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BMC Complementary Medicine and Therapies
A cross-sectional survey of complementary and alternative medicine use by children and adolescents attending the University Hospital of Wales
Nigel W Crawford1,
Domenic R Cincotta1,
Alissa Lim2 &
Colin VE Powell1
BMC Complementary and Alternative Medicine volume 6, Article number: 16 (2006) Cite this article
A high prevalence of CAM use has been documented worldwide in children and adolescents with chronic illnesses. Only a small number of studies, however, have been conducted in the United Kingdom. The primary aim of this study was to examine the use of CAM by children and adolescents with a wide spectrum of acute and chronic medical problems in a tertiary children's hospital in Wales.
Structured personal interviews of 100 inpatients and 400 outpatients were conducted over a 2-month period in 2004. The yearly and monthly prevalence of CAM use were assessed and divided into medicinal and non-medicinal therapies. This use was correlated with socio-demographic factors.
There were 580 patients approached to attain 500 completed questionnaires. The use of at least one type of CAM in the past year was 41% (95% CI 37–46%) and past month 26% (95% CI 23–30%). The yearly prevalence of medicinal CAM was 38% and non-medicinal 12%. The users were more likely to have parents that were tertiary educated (mother: OR = 2.3, 95%CI 1.6–3.3) and a higher family income (Pearson chi-square for trend = 14.3, p < 0.001). The most common medicinal types of CAM were non-prescribed vitamins and minerals (23%) and herbal therapies (10%). Aromatherapy (5%) and reflexology (3%) were the most prevalent non-medicinal CAMs.
None of the inpatient medical records documented CAM use in the past month. Fifty-two percent of medicinal and 38% of non-medicinal CAM users felt their doctor did not need to know about CAM use. Sixty-six percent of CAM users did not disclose the fact to their doctor. Three percent of all participants were using herbs and prescription medicines concurrently.
There is a high prevalence of CAM use in our study population. Paediatricians need to ensure that they ask parents and older children about their CAM usage and advise caution with regard to potential interactions.
CAM is a rapidly expanding industry that requires further evidence-based research to provide more information on the effectiveness and safety of many CAM therapies. Statutory or self-regulation of the different segments of the industry is important. Integration of CAM with allopathic western medicine through education and better communication is slowly progressing.
The use of complementary and alternative medicine (CAM) by children and adolescents is something that all health professionals involved in their care need to be aware of. CAM can be defined as, "diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy, or by diversifying the conceptual frameworks of medicine" [1].
Prevalence studies
A high prevalence of CAM use is well documented in children with a chronic illness, for example: oncology patients 42%, juvenile rheumatoid arthritis 70% and inflammatory bowel disease 72% [2–4]. Recent studies recorded significant usage of CAM in community paediatrics; 32% of children newly diagnosed with autism; 54% with behavioural problems and 56% in families of children with cerebral palsy [5–7].
Reported prevalence of use in adults ranges between 9–65% [8]. Fewer studies have been conducted in children, but a systematic review in 1999 found 9–70% of them used CAM. [9] More recent CAM studies in paediatric primary care showed a reported usage of 21–33 % [10, 11] and hospital based studies 12–53%[12–14]. This study used the same methodology as a research team based at the Royal Children's Hospital in Melbourne, Australia [15]. Their study in 2002 found an overall yearly prevalence of CAM use of 51%.
Few surveys have been conducted in the UK, a study of adult cancer patients in 2001 found a yearly prevalence of CAM use of 49% [16]. A paediatric study by Simpson et al. from 1996 study in the Bath area found a general paediatric outpatient prevalence of 21% [17] and in a recent Leeds study, use ranged between 12–62%, in a sample which included healthy children and those with a chronic illness [18]. In a population based childhood study CAM use was 18% [19].
It is an expanding industry; in 2000 MacLennan et al. repeated a 1993 representative population survey in South Australia [20, 21]. Extrapolation of expenditure in 2000 was AUS$2.3 billion in Australia and US$34 billion in the U.S. population. In Australia this represented a 62% increase and the expenditure on alternative therapies was nearly four times the public contribution to all pharmaceuticals. There is little data on CAM expenditure in the United Kingdom, in 1998 90% of CAM provision was purchased privately with an annual out of pocket expenditure of approximately £450 million [22]. In 2003 it was determined that £211 million was spent on herbal therapies alone [23]. These figures are from adult based studies, making it difficult to identify expenditure on children, but it could be hypothesised that as family spending on CAM increases a proportion of this will be for use by children and adolescents.
The use of CAM in the community at large, including children, is not just a clinical or hospital based issue. There are far reaching public health implications as highlighted by the House of Lords Report into CAM [24]. The American Journal of Public Health devoted an entire issue to complementary and alternative medicine in 2002 [25]. Especially important in children is the safety of CAM therapies, their potential for interactions and regulation of the CAM industry. The efficacy of these therapies is also a major issue, which further evidence-based research needs to address.
Methodological limitations
A major limitation of the few studies conducted into CAM in children is the variable methodology and this study aims to address some of these limitations. Ernst only included only 10 of a possible 100 studies in a systematic review because of these issues [9]. Some fundamental problems with study design included the fact that most used a self-administered questionnaire, which has significant limitations, including problems of confusion of the overall meaning of questions and misinterpretation of individual terms or concepts that cannot be clarified. This is particularly important in the CAM field where definition and clarification is so important. Self-administered questionnaires may often be incomplete and have a poorer response rate than an interview administered questionnaire. The size of previous studies has also been variable, as has the country survey's have been conducted in. This combined with a variable definition of CAM makes direct comparisons difficult. The time frame of CAM use is also often not clear, with many using 'lifetime prevalence', that is CAM use at any point in the past. This is prone to recall bias. A discussion on adverse effects was not mentioned in 70% of the papers reviewed and 90% of did not clarify the cost of these therapies. The review was conducted in 1998, but many of the problems outlined above still exist, with surveys on CAM use in children often being self-administered questionnaires and include lifetime prevalences.
The primary aim was to examine the use of CAM by children and adolescents in a tertiary children's hospital in Wales. This included those with acute and chronic illnesses. Secondary aims include: 1. Investigate association of CAM usage with socio-demographic factors, 2. Ascertain the frequency of CAM use, its cost and perceived helpfulness, 3. Explore patients'/parents' knowledge regarding the risks of side effects from CAM and their possible interactions with other therapies, 4. Identify whether CAM use is discussed with medical practitioners and whether inpatient medical records showed any evidence of appropriate documentation and 5. Examine the public health implications of CAM use
A cross-sectional survey of the use of CAM by children and adolescents was undertaken from January to February 2004 at the University Hospital of Wales (UHW), Cardiff. This is a tertiary paediatric centre with approximately 10,000 inpatients and 6,500 outpatients seen per year (Allaway J, personal communication, 2005). The questionnaire was based on that used in an identical study at the Royal Children's Hospital, Melbourne, Australia [15].
The sample population of 500 participants were divided into 100 inpatients and 400 outpatients. The age range was between 0–18 years. The outpatients were also in groups of 100, namely: endocrinology, general paediatrics, gastroenterology and respiratory. These groups were chosen to produce a broad cross-section of the tertiary hospital population. The sample was obtained by interviewing consecutive inpatient admissions and children attending the relevant outpatient clinics over the study period. None of the paediatricians caring for children at UHW were practitioners of any form of CAM.
Data were collected in a structured interview-administered questionnaire with the patient and/or parents/guardian. It took approximately 10–15 minutes to complete. There were four interviewers involved in the study (NC, DC, AR & DW). Three of interviewers were paediatricians in training and the fourth (DW) a pre-registration pharmacist. All were calibrated prior to commencement of the study, by discussing as a group questionnaire administration and recording of data. The questionnaire had been piloted in Melbourne and some of the difficulties in administering the questionnaire were discussed with their research team. The questions were predominantly of a closed nature with multiple categories, including areas for comments. The interviewers were not involved in the medical treatment of the patients and did not enter into discussions regarding their personal opinions about CAM. Any specific questions regarding therapies were directed to their treating medical practitioner.
Exclusion criteria included insufficient knowledge of English and those children/adolescents admitted to intensive care. Written consent was obtained prior to commencing the interview. All patients/parents were given an information sheet. The South East Wales Local Research and Ethics Committee and the Research and Development committee at UHW approved the study.
The type of CAM was divided into seven medicinal (naturopathic, herbal, homeopathic, Traditional Chinese medicine, health products, dietary and food supplements or non-prescribed vitamins and minerals) and thirteen non-medicinal (chiropractic, naturopathy, Traditional Chinese therapies, acupuncture, aromatherapy, iridology, therapeutic massage, reflexology, Buteyko breathing, kinesiology, reiki, hypnosis, special exercises or modified diet) therapies. There was also a free text area for CAM therapies not included on the list. Use of these therapies in the last year and past month was clarified. Non-prescribed vitamins and minerals were included as a CAM because a medical practitioner is not monitoring their use, despite them being taken as a medicine with therapeutic intent.
Statistical considerations
In determining the sample size a literature review was performed to determine the expected frequency of CAM usage. This was estimated to range between 10 –70%. [9] A sample size of 100 for each group (500 subjects in total) will estimate any proportion to within +/- 10%, or better, with 95% confidence. This sample size is also identical to that used in the in Melbourne study [15]. The data was entered into a Microsoft Excel© database and analysed using SPSS version 11.0©. Initial univariate analyses compared users and non-users of CAM. Proportions were compared using a Pearson chi-square test, with point estimate and 95% confidence intervals determined and a 'p value' of <0.05 considered statistically significant.
The data entry was checked by manually reviewing a computer generated random 5 percent of the data set at completion of the study. The stability of the questionnaire was reviewed by re-conducting the interview in a random 5 percent of respondents. This was done by telephone, 4–6 weeks after the initial interview. The interviewers were also compared, looking at any differences in CAM disclosure. Data has been collected and presented in an anonymous manner. All master copies of subject lists and questionnaires were retained securely within the Department of Paediatrics, UHW.
Five hundred and eighty patients were approached to complete 500 questionnaires. Five were excluded because of insufficient English language skills and 39 were missed because they left before being seen in busy clinics. Ten had already been seen in previous clinics or as inpatients and were therefore not re-interviewed. There were 23 who refused or did not fully complete the survey and 3 who did not have a legal guardian present. The interview was conducted with the index case (adolescent) in 7% of cases and their mother in 75%, father 17% and other guardian in 1%.
The study population of 500 interviewed was 52% male, with a mean age of 8 years (standard deviation 5.1 years) and a median of 7.8 years (range: 1 month to 19 years). The family income was greater than £20,000 for 52% of those studied. Tertiary education had been gained by 47% of mothers and 48% of fathers. Sixteen percent of families had private health cover that included cover of the index case.
Table 1. outlines 1-yearly CAM usage. The yearly prevalence of using at least one CAM was 206 out of 500 or 41%. The point prevalence of all CAM use in the last month was 26%. The prevalence of CAM use were very similar in the inpatients and the four different outpatient groups, except for being possibly slightly higher in the respiratory group (49%).
Table 1 1-year Prevalence of Complementary and Alternative Medicine (CAM) Use
Table 2 outlines the socio-demographic factors associated with CAM use. Those using CAM had a higher family income and parental tertiary education. There were no differences in CAM use with regards to gender, age, number of children in the household or private health insurance.
The most commonly used types of CAM are outlined in Figure 1. The most frequently used medicinal CAM were non-prescribed vitamins and minerals and herbal therapies. In non-medicinal CAM group aromatherapy and reflexology were the most commonly used.
Most common types of CAM used- medicinal and non-medicinal (percentage of total participants)
Table 2 Socio-demographic factors associated with CAM use
The use of prescription medications in the last month was 73% (358/493). The types of medications used were classified into the listed groups in Table 3. A total of 22% (108/493) used medications from more than one group. Five percent of participants had used herbal medicines in the last month and of those 68% (17/25) were also using a prescription medication. Thus 3% of participants overall were using herbs and prescription medications concurrently. Only 13% (32/256) of respondents knew there was the potential for interactions and of those, 56% (18/32) could actually specify one. Of those using CAM 5% (9/182) had experienced side effects. All of the side effects described were of a minor nature. The knowledge of any potential side effects of CAM was 15% (73/500) and 82 % (60/73) of those could name one. None of the 23 inpatients using CAM in the last month had this documented in medical or nursing notes.
Table 3 Use of prescription drugs in the past month. *Based on table by Madsen et al.[14] [N = 493]
Expenditure is depicted in Figure 2. There is a trend towards higher expenditure in non-medicinal CAM, which had a higher median cost (£5–20 per month) than medicinal CAM (£1–4 per month).
CAM was self- initiated (parent/participant/family/friend) in 74%, with much lower initiation/recommendation by doctors (6%) or CAM practitioners (14%), At least one CAM was perceived as helpful by 57% (117/206) of CAM users. The use of CAM was not disclosed to the medical practitioner in 66% (135/206)of cases. 52%(97/185) medicinal and 38% medicinal CAM as safe (19%), natural (9%) and available over the counter (7%). Quotes included: "Doctors don't have the time" or are "Not interested", "I wanted to tell the doctor but feel that they don't want to hear", "doctors not bothered by colic", or the "doctor is ignorant so would not be interested".
Expenditure on CAM (£ per month)
The four interviewers were compared with regards to disclosure of CAM use in the past year as shown in Table 4. The random data check revealed a maximum error rate of 0.7% (95%CI 0.4–1.3%). The stability testing of the questionnaire showed a 3.3% (95%CI 2.5–4.4%) difference in responses when the survey was re-conducted over the telephone.
Table 4 CAM use disclosure by interviewer
Our results with a yearly prevalence of 41% (95% confidence interval (CI) 37–46%) is in the upper range compared with studies worldwide [9]. Our general paediatric subgroup used 37% (95%CI 28–47%), which is higher than the general paediatric outpatient UK study in 1996 [17]. This may be a true increase in CAM use over that time, but confounders include; differences in the two outpatient populations, the definition of CAM used or the fact that our study was interview led, rather than a self-administered questionnaire, which may underestimate use. There was no statistical difference in the prevalence amongst the inpatient and outpatient groups with overlap of the 95% confidence intervals (Table 1). All of the four outpatients included patients with chronic illnesses and the high number of cystic fibrosis patients in the respiratory outpatients may partially explain their slightly higher prevalence. The prevalence in Cardiff is significantly lower the prevalence found in the Melbourne study (51%, 95% CI 47–56%) [15]. The reasons for this difference have been explored in a separate comparative analysis between the two tertiary centres [26].
Socio-demographic factors
Socio-demographic factors associated with CAM use were parental tertiary education and high income. This supports the view that CAM is associated with higher socio-economic status [12, 14]. Higher levels of education may lead to exposure to these therapies, especially given their high profile in the media. The lack of other socio-demographic factors implicated in CAM use from our study supports many of the previous surveys [11, 13, 27].
Nearly two-thirds of medicinal CAM cost less than £5 per month, with about one-third spent nothing per month. This supports the assertion that CAM may not be as expensive as is commonly believed, as concluded by a large Canadian study which found that CAM was less than CAN$20 in 37% of cases and more than CAN$60 in only 6% [27]. A BBC commissioned survey in 1999 of CAM use amongst adults in the United Kingdom approximated CAM expenditure of £14 per month with about one-third spending less than £5 per month [28]. Non-medicinal CAM tended to be more costly as seen in this study, with about one-third spending more than £20 per month and 13% spending more than £40. This may limit their availability and therefore prevalence, which was significantly less than medicinal forms of CAM (12%. versus 41%). Of note some non-medicinal therapies were 'free' because treatments such as therapeutic massage or reiki were provided at no cost by friends or relatives.
Disclosure of CAM use to medical practitioners is important if the issue is to be discussed and any potential interactions or adverse effects detected. In our study 66% did not disclose CAM usage to their doctor, which is similar to previous studies [15, 18, 29]. Reasons for lack of disclosure may reflect a perceived lack of acceptance by the physician. It is important part of doctor-patient communication that issues such as CAM is discussed in a nonjudgmental and open manner. The "don't ask, don't tell" status quo, [29] is also reflected in the fact that there was no documentation of recent CAM use in the inpatient notes. Poor communication is supported by other studies, which found few doctors (16%) ask about CAM use [30].
In a study of paediatricians and nurses attitudes to CAM, many using CAM themselves, but only 40% actually asked about CAM [31]. The main reason given for not discussing these therapies was a lack of confidence to do so because of minimal education about these therapies and the limited safety and efficacy data available.
Efficacy and perceptions
A review of 19 surveys between 1982 to 1995, looking into the referral patterns of physicians to CAM practitioners, highlighted the fact that decisions need to be based on efficacy studies, rather than "regional economics and cultural norms", and "somewhere between over enthusiastic belief and stubborn disbelief is a balanced perspective that will help patients and advance medical science" [32]. The perception of parents and adolescents of doctors as not being interested was commonly found in this study, with quotes including: "they were not interested", "did not have the time" or "wanted to tell the doctor but feel that they don't want to hear".
Integrative medicine refers to "looking at a broad range of therapies and considering those that have the best evidence of safety and effectiveness in the context of holistic care". [33] It has been strongly supported by The Prince of Wales's Foundation for Integrated Health [34] and is becoming an important component of medical education. Cohen provides a practical example of integrative care, focusing on the chronically ill, "as many of these patients could benefit from the services of CAM practitioners... and as evidence emerges that some CAM are effective then it becomes ethically impossible for the medical profession to ignore them". [35] Studies have found that CAM practitioners are keen on integration. [36]
One of the major concerns for medical practitioners regarding CAM use is safety. Despite popular belief, CAM is not always "natural" and "safe" or free of side effects, and there are many case reports of adverse events in children. These include: death, neurological disability, organ failure and organ puncture[37]. Possible interactions between medicinal CAM, particularly herbal remedies and prescription medications, is well documented [38]. When questioned the majority (87%) of adolescents or parents in this study could not name a potential interaction. It was determined that there was a 3% risk of a participant in the study concurrently taking a herb and prescription medication. This is quite a small number in our hospital-based population and may mean that the interaction potential is less than previously believed. All ingested therapies, however, have the potential to interact so communication and reporting of interactions remains very important. Up-to-date information about CAM is becoming more available with pharmacists, local drug advisory services and some Internet resources useful [39, 40].
Funding is a major issue for producing quality evidence-based research into CAM as resources are still allocated predominantly through traditional biomedical channels and in 1996 only 0.08% of funding in medical sciences was going into CAM [41]. As stated by Ernst; "The scientific establishment criticises the paucity of data and weakness of CAM hypotheses with one breath and with their next breath they withhold the money that would be essential for changing this situation" [42].
Following the House of Lords Science and Technology Committee report on CAM in 2000, there was a push for some CAM practitioners such as Osteopaths and Chiropractors to follow the medical model of statutory regulation as seen with the General Medical Council [24]. Alternatives to statutory regulation are self regulation, with development of national standards regarding training and competence. Welsh et al. looked in depth at the tensions and difficulties in CAM practitioners seeking self-regulation [43]. The Prince of Wales's Foundation for Integrated Health has also played an important role in this area [34].
All professions are prone to rogue practitioners, such as those outlined in the study of Traditional Chinese therapists treating atopic eczema with topical remedies that were shown on analysis to contain high levels of potentially hazardous steroids [44]. In these situations it is important that the public sees effective and visible disciplinary procedures.
Limitations of this study
There were a number of potential areas of bias in this study, namely: 1. Questionnaire 2. Interviewer, 3. Interviewee, 4. Sampling, 5. Language bias. The questionnaire itself may have produce bias towards the listed agents as it is not possible to include all CAM therapies and there was a free text area. This was minimised by extensive review of the literature and including 7 medicinal and 13 non-medicinal therapies in the interview led questionnaire. Of note 5 of the 20 therapies accounted for the majority of CAM use, with some CAM only being used by less than 2% of the study population.
Despite calibrating the interviewers with a view to obtaining consistent responses, it remains possible that inconsistencies in asking questions and recording answers occurred The interviewers [NC, DC, AH, DR] had variable amounts of CAM disclosed (Table 4) and in particular CAM use was much higher (63%) in the surveys conducted by DW. He was a pharmacy student whilst the other three interviewers were paediatric trainees. All interviewers were similarly attired, with no identifying features. DW interviewed only a small proportion of participants (13%).and none of the inpatient subgroup. DW may have had higher CAM disclosure because as the only pharmacist amongst the interviewers he may have been better at gaining information about medication use and CAM. Alternatively there could have been some potential bias in the parents/patients perceptions of the different interviewers, thus affecting disclosure. In particular, the role of the three doctors as interviewers may have led participants to feel that they would not approve of CAM use. This would produce an under-estimate of CAM use in our population. The fact that the interviews were conducted in a busy outpatient clinic and on the inpatient wards may have inhibited disclosure of CAM use in some cases.
Different responses may also be obtained when interviewing the patient or either parent about CAM. The knowledge and opinions regarding CAM may differ within the family. The mother (75%) was the person most commonly interviewed in the survey. The prevalence may be under-estimated in cases where a guardian with less knowledge about the child completed the questionnaire. This study asked about CAM use in the past year, which is prone to recall bias, as participants may find it difficult to remember exactly what therapies were used. Repeating the questionnaire over the phone showed that it had stability with only a 3.3% difference in responses. There was, however, no differentiation made between positive or negative differences and individuals may have started or stopped taking CAM in the two months between the two surveys. It is also possible that respondents were more educated about CAM after becoming involved in the study, affecting the responses in the repeat questionnaire.
A representative sample is difficult to obtain, but by approaching consecutive inpatient admissions and outpatient presentations, the potential for sampling bias was minimised. Only 80 cases were excluded and 10 of those were because they had been interviewed previously. Information was not obtained to directly compare the demographics or other details of the 80 excluded cases from the 500 respondents.
This study excluded a small number of subjects (5 in total) who had insufficient knowledge of English, leading to language bias. Whilst this is a small number overall, it may be expected from the literature and on general principles that this group is more likely to use CAM. Cost was a factor as this study was not funded and there were insufficient resources to provide questionnaires in different languages or provide independent interpreters. This study was also designed with the aim of doing a direct comparison of CAM use between Cardiff and Melbourne, so their methodology was replicated, including exclusion of those with insufficient English language skills. Whilst this strengthens the comparability of data it highlights the need for further research into specific ethnic groups and CAM subtypes utilised by them.
Applicability of the study
As outlined previously methodologies used in CAM surveys vary, reducing the comparability of studies and hence the applicability of our study elsewhere. The study population was a tertiary paediatric group based at one location, comprising children with acute and chronic illnesses. The results whilst not applicable to the general population, may apply to other tertiary paediatric centres with similar demographics and case-mix. Well-conducted population based studies are require to ascertain the overall use of these therapies in children.
This study confirms a high prevalence of use in our tertiary paediatric population. CAM cannot be ignored and medical practitioners need to be better educated about these therapies. As stated by Coulter, "CAM is here to stay and will continue to present challenges for conventional medicine of how to respond"[45]. Paediatricians need to specifically ask about CAM use and document this appropriately. It should be discussed with patients in an open, non-judgemental way. In particular patients and medical practitioners should be aware of potential interactions and liaise with their pharmacy or drug advisory department if required. This will help patients and their parents make more informed, safe choices. Further evidence-based studies are required to provide more information on the effectiveness and safety of many CAM therapies [46]. The public health implications of CAM are far reaching and include regulation of the industry and protection of the public through appropriate safety and monitoring measures. Integrative medicine is slowly progressing bringing together western allopathic medicine and CAM therapists through improved communication and education.
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Ernst E: Only 0.08% of funding for research in NHS goes to complementary medicine. Br Med J. 1996, 313: 882-
Ernst E: The "improbability" of complementary and alternative medicine. Arch Int Med. 2004, 164 (8): 914-5. 10.1001/archinte.164.8.914.
Welsh S, Kelner M, Wellman B, Boon H, Moving forward?: Complementary and alternative practitioners seeking self regulation. Sociol Health Illn. 2004, 26 (2): 216-41. 10.1111/j.1467-9566.2004.00387.x.
Ramsay HM, Goddard W, Gill S, Moss C: Herbal creams used foratopic eczema in Birmingham, UK illegally contain potent corticosteroids. Arch Dis Child. 2003, 88 (12): 1056-7. 10.1136/adc.88.12.1056.
Coulter ID, Willis EM: The rise and rise of complementary andalternative medicine: a sociological perspective. Med J Austral. 2004, 180 (11): 587-589.
Ernst E: Complementary and alternative medicine for children: agood or a bad thing?. Arch Dis Child. 2006, 91: 96-97. 10.1136/adc.2005.087163.
• Associate Professor Noel E Cranswick, Dr Sue Skull and Professor Mike South, Royal Children's Hospital, Melbourne Australia. All members of the Melbourne research team who developed the CAM questionnaire and methodology used in this study.
• Professor Robert Newcombe, Department of Epidemiology and Public Health, Cardiff University as supervisor of NC's MPH dissertation (Cardiff University) and for statistical assistance
• Dr Ajay Ready (AR) & Dean Whittle (DW) for interviewing participants.
• Ms Jenny Cope for designing the database and data entry and Mrs Janine Cincotta for assistance with data entry.
Department of General Paediatrics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
Nigel W Crawford, Domenic R Cincotta & Colin VE Powell
Department of General Paediatrics, The Royal Children's Hospital, Melbourne, VIC 3052, Australia
Alissa Lim
Nigel W Crawford
Domenic R Cincotta
Colin VE Powell
Correspondence to Colin VE Powell.
The author(s) declare that they have no competing interests.
NC was an interviewer and co-author of the drafted manuscript. DC was also an interviewer and co-author of the drafted manuscript. AL provided background information and the questionnaire on which this study was based [15]. CP conceived of the study and was supervisor of the project. All authors read and approved the final manuscript.
Crawford, N.W., Cincotta, D.R., Lim, A. et al. A cross-sectional survey of complementary and alternative medicine use by children and adolescents attending the University Hospital of Wales. BMC Complement Altern Med 6, 16 (2006). https://doi.org/10.1186/1472-6882-6-16
Accepted: 02 May 2006
Tertiary Paediatric Centre
General Paediatric Outpatient
Free Text Area
Submission enquiries: bmccomplementarymedicineandtherapies@biomedcentral.com


text:
Everyone Counts - Improving Outcomes for Patients
Publishing of consultant-level outcomes data
NHS England has begun the staged publication of mortality rates for individual hospital consultants in ten medical and surgical specialties. The information relates to clinical outcomes from planned procedures (not emergencies) and is part of the 'Everyone Counts' programme that is aimed at enabling members of the public to access information about outcomes after surgery and other procedures.
The data will initially be refreshed annually and publishing of data in this way will be mandatory from next year. You can find out more about the data, when it will be available for other specialties, where it comes from and what happens where a hospital or consultant is identified as having higher mortality rates from our FAQs below..
NGH carries out procedures in seven of the areas: interventional cardiology, vascular surgery, colorectal surgery, orthopaedic surgery, urological surgery, head and neck surgery, thyroid and endocrine surgery.
You can access the published data via NHS Choices here.
Welcoming the move to greater transparency and openness, Northampton General Hospital's medical director Dr Sonia Swart said: "We fully endorse this initiative by NHS England to ensure that patients are able to access accurate data regarding outcomes following surgery.
"We are very pleased to note that our data tells of a high standard of surgical and cardiological practice, with very low numbers of deaths from routine major surgical procedures. None of our surgeons or cardiologists has a higher than expected death rate."
All the surgeons and cardiologists involved at NGH have agreed that their data can be published, although we know that some of the data is still being reviewed for accuracy and may not yet be ready for immediate publication.
We are aware that some of our information may presently be incomplete, but we are making every effort to ensure that future information collection will be as comprehensive and reliable as possible.
How can I use the data?
The information published so far includes how many times each participating consultant has performed certain procedures and what their mortality rate is for those procedures. You can see whether or not the data for each consultant is within or outside the expected range. Consultants who fall outside the expected range are sometimes referred to as 'outliers'.
You can use this data to decide which consultant to choose for your care. However, there are some important issues to bear in mind when looking at the data.
For instance, the vast majority of the data has been through a process known as 'risk adjustment'. This is a way of accounting for the different mix of patients operated on by a particular consultant's team. Using risk adjustment, outcomes are calculated as if all consultants operated on the 'average' patient. This means that consultants who take on particularly poorly, high-risk patients or carry out the most complicated procedures don't appear to have an unfairly high mortality rate.
However, not all the data can be 'averaged out' in this way. Specific reasons for this are outlined in the introductory text for each set of results. Where risk-adjusted data is not available, actual (also called 'crude') clinical outcomes are shown. If the data is not risk-adjusted, a consultant may have a higher mortality rate simply because he or she takes on more difficult cases.
If you have questions or concerns having viewed specific results, please discuss these with your GP or consultant.
What will the NHS do where consultants have high mortality rates?
Any hospital or consultant identified as an outlier will be investigated and action taken to improve data quality and/or patient care.
When will data be available for other procedures and specialties?
The results published to date were selected because relevant data was already being collected for these procedures and specialties. It is likely the programme will be extended from 2014 when data for other conditions can be collected and analysed in a similar way.
The data comes from national clinical audits which continuously review medical practice to check that it is safe and seek ways to improve it. These audits are managed by 'audit providers' (usually academic institutions such as a university or royal college) which work with the specialist association. A specialist association is an independent, membership organisation, which represents a particular medical specialty.

redpajama_set_name: RedPajamaCommonCrawl


text:
Sede Italiana
Via G. Donizetti, 4
20122 Milano IT
Vertical ForestING
Search in the website
HomePress release corriere della sera | on the civil protection center of norcia
corriere della sera | on the civil protection center of norcia
Norcia Multipurpose and Civil Protection center, realized in record time on a project donated by Stefano Boeri Architetti and realized with the funds from Un aiuto subito – paid by the public of La7 and by the readers of Corriere – during the centre Italy 2016 earthquake, it has been confiscated.
So the architect Stefano Boeri explains the project and declares himself speechless.
I am ready to challenge whoever from a technical point of view: it is a temporary structure.
It is a structure built of prefabricated wooden panels, fixed with bolts and screws, that can be easily dismantled.
We have to be serious. That one is a zone that suffered a devastating earthquake. The Municipality asked us a safe structure where people without a roof could had stayed after the tragedy.
We carefully designed a light basement, with concrete beams and a foundations system easily removable. But if it is not ok i ask myself: will they sequester all the little houses, built in a housing emergency state, with a concrete base?
The area was pinpointed by the Municipality after a request of the Mayor coherent with the ordinances of the Civil Protection, that followed all the construction process together with the archeological authorities that were always with us. During the inauguration there were the special commissioner Vasco Errani and the President of the Region Katia Marini.
Stefano Boeri Architetti
MILAN | Via G. Donizetti 4, 20122
Milano IT
SHANGHAI | No.501 Jiujiang Rd.,
TIRANA | Rruga Pjeter Bogdani, 5, Tirana, AL
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Where to start. What a week of doom and gloom. I have been around race tracks since the age of twelve, you can do the maths, it's quite a while. I have seen sales that encourage investment, sales that have participants rushing like lemmings to the sea. This game isn't for those with no capacity to ride the punches.
Yes, the recent Ready to Run sale has seen more than the usual quota of backsides kicked. But can the sale result be laid at the feet of our Administrators, specifically, no. Now as you know nobody questions the performance of our respective boards more than I but I fear we are becoming our own doomsayers. If I was on the outside looking in, if I was asked to be part of a racing partnership, how would I react to the plethora of negative news. I think we need to know where we think we need to head.
The current crusade is justified, not because the world of racing is caving in, no, our belief is that we should be better placed if we were better administered. I could say do we know, well we have reports from Messara, Deloittes, Investec and that's only in the last twelve months. We do also have multiple individual opinions based on varying degrees of IQ. So what would change if we had another 50 m sloshing around, a portion would be required for infrastructure catchup, say 20m, leaves 30m for stakes across the three codes, at best 20m for gallops an average of 6k a race. We know it wouldn't happen as such, there would be a fight over the allocation with conflicting views on the trickle-down approach.
My point, how would this financial injection have changed all the recent headlines. Well, if the headline change was based on the improved financial returns to owners, what about the 80% that don't win any stakes either win or place. So, what we are seeking is a fair slice of the action, we want to be able to promote ourselves as a vibrant, fun, sport. The money is important, so are the people, the traditions, the NZ Racing brand. Even the non-winners, need to believe their losses are worth it.


It's taken 10 days, five city officials, two layers, one environmentalist, extraordinary patience, and strained relationships with neighbors, but at last, the city has blessed our 'replanting' plans which beautify the community walkway, provide a modicum of privacy to my home, and a support a fledgling bird habitat. And along with the blessings was an agreement to keep the plantings no higher than the ridgeline of the house, and the neighbors 'trim' permit was rescinded. The costs were large by any standards, the emotional upheaval and grief ridiculous, and all of it unwarranted and stupid. Acts of deception and lies led to the wholesale chainsawing of a lovely 13 year old tree – which all had agreed to trim – not chop down.
I'll say it again .. the only thing I find to fear in Mexico are Americans who want to transplant their complicated lives to this lovely serene town.
I sat by the sea this afternoon trying to figure out why this happened? What precipitated acts of bad judgment? In the end, I have to accept that I'll never understand. Instead, I'll watch as new plantings slowly fill the space that their predecessors once occupied, and thrill as the bird population rediscovers a habitat and sanctuary.
As I finish that sentence, a stunning road runner leaps onto the garden wall, flicks his head side to side, spies the grasshopper he's been chasing and takes off into the remaining tall tree. Yes, another wonder filled day.
This entry was posted in Baja Living, Birds, Casa de Catalina, Gardens/Plants, Loreto. Bookmark the permalink.


The concept of "Taiwan Folk Toy" comprises a book and a toy, exploring life in Taiwan in the 1940s and 1950s. The richly illustrated book shows a selection of colourful toys for children from that time. In their simplicity, these toys document a lifestyle that was still oriented towards local traditions which, to a certain extent, were still determined by natural processes. The book thus wants to bring back memories of a past when rural structures offered children many sensual impressions. The toys are meant to represent an era when life and interaction between people was characterised by humanity and hospitality. The other central element of the concept is a wooden toy. It is designed with colourful pictograms reflecting elementary everyday objects of historical rural life.
Via a symbolism of simple children's toys, "Taiwan Folk Toy" convincingly visualises people's life in the 1940s and 1950s. The conclusive entity of book and toy is the expression of a well thought-through concept. It impresses with its perfectly crafted design as well as with the selection of wood and Plexiglas as materials which further underline the high-quality appeal of the book.


The Cornish Life is a brand by Rosanna Clark. The registered sole trader address is The Old Mill, Mount Hawke, Truro, TR4 8BL. Correspondence should be sent to The Valley, Carnon Downs, Truro, TR3 6LQ. Email correspondence should be send to contact@thecornishlife.co.uk.


text:
Lenovo confirms Fujitsu PC business talks
Tags: #acquisition #financial #partnership #pc-industry #pc-market #personal-computer
Companies: #fujitsu #lenovo #nec
Fujitsu and Lenovo have announced a 'strategic cooperation' which will see the two companies join forces for development, design, and manufacturing of personal computers for sales worldwide.
Rumours that Lenovo and Fujitsu were interested in making a deal leaked earlier this month, when local sources claimed that Lenovo was looking to acquire Fujitsu's PC design, development, and manufacturing divisions. At the time, it wasn't clear what form the deal would take, with suggestions ranging from an outright acquisition to the formation of a joint venture following the same pattern as Lenovo's NEC partnership.
In a press release issued late last night the two companies have now confirmed the talks, stating that they are 'exploring a strategic cooperation in the realm of research, development, design and manufacturing of personal computers for the global market.' The deal concerns FCCL, a presently wholly-Fujitsu-owned subsidiary spun out in February this year to handle the company's personal computing interests. With a slowing market, though, Fujitsu is looking for ways to encourage FCCL's growth - and Lenovo, it seems, is eager to lend a hand.
'Through the cooperation, the two companies aim to create a successful model that leverages Fujitsu's global sales, customer support, R&D and manufacturing capabilities together with Lenovo's operational excellence to improve competitiveness in the dynamic global PC market,' the joint statement claimed, while warning that 'details of the cooperation are currently under discussion'.
The deal will not see the Fujitsu brand disappear, however, with the company still to sell own-brand PCs and provide after-sales support - though a phase-out is not off the cards for the future, mimicking Lenovo's deal with IBM for the ThinkPad family of laptops, which saw Lenovo manufacturing devices under IBM's name for a period before replacing Big Blue's logo with its own.
Financial terms of the deal, which will be funded through the Development Bank of Japan, have not been disclosed.
Lenovo finalises deal for Fujitsu's client computing business
Takes control of the new joint venture.
Lenovo confirms job cuts are coming
Axes a further two percent of its staff.
Lenovo starts sniffing around Fujitsu's PC business
Could invest, could form another JV.
October 7, 2016 | 09:18


text:
La Plaza CAMI de Itagüí    está situada en el centro de la ciudad de Itagüí - Colombia limitando con el Parque Simón Bolívar y la Iglesia de Nuestra Señora del Rosario. Hace parte del conjunto urbanístico del centro administrativo de la ciudad.

Historia
En 1990  el Gobierno de Itagüí aprueba la construcción de un conjunto urbanístico que funcionaría como centro administrativo y que a la vez  tuviera dentro de su estructura un espacio cívico y cultural. Así fue como  en el periodo 1991 -  1993 se construye el Centro Administrativo para la ciudad y la Plaza CAMI de Itagüí.

El nombre de la plaza
El nombre de la plaza viene de la estructura de la que hace parte, las siglas C.A.M.I. (Centro Administrativo Municipal de Itagüí).

Características
En sus espacios  se ubican esculturas relevantes como "El Flautista" de Rodrigo Arenas Betancur ,  y "La dama arpa", "La dama justicia" , "La dama flauta" de Salvador Arango.

Fachadas de la plaza
Se trata de una plaza porticada de planta circular, de 8 220 m² que está completamente cerrada por edificios de tres plantas, con 137 balcones en total que dan a la plaza. Dispone de cuatro entradas de acceso, de las cuales la más conocida es la del Parque Simón Bolívar, en la esquina suroeste de la plaza.

Usos
La plaza CAMI de Itagüí se convirtió desde sus inicios, en un escenario de numerosos actos públicos, como actos lúdicos para la familia, exposiciones de cine, pintura, teatro y música. Y en las fiestas navideñas es un sitio muy especial para los ciudadanos.

Véase también
 Plaza
 Itagüí
 Colombia

Referencias

Itagüí

redpajama_set_name: RedPajamaWikipedia


text:
Q: JavaScript/Node.js JSON.parse() Undefined I am receiving the error:
undefined:1
'{"completed_in":0.078,"max_id":333655176038719488,"max_id_str":"3336551760387
^
SyntaxError: Unexpected token '
    at Object.parse (native)
    at /home/tweets/10seconds.js:25:25
    at passBackControl (/home/tweets/node_modules/oauth/lib/oauth.js:367:11)
    at IncomingMessage.<anonymous> (/home/tweets/node_modules/oauth/lib/oauth.js:386:9)
    at IncomingMessage.EventEmitter.emit (events.js:117:20)
    at _stream_readable.js:895:16
    at process._tickCallback (node.js:415:13)

When parsing Twitter API JSON from the Search API.
The code I am using the parse this JSON is:
MongoClient.connect("mongodb://localhost:27017/db", function(err, db) {

 if(err) { return console.dir(err); }
  var collection = db.collection("tweets");

    while(run < 200){

        oa.get("http://search.twitter.com/search.json?q=morning&rpp=100&include_entities=true&result_type=mixed", access_token, access_token_secret, function(error, data) {
            var theTweets = JSON.parse(sys.inspect(data));

           collection.insert(theTweets, {w:1}, function(err, result) {});
           console.log(run);
        });
    run = run + 1;
    }

});

What could cause this?

A: Probably, the output of sys.inspect is not JSON it adds the quote '.

A: Why are you using sys.inspect?
If data is a JSON string, then use JSON.parse(data); and if it's an object already, well you don't have to use JSON.parse at all...

A: The problem is on the sys.inspect() call as already stated by the other answers and comments.
As stated in the nodejs documentation (http://nodejs.org/api/util.html#util_util_inspect_object_options):

Return a string representation of object, which is useful for debugging.

By the way, it seems they changed the sys module name to util.
You can easily make a small test by running the following code on an older node version.  It should throw your error:
var sys = require('sys');
var data = '{"test":1, "test2":2}';
sys.puts(JSON.parse(sys.inspect(data)));

And then remove the sys.inspect call. It should correctly parse the object:
var sys = require('sys');
var data = '{"test":1, "test2":2}';
sys.puts(JSON.parse(data));

redpajama_set_name: RedPajamaStackExchange


text:
Distilleries across the nation pivoting operations to make hand sanitizer
Distilleries across the nation pivot operations to make hand sanitizer
By: Elizabeth Ruiz
BOULDER, Colo. – At J&L Distilling Company in Boulder, Colorado, you'll find volunteers hard at work filling a couple hundred bottles per day with hand sanitizer.
"I've basically been living here. I've maybe been home two nights in the last two weeks," said J&L Distilling Company owner Seth Johnson.
Johnson is not a volunteer. He's the brains behind the operation. He's the owner of J&L Distilling Company and he's fully changed his business from one that makes vodka, gin, and liqueur into one that makes hand sanitizer – a resource in high demand at a time when the whole world is trying to stay virus free.
"I do have a stock of spirits that is dwindling quickly. But the need for hand sanitizer is so immediate and severe that I've basically switched over full-time to just making hand sanitizer," Johnson said.
Johnson says distilleries have an upper hand because the industry is so chemically driven.
"My still has 35 distillation stages per pass, so I'm able to get a very pure alcohol, which is the stuff you're supposed to be using for the hand sanitizer."
Johnson was a physicist before getting into the alcohol business. So, the change has him putting his science background to use in a different way.
"My column is special in that it's only six inches in diameter, but it's 17-feet tall so I get a lot of distillations per pass," Johnson said as he pointed to his distillation process.
He's following strict guidelines to make the hand sanitizer – which he wouldn't be able to effectively distribute without help of volunteers.
Anja Brannstrom started as a volunteer and has now become Johnson's administrative assistant. She handles sales and makes sure the hand sanitizer gets to the public.
"I can't sit at home when there's a need out there. What can I be doing? How can I help?" Brannstrom said.
Brannstrom says she was quick to join the cause because the wellness center she owns is currently closed. She was determined to continue helping people in some way. Little did she know how big the operation would become.
"We've gotten emails from people in California, in Boston, in far flung states, and unfortunately my answer to them is 'we're not allowed to ship it. Have you checked with your local distillers?'"
Since corporate clearance would have taken too long, SnoSan Hand Sanitizer can only be sold at local liquor stores and at the distillery's tasting room.
But other liquor producers all over the U.S. are making the same switch. According to Margie Lehrman, the CEO of American Craft Spirits Association, 75 percent of distilleries across the nation are producing hand sanitizer right now.
American Craft Spirits Association supports more than 2,100 distillers all over the country. Lehrman believes there are likely distilleries making hand sanitizer in every state.
"They are located throughout the United States, and because they have the necessary resources – which primarily is ethanol alcohol – to then begin making hand sanitizers, they're in a position to distribute it locally," Lehrman said.
The Food and Drug Administration has set guidelines and recipes for distillers to follow. To make it easier, ACSA is offering webinars to educate producers about hand sanitizer transportation and regulations.
"All the distillers that I know, know the rules, know the guidelines and are following them strictly," Johnson said.
Lehrman says nearly all distillers currently making hand sanitizer are donating their product to hospitals and first responders.
"Even though their bottom line has been hit pretty dramatically, they're giving it as a gift," Lehrman said.
"We've done a bunch of donations to groups doing outreach work with homeless, to hospice care, elder care, fire departments, post offices," Brannstrom added.
Johnson's business has benefited from donors as well. He says one particular person saved him from going bankrupt at the beginning of it all.
"I had an anonymous donor come up and give me a $10,000 check and just said 'use this to get it out there,'" Johnson said.
Johnson says he's thankful he can continue doing what he loves while positively impacting the community around him.
"So I'm going to produce as much as I can, give away a bunch, and sell a bunch, and we'll go from there," Johnson said.


Tool Palette is a horizontal scroll view. You can use some tools.
You can edit tile image with this Edit Area.
Two fingers long tap change mode to horizontal and vertical mirror mode.
If you tap thumbnail icon, the edit screen is zoomed. Tap again, return to defualt scale.


text:
Joseph Marie Verachtert (Noorderwijk, 31 maart 1866 - Geel, 19 mei 1941) was een Belgisch advocaat en politicus voor de Kath. Partij en het Katholiek Verbond van België.

Levensloop
Verachtert, geboren in Noorderwijk bij Herentals, was een zoon van Augustinus Verachtert uit Vorst en Florentina Daems uit Morkhoven. Hij promoveerde tot doctor in de rechten (1891) aan de Katholieke Universiteit Leuven en vestigde zich als advocaat in Geel. In Leuven was hij actief in het literaire gezelschap Met Tijd en Vlijt. Hij trouwde in 1892 met Maria Joanna Moortgat, kleindochter van de vroegere Geelse  burgemeester  Jacques Moortgat, hetgeen hem introduceerde in de socio-economische en politieke elite van Geel. Het echtpaar bewoonde op de  Grote Markt het grote  herenhuis van de familie Moortgat en kreeg twee kinderen: Maria Rosalia en Carolus Josephus.

In 1894 werd Verachtert verkozen in de Antwerpse provincieraad voor het kanton Mol. In 1896 werd hij verkozen als gemeenteraadslid van Geel en onmiddellijk aangesteld tot schepen. Hij had een Vlaamsgezind etiket en wilde zich ook een sociaal imago verwerven, door zijn activiteiten in de  landbouwsector en in de  ziekenkassen. Hij werd voorzitter van het Provinciaal Verbond van Veekweeksyndicaten en van het provinciaal Verbond der Paardenverzekering. Op ziekenfondsgebied stond hij in 1900 als voorzitter aan de wieg van de Geelse pensioenkas de Sint-Dymphnagilde. Hij was ook actief in de ziekenkas Sint-Amandusgilde. Vanaf 1901 zetelde Verachtert bovendien in het overkoepelende Verbond der Pensioenkassen / Verbond der Voorzienigheidskassen van het arrondissement Turnhout.

Bij de parlementsverkiezingen van 1900 nam hij plaats op de opvolgerslijst van de katholieke partij. Hetzelfde jaar werd hij bestendig afgevaardigde voor de provincie Antwerpen. Als gedeputeerde kon hij mee zorgen voor de provinciale subsidies van de mutualiteiten en van landbouwinitiatieven. Vanuit de provincie werd hij ook voorzitter van de Provinciale Bijzondere Commissie van Onderlinge Bijstand en Maatschappelijke Werken Antwerpen en van de Commissie tot Aanmoediging van de Volksbibliotheken en de Vlaamse Letterkunde. In 1912 nam hij een verkiesbare plaats in en deed zijn intrede in de Kamer. Hij vervulde dit mandaat tot in 1929. Van 1932 tot 1936 was hij Provinciaal senator. In 1921 voerde Verachtert de gemeenteraadslijst aan die de verkiezingen won. Hij werd burgemeester en bekleedde dit ambt totdat hij, twee maanden voor zijn dood, in maart 1941 tijdens de Tweede Wereldoorlog door de Duitse bezetter werd afgezet.

Katholieke Partij (België)-politicus
Katholiek Verbond van België-politicus
Schepen van Geel
Burgemeester van Geel
Antwerps provincieraadslid
Gedeputeerde van Antwerpen
Belgisch volksvertegenwoordiger
Belgisch senator
Belgisch advocaat


What?! If you have heard about amber necklaces you've probably heard about them in conjunction to teething babies. Amber Crown does in fact make teething necklaces for our adorable babies but they also make amber necklaces for our furbabies. Why though? There is a really great reason for getting your cat or dog a necklace and it isn't so that your furbabies match your human babies haha.
• When worn on pet the friction from the fur releases aromatic terpines from amber that repels ticks and fleas.
• Static electricity generated when amber is rubbed against the pet's fur makes parasites uncomfortable and unable to cling to hairs.
– It is waterproof, odor free, safe for humans and animals, no secondary effects on your pet, family or house.
– 100% chemical free, non-toxic, no insecticides.
– Can be used for dogs and cats, puppies and kittens, even if they are allergic, pregnant or nursing.
The collars come in 8 different sizes even large for pretty big doggies! I happen to think these collars look beautiful as I'm pretty obsessed with the amber necklaces already with my kiddos. The collars have really nice leather ends also. All necklaces are raw Baltic amber, keep in mind this repels but if your pet is infested you might have to treat the issue then use this as a future preventative. Nothing wrong with using more than one form of natural flea and tick repellent!
I myself have 2 inside cats now, Zeta and Atticus. I tried this collar out on Atticus and he seems to like it. He does not however go outside at all because where we live all types of critters and things bigger than them roam and I'd rather him and my other cat not be gobbled up. That being said I can say it is effective in our situation in the event of any fleas or ticks ever getting in our home but he wont be testing this outdoors. If you are new to amber, it is not a stone but actually fossilized conifer tree resin, it is beneficial to both humans and our furry friends and honestly it is something I feel way more comfortable having as a flea and tick repellent in my home. Things need to be kid safe in our home.


Good morning community. For those of you not aware, Destructoid has a forum. Within that forum is a thread, a thread where the Destructoid community routinely posts the games they've completed as they complete them. Then, it's left up to a a solitary user to update the list once a month. This year that job has fallen on Technophile, our resident forum admin. I'm in charge of transferring the list to the community blogs, so those of you who aren't into the forums can see it and possibly become enthused about participating. Do not post your completed games here. Do that in the forum thread.
This transfer is a few days late, and for that I apologize. I was tasked with editing in all of the bold, but beside that, I'm a little on the OCD side. I went in and made the usernames pop out a little bit more, as well as editing in a universal format for the little bonuses you guys tack on, and making sure everything was spelled correctly. I know; I'm crazy.
251 games completed in January. Nice showing guys.


text:
Ethanol plants reach settlement with EPA
By Mary Losure
The U.S. Environmental Protection Agency will require ethanol plants in Minnesota to install millions of dollars worth of pollution control equipment, under a settlement announced Wednesday in St. Paul. The agreement is expected to be a model for the ethanol industry nationwide.
The Gopher State Ethanol plant in St. Paul. Complaints against the plant this spring triggered an investigation of air emissions at the plant, and others across the Midwest.
(MPR Photo/Mary Losure)
The EPA began widespread testing of ethanol plants after citizens' complaints about Gopher State Ethanol, a converted brewery in St. Paul, triggered an investigation of air emissions there. Testing at Gopher State, and later at plants across the Midwest, showed they emitted high levels of carbon monoxide and other pollutants. This spring, the EPA summoned industry represenatives to Chicago to begin negotiations on how to solve the problem.
The settlement announced by EPA regional administrator Tom Skinner will require 12 of Minnesota's 14 ethanol plants to install pollution control technology that will cost about $2 million per plant. Skinner says it will reduce emissions of what are known as volatile organic compounds, or VOCs, by 95 percent. Those chemicals include formaldehyde and others that are known to cause cancer in animals.
"In terms of excess emmissions from ethanol plants in Minnesota, this could be described as the beginning of the end. The next step is to get those control measures in place," says Skinner. "As to the rest of the country, this really is the end of the beginning. We are going to use these settlements as a model and export that model to other regions."
EPA regional administrator Tom Skinner announced the agreement with 12 Minnesota ethanol plants. They will be required to install pollution control technology that will cost about $2 million per plant.
The settlement requires ethanol plants to install thermal oxidizers -- devices that burn off VOC emmissions before they can leave the stack. The plants will also face stricter limits on other pollutants. The agreement gives plants from one to three years to comply. The EPA will also require each facility to pay fines ranging from $29 to $39,000.
Most of the state's ethanol plants are owned by farmers. Ethanol coalition spokesman Randy Doyal says the $2 million cost of the new equipment is significant. It amounts to about 5 percent of the total cost of building a new ethanol plant.
"The farmers are going to have to pay the cost, and I can tell you they're not very happy about it," says Doyal. "But they're going to do it, because they feel the same way that most of us who own the facilities do -- that it's something we have to do to be good environmental neighbors."
Doyal said the cost could put Minnesota ethanol plants at a competitive disadvantage at first. But he said it might give them an edge later, as other plants are forced to comply with emission standards as well.
John Birrenbach lives three blocks from the Gopher State Ethanol plant in St. Paul. He and many of his neighbors have complained about the odor and pollution coming from the plant. He's hoping the Minnesota Pollution Control Agency will take a more aggessive role in monitoring the plant.
Two Minnesota ethanol plants, Al-Corn Clean Fuel in Claremont, and Gopher State Ethanol in St. Paul, have already installed thermal oxidizers. The oxidizer in St. Paul has been plagued with problems and is currently out of order. People living nearby have continued to complain of odors and ill health effects.
Neighborhood residents learned of the press conference only a few hours before it took place, but a few turned out for the announcment. John Birrenbach lives three blocks from the plant. He says the thermal oxidizer has helped reduce the odor some, but is not the complete answer. But he was encouraged to see representatives of the Minnesota Pollution Control Agency appear alongside the EPA and Justice Department officials.
"I'm hoping -- with the MPCA now actually on our side instead of being on the side of the ethanol industry, and allowing them to put forth all of this kind of stuff -- that maybe now we'll get some closer monitoring of the plant, and maybe be able to keep them in compliance," says Birrenbach.
The agreement gives Gopher State one year to meet Clean Air Act requirements. An MPCA spokeperson says the thermal oxidizer is expected to be back in operation in eight weeks.
More from MPR
Complaints about Gopher State lead to crackdown (Sept. 23, 2002)
Sustainable Minnesota ethanol information
Governor's Ethanol Coalition
Minnesota Pollution Control Agency News release announcing settlement


If you are looking for a home in the picturesque state of Vermont, you probably already understand the beauty the area has to offer. With its stunning landscape, rolling hills, country roads, and postcard villages, Vermont is like a dream destination, offering you the perfect place to settle down, raise a family, or retire.
Keep in mind that the USDA loan program was created to help build the nation's rural areas. Because of this, homes located within major cities are not USDA Loan Eligible.
The good news is that a surprisingly large number of Vermont homes do qualify, some of which lie just outside of major metropolitan areas. To be eligible, the Vermont property must be located outside of city limits and within an area of less than 20,000 residents. For more information on Vermont USDA Loan eligibility requirements, please fill out the application on this page, or call one of our certified USDA Loans Agent at 1-866-854-4242.
Credit History: The USDA Loan program does not have a strict credit score guideline. Rather, it evaluates your credit history in an effort to ascertain your willingness to meet repayment obligations.
Income Limits: If the home is in an eligible area, you must not exceed the current yearly USDA income limit set for your county. View the chart below for a list of Vermont USDA Loan Income Limits by county.
Remember, Consumer Real Estate Finance Co. is here to answer all your questions. For help applying for a Vermont USDA Loan, contact us today.


Clariant, a world leader in specialty chemicals, co-hosted the 2nd Clariant Chemistry Day with the Chemistry Department of the University of Basel and the University of Applied Sciences and Arts Northwestern Switzerland (FHNW) on Thursday April 10, 2014 in Basel, Switzerland.
The event, held at the PharmaCenter of the University of Basel, was opened by Prof. Dr. Edwin C. Constable, Scientific Chairman & Award Committee, Prof. Dr. Gerda Huber, Director University of Applied Sciences and Arts Northwestern Switzerland FHNW, School of Life Sciences, and Dr. Martin Vollmer Chief Technology Officer, Clariant International Ltd. A program of guest lectures and poster presentations promoted latest R&D advances in the field of CleanTech to an invited audience of young researchers from the two universities and Clariant scientists. The Clariant Chemistry Day aims to support basic research and improve technology and knowledge transfer between academia and industry in order to strengthen the knowledge base for Clean Tech in Switzerland.
In addition, the event also marked the announcement of the "Clariant CleanTech Award" 2014.The Award honors outstanding scientific achievements in the field of Sustainable Chemistry such as resource efficiency, renewable energy, environmental protection. Endowed with a total of CHF 15 000, the Clariant CleanTech Award is open to researchers from both Swiss universities and is judged by the Scientific and Award Committee.
This year, the two first prizes of CHF 5000 were presented to Annika Büttner and Christoph Gasser for their innovative research in the respective areas of solar energy, and biocatalysis. The ceremony was followed by the 2nd Clariant CleanTech Lecture held by Prof. Dr. Anders Hagfeldt from the University of Uppsala, Sweden.


text:
Index of Chapters:
Elizabeth's Family
Interpreting the Letters
Stateside Letters
From England
Return to England
Origin of the letters
Elizabeth Donnellan received her Master of Arts degree in social work in 1941 and was hired by the Red Cross in 1943 as a social worker in service to the armed forces. She was sent to the East Coast, then to England and Europe arriving on the beaches of Normandy by August, 1944.
A budding author, Elizabeth was a typist and had access to a typewriter throughout her tour of duty. She wrote long, articulate, chatty letters describing the people, places and events of her time. A number were handwritten and most, but not all, are dated.
This is epistolary writing which has a long and well accepted literary history. The Bible contains "Epistles" by Paul, Timothy, Jude and "The Epistles of St. John." C. S. Lewis used the form for "The Screwtape Letters." Bram Stoker's "Dracula," Pierre Choderlos de Laclos' "Les Liaisons Dangereuses" and "Doogie Howser, M. D." are examples of the form used successfully in literature and television. Alice Walker's "The Color Purple" uses letters to tell her story.
There is an arc to Elizabeth's letters which only appears with a chronological reading beginning with her Red Cross stint at Walter Reed Hospital in Bethesda, Maryland. She falls in love, crosses the Atlantic Ocean where she meets friends who will be with her throughout the war, then somehow falls out of love. She travels the length of Britain and visits various countries on the Continent. Her two years in service read like the feats of a heroine in an adventure novel.
These are young people participating in war who have access to tools and can make of those tools toys for an adventure.
This book contains approximately 50 letters which were conserved by her siblings. These have been transcribed and annotated. In addition, original photographs which Elizabeth took have been discovered and are included.
Copyright 2016 by NetNovels
This is a work of historical fiction. Names, characters, places, and incidents are either taken from original source material, i. e. the letters of Elizabeth Donnellan, or researched to the best of the author's ability to compliment, expand or explain those letters.
Reproduction in any form without prior written permission is prohibited
NetNovels Publishing Company
Published in the United States of America
"Elizabeth's War Letters" by H. W. Moss


One night in Malenadu, due to an unexpected situation, a stranger takes shelter in Manjappaiah's house. Two other boys also take shelter on the same night. Policemen who come searching for two other boys also stay at Manjappaiah's house. The story unfolds, when each of them try to search for answers to recollect their past.
Gharge Karehaklu, been in the Entertainment Industry since past 15 years. He has got a masters degree in literature and worked as a lecturer for a short time. As dialogue and scriptwriter have worked in more than 3000 episodes under many senior directors for various tv channels. His directorial debut Seshu in 2012 was featured at International Children's film festival and was recognized for the State award. Anuttara is his second directorial attempt.


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text:
Unpardonable Sin - What Does the Bible Say?
Church Discipline
Church History / Biographies
Pastors & Elders
Women's Roles
The Fear of God
The Holiness of God
Evangelizing Children
Witnessing to Lost Family
Examine Yourself
Once Saved Always Saved?
Regeneration / Born Again
Anger & Bitterness
Anxiety & Worry
Killing Sin
Sexual Sin
Baptismal Regeneration
Easy-Believism
Seventh-Day Adventism
DateTitle Sort Ascending
What Question Do You Get Asked the Most? Unpardonable Sin
Tim Conway 2 years ago | Topic: Unpardonable Sin
Tim Conway was asked about what question he gets tired the most of hearing as a pastor. His answer was that he has constantly had questions from people who are tormented by the belief that they have committed the unpardonable sin.
Think You've Committed the Unpardonable Sin? Find a Promise
Are you despairing because you believe you've committed the unpardonable sin? You don't so much need the words and counsel of people; you need a promise from God's Word...
I'm 99% Sure I Committed the Unpardonable Sin
People are often plagued with the thought they've truly committed the unpardonable sin. What kind of counsel do these people need?
Afraid I Committed The Unpardonable Sin
Tim Conway 5 years ago | Topic: Unpardonable Sin | Bible: Matthew 12:31
Do you fear that you have committed the unpardonable sin? You may have, but nevertheless run to Christ. You say, "Isn't that a contradiction?"
Will God Give Me Life?
Tim Conway 6 years ago | Topic: Unpardonable Sin | Bible: 1 John 5:16
True life is to know the Lord intimately, but sin interrupts this. One of the greatest griefs behind sin is how it affects the Christian's fellowship with the Lord Jesus Christ.
What is the Sin that Leads to Death?
First John 5:16 says that "there is sin that leads to death" and in the context of this letter he is dealing with those false prophets that are false to the true Christ.
The Unpardonable Sin
Ichabod Spencer 7 years ago | Topic: Unpardonable Sin
It is not the unpardonable sin which hinders your being a Christian; but your wickedness of heart, your pride, vanity, and insincerity.
What Hebrews 10:26 Does Mean (Part 2)
Tim Conway 10 years ago | Topic: Unpardonable Sin
The Scriptures teach that where there is forgiveness through Christ there is no longer any offering(Heb 10.18) that a person needs to make for the atonement of their sins. The Scriptures also teach that if you reject the truth of Christ, which is the only place of forgiveness, there remains no longer any other place to find a sacrifice for your sins(Heb. 10.26).
What Hebrews 10:26 Does Not Mean (Part 1)
Christians fear and tremble by design, Jeremiah 32:40 says so. This is not the type of fear that draws people away, it is the type of fear that draws them nearer.
The Unpardonable Sin – Blasphemy Against the Holy Spirit
How do I know that I have not sinned to a point where I cannot be forgiven? What if I have committed to the unpardonable sin?
Should I Be Scared of Hebrews Chapters 6 and 10?
Tim Conway 13 years ago | Topic: Unpardonable Sin, Once Saved Always Saved?
Should we be afraid of verses like this? For it is impossible, in the case of those who have once been enlightened, who have tasted the heavenly gift, and have shared in the Holy Spirit, 5andhave tasted the goodness of the word of God and the powers of the age to come, 6and then have fallen away, to restore them again to repentance, since they are crucifying once again the Son of God to their own harm and holding him up to contempt. - Hebrews 6:4-6