it-all” . However, as a steadily decreasing number of GPs (especially in rural areas) are facing an increasing number of patients with complex needs, the role of healthcare assistants is being expanded to include not only administrative and simple tasks but also more complex ones, such as managing patients with chronic heart failure , osteoarthritis , and depression . Since registered nurses do not work in German primary care, expanding the role of health care assistants to permit them to take greater responsibility provides important benefits for GPs . The complex intervention described here was designed to be provided in addition to standard care of orally anticoagulated patients in general practices. It can be implemented in everyday care without the need to employ additional staff. Furthermore, recently developed reimbursement schemes in primary care (e.g. GP-centred care contracts) increasingly reimburse extra spending on specifically trained healthcare assistants and this is likely to further expand their role [35, 52].
Team-based care and task substitution help to maintain quality of care delivery in the face of growing demand for care among ageing populations, the increased prevalence of chronic diseases, and a shortage of GPs (particularly in rural areas of Germany). According to GPs, task shifting improves cooperation and information sharing in practice teams .
Strengths and limitations
To the best of our knowledge, PICANT is the largest cluster-randomised controlled trial to have been conducted on the effect of a complex intervention that includes practice-based case management, self-management of OAT and additional patient education on therapy-related knowledge about oral anticoagulation in Germany. In addition to the large sample size, the strengths of the trial also include the long-term intervention period of 24 months. With the support of GPs and HCAs, the intervention is feasible in a ‘real world’ setting and does not require new personnel or the creation of new interfaces. According to the literature, team-based care involving HCAs is associated with greater patient satisfaction  and possibly with greater patient compliance as well. A trusting relationship to the care-provider is considered to be an important criterion in patient-oriented case management . In this trial, patients on DOACs were also taken into account since there is a need for an analogous education programme, as explained above.
We acknowledge a potential selection bias, since a higher percentage of participants performed self-management compared to non-participants (11.6% vs. 7.0%). Participants may therefore have been more motivated than the eligible population from which we drew the sample. However, in terms of age and sex, no relevant differences between participants and non-participants could be identified. Up to now, the effectiveness of the complex intervention has only been evaluated in terms of whether it leads to an increase in patient knowledge about oral anticoagulation. We have not yet analysed the relationship between greater knowledge and improved clinical outcomes such as bleeding and thromboembolic complications, as well as time in the INR target range. Since the intervention is complex, evaluations stemming from qualitative interviews with participants need to be assessed in order to completely understand the mechanism of action. We have not referred specifically to the Medical Research Council guidance for the evaluation of complex interventions  since we did not strictly follow all the guideline’s recommendations on process evaluation. However, key guideline recommendations were taken into account in the development, evaluation and implementation of the intervention.
A notable loss to follow-up occurred at 24 months, which is a common problem in primary care trials (79 of 736 patients, 9.0% in the intervention group vs. 12.4% in the control group). The reasons for this were death or the patient’s decision not to participate any further. Vormfelde and colleagues reported that 95.4% of patients in the intervention group completed the 6-month follow-up assessment, compared with 88.7% in the control group . Nonetheless, our analyses reveal that the impact of the intervention on patient knowledge remained statistically significant, despite missing data resulting from nonparticipation in follow-up assessments. Our educational training intervention and the cluster design of the trial did not permit the practice team, patients and researchers to be blinded to group assignment.
A further limitation of this study is that we used a patient questionnaire on OAT knowledge that was originally developed for VKA patients . It would have been difficult to distribute different questionnaires for patients taking different oral anticoagulants (VKA and DOACs) because a DOAC knowledge questionnaire of comparable quality was not available in 2011, and because a relatively high proportion of patients switched therapy in the course of the trial (mainly from VKA to DOACs, but also from DOACs to VKA). For future research projects, however, we recommend revising the questionnaire by creating three modules (one common module on general safety, one module with VKA-specific questions and one module specific to DOACs). The need for education remains, even when vitamin K antagonists are replaced by direct oral anticoagulants. Since a readily available monitoring test does not exist for DOACs and dosing depends on renal function, patients should therefore be informed about safety-relevant aspects of their anticoagulant therapy. Amara et al. have recently shown that there are major knowledge gaps among DOAC patients : Only 53.9% of all DOAC patients were aware of the fact that regular monitoring of renal function is recommended for patients taking DOACs.
Our study showed that patient knowledge of INR target ranges, the proper use of medication to avoid drug interactions (e.g. with over-the-counter analgesics), and the recognition of emergencies such as strokes or bleeding complications, is often lacking. A complex intervention including general practice-based case management, self-management of OAT and additional education for patients and practice teams can lead to growth in patient knowledge. Since this intervention is only dependent upon the involvement of the entire general practice team and requires no additional interface, it would be possible to establish it as a measure to improve oral anticoagulation management in the German primary care sector. The need for education remains, even when vitamin K antagonists are replaced by direct oral anticoagulants. Since a readily available monitoring test does not exist for DOACs, and dosing depends on renal function, patients should be informed about safety-relevant aspects of their anticoagulant therapy. Educational programmes should contain standardised, clearly defined content focusing particularly on the safety-relevant gaps in knowledge that were identified in the baseline population. Patient education needs to be comprehensive and comprehensible, especially for older patients. Moreover, it can be presumed that patients should be educated more than once if a satisfactory level of patient knowledge is to be maintained.
Daily Defined Doses
Direct oral anticoagulants
Global Anticoagulant Registry in the FIELD
Health care assistant
International Normalised Ratio
Oral anticoagulation therapy
Primary Care Management for Optimised Antithrombotic Treatment
Randomised controlled trial
Vitamin K antagonists
Schwabe U, Paffrath D. Arzneiverordnungs-Report 2015: Aktuelle Daten, Kosten, Trends und Kommentare. Berlin: Springer Verlag; 2015.
Hua TD, Vormfelde SV, Abed MA, Schneider-Rudt H, Sobotta P, Chenot J-F. Orale antikoagulation in der hausarztpraxis. Z Allg Med. 2010;86:382–9.
Nilsson GH, Bjorholt I, Krakau I. Anticoagulant treatment of patients with chronic atrial fibrillation in primary health care in Sweden - a retrospective study of incidence and quality in a registered population. Fam Pract. 2004;21:612–6.
Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213–20.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest J. 2012;141:e419S–94S.
Institute for Safe Medication Practices. ISMP’s List of High-Alert Medications. 2014. http://www.ismp.org/Tools/highalertmedications.pdf. Accessed 22 Sept 2016.
Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians evidence-based clinical practice guidelines. Chest J. 2008;133:160S–98S.
Lamassa M, Di Carlo A, Pracucci G, Basile AM, Trefoloni G, Vanni P, et al. Characteristics, outcome, and care of stroke associated with atrial fibrillation in europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke. 2001;32:392–8.
Arzneimittelkommission der deutschen Ärzteschaft. Leitfaden “Orale Antikoagulation bei nicht valvulärem Vorhofflimmern” (2., überarbeitete Auflage); 2016. http://www.akdae.de/Arzneimitteltherapie/TE/LF/PDF/OAKVHF.pdf. Accessed 30 Nov 2016.
Schwabe U, Paffrath D. Arzneiverordnungs-Report 2016: Aktuelle Daten, Kosten, Trends und Kommentare. Berlin: Springer Berlin Heidelberg; 2016.
Camm AJ, Ambrosio G, Atar D, Berge E, Cools F, Fox KAA, et al. Patterns of uptake of non - vitamin K antagonist oral anticoagulants in Europe: an analysis from the GARFIELD - AF registry. Eur Heart J. 2015;36 suppl 1:242. P1513, 30 Aug 2015.
Holbrook A, Dormuth C, Morrow R, Lee A, Troyan S, Li G, Pullenyegum E. Comparative effectiveness and safety of oral anticoagulants for atrial fibrillation in real-world practice: a population-based cohort study protocol. BMJ Open. 2016;6:e013263.
Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369:1206–14.
Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GYH. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med. 2010;123:638–645.e4.
Saal K, Hoffmann B, Blauth E, Rohe J, Beyer M, Harder S, Gerlach FM. Analyse des Behandlungsprozesses bei der oralen Antikoagulationstherapie zur Identifikation von Sicherheitsproblemen in der hausärztlichen Versorgung. Z Allg Med. 2009;85:148–55.
Chenot J-F, Hua TD, Abu Abed M, Schneider-Rudt H, Friede T, Schneider S, Vormfelde SV. Safety relevant knowledge of orally anticoagulated patients without self-monitoring: a baseline survey in primary care. BMC Fam Pract. 2014;15:104.
Nasser S, Mullan J, Bajorek B. Challenges of older patients’ knowledge about warfarin therapy. J Prim Care Community Health. 2012;3:65–74.
Palareti G, Legnani C, Guazzaloca G, Lelia V, Cosmi B, Lunghi B, et al. Risks factors for highly unstable response to oral anticoagulation: a case-control study. Br J Haematol. 2005;129:72–8.
Tang EOY, Lai CSM, Lee KKC, Wong RSM, Cheng G, Chan TYK. Relationship between patientsʼ warfarin knowledge and anticoagulation control. Ann Pharmacother. 2003;37:34–9.
Schaefer C, Wuillemin WA, Kessels A, Jacobson A, Nagler M. Predictors of anticoagulation quality in 15 834 patients performing patient self-management of oral anticoagulation with vitamin K antagonists in real-life practice: a survey of the International Self-Monitoring Association of Orally Anticoagulated Patients. Br J Haematol. 2016;175(4):677–85.
Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15:625–51.
Wofford JL, Wells MD, Singh S. Best strategies for patient education about anticoagulation with warfarin: a systematic review. BMC Health Serv Res. 2008;8:40.
Wong PYH, Schulman S, Woodworth S, Holbrook A. Supplemental patient education for patients taking oral anticoagulants: systematic review and meta-analysis. J Thromb Haemost. 2013;11:491–502.
Christensen TD, Johnsen SP, Hjortdal VE, Hasenkam JM. Self-management of oral anticoagulant therapy: a systematic review and meta-analysis. Int J Cardiol. 2007;118:54–61.
Heneghan C, Ward A, Perera R, Bankhead C, Fuller A, Stevens R, et al. Self-monitoring of oral anticoagulation: Systematic review and meta-analysis of individual patient data. Lancet. 2012;379:322–34.
Siebenhofer A, Jeitler K, Horvath K, Habacher W, Schmidt L, Semlitsch T. Self-management of oral anticoagulation. Dtsch Arztebl Int. 2014;111:83.
Heneghan CJ, Garcia-Alamino JM, Spencer EA, Ward AM, Perera R, Bankhead C, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2016;7. http://dx.doi.org/10.1002/14651858.CD003839.pub3.
von Korff M, Goldberg D. Improving outcomes in depression. BMJ. 2001;323:948–9.
Peters-Klimm F, Campbell S, Hermann K, Kunz CU, Muller-Tasch T, Szecsenyi J. Case management for patients with chronic systolic heart failure in primary care: the HICMan exploratory randomised controlled trial. Trials. 2010;11:56.
Rosemann T, Joos S, Laux G, Gensichen J, Szecsenyi J. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum. 2007;57:1390–7.
Gensichen J. Case management for depression by health care assistants in small primary care practices. Ann Intern Med. 2009;151:369–78.
Siebenhofer A, Ulrich LR, Mergenthal K, Roehl I, Rauck S, Berghold A, et al. Primary care management for optimized antithrombotic treatment [PICANT]: study protocol for a cluster-randomized controlled trial. Implement Sci. 2012;7:79.
Ulrich L-R, Petersen JJ, Mergenthal K, Roehl I, Rauck S, Erler A, et al. Eine monitoring-liste für ein hausärztliches case management bei oraler antikoagulation. Z Allg Med. 2013;89:165–71.
Ulrich L-R, Mergenthal K, Petersen JJ, Roehl I, Rauck S, Kemperdick B, et al. Anticoagulant treatment in German family practices – screening results from a cluster randomized controlled trial. BMC Fam Pract. 2014;15:170.
Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud. 2015;52:727–43.
Hua TD, Vormfelde SV, Abed MA, Schneider-Rudt H, Sobotta P, Friede T, Chenot J-F. Practice nursed-based, individual and video-assisted patient education in oral anticoagulation-protocol of a cluster-randomized controlled trial. BMC Fam Pract. 2011;12:17.
Leitliniengruppe Hessen. Hausärztliche Leitlinie Antikoagulation [Guideline Anticoagulation for General Practitioners]. http://www.pmvforschungsgruppe.de/pdf/03_publikationen/antikoagulation_ll.pdf. Accessed 22 Sept 2016.
Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin [German Society of General Practice and Family Medicine. Neue orale Antikoagulantien (bei nicht valvulärem Vorhofflimmern). http://www.degam.de/files/Inhalte/Leitlinien-Inhalte/Dokumente/S1-Handlungsempfehlung/S1-HE_NOAK_Langfassung.pdf. Accessed 22 Sept 2016.
Vormfelde SV, Abed MA, Hua TD, Schneider S, Friede T, Chenot J-F. Educating orally anticoagulated patients in drug safety: a cluster-randomized study in general practice. Dtsch Arztebl Int. 2014;111:607–14.
Deck ED. The effect of an educational intervention on oral anticoagulation therapy knowledge in primary care (dissertation). Evid Based Pract Project Rep. 2015;72:1–101. http://scholar.valpo.edu/cgi/viewcontent.cgi?article=1072&context=ebpr.
Clarkesmith DE, Pattison HM, Lane DA. Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation. Cochrane Database Syst Rev. 2013;6. http://dx.doi.org/10.1002/14651858.CD008600.pub2.
Saligari E, Belle L, Berry C, Gonod M, Poiré V, Picard A, et al. Évaluation d’un programme d’éducation des patients sous antivitamine K. Ann Cardiol Angeiol. 2003;52:297–301.
Winans ARM, Rudd KM, Triller D. Assessing anticoagulation knowledge in patients new to warfarin therapy. Ann Pharmacother. 2010;44:1152–7.
Clark CM, Bayley EW. Evaluation of the use of programmed instruction for patients maintained on Warfarin therapy. Am J Public Health. 1972;62:1135–9.
Polek C, Hardie T. Warfarin use post hospitalization: pilot comparative effectiveness of telephone follow-up. Rehabil Nurs. 2012;37:80–7.
Völler H, Dovifat C, Glatz J, Kortke H, Taborski U, Wegscheider K. Self management of oral anticoagulation with the IN Ratio system: Impact of a structured teaching program on patient’s knowledge of medical background and procedures. Eur J Cardiovasc Prev Rehabil. 2004;11:442–7.
Janoly-Dumenil A, Bourne C, Loiseau K, Luaute J, Sancho P-O, Ciancia S, et al. Oral anticoagulant treatment - evaluating the knowledge of patients admitted in physical medicine and rehabilitation units. Ann Phys Rehabil Med. 2011;54:172–80.
Alphonsa A, Sharma KK, Sharma G, Bhatia R. Knowledge regarding oral anticoagulation therapy among patients with stroke and those at high risk of thromboembolic events. J Stroke Cerebrovasc Dis. 2015;24:668–72.
Sterne JAC. Sifting the evidence- what’s wrong with significance tests?: Another comment on the role of statistical methods. BMJ. 2001;322:226–31.
Innasimuthu AL, Kumar S, Akter S, Borer JS. New oral anticoagulants: great promise for therapeutic advance but great knowledge gaps remain to be filled. Cardiology. 2013;126:41–9.
Bleckwenn M, Dinkel K, Weckbecker K, Mücke M. Einsatz der Neuen oralen Antikoagulanzien in Hausarztpraxen. Z Allg Med. 2016;92(1):28–32.
Mergenthal K, Leifermann M, Beyer M, Gerlach FM, Guthlin C. Delegation hausärztlicher Tätigkeiten an qualifiziertes medizinisches Fachpersonal in Deutschland - eine Übersicht. Gesundheitswesen. 2016;78:e62–8.
Gensichen J, Guthlin C, Kleppel V, Jager C, Mergenthal K, Gerlach FM, Petersen JJ. Practice-based depression case management in primary care: a qualitative study on family doctors’ perspectives. Fam Pract. 2011;28:565–71.
Wen J, Schulman KA. Can team-based care improve patient satisfaction? A systematic review of randomized controlled trials. PLoS One. 2014;9:e100603.
Gensichen J, Guethlin C, Sarmand N, Sivakumaran D, Jager C, Mergenthal K, et al. Patients’ perspectives on depression case management in general practice - a qualitative study. Patient Educ Couns. 2012;86:114–9.
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.
Amara W, Larsen TB, Sciaraffia E, Hernandez Madrid A, Chen J, Estner H, et al. Patients’ attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association. Europace. 2016;18:151–5.
The authors would like to thank Phillip Elliott for proof-reading the manuscript. We would like to express our gratitude to Prof. Dr. med. Chenot who provided us with the questionnaire developed by Dr. med. Duc Hua. We would also like to thank the practice teams and patients of the 52 general practices participating in the PICANT trial.
The PICANT trial was funded by the German Federal Ministry of Education and Research (grant number 01GY1145). The funding body was neither involved in the design of the study, nor in the collection, analysis, and interpretation of data or in writing the manuscript.
Availability of data and materials
The datasets analysed during the current study are available from the corresponding author on reasonable request.
VM, JJP and AS wrote the first draft of the manuscript. AS, LRU, KM, FMG and JJP wrote the study protocol of the PICANT trial. AS, LRU, KM, SSR, BK, SR and JJP were responsible for data collection and monitoring. VM and JJP processed the patient knowledge data and calculated the sum scores. GP and AB conducted the statistical analyses. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The study was approved on the June 26th, 2012 by the ethical review committee of the University Hospital, Goethe-University Frankfurt, Germany (Reference-No 49/09). Patients who met the inclusion criteria had to sign an informed consent form to enrol in the trial.
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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Cite this article
Maikranz, V., Siebenhofer, A., Ulrich, LR. et al. Does a complex intervention increase patient knowledge about oral anticoagulation? - a cluster-randomised controlled trial. BMC Fam Pract 18, 15 (2017). https://doi.org/10.1186/s12875-017-0588-2
- Oral anticoagulation
- Patient education
- Case management
- General practice
- Patient knowledge


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Previous Names:?Birmingham County Asylum (Rubery Hill), 1st Birmingham War Hospital
Location:?Bristol Road, Rednal, Worcestershire
Principal Architect: William?Martin & John Henry Chamberlain
Layout:?Standard Pavilion Plan
Status:?Closed, mostly demolished
Opened:?4th January 1882
The new Birmingham Borough Asylum was constructed and opened in 1882 in response for demand for more capacity for the City?s lunatic inmates. The existing borough asylum at Winson Green was already thirty years old by the time the new site was ready and the surrounding area was already substantially developed. The new development, originally to be developed for occupation by chronic patients was located in a comparatively rural location close to the villages of Rubery and Rednal on land which sloped toward the southeast.
The asylum was developed along the pavilion plan lines with large capacity barn-like dormitories and day rooms. Two male and two male pavilions were located either side of a central chapel and all were linked by a linear corridor. To the other side of the corridor stood the laundry, with the administration block and medical superintendent?s residence clustered around the drive from the Bristol Road to the south. A lodge was provided at the foot of the drive, which also continued north past the main buildings to a detached works and boiler house complex and thereafter to another lodge and gate on Rubery Lane which provided the goods entrance to the site.
The buildings were constructed in brick with timber gable decoration and terracotta detailing with some elements of gothic design. The materials were largely sought from the area and consisted of local red brick with tiled roofing. The windows were double hung sashes. The main ward blocks were characterised by multiple dormer windows breaking up the roofline, with matching vents on the chapel. The hospital was extended to either end in 1893-7 with additional ward pavilions and a burial ground on Bedlam Lane, but further extensions were limited once new developments took place in the new century.
Birmingham City Council determined that additional space would be better provided by constructing a third asylum complex, located close enough to Rubery Hill so that the new asylum could be co-managed with that asylum. The new asylum was built at Hollymoor farm and considerably closer to the villages of Longbridge and Northfield and opened in May 1905. Hollymoor was to become the site where most further development was concentrated and Rubery Hill subsequently took on a less prominent role in the development of treatment and therapies with its primarily long stay population.
World War I brought about a major upheaval at both Rubery Hill and Hollymoor Asylums as both hospitals were vacated to provide space for the military to use the complexes for war casualties, becoming the First and Second Birmingham War Hospitals. Many of the inmates were relocated to other asylums in the area, particularly the Staffordshire Asylum at Cheddleton, near Leek.Elsewhere in the City, the Birmingham University at Edgbaston became the First Southern Military Hospital with the Highbury estate as an annexe.
The buildings were returned to Birmingham City Council after 1919 and was then renamed as Rubery Hill mental hospital with extensions being made into the ariring courts to provide additional space. A detached wing was also constructed to the south west. By World War II the Hollymoor Complex was once again taken over by the services as Northfield Military Hospital and patients transferred to Rubery Hill and surrounding hospitals. The creation of the National Health Service saw the return of Hollymoor and the separation of management for both hospitals. The 1960?s brought about a reduction in bed numbers which had peaked in the mid 1950?s. The administration building was heavily remodelled to expand it’s upper floor, losing the characteristic gable over the main entrance in the process, with large metal windows installed.
The extensive surrounding agricultural land forming part of the estate formed an attractive resource for development for additional healthcare purposes. Between Hollymoor and Rubery Hill two complexes were built both accessed from a driveway on Bristol Road, close to the Colmer?s Farm Schools. The first to open was the Joseph Sheldon Geriatric Hospital, opened in 1964 by it?s namesake – a notable geriatrician and expert on the elderly from Wolverhampton and had capacity for 160 patient?s. The structure was largely single storey and functional in design comprising two large pavilions either side of a central reception and service area and stood a short distance south of the lane linking Rubery Hill and Hollymoor at it?s junction with Bedlam Lane. The former burial ground, by this time disused was located a short distance directly to the north. The second complex was named the John Connolly Hospital after the notable psychiatrist and former Superintendent of Hanwell in the early 19th century. The hospital was to form an additional psychiatric unit combining 90 inpatient beds with outpatient facilities and modelled on the nascent therapeutic community mode. This had its roots at Hollymoor during its time as the Northfield Military Hospital had been initially known as the ?Northfield Experiment?.
Gradually development took place to which were to reduce new long stay patients and wards were gradually combined and closed. Acute services were developed in the district general hospitals in the area. The need for the complex of hospitals between Northfield and Rubery was beginning to disappear and the extensive grounds were to provide an incentive for sale and redevelopment.
Rubery Hill was the first of the hospitals to close was, being largely vacated during 1992 and closing officially in 1993. Hollymoor and the Joseph Sheldon were to follow in 1994 and John Connolly Hospital in 1995 with remaining services transferred to Solihull Hospital.
Since closure the majority of buildings at Rubery Hill were demolished, as were all of those at the John Connolly and Joseph Sheldon Hospitals. The lodge and approach drives remain to the north and south of the complex along with the former superintendent?s residence and chapel which have since been converted to new uses. Housing occupies the remaining Rubery hill site. A cluster of old works buildings also survived in conjunction with the district stores close to the north drive. The site of the John Connolly and Joseph Sheldon sites has been lost within the Great Park leisure development.


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The authors of a new study say that patients with certain mutations appear to respond to zanubrutinib, which had a favorable safety profile.
Brukinsa (zanubrutinib) monotherapy has resulted in modest responses in patients with non-germline diffuse large B-cell lymphoma (non-GCB DLBCL) and may be a meaningful treatment option for some patients based on screening by biomarkers, according to a new study.
The report, published in Blood advanceswas based on a single-arm, multicenter, phase 2 study of 41 patients with relapsed or refractory non-GCB DLBCL.
The authors wrote that recent advances in the study of DLBCL indicate that the type of cancer is actually a group of disorders, rather than a single disease. Phenotypes include germline center B-cell lymphomas and non-germline center lymphomas. Immunotherapy with rituximab (Rituxan), cyclophosphamide, doxorubicin (Adriamycin), and prednisolone is usually the first-line treatment for patients with DLBCL; however, many patients are refractory to treatment or experience a relapse, often resulting in poor outcomes.
Zanubrutinib is an oral Bruton’s tyrosine kinase (BTK) inhibitor that has been shown to have a favorable safety profile and positive outcomes in several B-cell malignancies. other B-cell cancers, the authors wanted to know if the therapy might be effective in non-GCB DLBCL.
The investigators enrolled 41 patients in their phase 2 study, with the aim of seeing whether these patients with relapsed or refractory disease would benefit from 2 daily oral doses of 160 mg of zanubrutinib. Their primary endpoint was overall response rate (ORR), with progression-free survival (PFS) and duration of response (DOR) as secondary endpoints. Overall survival (OS) was an exploratory endpoint.
After a median follow-up of 6.8 months, investigators said 29.3% of patients responded to treatment, with a complete response (CR) rate of 17.1%. Median DOR was 4.5 months, PFS was 2.8 months, and OS was 8.4 months, they added.
At the time of data closure, only 4 of 37 patients were still taking the drug. Almost half of patients (48.8%) experienced grade 3 or higher adverse events (AEs), but only 4 patients discontinued the drug due to AEs. No patient presented with major bleeding, atrial fibrillation and/or flutter. Among the most common treatment-related AEs were decreased neutrophil count (9 patients), hypokalaemia (7 patients), and decreased platelet count (5 patients). Twenty-four patients died, most (19) of progressive disease.
Investigators retrospectively performed biomarker testing on study patients. They found that patients with both CD79B and MYD88 the mutations appeared to have antitumor activity. This group of patients was also found to have poor outcomes with standard immunochemotherapy.
“Our genetic analysis results also suggested the potential activity of zanubrutinib in these DLBCL subsets (ORR, 50%; 3/6),” the authors reported. “An improved biomarker strategy beyond GCB vs. non-GCB classification may help target DLBCL more precisely.”
They noted several limitations to their findings, including the small sample size and poor representation of patients who had previously undergone autologous stem cell transplantation (4 patients).
“Notwithstanding these limitations, the overall activity of zanubrutinib in DLBCL R/R appears similar to that of other BTK inhibitors, but with a suggestion of improved tolerability compared to ibrutinib,” they wrote.
They concluded that zanubrutinib deserves further study in this patient group, with particular emphasis on mechanism-based combination therapy development and biomarker-based patient selection.
Yang H, Xiang B, Song Y, et al. Zanubrutinib monotherapy for relapsed or refractory non-germ-center diffuse large B-cell lymphoma. Adv of blood. 2022;6(6):1629-1636. doi:10.1182/bloodadvances.2020003698

domain: biology


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US Dollar Index Price Analysis: DXY extends bounce off nearby support line to tease 90.00
- DXY pauses around short-term key support line after two-day downtrend.
- Bearish MACD, failure to cross 200-SMA favor sellers.
- 61.8% FE gains market attention below the fortnight-old immediate support.
US dollar index (DXY) fades the late Monday’s corrective pullback around the 90.00 threshold during early Tuesday’s trading. Even so, the greenback gauge versus the major six currencies probes the bears after consecutive two-day declines in the recent past.
Given the bearish MACD and failures to cross the 200-SMA, the US dollar index is likely to break the stated support line, around 89.90.
Though, any further downside will have multiple barriers near 89.70 and 89.50 before the DXY sellers could attack 61.8% Fibonacci Expansion (FE) of April 16 to May 25 downtrend, around 89.20.
Alternatively, further recovery will eye for the 90.30 resistance before confronting the 200-SMA level of 90.41. Also acting as an upside filter is the monthly peak surrounding 90.62.
In a case wherein the DXY buyers refresh the monthly top, the mid-May high near the 91.00 and multiple tops marked since late April surrounding 91.45 will gain the market’s attention.
DXY four-hour chart
via FXStreet News https://ift.tt/3tYkUTd
June 7, 2021 at 06:39PM

domain: finance


A reservist who died alongside a colleague during an assessment for the Territorial Army's SAS section on the hottest day of the year was pursuing his dream, his family said today. Lance Corporal Craig Roberts died during a military exercise in the Brecon Beacons on Saturday.
In a statement issued through the Ministry of Defence today, Mr Roberts's father Kelvin said:
We are all devastated at the loss of our beloved Craig; this has left a massive hole in all our lives.
We wholeheartedly supported Craig in his military endeavours and it gives us some comfort, though great sadness, that he died in the pursuit of his dream.
Next month Craig was due to start a new post in the office of the Secretary of State for Education and we were all very proud of him.
More top news
As Christians in London celebrate All Saints Day and prepare to mark All Souls Day, find out the true meaning behind these special events.
Temperatures reached 23.6C at both Kew Gardens in west London and Gravesend in Kent.
As the housing crisis deepens in London, ITV investigates the extortionate fees being charged by estate agents.


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Joffrey Memorial Season Set by Ballet Company
Published: August 21, 1988
A new ballet by James Kudelka and the revival of George Balanchine's ''Cotillon'' will be presented by the Joffrey Ballet in its Robert Joffrey Memorial Season at City Center, from Oct. 26 to Nov. 13.
The Balanchine ballet, a 1932 work set set to music by Chabrier, is considered a lost masterpiece. Mr. Kudelka's ''Concerto Grosso'' is set to music by Jean Papineau-Couture.
Other highlights are the company premiere of Eugene Loring's ''Billy the Kid'' and a revival of Michel Fokine's ''Petrouchka.'' The company will also perform excerpts from ''Remembrances,'' a 1973 work by Mr. Joffrey, who died this year, and revivals of ''Suite Saint-Saens'' and ''Viva Vivaldi,'' both by Gerald Arpino, the Joffrey's new director. Mr. Joffrey's production of ''The Nutcracker'' will be performed from Nov. 18 to Dec. 4.


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About a month ago, we had a team of general repair and building men in to do some work on our outbuilding. More on the outbuilding later though. Perhaps even way way later. We also got them to fix something that’s been irritating us since we moved into our house.
In the corner of the sunroom, is a really large steel pipe. I presume this sunroom was the original house’s old stoep thus that pipe would have been “outside”. But seeing as the old stoep is part of the inside of the house, the pipe is only an eyesore.
We had it cut smaller so we can strategically place furniture to disguise its ugliness.
But then, as the pipe was being removed, we found that there was pressed ceiling hiding underneath the ceiling board.
Although a little damaged it is nothing hubby and I can’t fix. Tons of elbow grease later and I’m ready for this ceiling to be done and the walls to be repainted.
Alas, these things take time. And they take even more time when you do them yourself.
I can tell by this last photo that all the hard work will be worth it. Can you picture it yet?


Fiji ginger breaks through into lucrative Australian supermarket chains
A Fiji ginger producer has been able to break into the lucrative Australian market with the aid of Pacific Trade Invest Australia (PTI).
The agency helped the Navua based Kaiming Agro Processing break into the export market by assisting with the purchase of a date encoding machine.
The company's crystallised ginger is now for sale in the Coles and Aldi supermarket chains in Australia.
Mona Mato, Pacific Trade Invest Australia's manager of export services, told Bruce Hill that adding value to products and exporting them is the way forward for Pacific food producers.