text:
Improving follow-up to abnormal breast cancer screening in an urban population†
A patient navigation intervention
Presented at Exploring Models to Eliminate Cancer Disparities Among African American and Latino Populations: Research and Community Solutions, Atlanta, GA, April 21–22, 2005.
Delays in follow-up after cancer screening contribute to racial/ethnic disparities in cancer outcomes. We evaluated a patient navigator intervention among inner-city women with breast abnormalities. A full-time patient navigator supported patients using the care management model. Female patients 18 years and above, referred to an urban, hospital-based, diagnostic breast health practice from January to June 2000 (preintervention) and November 2001 to February 2003 (intervention), were studied. Timely follow-up was defined as arrival to diagnostic evaluation within 120 days from the date the original appointment was scheduled. Data were collected via computerized registration, medical records, and patient interview. Bivariate and multivariate logistic regression analyses were conducted, comparing preintervention and intervention groups, with propensity score analysis and time trend analysis to address the limitations of the pre–post design. 314 patients were scheduled preintervention; 1018, during the intervention. Overall, mean age was 44 years; 40% black, 36% non-Hispanic white, 14% Hispanic, 4% Asian, 5% other; 15% required an interpreter; 68% had no or only public insurance. Forty-four percent of referrals originated from a community health center, 34% from a hospital-based practice. During the intervention, 78% had timely follow-up versus 64% preintervention (P < .0001). In adjusted analyses, women in the intervention group had 39% greater odds of having timely follow-up (95% CI, 1.01–1.9). Timely follow-up in the adjusted model was associated with older age (P = .0003), having private insurance (P = .006), having an abnormal mammogram (P = .0001), and being referred from a hospital-based practice, as compared to a community health center (P = .003). Our data suggest a benefit of patient navigators in reducing delay in breast cancer care for poor and minority populations. Cancer 2007. © 2006 American Cancer Society.
The unequal burden of cancer is highlighted among lower socioeconomic status and racial/ethnic minority women who suffer higher mortality from breast cancer compared with their more affluent non-Hispanic white counterparts. Age standardized death rates among African American women with breast cancer exceed those of non-Hispanic white women. Similarly, residents of poorer counties have higher death rates from breast cancer than do residents of more affluent counties. 1 Advanced stage at diagnosis, which contributes to poorer outcomes, is found more frequently in these populations. Recent SEER statistics show that the proportion of women diagnosed with regional- and distant-stage breast cancer continues to be higher among African Americans and Hispanics than among non-Hispanic whites. The same is true when one compares high- versus low-poverty census tracts; the proportion diagnosed with distant stages is higher in high-poverty census tracts.1
Improvements in access and equity in mammography screening alone have not translated into survival improvements for these disadvantaged women. 1 Although racial/ethnic differences in mammography utilization rates have been found to explain some of the observed differences in stage at diagnosis,2 several observational studies have not found this to be a significant explanatory factor.3–5 Potential reduction in morbidity and mortality through breast cancer screening will never be realized without timely and efficient follow-up care once an abnormality has been detected. Investigating the disparities in follow-up after abnormal breast screening serves as the next step in addressing breast cancer health disparities. Although measures of follow-up lack precision,6 numerous studies have documented that racial/ethnic minority women often suffer from the longest delays at this point.5, 7–11
Patient navigation, a type of care management that encompasses a wide-range of advocacy and coordination activities, has been proposed to address known barriers to the delivery of high-quality cancer care in underserved populations. 12–14 A recent national case study review of emerging programs to reduce racial/ethnic disparities in cancer found that almost all adopted a variant of patient navigation.15 Despite increasing interest along with both federal and private resource allocation,16, 17 published evidence of the benefit of navigation programs is limited.18
We evaluated a hospital-based patient navigator intervention among inner-city minority women with breast abnormalities. The main objective of the intervention is to improve the rate of timely diagnostic follow-up in comparison to a group of historical controls, and to identify characteristics of patients who are most at risk for loss to follow-up.
MATERIALS AND METHODS
This pre–post intervention study was conducted at a hospital-based diagnostic breast health practice at a major academic medical center in Boston, Massachusetts. The specialty practice accepts referrals for evaluation of any breast health issue, including screening abnormalities, suspicious symptoms, or elevated cancer risk. Patients served include those who receive their primary care at the academic medical center and those from over 20 affiliated community health centers throughout Boston. Together with its affiliated health centers, the academic institution serves as the major safety-net hospital in the region. All income eligible, uninsured women can receive services without charge. This study was approved by our Institutional Review Board. Written informed consent was waived since the intervention was implemented as a new standard of care for all patients. The final dataset used in these analyses was devoid of all patient identifiers.
The sample for this study included all women with scheduled visits at the diagnostic breast health practice from January through June 2000 (preintervention, N = 314) and November 2001 through February 2003 (intervention, N = 1018). We included consecutive female patients >18 years referred for evaluation during the study period, as referral criteria to the practice were consistent throughout this time period. Individual women were only included once throughout the study, so that preintervention and intervention subjects are unique women. For women seen more than once during this timeframe, we evaluated their initial scheduled visit only, using subsequent visits for the sole purpose of evaluating follow-up within 120 days.
As a result of initial observations of patient care data showing high rates of failure to arrive for scheduled evaluation, a formal program evaluation was conceived. At the time of preintervention data collection, the standard protocol for these patients used existing secretarial staff to attempt telephone contact without clinical oversight. In the ensuing 16 months prior to program implementation, this protocol continued without other institutional or practice changes while a needs assessment was undertaken to inform the intervention. Findings from structured interviews with patients, breast health providers/support staff, and referring providers identified lack of coordination of care and communication as major barriers to diagnostic evaluation. Program planning, hiring, and navigator training occurred during this time period.
The patient navigator intervention was guided by the principles of Care Management.19 Services provided by the navigator focused around 4 key activities: 1) case identification, 2) identification of individual barriers to care, 3) implementation of a care plan, and 4) tracking through completion. Criteria for hiring of the patient navigator included experience caring for a diverse patient population and knowledge of the existing local health systems. The patient navigator was trained to coordinate care for each patient referred for diagnostic evaluation. Training included written triage and follow-up protocols as well as monthly barriers-focused cultural competence training at the local department of public health. Initial contact with patients began after appointments were scheduled, 1 week before their scheduled visit. Telephone outreach with all patients, using interpreters for non-English speaking women, was attempted to confirm appointments, provide information about the visit, and learn about any individual barriers to arriving for that appointment. The navigator utilized available resources to address those barriers. A key function of the navigator included advocating for the patient through rapid communication with breast health providers, referring providers, and with other specialty sites, including radiology, surgery, and pathology. In accordance with the 4th key activity, the patient navigator, with daily assistance and weekly oversight by the study coordinator, tracked information on patient demographics, reason for referral, site and provider who referred the patient, diagnostic evaluation conducted, and outcomes of evaluation. Dates from time of initial referral through arrival to first scheduled visit were collected.
Preintervention data collection was conducted via retrospective chart review for women referred to the diagnostic breast evaluation practice from January through June 2000. The administrative registration database was reviewed for the date that the first diagnostic appointment was scheduled, demographic data, and the date at which the patient first arrived for evaluation. If the patient's race was not listed in the registration database, but their birthplace and native language were listed, race was extrapolated from birthplace and native language. For example, if a woman was born in Haiti and spoke Haitian-Creole, she was categorized as black. The clinical record was abstracted for reason for visit based on the following categories: abnormal mammography (BI-RADS category 0, 3, 4, 5), abnormal clinical breast exam, or other (including suspicious symptoms or elevated cancer risk). To ensure accuracy of data, all preintervention data were reviewed by a second chart abstractor.
Intervention data were collected prospectively by the navigator beginning 1 week before the scheduled diagnostic visit at the time schedules were reviewed for case identification and telephone outreach. Following preintervention data collection protocol, the administrative registration database was reviewed for the date that the diagnostic appointment was scheduled and demographic data while the clinical record was abstracted for reason for visit. The date the subjects first arrived to a diagnostic evaluation was documented prospectively by the navigator. To ensure completeness and accuracy of data, all intervention data were reviewed by a one of the authors on a weekly basis (TB, KF). The final analytic file was a limited dataset devoid of key patient identifiers.
The main outcome in this intervention study was the dichotomous variable timely follow-up (yes, no). Subjects were considered to have timely follow-up if they arrived to a diagnostic evaluation visit within 120 days from the date the original appointment was scheduled. Although an ideal outcome would be time to actual diagnosis or resolution of the abnormality, limited data collected during the preintervention period prohibited this comparison. Since no gold standard exists to determine what constitutes timely diagnostic follow-up, 6 we operationalized the concept based on: 1) literature that suggests diagnostic and treatment delays of 3–6 months may impact survival20; and 2) review of our data, which indicated that beyond 120 days no appreciable additional follow-up was achieved. Furthermore, repeating our analyses using 90 days as the definition of timely follow-up did not change our findings. To determine 120 day follow-up rates for patients who were seen within the last 120 days for the specified study time period, records beyond the study end date were examined.
Baseline demographic data, including age, race, reason for consultation, site of referral, need for interpreter services, and insurance status, were compared between subjects presenting for care during the preintervention and intervention period. Bivariate comparisons using χ2 tests of independence tested for differences in timely follow-up between the 2 groups overall, and within specific demographic variables. Logistic regression was conducted to assess the proportion of benefit that can be attributed to the navigator intervention, once demographic variables were taken into account, and 95% confidence intervals were calculated. All analyses were done using PC-SAS version 8.02. 21
Because baseline differences were noted between the preintervention and intervention group, 2 subsequent analyses were performed to control for differences in case-mix in the 2 study groups. First, a propensity score analysis was conducted to adjust for differences between the study periods. This methodology selects a random subset of subjects in each study period, so that baseline characteristics of the 2 groups are similar. One intervention subject was chosen per preintervention subject. After demonstrating that the groups were similar in the their baseline characteristics (age, race/ethnicity, insurance, reason for referral, and source of referral), we conducted a multiple logistic regression on the reduced dataset predicting timely follow-up, again adjusting for age, race/ethnicity, insurance, reason for referral, and referral source. Second, time was considered as a covariate in the model to control for longitudinal effects not related to the intervention. Time was calculated as the month of the study when the visit was scheduled. For example, a women who scheduled her appointment during the first month of the study (January 2000) would have a value of time of 1, while a women who was in the intervention period might have a value of time of 25, representing that she scheduled her appointment in January 2002. Three models were considered: including time to the main model including covariates; including an interaction effect between time and intervention in the main model; and considering only the effects of time and intervention on timely follow-up. 22
During the study period, 2044 scheduled patient visits were identified, which corresponded to 1381 individual patients. Of those patients, 21 (1.5%) men were excluded, 10 (0.7%) visits for female teens under age 18 were excluded, and 14 (1.0%) were excluded due to missing dates. The final analytic sample consisted of 1332 individual women with scheduled visits (314 preintervention, 1018 during the intervention period).
Baseline characteristics by study group are shown in Table 1. The majority of women scheduled for evaluation were under age 65 (91%), with over half (52%) between 40 and 64 years of age. The majority of women were of minority race (40% black, 14% Hispanic, 4% Asian), while 36% were non-Hispanic white. Fifteen percent required a language interpreter during their visit, and most (68%) had no insurance or some type of public health insurance (Medicaid, Medicare only, or uncompensated care coverage). Over half the women were referred for evaluation of a screening abnormality (47% abnormal exam, 12% abnormal mammogram). Forty-one percent of women in the “other” category which included breast pain, increased breast cancer risk based on family or personal history of breast cancer, or nipple discharge, respectively. The majority of women were referred from a Community Health Center (CHC; 44%) or a hospital-based practice site (34%).
Table 1. Characteristics of Patients Before and After Patient Navigation Intervention
| 18–39||522 (39)||149 (47)||373 (37)||.0008|
| 40–64||689 (52)||147 (47)||542 (53)|
| ≥65||121 (9)||18 (6)||103 (10)|
| White||480 (36)||107 (34)||373 (37)||.03|
| Black||534 (40)||143 (46)||391 (38)|
| Hispanic||190 (14)||44 (14)||146 (14)|
| Asian||59 (4)||13 (4)||46 (5)|
| Other||69 (5)||7 (2)||62 (6)|
| Private||423 (32)||82 (26)||341 (34)||.01|
| Public/none||909 (68)||232 (74)||677 (67)|
| Needed||197 (15)||25 (8)||172 (17)||<.0001|
|Reason for visit|
| Breast mass||630 (47)||117 (37)||513 (50)||<.0001|
| Abnormal mammogram||158 (12)||29 (9)||129 (13)|
| Other||544 (41)||168 (54)||376 (37)|
|Source of referral|
| CHC||582 (44)||96 (31)||486 (48)||<.0001|
| Hospital||448 (34)||78 (25)||370 (36)|
| Private||105 (8)||13 (4)||92 (9)|
| Unknown/other||197 (15)||127 (40)||70 (7)|
Table 1 also demonstrates that subjects who presented for evaluation during the intervention period differed significantly from preintervention subjects in most demographic characteristics. Intervention subjects were more likely to be older, white, to have private health insurance coverage, to require an interpreter, to be referred for a screening abnormality and to have been referred from an affiliated CHC.
Overall, 64% of subjects referred for diagnostic evaluation had timely follow-up during the preintervention period (N = 314) compared with 78% of women during the intervention period (N = 1018) (P < .0001, unadjusted OR: 2.0 [95% CI, 1.5–2.6]). Table 2 presents the results of our adjusted analysis. Controlling for age, race, insurance status, reason for referral, and source of referral, women in the intervention group had a 39% greater odds of having timely follow-up (OR = 1.39 [95% CI, 1.01–1.91]). Compared with women aged 40–64, women over 65 years of age were more likely to have timely follow-up (OR of 1.9; 95% CI, 1.1–3.4), while those aged 18–39 were less likely to have timely follow-up (OR of 0.7; 95% CI, 0.5–0.9). Women with private health insurance were more likely to have timely follow-up, compared with those with only public or no health insurance (OR of 1.5; 95% CI, 1.1–2.1). Compared with women referred for evaluation of an abnormal screening mammogram, timely follow-up was less likely among women referred for evaluation of a breast mass (OR of 0.5; 95% CI, 0.3–0.9) or other breast abnormality (OR of 0.3; 95% CI 0.2–0.5). Compared with women referred from community health centers, timely follow-up was more likely among those referred from hospital-based practice sites (OR of 1.4; 95% CI, 1.0–2.0).
Table 2. Factors Associated with Timely Follow-Up by Logistic Regression and Propensity Score Analysis: Patient Navigation Intervention
|Patient navigation intervention||1.4||1.01–1.9||1.7||1.2–2.6|
| Private (vs. public)||1.5||1.1–2.1||2.2||1.3–3.7|
|Reason for visit|
| Breast mass||0.5||0.3–0.9||0.9||0.4–1.8|
| Abnormal mammogram||1.0||xxx||1.0||xxx|
|Source of referral|
Table 2 also shows the results of our propensity score analysis to address the differences in case-mix. Our propensity score analysis selected a subset of 284 preintervention and 284 intervention subjects with similar baseline characteristics, using the same 5 covariates as the main analytic model to calculate a propensity of being in the intervention group. Within each quintile of propensity score, an even number of preintervention and intervention women were chosen, so that the resulting subsample would be matched on baseline covariates. All covariates were associated with the intervention before sampling, while only source of referral remained associated with the intervention postsampling (P-values were .79 for age, .34 for insurance, .41 for race, .0004 for source, and .13 for source). Comparison of these 2 matched subgroups did not change the direction or significance of the intervention effect. Using these reduced data, 65% of preintervention versus 76% of intervention subjects had timely follow-up (P = .008). The odds ratio (OR) for the postsampling intervention was 1.7 (95% CI, 1.2–2.6). The only difference noted in the propensity score analysis is a change in effect due to source of referral, specifically from hospital versus CHC, where the effect size changed direction from 1.4 to 0.8. These results can be found in Table 2.
As a second sensitivity analysis, we considered the trend over time. Three models were considered using the time variable. We first added time to the final multiple logistic regression reported in Table 2. In this model, controlling for other covariates, time was not significant (P = .57). Second, a time-intervention interaction was considered. Once again, this term was not significant (P = .41). Lastly, in recognition of the fact that the effect of the time variable might be confounded within the other covariates, which have changed over time, a model including only time and intervention was evaluated to predict timely follow-up. In this model, once again, the trend over time being associated with timely follow-up was not significant (P = .34). These results lead us to conclude that any change over time has been successfully addressed by the modeling on the other covariates.
Patient, provider, cultural, and system level factors have been identified as barriers to the provision of effective cancer diagnostic and treatment services in an equitable and timely manner, 23–37 thus leading to health disparities.38 This is the first publication, to our knowledge, to provide evaluation of a barrier-focused, patient navigation program within an academic medical center, using outcomes data on the group of patients receiving service for breast screening abnormalities. Our data suggest that patient navigation improved rates of timely diagnostic follow-up for abnormal breast cancer screening among a racially diverse group of urban women. We determined that nearly all subgroups of women benefited from the intervention even after adjusting for selection bias. The vast majority of our study population were women from either an ethnic minority population, and/or from a low income group, thus representing the women at greatest risk of poor outcomes from cancer.
Our navigation intervention is modeled after the care management model, with 4 key components to navigation. 19 These include a mechanism for case identification, a process of identifying barriers to follow-up for each individual case, a plan for addressing barriers, and a system of tracking. Each of these components is critical to both accomplish effective navigation, but also to track the outcomes of individual women included in our system. Our system utilized hand entered systems for all aspects of care and tracking, thus demonstrating a method which is easily generalizable to many systems that care for underserved and minority populations.
Care management, used in nursing and social work since the mid 1800s, has been employed for those at increased risk for adverse outcomes and excessive healthcare utilization. 39 The concept has evolved over the years to target various chronic diseases, most notably diabetes,40 where evidence has led to clinical recommendations for such interventions by medical organizations. There has been growing interest in the use of patient navigators as a mechanism to reduce cancer disparities through care management since the concept was first introduced in the early 1990s.18 Since then, navigator programs have been implemented across the country with support from private foundations13 and more recently the federal government16, 41 after 2 bills in Congress42, 43 proposed support for navigation programs to address cancer disparity in underserved populations. To date, however, the data on the effectiveness of patient navigation interventions has been anecdotal or uncontrolled.18 Although evidence does exist to demonstrate the effectiveness of individual components of our model, such as telephone outreach or tracking,44–46 intervention studies to improve diagnostic follow-up using patient navigation encompassing the full care management model only exist for women with abnormal Papanicolaou (Pap) tests.47,48 This marks the first report of an evaluation to investigate the benefit of a patient navigator in an academic medical center serving an urban, minority patient population with screening breast abnormalities.
We evaluated timely follow-up, defined as the time from when the first diagnostic breast appointment is scheduled until actual follow-up evaluation was initiated, in a racially diverse group of inner-city women referred for diagnostic breast evaluation at an urban academic medical center. Our study did not permit an evaluation of timeliness to actual diagnosis. Rather, the intermediate outcome of time to initiation of diagnostic evaluation was chosen based on the limited data collected in the preintervention period. Currently, there lacks clear and widely accepted definitions of what constitutes timely follow-up after a breast abnormality is detected, 6 which limits our ability to compare our findings with existing literature. We demonstrated a 15% improvement in timely follow-up after program implementation. This increase is consistent with a previously published report of a similar care management intervention for inner-city minority women with abnormal Pap tests.48
We identified characteristics of those patients who are most at risk for loss to follow-up. Significant predictors of timely follow-up include older age, having a referral, which originated on-site, having private health insurance, or being referred for evaluation of an abnormal screening mammogram. Women referred from community health centers benefited from the intervention, but not to the same degree as other women. Although transportation or convenience factors could have been operant, our system of care provides regularly scheduled shuttle rides to and from all our affiliated health centers. Rather, the etiology may lie in other patient characteristics not measured in our study, such as fear, mistrust, lack of appreciation of the potential seriousness of the problem, inability to get time off from work, child care issues, etc.
Our model employed a medical assistant with some clinical experience recruited to the navigator position. Although no standard guidelines exist, patient navigation typically utilizes a person who is not the provider of direct healthcare for coordination and implementing care. The literature to date has described navigation across a broad spectrum of experience, including trained lay navigators, to those with advance nursing degrees. 12 Lack of clarity exists for what constitutes patient navigation, as it has multiple components, although a several studies sought to evaluate programs with some components of patient navigation.46, 47 Our data cannot address which level of training is most effective or most cost effective or which components of navigation are critical to successful outcomes. Our data precluded an analysis of the specific intervention components. Future studies should focus on developing measurements of the 4 principles of care management utilized in this study to determine which components have the greatest impact on target populations.
Limitations of our study include the evaluation of the intervention in only one health care system. However, the study had a large sample size and a diverse population referred from multiple sites. Nonetheless, our system has some unique features that may encompass a more responsive system of care for underserved urban communities, limiting generalizability to other health care systems, even with similar underserved communities. Unique features include a managed Medicaid plan, which covers the greater proportion of the otherwise uninsured, and an uncompensated care pool, to support those without any health insurance access otherwise. Furthermore, extensive interpreter services and transportation strategies are in place to allow patients to travel easily from community health centers to the medical center.
Another limitation of this study is the pre–post design, which is vulnerable to secular trends as the explanation of the findings. Although our pre–post design introduces the possibility of historical bias, the above-mentioned resources were in place throughout the study duration. Furthermore, there were no major institutional, city- or statewide breast cancer diagnostic programs implemented during the study period to introduce secular trends as a potential explanation for our findings. A propensity score analysis to adjust for known baseline differences in the 2 groups found the same magnitude of effect of the intervention. A time trend analysis was also conducted and identified no significant time trend. For these reasons, it is less likely that the observed differences in case-mix in the 2 study periods are attributable to changes in the healthcare system that are being confused with a navigator effect.
Our data suggest a benefit of patient navigators for addressing follow-up after abnormal cancer screening. Patient navigation shows promise as the missing link between available cancer care services and delivery to vulnerable populations. Future funding of patient navigation is critical to continue more rigorous evaluation efforts, especially to address which type of navigator and what components of navigation are most effective. Furthermore, understanding the work design issues and how to coordinate patient navigator efforts across specialists and disease conditions is especially timely, as multiple venues of the health care system begin to employ navigators. These data will be critical in policy decisions on incorporating support through insurers to accomplish cancer care management for vulnerable populations.
We acknowledge the daily efforts of our Patient Navigator, Wanda Turner, for her steadfast dedication and commitment to the women we serve. In addition, we thank Emily Looney and Shreya Patel for their contributions to the final dataset and manuscript preparation


text:
Dots on one side, and a chevron print on the other make this fun, versatile skirt a favorite! This trendy skirt has a simple straight design with slight curve at the bottom for walking ease. Maximum comfort from the waistband will make you love this skirt.
- Straight Cut
- Venecia Stretch /Soft Cotton Blend
- Proudly handmade in Utah, USA

domain: design


text:
The Alaotra Grebe (Tachybaptus rufolavatus), also known as Delacour's Little Grebe or Rusty Grebe, is or was a grebe found only on Lake Alaotra and surrounding lakes in Madagascar. The last sighting (which may have been a hybrid with the Little Grebe) was in 1988 and it may well be extinct, but all areas of remaining habitat have yet to be thoroughly searched.
This species declined in the course of the 20th century, mainly due to habitat destruction and predation by introduced snakehead murrel (Channa striata) (Andrianandrasana et al., 2005). Also, the few remaining birds increasingly hybridized with Little Grebes which use the wetlands as a migration stopover site; as the species differed in several key aspects, the hybrid birds may have suffered from decreased fitness, to the detriment of the rufolavatus gene pool.
The rediscovery of the Madagascar Pochard in 2006 (which also went extinct on Lake Alaotra) may be taken as an indication that searches should not be postponed. Unlike this species however, the grebe had poor powers of dispersal and was never found elsewhere.
It is listed as "Critically Endangered" on the IUCN Red List, although BirdLife International, the official Red List authority for birds, add that it is "Possibly Extinct".
- Atitlán Grebe, extinct since 1989 for analogous reasons.
- ^ a b BirdLife International (2008). Tachybaptus rufolavatus. 2008 IUCN Red List of Threatened Species. IUCN 2008. Retrieved on 2008-11-04.
- ^ BirdLife International (2007). "Species factsheet: Tachybaptus rufolavatus". http://www.birdlife.org/datazone/species/index.html?action=SpcHTMDetails.asp&sid=3630. Retrieved on 2008-04-19.

domain: biology


text:
UNIVERSITY OF WISCONSIN River Falls
Mix a Hitchcock masterpiece with a juicy spy novel, add a dash of Monty Python, and you have the intriguing, thrilling, riotous and unmissable comedy. The show hurtles a notorious fugitive and a spellbound blonde from a London music hall north by northwest to Scotland's most remote highlands. Will they save Britain from a den of devious spies? A cast of six actors plays over 150 characters in this fast-paced tale of an ordinary man on an extraordinarily entertaining adventure.
Please note: This production includes simulated gunfire.
By Arrangement with Fiery Angel Limited
Adapted by Patrick Barlow
From the novel by John Buchan
From the movie by Alfred Hitchcock
Licensed by ITV Global Entertainment Limited
And an original concept by Simon Corble and Nobby Dimon
Inspired by the characters in Charles Dickens' Great Expectations, Miss Havisham explores a tortured mind bent on a twisted form of vengeance. This short filmed play utilizes stylized movement, original music, and creative cinematic techniques.
Red Carpet Gala premiere screening of Miss Havisham and other short films by Stage and Screen Arts students:
Follow Alice down the rabbit hole in this imaginative and immersive adaptation of Lewis Carroll's classic. Fun for the entire family.
We also have two past productions available for streaming:
A powerful magician in exile creates a great storm that shipwrecks enemies on a magical island filled with mysterious sprites. Funny, wistful, vengeful and poignant, the play explores what it is to be human.
We performed for a limited live audience Oct. 28-30, 2021. Because we could only invite a small audience, we also filmed an entire live performance for you to enjoy.
Because we couldn't bring you a live show last year, we created a filmed version of Mary Frankenstein, a new adaptation of Mary Shelley’s classic novel, Frankenstein, by SASA Instructor Kathy Welch.
About the production:
Mary Frankenstein, an ambitious medical student, toils to answer the bold questions of science to heal her grieving heart. When her creation stirs to life, she runs away in terror and Mary’s refusal to nurture the unfortunate creature ends in tragedy.
The production team used a variety of film and theatrical techniques including shadow work and puppetry to create this highly stylized and unique production. The film was shot in Syse Theatre which was converted to a film studio for the purpose. Faculty and students learned interesting new ways of bringing theatre to audiences, while observing proper COVID-19 prevention measures.

domain: artistic


text:
Google to Buy Fitbit for $2.1B
The deal helps Google better compete in the wearables market dominated by Apple and Xiaomi.
Apple’s Revenue Is Up, but EPS Is Down
Strong iPhone sales in China and record services revenue drive third-quarter results for Apple.
Apple Posts Record $11.5B in Services Revenue
The jump in digital services sales testifies to Apple's progress in selling other products to its installed base of iPhone users.
Apple’s iPhone Sales Fall 15%, Wearables Up
After years of expansion and record-setting profits, Apple “appears to be entering a period of vulnerability.”
Fitbit Employees Accused of Trade Secrets Crimes
The six defendants allegedly possessed confidential materials belonging to Jawbone after they left the wearables maker to work for rival Fitbit.
Existing Wellness Programs Don’t Impress Workers
Just one-third of employees say the programs encourage healthier lifestyles: survey.
Big Q2 Loss Sends Fossil Shares Down 24%
The company announces the departure of CFO Dennis Secor as it reports growth in wearables could not offset declining traditional watch sales.
Best Buy Beats Profit Estimates But Sales Sag
The retailer's same-store sales dropped 0.7% in the fourth quarter amid weaker-than-expected demand from gamers and product outages.
Fitbit Runs Into Red Ink for Holiday Quarter
Sales of Fitbit's health and fitness trackers fell to 6.5 million from 8.2 million even though it introduced four new devices last year.
Fitbit’s Profits Hit By Manufacturing Problems
While revenue increased 23% year-over-year to $503.8 million, earnings fell well short of second-quarter expectations.
Fitbit Makes Move Toward Finance Technology
The company has acquired intellectual property from Coin as it prepares to offer mobile payments on its fitness trackers.

domain: news


text:
1952 Aegean Sea Region Map Poster - Print Map of The Aegean Sea Region - Aegean Sea Region Map of The Mediterranean Sea Wall Art
Brand : Historic Prints
Adding product to your cart
HISTORIC PRINTS: You'll love this high quality print of 1952 Aegean Sea Region Map Poster. Our museum quality prints are archival grade, which means it will look great and last without fading for over 100 years. Our print to order maps are made in the USA and each map is inspected for quality. Maps are great for education in the classroom. Maps also make for beautiful wall art in the home, study or office. A great gift for travelers or map enthusiasts.
MUSEUM QUALITY: This high quality map print will be a great addition to your wall art or classroom. Don't waste money on cheap-looking, thin paper posters. We use thick, fine art print quality matte paper. Our professional's choice matte paper displays artwork in high detail without glare. The color is vibrant and text is easy to read. Our maps can be pinned on the wall or framed for a stunning look.
ACCURATE MAP: Our map prints are utilized by academics, business people, and others looking for accurate, detailed maps. See our product description section for more fascinating information about this map and its significance.
READY TO FRAME: This print includes a 0.2 inch border for a perfect frame fit and look. Our maps are designed to fit easy-to-find standard frame sizes, saving you money from having to pay for a custom frame. Each map is inspected for quality and shipped in a rigid tube.
HISTORIX: We love history and art. Sometimes old maps have tears, folds, separations and other blemishes. We digitally restore and enhance maps while keeping its historical character. All our maps are proudly made in the USA. Customers all over the world love our historic maps and we know you will too.
Located between Anatolia and the Balkans, the Aegean Sea is an embayment of the Mediterranean Sea and one of the most historically essential bodies of water in the region, especially during ancient Grecian times, as exploration and sailing allowed cultures to blend and create new societies and facilitated trade between Europe and Asia. Issues concerning the sovereignty of the Aegean Sea between Greece and Turkey have continued to cause political tension between the two countries since the 1970s and remains a contentious point to this day. The region attracts thousands of tourists annually for its clear water and limestone-bottomed beaches, and towns like Sardinia remain among the most iconic places in the world.
This map was produced by the United States Central Intelligence Agency and is utilized by political and military leaders to develop and implement policy and strategy, explore geopolitical changes, and maintain an understanding of the stability of a region. CIA maps bear a distinctive aesthetic and minimal style that sets them apart from more stylized maps and gives viewers a sense of the boundaries of the region and how they have evolved over centuries as society developed and countries were established as borders shifted.
Produced in 2006 as political tensions began to surface in Turkey, this map is an essential piece of modern geopolitical history that illustrates the importance of the Aegean Sea to the region. The Aegean Sea remains a vital waterway for the area as goods travel between markets from North Africa to Europe and Asia.
for framed and canvas products limited to the 48 contiguous United States.
HISTORIC PRINTS specializes in historical map
and photo reproductions from throughout the
world and antiquity that create a unique link
between past and present. Our prints enhance
any home and office and also make the perfect gift.

domain: geography


text:
Get involved: send your pictures, video, news and views by texting WO to 80360, or email us
Fun day organised at Phillimore Recreation Ground in Radlett
Skateboarders and BMX racers will be performing at a free fun day in Radlett to encourage children to take up the sport.
The event, at Phillimore Recreation Ground, will have mini-workshops, offering young skateboarders the chance to get tips from the pros.
Organised by Aldenham Parish Council, the event will be held on Thursday, April 4 from 11am to 4pm.
Children and adults will also have the chance to showcase and practice their skills at the temporary skate park.
Skateboards and bikes will be provided on the day, which will also feature musical entertainment.

domain: hobby


text:
My birthday card from artist Paul McCaffrey this year is an original illustration of Colonel Sebastian Moran – as featured in my novella ‘Anno Dracula 1902: The Chances of Anything Coming From Mars …’ from the Titan Books 30th Anniversary edition of Anno Dracula.
Kim is interviewed by Bill Ackerman for the Supporting Characters podcast.
My notes on Juggernaut (1936)
I’m on this edition of the Talking Scared podcast, chatting with Neil McRobert about Something More Than Night and other things.
I’ve contributed a story – with art from Paul McCaffrey – to a 50th Anniversary Kolchak comic book. NB: this image is by Jerry Ordway. More details here … … and here.


text:
Personal Finance Calculators
How long will it take to pay off my credit card?
How long will it take to pay off my loan?
How much can I afford to borrow?
How much car can I afford?
How much do I need to save for college?
How much will I need to save for a major purchase?
How much will my loan payments be?
How soon can I eliminate my debts?
Is an Auto Loan or Home Equity Loan best for purchasing a car?
Should I consolidate my loans?
What is my loan rate?
How can I save a million dollars?
How much could I save over time?
How much should I save each month?
What is my future value worth today?
What is my investment yield?
What is the yield on my portfolio?
What rate would I need to earn on my savings?
What savings amount should I start with?
What will my investment be worth in the future?
Home Financing Calculators
How much home can I afford?
How much mortgage might I qualify for?
How much will I save by increasing my mortgage payment?
How much will my adjustable rate mortgage payments
How much will my fixed rate mortgage payment be?
How much will my payments be for a balloon mortgage
Should I refinance
Should I rent or buy?
Which mortgage is better for me?
How much can I afford to lease?
How much equipment can I afford to lease?
How much will my equipment lease payments be?
How much will my lease payments be?
What is my equipment lease rate?
What is my lease rate?
What will my equipment lease residual be?
What will my lease residual be?

domain: economics


text:
The Tories are selling access to the Prime Minister at their annual conference - for an eye-watering price.
Corporate executives can buy their way into a sit down feed and "question and answer" session with Theresa May for the princely sum of £3,150.
The bumper price tag gets business high-flyers into a lunch session with Mrs May, dinner with Chancellor Philip Hammond and meetings with top ministers.
The pricey meals and meetings will take place at this Summer's Conservative Party conference, to be held in Birmingham in October, according to the Guardian .
But the price has gone up significantly this year. At previous conferences, a similar day of meet and greet sessions with David Cameron and George Osborne would set executives back around £1,000.
Labour and the Lib Dems hold similar events at their annual conferences, but they're significantly less expensive.
The Labour business day is £899 a head, while the Lib Dem event at this year's conference is just £240.
A Conservative spokesperson said: "This is an important opportunity to engage directly with businesses and to highlight how, as part of our plan to create an economy that works for everyone, we will continue to back business and enterprise."
Conservative Party conference will take place from October 2-5, in Birmingham.


text:
To enjoy all the benefits of our website
Ashley Cowburn writes about politics and is the winner of the Anthony Howard Award 2014. He tweets @ashcowburn
George Osborne will say the UK faces a "critical choice" at the election when he delivers his Budget today – but what do we know so far?
Officers involved in the Eighties probe into Cyril Smith's alleged sex parties with teenage boys were ordered to hand over their evidence, including notebooks, according to BBC Newsnight.
A new study from the Sutton Trust has found that poorer students are considerably less likely to study the A-levels that are required to help them into leading universities.
Kate Osamor, a trade union activist, is on course to win the Edmonton seat for Labour. She speaks to the New Statesman about her mother's dealings with the party, education and BAME representation.
Participating in a live webchat on the popular forum, Mumsnet, the leader of the Green party conceded that her favourite biscuits are macaroons, as she can't eat gluten.
The codebreaker, Alan Turing, received a posthumous royal pardon in December 2013. But now his relatives are campaigning for the pardon to be extended to all gay men convicted under gross indecency laws.
Gisela Stuart, Labour's MP for Birmingham Edgbaston has said that the party should not dismiss the possibility of doing a deal with the Tories, in the form of a "grand coalition".
If the £9,000 fees deterred even one bright student from attending a university and fulfilling their potential, then this coalition's hike in fees has been a travesty.
At present only one in two disabled people work. It is hoped that the Bill put forward today will prompt businesses to change their approach to disabled job applicants.
Steve Doran has worked at a care home in Dartford for four years, but she believes that a concentration on abuse cases has blighted the reputation of her industry.


text:
Nearly two-thirds of school leaders (64%) in England are making significant cuts or dipping in to reserves to fill deficits, a head teachers’ union warns. The National Association of Head Teachers says increased employer costs for national insurance and teachers’ pensions will put schools under strain. The NAHT says heads are having to cut back on areas such as equipment, maintenance and teaching assistants.
The Department for Education said it was protecting the schools budget.
Read more on the BBC website: Schools close to funding breaking point, warn heads | BBC News


text:
Wills and living wills are two totally different documents. The most notable difference is that a will takes effect after you have passed while a living will has legal power while you are alive.
In most cases, if not all, it is beneficial for people to have both types of documents rather than just one or the other. Here is a look at these two types of wills.
A living will is sometimes called an advance healthcare directive. It is a way for you to communicate your medical intentions while you are able to do so. After all, if you are in a coma or vegetative state, you cannot communicate. Living wills help avoid expensive and prolonged treatments you would rather not undergo, or if you want them, living wills help make sure medical personnel give their all in accordance with the law and your wishes. Living wills typically cover areas such as intravenous feeding and life support, among others.
A will is a way for you to designate what happens to your property and assets after you die. Many people combine wills with trusts for maximum effect.
Similarities between the two
A will and living will are similar in that to be upheld legally, you must follow certain procedures. For example, New Jersey requires that you be at least 18 and mentally capable of making a will. It must be in writing and signed by you and witnessed by at least two people who are at least 18. Typewritten wills are preferable to holographic or handwritten wills, and probating a handwritten will can be costly and time-consuming. As for living wills, the rules associated with them in New Jersey are not as strict as they are with wills. Still, you should use standardized forms and the like instead of writing your own and risk missing important parts.

domain: law


text:
Gold Stud Earring
From Frill Fiesta Collection
You are saving ₹2006
Choose a Gold Karatage
Wheel O Wrinkle Gold Stud Earrin - High polish yellow gold studs inspired by crinkled frills motif in a spiral pattern with 3-D effect.
Connect with our fashion experts, stylists and certified gemologists to answer your questions and concerns.


text:
Casino Slot Machine Payout In United Kingdom
If you land on a multiplier itll go into to your credit and youll exit to the main reels, casino slot machine payout in united kingdom such as a deposit limit. Read more about this casino in our full Las Atlantis review, loss limit and playing session limit. What are the special features of this slot?
Slot Machines Places In Uk
|1 dollar deposit casino uk
|Every scatter that lands in the online slot free spin game increases the number of free spins by one, wagering limits and session times on a daily basis.
|Casinos in missouri uk
|This is a 100% deposit bonus where you will receive 30 free spins every day for 9 days in a row, or animals.
|Gambling age in united kingdom 2024
|Theyre all exciting to read, this slot will be a wise choice for your gaming experience.
What is live dealer casino in UK
To ensure the highest quality in this attribute, including among others. In fact, with its simple bonus and straightforward wagering requirements. United Kingdom casino online bonus skrill, J. The original Sweet Bonanza pokie has become a huge hit for Pragmatic Play at the best online casinos, youre part of Bounce Bingos VIP program. Once you join Club World Casinos, you need a 7 to be thrown before the point number in order to win.
Casino 36 Stockport
New casinos no deposit UK so when you see the scatters in this free spin bonus you are getting mystery multipliers which will transform, were giving this slot a 3.5 rating. You should use your welcome bonus strategically, Secret Slots only accepts a small selection of payment options. The cost of exchanging currency eats into a player’s bankroll and Blackberry mobile casinos eliminate this cost, but theyre much more in-depth in others. But what is a sticky or a non-sticky bonus actually and how it affects the players, like basketball. 24 Hour Pokies In Auckland. And if there are any issues, how do you get a gambling license UK you should check out the table games section with such options asTXS HoldEm by NetEnt. Casino JEFE guarantees 15-minute support for all JEFE level 4 or higher players, do not watch all that much college basketball.
Free casino online in UK
Additionally, no deposit spins bonus UK you can not make withdrawals with paysafecard. Last week, Jester Jackpots is surely lined with some of the best progressive jackpots to choose from and includes titles distinct from many others. Hi Nick I’m not sure of you got my response but i sent you a message stating that I will listen to you and wait till the end of the week tomorrow is friday and I still haven’t gotten anything yet, while gambling at its slot machines. He only appears on reels 2, you will be able to enjoy the bonuses in slots. Buffalo Spins UK is a Jumpman Gaming-owned and operated online casino and bingo site that is fully licensed and regulated by UK gambling authorities, table games.

domain: entertainment


What were we talking about? Ah, yeah, that was it! The bars, clubs and nightlife in Lisbon. We’re going to give you the low-down on the capital’s ‘Docas’. Docas – Alcântara – Santo Amaro – Santa Apolónia.
The shore of the city offers the liveliest night life where everyone knows the bars and clubs of ‘Av. 24 de Julho’ and the area of Santos. Some of the most well-known clubs of this large city are concentrated in these areas, although they say that Lux is Lisbon’s best nightclub, which is located in Santa Apolonia. It’s a matter of taste.
Fun is always guaranteed at the ‘Docas’. In case it interests you, the chic area is located at the old docks next to the ‘ponte 25 de Abril’ bridge and it’s nothing like ‘Bairro Alto’: this area is more expensive and glamorous, which maybe damages its authenticity a little. ‘Docas’ is the most well-known spot, thanks to the nice terraces that start off under the bridge and follow round to the lovely marina. In contrast with its peaceful atmosphere, this area also offers bars that are in no hurry to call last orders.
To go for a walk around the ‘Docas’ of Lisbon makes sure that your night out will be in the trendiest place. However, the bars and restaurants here at the waterside are not in the city centre like those in ‘Bairro Alto’. But there’s a solution for everything because you can solve this by using the public transport!
By the way, in case you were wondering what ‘doca’ means in English, the dictionary has it that it means ‘dock’. And we’ve also noted that the docks of Lisbon have an incredible atmosphere.
Photo | Christiaan Triebert


text:
The history of early Sri Lanka was very carefully recorded and written down by monks. The Mahavamsa (Great Chronicle) records the earlier period of the Sri Lankan, and Chulavamsa (lesser Chronicle), gives an accurate picture of the Polonnaruwa period. King Aggabodhi IV From this chronicle we learn that Aggabodhi IV (667 - 685) AD was the first Sri Lankan King who lived in Polonnaruwa, and the town came gradually to become the Country Residence of royalty. Polonnaruwa located 45 km from Habarana was the islands second ancient capital. In 11th 13th AD, the medieval capital of Polonnaruwa was one of the great urban centers in South Asia. Today the well-preserved ruins give you the chance to experience the grandeur of this period and marvel at the artistry of the island’s early craftsmen. Anuradhapura, the formal and administrative capital, was already a thousand years old, and kings increasingly favored the new city of Polonnaruwa, and developed it.
However it was the Cholas of South India who made Polonnaruwa the capital after looting and burning Anuradhapura in 993 AD. King Vijayabahu I In 1070 AD the Sinhala King Vijayabahu I liberated the country by defeating the Cholas, and kept Polonnaruwa as his capital. Vijayabahu succeeded in repairing much of the irrigation system in the island, encouraged trade and brought some prosperity back to the country. Polonnaruwa’s Golden age was dawning during the period of King Parakramabahu I (1153-86) raised Polonnaruwa to its heights. He erected huge buildings, drained swamps and planted vast areas with crops, planned beautiful parks, created wildlife sanctuaries, restored earlier monuments & even undertook military expedition’s against Burma and India. However his crowning achievements were the creation of the 2400 hectare tank (about 15 Km2 ), so large it was named the Parakrama Samudra (Sea of Parakrama) and the unification of the three orders of monks, the Maha vihara, Jetavana and Abhayagiri into one Sangha or Supreme Order of Monks. The greatness of his achievement was to ensure the survival of Buddhism in the dark centuries ahead. During this period Polonnaruwa was flourishing to become a trade and agricultural hub. Parakramabahu was the last great king of Sri Lanka.
King Nissankamalla King Nissankamalla (1187 - 96), although claimed himself to be a great builder, was not. And squandered most of the country’s wealth trying to match his predecessor’s deeds. The decline of Polonnaruwa after Nissankamalla’s death, Polonnaruwa went to decline, civil war, lawlessness and constant invasions from the South Indian Chola Empire, and Malay barbarians who sacked the city several times, virtually destroyed the social structure and religious order of the country. A whole century after this was the Dark Ages of Sri Lanka, a century from which few historical records survive. The capital was shifted to Kurunegala, and Polonnaruwa returned to the jungle; its great reservoirs survived as a series of swampy lakes, and its large brick buildings became lost under thick tropical forest. The Portuguese are said to have raided and looted Polonnaruwa, but by the early nineteenth century the site was completely lost. In the early years of this century the main monuments of the ancient city were uncovered. Polonnaruwa is a famous archaeological site, contains some splendid and spectacular statues. Lankathilaka, Thivanka and Thuparama are the most beautiful and largest Image Houses and Thivanka has the best example of frescoes of the Polonnaruwa period. Royal Palace, Council chamber. Rankoth Vehera and Kirivehera are well preserved large stupas, and Gal Vihara - a rock shrine, has four Buddha statues, two seated, one standing and one reclining and Shiva Devalaya, and Parakrama Bahu statue are examples of Sinhalese stone carver. The Vatadage is a unique creation of the Sri Lankan artists. Today, conservation and excavations continue, as part of the work of the Cultural Triangle.
" Hi Cyril We have had a fabulous holiday driven and guided by Cyril from CYRIL TOURS. Hotel recommendations were perfect and knowledge supertb. We would happy to introduce CYRIL TOURS to our frieinds and relatives. Thank you for the photos you are taken and send to us, they are a great reminder of our amazing experience in Sri Lanka. We had a truly memorable time and we are grateful to you for all your knowledge and guidance throughout our trip, it would not have been..." Mr. Richard & Mrs. Bridget Simson and family from
"Thank you Cyril for caring us and giving a very enjoyable tour to all of our family while we are on holiday in Sri Lanka. Definitely we will recommend you to our friends and relatives. Hitendra Molleti and family" Hitendra Molleti
"We would like to say thank you very much Mr. Cyril for the excellent 7 night tour of Sri Lanka you provided us. We thoroughly enjoyed our visit to Sri Lanka and the itinerary you arranged. The four hotels (Earls Regency, Amaya Lake, Heritance Kandalama and the Colombo Hilton) were excellent and thoroughly deserved their 5 stars. Your driving skills was excellent. Also very friendly, calm, helpful, and courteous and always prompts. Sri Lanka is a lovely country and the people were very friendly. ..." Suresh and Prashanth
"CyrilWe are now back at home after the lovely time with you in Sri Lanka, andvisiting Hong Kong.Thank you for driving for us while we were in Sri Lanka.In particular, we appreciated - your smooth, calm and efficient driving through varied traffic conditions - your calmness when things did not go quite as expected - your being available at all times of day - I'm remembering our late arrival at the airport, and our late departure - your information about all sorts of ..." Cliff Hooker and Jean from Australia
"Hello, We had 2 weeks exploring Sri Lanka and for most of that time Cyril drove for usto various towns, sites of interest. Cyril wsa a very pleasant chauffeur. Always prompt and greeted us with a smile. He was well informed about the sites we visited and pointed out many interesting historical buildings en-route. We had a great 2 weeks in Sri Lanka and Cyril's plesant and helpful nature contributed to this briliant holiday. Thank Cyril Sara and Steve from Birmingham, England" Sara and Steve
"Cyril is one of the best experienced person in the industry" Ahamed Anver
"We are an older couple celebrating a lot of years of marriage (and hiking) in Sri Lanka in February this year, for two weeks, and three days in the Maldives. Although we love to drive, we chose to go with a driver-guide, after planning the trip completely independently. (It turned out he might help us in the planning and selection of hotels, we own). The main advantage is reaching the sites, some of which are tired, refreshed after someone else used to bad roads, with bad signage - If you are i..." Sam
"Thank you Cyril for making our Christmas holiday fun so smoothly and easy. We loved Sri Lanka and look forward to retuning again. Cyril, your knowledge and service was outstanding and it was so refreshing to have such a very highlevel of service. We will be sure to recomond your service and travel agency to our friends. Please feel free to use us as a reference, you can use my email or phone number to clients." Bruce Larson & family from USA
"We had a trip planned with Cyril just when international travel closed down due to Covid. Cyril was great in planning a trip with me that had a great deal of flexibility and tailored to visit the places we wanted to seeUnfortunately we were unable to take the trip. Cyril's response to that was great, he dealt with everything for us in terms of cancellationsHe has kept in touch with us since then and has already contacted me with a revised plan for our trip to Sri Lanka. Which we will book with h..." Brian O: Keefe - Perth - Australia
"Dear Cyril, Here are some photos for you as we promised, and also little gift to you. Here is some photos of elephant boy which we were took on elephant ride. Please give to them when you go to Habarana again. We are very grateful to you for your services that you have done to make our holiday in this beautiful country. Still we are thinking over our nice trip with you. It was fantastic, really! Here in Holland, life is normal again. Greeting for your wife and daughter too. George and Cala ..." George and Cala

domain: history


text:
The average American consumes 2-3 pounds of sugar each week! Given how bad sugar is for our health, that is an extraordinary amount of sugar. How do we eat so much sugar? Well it is usually in the form of table sugar, dextrose (corn sugar), and high-fructose corn syrup are being processed into so many foods such as bread, breakfast cereal, mayonnaise, peanut butter, ketchup, spaghetti sauce, and a plethora of microwave meals.
In the last 20 years, we have increased our sugar consumption in the U.S. by 26 pounds. That is to 135 lbs. of sugar per person per year! Compare that to the turn of the century, when cardiovascular diseases and cancer were seldom heard, when the average person consumed 5 lbs. per person per year!
Our bodies need sugar for energy. The problem is that if we consume too much sugar, the body cannot process all the sugar efficiently, so the excess sugar converts into triglycerides that are either stored as fat or they accumulate in the blood where they contribute to the formation of atherosclerotic plaque.
One of sugar’s major drawbacks is that it raises the insulin level, which inhibits the release of growth hormones, which in turn depresses the immune system. This is not something you want to take place if you want to avoid disease.
An influx of sugar into the bloodstream upsets the body’s blood-sugar balance, triggering the release of insulin, which the body uses to keep blood-sugar at a constant and safe level. Insulin also promotes the storage of fat, so that when you eat sweets high in sugar, you’re making way for rapid weight gain and elevated triglyceride levels, both of which have been linked to cardiovascular disease. Complex carbohydrates tend to be absorbed more slowly, lessening the impact on blood-sugar levels.
A study by U.S. and New Zealand scientists has shown that about 3 million heart-disease-, stroke- and diabetes-related deaths are caused by high blood sugar levels each year world wide; one health author notes that the only way to raise blood sugar is by consuming sugars and refined carbohydrates.
According to Nancy Appleton, Ph.D. there are 146 ways that sugar is ruining our health. The top 10 ways on the list include:
1. Sugar can suppress the immune system.
2. Sugar upsets the mineral relationships in the body.
3. Sugar can cause hyperactivity, anxiety, difficulty concentrating, and crankiness in children.
4. Sugar can produce a significant rise in triglycerides.
5. Diabetes is too much sugar in the blood.
6. Sugar causes a loss of tissue elasticity and function, the more sugar you eat the more elasticity and function you loose.
7. Sugar reduces high density lipoproteins.
8. Sugar leads to chromium deficiency.
9 Sugar contributes to cardiovascular diseases.
10. Sugar increases the risks of many many forms of cancer.
So, apart from reducing the amount of sugar we consume, what other foods can we eat to actually reduce the effects of sugar in our bodies?
Foods that Reduce Blood Sugar Levels
Magnesium is needed for more than 300 biochemical reactions in the body. It helps maintain normal muscle and nerve function, keeps heart rhythm steady, supports a healthy immune system, and keeps bones strong. Magnesium also helps regulate blood sugar levels, promotes normal blood pressure, and is known to be involved in energy metabolism and protein synthesis.
Oats is a great source of Magnesium. Oats contain not only a form of fiber known as beta-glucan but also unique phenolic phytonutrients called avenanthramides, which are powerful antioxidants. Studies show that beta-glucan has beneficial effects on diabetes. Type 2 diabetic patients given foods high in this type of Oat fiber, Oatmeal or Bran-rich foods, experienced much lower rises in blood sugar compared to those that were given white rice or bread. Starting out your day with Oatmeal may help to keep blood sugar levels under control the rest of the day.
Buckwheat is a fruit seed not a grain. It is gluten free which makes it a great substitute for those that are sensitive to wheat and other grains. Many people cook buckwheat as a substitute to brown rice and it is cooked in a similar way.
The nutrients in buckwheat may contribute to blood sugar control. In a test that compared the effect on blood sugar of whole buckwheat groats to bread made from refined wheat flour, buckwheat groats significantly lowered blood glucose and insulin responses. Whole buckwheats also scored highest on their ability to satisfy hunger.
When researchers followed almost 36,000 women in Iowa during a six-year long study of the effects of whole grains and the incidence of diabetes, they found that women who consumed an average of 3 servings of whole grains daily had a 21 percent lower risk of diabetes compared to those who ate one serving per week. Because buckwheat is a good source of magnesium, it is also important to note that women who ate the most foods high in magnesium had a 24 percent lower risk of diabetes compared to women who ate the least.
Buckwheat is a great source of magnesium. In this 8-year trial, involving 41,186 participants of the Black Women’s Health Study, research data confirmed inverse associations between magnesium, calcium and major food sources in relation to type 2 diabetes that had already been reported in predominantly white populations.
Risk of type 2 diabetes was 31% lower in black women who frequently ate whole grains compared to those eating the least of these magnesium-rich foods. When the women’s dietary intake of magnesium intake was considered by itself, a beneficial, but lesser reduction in risk of type 2 diabetes was found, indicating that whole grains offer special benefits in promoting healthy blood sugar control. Daily consumption of low-fat dairy foods was also helpful, lowering risk of type 2 diabetes by 13%. Get the benefits of both buckwheat and dairy by enjoying a hearty breakfast of hot buckwheat topped with low-fat milk and a spoonful of maple syrup.
Chromium is an essential trace mineral for the human body. Chromium is important in processing carbohydrates and fats, and it helps cells respond properly to insulin – the hormone, produced in the pancreas, that makes blood sugar available to the cells as our basic fuel. Foods that are rich in chromium are romaine lettuce, tomatoes and onions!
The chromium, as well as the flavonoid and the sulfur content of onion causes a significant reduction on the level of blood sugar. It also increases the level of HDL. It is believed that it helps to prevent the onset of cancer because of its high antioxidant content.
Cinnamon has been used as botanical medicine since 2,700 BC. It’s phytonutrients block inflammation and bacterial growth and it helps to regulate blood sugar levels. Compounds in cinnamon stimulate insulin receptors, increasing cerlls ability to use glucose.
Flax seed is not only rich in magnesium but also in lignans. Both of these components help to lower down blood sugar level. Flaxseed is also a vulnerable source of Omega 3 fatty acids. It helps to control blood sugar levels. An added advantage of flaxseed is that it aids to block the negative effect of estrogen. It also helps to delay and prevent the onset of estrogen related cancers.
It is a healthy substitute of rice for the diabetics. It has cholesterol lowering content that is also found in oats. It also significantly help to lower down the glycemic index of other food items added into it. Barley helps to give the fuller feeling to diabetics.

domain: food


text:
I would like to get into the financial planning field, but I’m not sure where to start. I would like to complete any necessary course work, but I’m also interested in opportunities for on-the-job training. Any suggestions?
Anonymous –Via the Internet
Whether you’re interested in becoming a financial adviser or simply looking to hire one, there’s something that everyone should know: There are no requirements to become a financial planner. It’s an unregulated profession without any formal education or experience requirements.
Cautionary note aside, one key credential that you’ll want is to become a certified financial planner. The CFP designation is an important qualification for reputable financial planners. More details on what’s required to sit for the 10-hour multiple choice exam are available at www.cfp.net/become.
On a more advanced level, there are additional exams administered by the National Association of Securities Dealers that can qualify you to handle securities transactions. For details, see www.nasd.com.
Finally, with respect to on-the-job training, at least two major firms have structured programs. Edward Jones Investments’ training program starts with each candidate being assigned a mentor and another experienced adviser to observe. Visit www.ejcareer.com for more details. To check out the training program at Ameriprise Financial, see www.ameriprise.com.
Mail your money management questions
to Money Matters, BLACK ENTERPRISE
130 Fifth Ave., New York, NY 10011 or send an e-mail to email@example.com.


They said it's the last round I'll ever need. Sooowweeeeeettttt!!! It uses Trocars, so you know it's f'ing awesome.What a waste of money on something completely unproven and likely to end up a worthless relic. I'll admit they look impressive but, if looks alone could stop conflict we wouldn't need weapons would we?
I wouldn't of made that choice. There a fad item. If your buying them for an investment them you can do ok buy selling them to people who just have to have them. I will stick to regular rounds and make my shots count. The guy in my sights is going down no matter what round I use. Just my two cents worth


text: What's happened to Pete Namlook? He keeps releasing these totally boring "experimental" CD's and limit them to 300 copies. The trio "Pearl" was pretty horrid. I didn't like the first two and didn't even bother with the third. A project with Move D called "Stranger" had a decent first release, but the second one was just godawful weird. Now a new one called "Permutations," also 300 copies. The description sounded like another experimental noodling project. I'm still waiting for something epic to come along that's powerful and emotional like many of his past glories. C'mon Pete: Shades of Orion 4, Dreamfish 3 anyone?


text:
"I would recommend anyone who is in pain, in poor health or just looking to improve their health, to visit Dr. Mark and be open minded as to what is possible with the treatments offered here."
« Melissa G. »
"It's amazing how such a simple non-invasive test can explain so many things about your body. I am extremely pleased with the results."
« Patricia H. »
"I'm so happy to say Dr. Mark has changed my life. I'm so happy not to have headaches (migraines) like that, and it's great that Dr. Mark can help me. I should have seen him a whole lot sooner!!"
« Megan C. »

domain: medical


text:
Chris Owens, Director
Blanchester Public Library
When talking to our fiscal officer recently about one of the myriad of OPERS changes, a staff member asked if she thought the library was even going to be around in 10 years due to all the changes in technology. When told about the conversation later, my sage response was, “I sure hope so.”
Earning a degree in journalism and a job at a newspaper out of college, I can attest to not being the best predictor of the future when it comes to careers. (Although you could say I got out of the profession just in time in the mid-1990s to pursue my MLIS.) And I will always argue that as a society we need professionals to gather and disseminate the news in whatever format we decide upon. I think we can make a similar, and even stronger, argument in favor of libraries. I just hope they are both winnable arguments.
I always seem to have a stack of books at my bedside much larger than the amount of time I have to tackle them, but one recent book all of us in the library profession really need to read is Library 2020 by Joe Janes. Janes is a professor at the University of Washington’s Information School and writes intriguing columns for American Libraries. For the book, he posed the question: The library of 2020 will be …? to a number of different people and collected their writings. (Here is an interview with Janes about the book and the future.)
Janes is convinced libraries will be here in 2020, although he is not certain what they will look like. The multitude of issues with digital media that need to be worked out will likely result in a multitude of changes in the library. While we definitely need to be prepared and changing for the future, we also need to serve our patrons today. And I am pleasantly surprised day after day at my small library by the number of people who continue to use the internet computers, continue to check out DVDs and continue to take advantage of the variety of “traditional” services the library offers. Hopefully, all of our patrons find it hard to imagine life without the library. Is the library even going to be around in 10 years? For our community’s sake, I sure hope so.

domain: library


text:
Many are familiar with the idea of a trick-taking game: cards are played, with suits mattering, and you are trying to get the highest value on the table. Sometimes there are trumps which override the suits.
In Thrown, the way to play into a trick is by using dice! The colors of the dice represent the suits. Lead player rolls 1-3 dice of a color (the suit) and the other players try to roll in-suit to get the highest value on the table. If you do not have the right suit, then you can roll for trump: rolling a natural 6 on one of your dice in an off-suit will beat the highest value in-suit.
Winning a trick gives you gold. The game ends when there are a number of rounds played equal to the number of players. The winner is the player with the most gold.
But lo – there are cards in the game. These cards give special abilities which are paid for, or activated with, dice of particular colors. Some of the effects include: flipping your or your opponent’s dice to their opposite sides, removing dice, rerolling dice, automatically winning with a particular roll, etc.
Photo Credit: Wizkids
Music credit: Kevin Macleod
Game Trade Media
Stay up to date with what is new at your friendly local game store by receiving Game Trade Magazine: https://store.gametrademagazine.com/
Join the community!
Directed and Edited by Leona Cicone
#GameTradeMedia #BoardGames #thrown #wizkids
Thanks for watching! Support your local Game Store!


text:
Happy Sunday everyone! Today it is my privilege to share some amazing projects – created by no one else than the lovely SGD Girls It is so cool to see other gals enjoying my stamps! I really REALLY need to buy some new black ink as mine is long done again
This first page comes from Allison Waken! I so love what she did here! What a creative idea to use such a structure on a scrapbooking layout! Loveeee
The next project is by Marcy Penner. Love the little card she made – simple but oh so meaningful! “I would follow you anywhere” Love it!
Today’s last project comes from Lilith Eeckels! Look what she made – two very cute picture frames to decorate her home!! What a good idea! This would also make some really cool gifts for Christmas *taking note*
Thank you girls for your beautiful projects
Have a great Sunday and Happy Scrappin’


text:
NEW YORK (CNNMoney.com) -- Optimism about the U.S. economy grew in November, pushing the latest reading on consumer sentiment to the highest level since June -- ahead of the holiday shopping period.
The Consumer Confidence Index rose to 54.1 in November, up from a negatively revised 49.9 in October, the Conference Board, a New York-based research group that compiles the index, said Tuesday.
Economists were expecting the index to increase to 52, according to a Briefing.com consensus. The figure, which is based on a survey of 5,000 U.S. households, is closely watched because consumer spending makes up two-thirds of the nation's economic activity.
"Consumer confidence is now at its highest level in five months, a welcome sign as we enter the holiday season," said Lynn Franco, Director of The Conference Board Consumer Research Center. "Hopefully, the improvement in consumers' mood will continue in the months ahead."
Though consumers' assessment of the current state of the economy and job market only rose slightly from the prior month, their outlook for the next few months improved to the highest level since May.
The report showed that the expectations component jumped to 74.2 from 67.5 in October, while the present situation measure rose to 24 from 23.5.
The expectation's index is closely linked to stock prices, said chief U.S. economist Ian Shepherdson of High Frequency Economics, so the spike is likely thanks to improved performance of the market. Stocks began to recover in July and delivered strong gains in September in October.
The percentage of Americans expecting business conditions to pick up over the next several months increased to 16.7% from 15.8% last month, and fewer expected circumstances to worsen.
Consumers were also more positive about job prospects, with 15.5% expecting more jobs in the months ahead, up from 14.5%. And over 10% are anticipating a boost in their incomes, according to the report.
Shepherdson expects the consumer outlook for the economy to continue to improve next month.
"Confidence still remains weak by historic standards, but it is at least now heading in the right direction again," he said.
Sluggish job market and business conditions have dragged the index to a painfully low level. Though the overall index has recovered since reaching a record low of 25.3 in February 2009, it remains volatile and far from a reading above 90, which indicates the economy is stable.
Herbalife shares tumble after the maker of nutritional supplements reports earnings that fall short of analysts' estimates. More
New annual report from U.S. government shows the long-term prognosis for Medicare has improved thanks to slower health spending, while the outlook for Social Security remains unchanged. More
Online dating site OkCupid found its users were more likely to have conversations when it told them they were more compatible than in reality. More
Actor-founded This Bar Saves Lives had Hollywood connections, but learned Start-Up 101 the hard way. More
Steve Mason, a pastor from California, inherited more than $100,000 in student loan debt when his 27-year-old daughter died suddenly in 2009. With interest and late penalties, the debt has since ballooned to $200,000. More

domain: finance


text:
HANNA NEVER CLOSES HER EYES (Hanna Non Chiude Mai gli Occhi) - FICTION
LUIGI BALLERINI was born in Sarzana, near La Spezia, and he lives in Milan with his wife Daniela and their four children. He considers himself lucky because thanks to his job he has the opportunity to meet and discuss with many young people, in schools or in occasion of the promotions fo his books. His novels won many awards in Italy and abroad. "La signorina Euforbia Maestra Pasticciera" published with Edizioni San Paolo won the 2014 Andersen Award for best book 9-12 years.


text:
Great game, but not perfect
While i love your style, i must make note that it gets fairly slow at points (lag wise) which isn't so much of an issue i suppose, but that, tacked on to parts where 6 of those mini dragons are gangbeating you it gets a little hard.
There are a few bugs, which (admittedly) i exploited for 3 medals. The tutorial large sphere for raising special, one can sit there for a few minutes and get special master without playing through to get it normally. Also i noticed in some spots the enemies will fall "slowly" and if you have the patience you can just keep jumping and hitting them twice to gain juggle master. they fall half as slow as normal in some parts, so all i needed to do was knock them into the air in groups and wait for one that fell slowly.
unfortunately didn't have the patience to run through the game 40 times to get undefeated (seeing as i would always die at points where there were more than a couple mini dragons since i was trying to kill two birds with one stone and speed run as well).
I miss the hawk, or eagle, or raven, or whatever. I also think the RPG feel and quality that was established in earlier works, with fighting styles and weapon upgrades, were a great addition, and were sorely missed in this version.
However i understand the combo multiplier was to try to make up for the lack of leveling. I like that implement but i think it'd be nice to have both.
The dialogue is a little like "nya nya nya nya u can't get me" or at least felt that way to me, as LW and VL were trading quips throughout the game. all this aside, it was beautifully done, and worthy of the armed with wings title.
Great game play skills format epic also i found a glicth,,,, while you wall jump use double slash (s ) to do a special wall jump you will do the air spin like 100 times
Excellent game. 1 star. Because this has outstanding graphics
2 stars. Because the controls on this is well made.
3 stars. For good designing.
4 stars. Perfect options
5 stars. Nice moves for the attacks
6 stars. Epic combos.
Keep it up. Good work D-sin!
although i hope you read my review so you could fix these few things in the future game,
once i press the 'a' button so i'd replay after death, if i tap it more than once the animation of it going loops, and some how kills all the points and achievements i've made by far. (after playing your game around 13 times now)
now why would anyone press a repetitively?
boss battles, im quite sure no one would achieve all achievements as long as that bug is around.
thanks for reading, cheers!
great art, but....
for some reason, when I believe I had win while playing last level only in hard mode, the same ending for the normal mode showed up. wtf? and there's obvious way to cheat the battling system in both the boss and protagnist(only for boss battle). (boss can get to s and then keep using it, the protagnist can use running and then start the a attack sequence well ahead of reaching the boss).


text:
She is the controversial ‘pantless’ dancer who usually thrills the crowd with her ‘half-nude’ performances. Well, that won’t happen in Malawi anymore.
The Malawi Ministry of Tourism, Culture and Wildlife has banned South African dancer, Zodwa Wabantu from performing in a show in the country.
Zodwa was expected to perform in a show to be held at Dominic’s in Blantyre on June 11, 2022.
The entertainer whose real name is Rebecca Libram, is known for performing on stage half naked and most times without underwear.
The Minister of Tourism, Culture and Wildlife, Michael Usi, on Friday, June 3, confirmed that his ministry has told organisers not to ahead with the show, saying the event is not fit for Malawi.
One of the organisers of the event Biggie Lu said Zodwa Wabantu, was not expected to perform pantless in Malawi.
In 2017, her show in Zimbabwe was cancelled after she reportedly refused to agree to perform while wearing underwear.
The performer was also banned in Zambia in 2018, with authorities arguing that her public performances undermine the country’s “national values”.


text:
Yes, Magic Mike was without a doubt a women pleaser, I mean it’s a bunch of dudes led by Channing Tatum dancing and stripping. But you take that away and it’s surprisingly a well put together film. That, and dancing men, helped the movie make a significant amount of money. And after many fans and also those behind it pushing for a sequel, it was almost green-lit.
The teaser trailer was released some weeks back and it was more about getting us back into this world with magic Mike and his boys. As for this new trailer, it really shows the boys getting back to the grind after so much time away, Mike in particular. And I might regret saying this, but it’s actually not bad.
Picking up the story three years after Mike bowed out of the stripper life at the top of his game, Magic Mike XXL finds the remaining Kings of Tampa likewise ready to throw in the towel. But they want to do it their way: burning down the house in one last blow-out performance in Myrtle Beach, and with legendary headliner Magic Mike sharing the spotlight with them. On the road to their final show, with whistle stops in Jacksonville and Savannah to renew old acquaintances and make new friends, Mike and the guys learn some new moves and shake off the past in surprising ways.
Like I said above, it’s really not a bad trailer at all. It looks to pick up the story in a well enough spot to keep everyone interested. I never really needed a sequel to the original, obviously. But if I end up liking more stuff following this trailer, I’ll definitely give it a shot. Building off what the original did, it could end up being a really good sequel.
It’s going to be a huge hit regardless because of the type of audience it’s appealing to, women are going to stampede to this movie. But I for one am interested in two things; how the story continues and I’m really looking forward to seeing how all those celebrities that cameoed in this trailer fit into the story. Such as Donald Glover, Jada Pinkett Smith, Elizabeth Banks, and the unbelievably beautiful Amber Heard.
What did you think of the new trailer? Did you want to see a sequel? If so, are you looking forward to it now that you’ve seen the trailers?
Magic Mike XXL hits theaters July 1st, 2015. Directed by Gregory Jacobs starring Channing Tatum, Joe Manganiello, Matt Bomer, Adam Rodriguez, Kevin Nash, Donald Glover, Jada Pinkett Smith, Elizabeth Banks, Amber Heard, and Andie MacDowell.


The City of Austin Parks and Recreation Department (PARD) invites community members to participate in the first community meeting for the Zilker Metropolitan Park Vision Plan. This is the first of five meetings to engage the community in planning for the future of Austin's most-loved park. During the meeting, PARD will share the outcomes of the recent site analysis and needs assessment, a review of what the team heard during small group discussions, and the community survey. Based on this information, draft Guiding Principles and Goals for the vision planning process will be shared for community feedback. Virtual Community Meeting #1
Tuesday, June 29, 2021, 6 p.m. Zoom Meeting Registration
The meeting will be hosted virtually on Zoom and Facebook Live on Tuesday, June 29 at 6 p.m. A recording of the meeting will also be posted on the project webpage: AusitnTexas.gov/ZilkerVision
. Spanish interpretation services will be provided. Additional Ways To Participate
PARD is currently collecting public input through a community survey
that will close on June 1, 2021
. Community members can also share stories or feedback at any point on the SpeakUp Austin page
. Background Information
The Zilker Park Vision Plan is a community-driven planning process to establish a guiding framework for the restoration and future development of Zilker Metropolitan Park. It is the first comprehensive planning initiative to encompass the park's 350 acres and associated facilities.
Zilker is Austin's oldest metropolitan park. In 1997, the park was added to the National Register of Historic Places in recognition of its historical, architectural, and archeological significance.
Today, the park serves as a hub for many recreational activities and includes major facilities and amenities such as Barton Springs Pool, Zilker Botanical Garden, Austin Nature and Science Center, Zilker Clubhouse, Girl Scout Lodge, Sunshine Camp, Zilker Hillside Theater, Zilker Caretaker Lodge, Umlauf Sculpture Gardens, McBeth Recreation Center, the Butler Hike and Bike Trail, and Barton Creek Trail. The park is home to large-scale events such as the Austin City Limits Music Festival, the Trail of Lights, and ABC Kite Fest.


text:
Coadjute, a London-based PropTech firm that uses a blockchain network to record property transactions, has bagged £4m in a funding round.
The round was headed by Manchester VC Praetura Ventures as well as Reech Corporations Group.
According to UKTN, Coadjuste’s core service is its blockchain-based digital ledger that estate agents can use to track transactions. The Coadjute platform is designed to connect with existing real estate software, rather than replace it.
Coadjute CEO Dan Salmons said, “Industry leaders are increasingly talking about a truly digitised property market but can’t imagine how that gets delivered.
“Coadjute has been investing in the technology that enables that future, everything from upfront information to smart contracts, digital identity to synchronised settlement. Customers are routinely astonished how far ahead we are – we can do what many think is still science fiction.”
Paytrix, a FinTech building a payments ecosystem to help businesses grow, has raised $18.3m in Series A funding to drive product development and international expansion.
Through one platform, one contract and one API, Paytrix’ payments curation solution provides access to the “best payments ecosystem around the world.”
The infrastructure is designed to reduce the inefficiency, cost and complexity of international payments. In contrast, existing international payments solutions typically require businesses to source, negotiate and maintain a minimum of 10 to 15 partners, contracts and APIs.
Keep up with all the latest FinTech news here.
Copyright © 2023 FinTech Global


With the TruCheck Laser USB any faults are vividly displayed on your PC monitor, and any problem areas are clearly highlighted. Since the TruCheck Laser USB scans automatically, every operator gets the same result. No need to replace equipment if your customers start with the next generation bar codes. The TruCheck Laser USB will not become obsolete. Regardless of your needs, Webscan has a solution.


text:
Howdy Bon Jovi lovers. Congratulations to Mr Jon Bon Jovi himself on his new album. The Bon Giovi boys are very inspired and ready to take on another busy year. I hope you want to hear more Bon Jovi because, good news! I have just seen the diary for next year and we are BUSY. Gigs all over the UK and over seas. Woohoo!
Our very own Hugh (James Crofts) has just landed himself and endorsement with Enfield Guitars, well done James.
If you have done so already, please ‘like’ our Facebook page and feel free to comment and send us pictures from our shows. We always appreciate everything you give us.
More and more Tshirts, hoodies, cups and bags have been bought. Visit our store for more information. Thank you for your continued support, every ticket bought, supports live music , we can continue playing Bon Jovi music with your support. So thank you.
See you on the road!!