text:
Xavier Sánchez Choez ORCID: orcid.org/0000-0002-8258-87461,2,
María Luciana Armijos Acurio1 &
Ruth E. Jimbo Sotomayor1,2
Upper respiratory tract infections are the leading cause of misuse of antibiotics, a problem that leads to unnecessary adverse events and antibiotic resistance. Antibiotic prescription in Ecuador was analyzed in order to evaluate the state of antibiotic prescribing for upper respiratory tract infections. Both the appropriateness and adequacy of prescribing was evaluated. Appropriateness represents the percentage of prescriptions that are indicated; adequacy refers to the percentage of patients requiring antibiotics who are treated.
The aim of the study is to analyze the appropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador. This is a cross-sectional study of patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with upper respiratory tract infection as a primary diagnosis.
We included a total of 1393 patients in the analysis. Out of the 1393 patients identified, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%, and 51 required antibiotics, reflecting a real need of antibiotics of 3.7%. Appropriateness: Of these 523 patients who were treated, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. Adequacy: When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%.
The results of our study report a 90.25% of inappropriate prescription. The antibiotic prescription, appropriate prescription, and adequate prescription rates show the need for implementation of strategies in order to reduce them. Related aspects regarding prescriber's behavior and the patient's expectations should be analyzed.
Appropriate and adequate use of drugs is now one of the most commonly debated topics in public health. According to the WHO, only 50% of all prescribed medications are dispensed or sold in an appropriate way [1]. On the other hand, about one third of the world population lacks access to drugs considered as essential drugs by the WHO [2]. According to the WHO, the rational use of drugs requires that "patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community" [3]. The appropriate prescription rate is the number of cases that need treatment divided by the number of cases that receive it. It has the objective of maximizing the effectiveness of a treatment, minimizing the risk and costs, and taking into consideration the preference of the patients [4]. Adequate prescription rate is the number of cases that needs and receives treatment divided by the number of cases that need it. Adequate prescription allows us to analyze if patients that require treatment are receiving it.
Differences in prescription can be due to both the prescriber and the patient. Studies have shown that factors like gender, multi-morbidity and previous personal experiences can influence prescription [5, 6]. Prescription is also influenced by the health provider's knowledge of evidence based medicine, current guidelines, personal experience and lack of time or availability of drugs [7].
A 2016 study by Fleming-Dutra et al. in the United States shows a rate of inappropriate oral antibiotic prescription of about 50% in upper respiratory tract infection (URTI), adjusted by age and diagnostic in adults and children [8]. Another study in children in France finds results that suggest a 76% rate of inappropriate prescription of antibiotics for any pediatric diagnosis in primary health care and that URTI are the leading cause of misuse of antibiotics. [9].
A prospective study with 3402 patients with acute cough from 13 European countries analyzed the variation in prescription of antibiotics in primary care. Their results showed a high prescription rate, in all countries included that ranged between 20 and 90% (media of 53%) [10]. Another study from four Latin American countries found that 33% of patients with a suspicion of URTI in primary care centers that were included in the study were prescribed antibiotics [11].
Even though resistance to antibiotics is a natural phenomenon in bacteria, human activities have potentiated its expansion, favoring the appearance of resistant strains. The lack of efficient practices for prevention and control of infections has also contributed to the emergence of new resistances [12]. The inappropriate use of antimicrobials increases the risk of drug-resistant microorganisms [13].
Costelloe, et al. in 2010, demonstrate a strong association between the prescription of antibiotics in primary care and antimicrobial resistance in URTI [14]. It has been reported that antibiotic resistance to microorganisms such as Staphylococcus aureus, enterococci, and gram-negative bacilli, are associated with an increase in mortality, morbidity, days of hospitalization and health costs [15]. The increase in health costs associated to antibiotic resistance is due to the longer duration of disease and the need for additional diagnostic tests and high-cost antibiotics. [16].
Due to the large impact on health, antibiotic prescription in Ecuador was analyzed in order to evaluate if the tendency aligns with the misuse of antibiotics occurring around the world. Defining the scope of the problem will allow for further analysis and policy implementation in the country.
The aim of this study was to analyze the appropriateness and adequacy of antibiotic prescription for URTI in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador in the District 17D03 during 2015. The design of this cross-sectional study of the appropriateness and adequacy of antibiotic prescription imitates similar studies from different settings [8, 17,18,19] allowing us to obtain comparable results. We considered "Appropriate prescription rate" as the number of appropriate antibiotic prescriptions divided by all patients receiving antibiotics. Our definition of "Adequate prescription rate" is the number of patients that need and receive antibiotics divided by the number of patients that need it. The purpose of measuring the appropriate prescription rate is to identify the over-prescription that could be occurring. On the other hand, the purpose of analyzing the "Adequate prescription rate" is to identify cases of patients that needed antibiotics and did not receive treatment.
The data source for the variables included in this study are the Electronic Health Records (EHR) of all the patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with URTI as a primary diagnosis. This district has been using EHR since 2010. Prescribers enter the information directly into the EHR on a computer during the outpatient appointment. Information was manually extracted from the EHR simultaneously by two peer reviewers, according to the following criteria:
Inclusion criteria: Patients 3 months of age and above who required clinical care for URTI in the Ambulatory Health Centers of the Ministry of Public Health in the District 17D03 in 2015.
Exclusion criteria: 1) Patients who received clinical care in the ambulatory health centers of the Ministry of Public Health that are not a part of the D1703 district; 2) Patients who received clinical care in ambulatory health centers that are not a part of the Ministry of Public Health in the D1703 district.
The International Classification of Disease (ICD) – 10 was used for selection of the diagnosis criteria for URTI, where we considered codes J00-J06, J10, J11, H65, H66 (Table 1). After individual data extraction, information was compared, and reached a consensus of inclusion or exclusion for each patient. An additional text file of description of variables shows the variables collected for the analysis of appropriateness and adequacy of antibiotic prescription (see Additional file 1).
Table 1 ICD-10 Codes considered as "upper respiratory tract infections" for the purpose of this study
The patients included in this study were those attended by the 5 types of health professionals that work in the designated health center and that diagnosed patients with URTI. These health professionals are classified as:
Rural Medical Trainees: Medical Doctor that has recently completed their degree and is performing a year of community service as a health professional in a rural location as a prerequisite for medical practice in Ecuador.
General Practitioner: Medical Doctor that has completed the year of community service as a health professional and can practice medicine freely in Ecuador.
Family Medicine Doctor: Medical Doctor that has performed a postgraduate degree of 3 years in General Practice and is considered a specialist in Ecuador.
Psychiatrists: Medical Doctor that has performed a postgraduate degree of 3 years in Psychiatry and is considered a specialist in Ecuador.
Pediatricians: Medical Doctor that has performed a postgraduate degree of 3–4 years in Pediatrics and is considered a specialist in Ecuador.
The sample was defined as all the patients that met the inclusion criteria and that had complete information in their EHR. Our sample is of 1393 patients.
Assessment of appropriateness and adequacy of antibiotic prescription
For this study, "Appropriate antibiotic prescription" is considered according to the standards defined in the Clinical Guideline for "Respiratory Tract Infections (self-limiting): prescribing antibiotics CG69" by the National Institute for Health and Care Excellence (NICE), considering the lack of a National clinical guideline for URTI in Ecuador. Table 2 describes the criteria for cases that needed antibiotic prescription according to each ICD category, as described in the NICE Clinical Guideline. Need for antibiotics was assessed by two reviewers separately in order to identify the cases that met the criteria for antibiotic prescription. When a data inconsistency was found in the EHR, the agreement was reached by consensus by the reviewers. We assessed appropriateness of the prescription by identifying the cases that needed treatment divided by the number of cases that received it. We assessed adequacy of the prescription by identifying individual patients that required antibiotic treatment according to Table 2 and evaluated if they received it or not.
Table 2 Guide for Classifying Appropriate Antibiotic Prescription: using ICD-10 codes to classify appropriate diagnosis of disease according to the symptoms and signs presented in the patients in the sample
The antibiotic prescription rate was defined as the number of antibiotic prescriptions divided by all patients diagnosed with URTI.
The variables included in this study were qualitative dichotomous and categorical variables and quantitative continuous variables, an additional text file of description of variables shows this in more detail (see Additional file 1). We performed a descriptive analysis with qualitative variables through frequency distributions, proportions and rates; and of quantitative variables through measures of central tendency and dispersion. We then performed statistical tests to determine the association between antibiotic prescription and several variables through a logistic regression. This regression analyzes the relationship between a dependent variable, antibiotic prescription, and independent variables, controlling for potential confounders. The independent variables were chosen by theoretical relationship to the dependent variable and through bivariate logistic regression models, an additional text file of variables considered for the regression models shows this in more detail (see Additional file 2). In the model we only included variables with a p value of < 0.25. These variables were: gender of prescriber, hours dedicated to clinical practice and category of health professionals. We excluded patient age, prescriber age and gender of patient due to their lack of statistical significance.
For the only categorical variable included, category of health professionals, we analyzed each category and decided to exclude Psychiatrists, due to the low number of consults included in the data. Then we reintroduced some variables that according to literature could be potential confounders (prescriber age and patient age) one by one creating an extended model, but did not find anything of significance. In order to choose between the models to be used, we used Akaike's Information Criteria (AIC). The formula for the final model was:
Log(antibiotic prescription) = b0 + b1*i.levelhp_cate + b2*gender_prescriber + b3*hours_clinical
Where i.levlehp_cate is health professional categorized by type, gender_prescriber is the gender of the prescriber, and hours_clinical is the hours dedicated to clinical practice.
We used STATA v14 and Microsoft Excel as statistical software.
Adequacy of dosage and duration of prescription of antibiotics
We analyzed adequate dosage of antibiotics based on several clinical Guidelines defined in Table 3 [20,21,22,23,24,25]. This analysis consisted in categorizing prescriptions in those that were under the recommended dose, over the recommended dose, and adequate dose. We also analyzed the number of prescriptions that met the recommended amount of days of treatment. We considered 7 to 10 days as the adequate duration of treatment for all antibiotics included, except for Azithromycin and Penicillin benzathine. We considered 5 days as an adequate duration of treatment for Azithromycin and a single dose for Benzathine penicillin. To define the duration of treatment we used the same clinical guidelines used for the definition of adequate dosage. This analysis was done for each prescription in the patients included in this study.
Table 3 Antibiotic Regimens Recommended for URTI
The general characteristics of our sample are described in Table 4.
Table 4 Characteristics of the sample
Adequacy and appropriateness of antibiotic prescription
We included 1393 patients that met our inclusion criteria in the analysis that were attended by 21 health professionals (4 Rural Trainees, 7 General Practitioners, 6 Family Medicine Doctors, 3 Pediatricians and 1 Psychiatrist). Out of the 1393 patients, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%. Of these 523 patients, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. The 51 patients in our sample that needed antibiotics represent 3.66% of all patients. When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%. We then debriefed the data by different diagnosis according to the ICD-10 codes (Table 5). Acute nasopharyngitis (J00), also known as common cold, represents 41.73% of all diagnoses. Only 2.41% of the cases of common cold had other criteria requiring antibiotics and 2.91% of the cases received antibiotics. Nevertheless, of the cases of J00 that needed antibiotics, only 5.88% received them, the rest of antibiotics prescribed were for cases where it was not needed. This scenario is very different when analyzing prescription for J02, J03 or J06. The results for J02 show us that 51.3% of patients with this diagnosis were prescribed antibiotics, when only 2.94% needed them. The case for acute tonsillitis (J03) is that 83.13% of the cases were prescribed antibiotics, when 9.64% needed them. For Acute upper respiratory infections of multiple and unspecified sites (J06) 61.5% of cases were prescribed antibiotics, when none of them needed them. In the case of suppurative and nonspecified otitis media (H66), all of them needed antibiotics and were all accurately prescribed.
Table 5 Appropriateness and adequacy of antibiotic prescription according to ICD-10 diagnosis code
Our data includes a classification of all health professionals working at the health center that can prescribe antibiotics. These categories are defined as: General Practitioners, Rural Medical Trainees, Family Medicine Doctors, Pediatricians and Psychiatrists. The results for the analysis of antibiotic prescription depending on the classification of health professionals are shown in Table 6.
Table 6 Appropriateness and adequacy of antibiotic prescription according to health professionals
Our final multiple logistic regression model included antibiotic prescription as a dependent variable and classification of health professional, sex of prescriber and hours of clinical practice of the health professional as independent variables. We found a statistically significant difference in antibiotic prescription by classification of health professional. We used Family Medicine Doctors as the category of reference for the variable of categories of health professionals. When holding gender of prescriber and hours of clinical practice constant, the odds of antibiotic prescription compare to Family Medicine Doctors was of 4.62 times for Rural Medicine Trainees, 2.58 times for Pediatricians and 1.78 times for General Practitioners. When adjusting for classification of health professional and hours of clinical practice, there was no statistically significant difference in prescription between male and female health professionals (Table 7).
Table 7 Odds Ratios of antibiotic prescription
Without regarding appropriateness or adequacy of prescription, we analyzed adequacy of dosage of all antibiotic prescriptions. The average number of days of treatment prescribed was of 7.26 days (range 1–15 days) with a mode of 7 days. The distribution of antibiotic classes used are shown in Fig. 1.
Distribution of types of antibiotics used. Legend: TMP-SMX: Trimethoprim-sulphamethoxazole
Out of the 523 patients that received antibiotics, 493 (94.3%) were prescribed one antibiotic and 30 (5.7%) were prescribed a combination of antibiotics. The two types of combinations prescribed were 'Benzathine penicillin + Amoxicillin' in 26 patients (86.7%) and 'Benzathine penicillin + Azitromycine' for 4 patients (13.3%). Neither one of the combinations of antibiotics used can be considered as appropriate prescription.
Out of the 337 children that were prescribed antibiotics, 7 received a combination of antibiotics, resulting in 344 antibiotics prescribed in children (single or in combination). Considering weight was reported for all the children included in this study, we were able to calculate the adequate dose for treatment in this group of patients.
Amoxicillin was prescribed in 272 (79.06%) times in children (Fig. 2), of which 6.99% were prescribed with an adequate dose. Out of all the antibiotics prescribed, 16.86% were prescribed with an adequate dose, 48.26% did not reach the adequate dose and 34.88% went over the adequate dose. The description of adequate doses of each antibiotic prescribed for children can be found in Table 8 with further details in Fig. 2.
Amoxicillin used doses in children. Legend: Doses of 50–50.9 mg/kg/day and 80–90.9 mg/kg/day are considered as adequate according to different diagnosis
Table 8 Appropriateness of antibiotic dose
Out of the 186 adults that were prescribed antibiotics, 23 received a combination of antibiotics, resulting in 209 antibiotics prescribed in adults. Amoxicillin was prescribed 105 times in adults, all of which were prescribed with an adequate dose. Out of all antibiotics prescribed in adults, 93.30% were prescribed with an adequate dose, 0% did not reach the adequate dose and 6.70% went over the adequate dose. The description for the adequate dose of each antibiotic prescribed for adults can be found in Table 8 with further details in Fig. 2.
We then analyzed the number of prescriptions that met the recommended duration of treatment. Out of all the prescriptions, 85.66% met the recommended duration of antibiotic treatment, 9.37% were prescribed less than the recommended duration and 4.97% went over the recommended duration (Table 9).
Table 9 Duration of Prescription of Antibiotics
The results of our study report a 90.25% of inappropriate prescription in the Health Center that we evaluated. An estimated average of antibiotic prescription appropriateness from studies around the world, mostly including high – middle income countries, is of about 50% [8, 26,27,28,29,30,31]. A review of 344 studies between 1990 and 2009 on the treatment of childhood infections in 78 low-middle income countries reported that a high percentage of viral upper respiratory tract infection cases were being treated with antibiotics, with this percentage increasing over time (from 42% before 1990 up to 72% in 2006–2009) [32]. This same study reports 47.1% of inappropriate antibiotic use in URTI in lower-middle income countries and 25.8% for Latin America.
This means that our study reflects almost one eighth of appropriate prescription as compared to other countries around the world. This astonishing number allows us to realize the amount of work that needs to be done locally to improve this rate.
Studies analyzing the same issue also evaluated the rate of antibiotic prescription and compared their results to a baseline. These studies did not consider if those prescriptions were necessary or not or if the dosage of antibiotics was adequate, but they did calculate the rate of antibiotic prescription that we can compare our study to. Cordoba, et al. [11] published a study in 2016 that evaluated antibiotic prescription in patients with a suspected diagnosis of URTI in primary care health centers in four Latin-American countries. The reported antibiotic prescription rate was of 35% in Argentina, 40% in Bolivia, 24% in Paraguay and 27% in Uruguay. Another study by Doubova et al. [33] in Mexico reported more than 61% of children diagnosed with non-streptococcal URTI received antibiotics after the first visit to the health facility. These studies did not evaluate the appropriate prescription rate but show that in a comparable context the rate of antibiotic prescriptions is very similar.
A study about Denmark and Iceland published in 2015 [34] evaluated antibiotic prescription in URTI by general practitioners. The results demonstrate a prescription rate of 59.3% in Denmark and 75.8% in Iceland. Appropriate antibiotic prescription was also assessed by analyzing days of symptoms and Centor Criteria, possibly underestimating inappropriate use. Their results show a rate of 16.4% for sinusitis and 26.3% for pharyngitis in Denmark and 17.8 and 21.3% in Iceland. Another study done in 6 countries [35] (Switzerland, Denmark, Argentina, Spain, Russia and Lithuania) reported a 50% inappropriate prescription rate and close to 100% inappropriate prescription for rhinopharyngitis and otitis media. These studies show very low appropriate antibiotic prescription rates like the one we found in our study.
It is as important to note the cases of inadequate care, where patients needed antibiotics and did not receive them. Of the total number of cases that required antibiotic prescription, 35.2% did not receive antibiotics. Considering the 93.7% of over-prescription, we would recommend further studies to identify the cause of this rate.
When we analyze the data by diagnosis, we see that the antibiotic prescription rate for common cold is very low, as it should be according to the clinical guideline used to describe appropriateness of prescription for this study. This allows us to see that the common cold is not a major problem of antibiotic prescription in this case. The data shows that with any diagnosis different from a common cold, health professionals at this health center tend to prescribe antibiotics at a much higher rate. There is a particular concern with "acute upper respiratory infections of multiple and unspecified sites" (J06), where the group of identified symptoms can reflect other diagnosis, but are classified in this category that leaves an open diagnosis. In this case, patients received antibiotics at a high rate, where it is not appropriate in any case. It seems that the vague definition of this category allows for a lot of variation in treatment prescribed.
In Ecuador, all Medical graduates must do a year of training in a rural area in order to be able to practice as a General Practitioner. In North America and Europe, the General Practitioner is being replaced by Family Medicine Doctors, but in Ecuador the General Practitioner is still the most common type of doctor. In our study, when classifying by health professions, Family Medicine Doctors have the lowest odds of prescribing antibiotics. This could be due to the additional years of training that are required to fulfill that degree, giving them the necessary tools to act. The clinical guideline used in this study does not take into consideration psychiatric comorbidities as a parameter for prescription. Even though psychiatric patients tend to have associated comorbidities that are not considered in this study, patients in primary care health centers usually do not have severe psychiatric disorders that could justify an antibiotic prescription due uniquely to their psychiatric condition.
A study by Del Fiol et al. [36], that analyzes the use of antibiotics in children in two Health Centers in Brazil, reports that 50% of the prescribed dosages of amoxicillin are under the recommended amounts according to Brazilian guidelines. These results are similar to those in our study that show 57.35% of prescriptions were under the recommended dose for the same antibiotic in children.
One of the most relevant limitations in our study is the fact that we relied on retrospective information from EHR. The EHR used in this district allows for registration of all possible variables, but health professionals in many occasions fill in only what is relevant to them about the current reason of consultation, leading to possible incomplete records. Even though during the consultation the health professional may not include the patients' medical history, like history of prematurity, previous hospitalization and some comorbidities, they are able to find this information in the records and can refer to them in order to decide on diagnosis and treatment. This thought process is not contemplated in our analysis, turning it into a limitation for our study and a possible underestimation of appropriate prescription in some cases. Nevertheless, all the variables described in the clinical guidelines were both registered in all patients included and considered for analysis.
Another limitation is the lack of a National Clinical Guideline for upper respiratory tract infections, forcing us to use the NICE guideline. NICE Guidelines consider a global context, instead of only local studies, for their recommendations, which is why we considered this guideline to be appropriate for our study. Ecuador's Minister of Health recommends the use of international guidelines when there is no local guideline provided. NICE guidelines are always taken into consideration when developing national guidelines in Ecuador, which is why we chose this as our reference.
Another limitation to our study is that the sample comes from only one health center. This is due to the lack of an EHR that can report the included variables for each patient, which led to having to extract all the data manually.
Finding a difference both between health professionals in the amount of antibiotics each prescribe can be helpful when targeting individuals for educational plans about antibiotics. If these variables were analyzed in each health center, the specific health professionals that need educational interventions about the appropriate use of antibiotics can be targeted.
In the health center in Ecuador included in the study there is a high rate of inappropriate prescribing of antibiotics; these findings support the need for implementation of strategies to reduce the prescription of antibiotics. Creating this baseline for the whole country instead of one health center could be the first step to realizing the scope of the problem in Ecuador. The antibiotic prescription, appropriate prescription and adequate prescription rates all underscore the need for further research and specific policy analysis and implementation in developing countries. Knowing that inadequate antibiotic prescribing is a problem in this local setting can contribute to an appropriate prescription policy.
EHR:
International Classification of Disease
NICE:
National Institute for Health and Care Excellence
URTI:
Promoting Rational Use of Medicines: Core Components - WHO Policy Perspectives on Medicines, No. 005, 2002. [cited 2017 Feb 17]. Available from: http://apps.who.int/medicinedocs/en/d/Jh3011e/
The World Medicines Situation: Chapter 7. Access to essential medicines. [cited 2017 Nov 15]. Available from: http://apps.who.int/medicinedocs/es/d/Js6160e/9.html
WHO | Rational use of medicines. WHO. [cited 2018 Jan 25]. Available from: http://www.who.int/medicines/areas/rational_use/en/
Guide to Good Prescribing - A Practical Manual. [cited 2017 Nov 15]. Available from: http://apps.who.int/medicinedocs/en/d/Jwhozip23e/
Morgan SG, Weymann D, Pratt B, Smolina K, Gladstone EJ, Raymond C, et al. Sex differences in the risk of receiving potentially inappropriate prescriptions among older adults. Age Ageing. 2016;(May):afw074.
Lopez-Vazquez P, Vazquez-Lago JM, Figueiras A. Misprescription of antibiotics in primary care: a critical systematic review of its determinants. J Eval Clin Pract. 2012;18(2):473–84.
Voigt K, Gottschall M, Köberlein-Neu J, Schübel J, Quint N, Bergmann A, et al. Why do family doctors prescribe potentially inappropriate medication to elderly patients? BMC Fam Pract. 2016;17(1):93.
Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016 May 3;315(17):1864–73.
Al-Tawfiq JA, Alawami AH. A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic. Ann Thorac Med. 2017 Jan 1;12(1):51.
Butler CC, Hood K, Verheij T, Little P, Melbye H, Nuttall J, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242.
Article PubMed PubMed Central CAS Google Scholar
Cordoba G, Caballero L, Sandholdt H, Arteaga F, Olinisky M, Ruschel LF, et al. Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America. J Antimicrob Chemother. 2017;72(1):305–10.
OMS | Resistencia a los antimicrobianos. WHO. 2015;
Word Health Organization (WHO). WHO Global Strategy for Containment of Antimicrobial Resistance WHO Global Strategy for Containment of Antimicrobial Resistance World Health Organization 2001.
Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:c2096.
Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis. 2006;42(Supplement_2):S82–9.
Word Health Organization. Antimicrobial resistance. WHO. In: World Health Organization; 2017.
Butt AA, Navasero CS, Thomas B, Marri SA, Katheeri HA, Thani AA, et al. Antibiotic prescription patterns for upper respiratory tract infections in the outpatient Qatari population in the private sector. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 2017;55:20–23.
Dekker ARJ, Verheij TJM, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Fam Pract. 2015;32(4):401–7.
Kotwani A, Holloway K. Antibiotic prescribing practice for acute, uncomplicated respiratory tract infections in primary care settings in New Delhi, India. Trop Med Int Health TM IH. 2014;19(7):761–8.
Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am. 2012;55(10):1279–82.
Harris AM, Hicks LA, Qaseem A. High value care task force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425–34.
Lieberthal AS, Carroll AE, Chonmaitree T, Ganiats TG, Hoberman A, Jackson MA, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–99.
Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJC, Hicks LA, et al. Executive summary: IDSA clinical practice guideline for acute bacterial Rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041–5.
SECRETARIA DE SALUD. Diagnóstico y manejo de la infección aguda de vías aéreas superiores en pacientes mayores de 3 meses hasta 18 años de eda. 2016 [cited 2018 Apr 5]. Available from: http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/062_GPC__InfAgVASde3mesesa18a/INFECCION_VIAS_AEREAS_EVR_CENETEC.pdf
SECRETARIA DE SALUD DE MEXICO. Diagnóstico y Tratamiento de Faringoamigdalitis Aguda. 2009 [cited 2018 Apr 5]. Available from: http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/073_GPC_Faringoamgaguda/Faringo_ER_CENETEC.pdf
Shamsuddin S, Akkawi ME, Zaidi STR, Ming LC, Manan MM. Antimicrobial drug use in primary healthcare clinics: a retrospective evaluation. Int J Infect Dis. 2016 Nov 1;52:16–22.
Butt AA, Navasero CS, Thomas B, Marri SA, Katheeri HA, Thani AA, et al. Antibiotic prescription patterns for upper respiratory tract infections in the outpatient Qatari population in the private sector. Int J Infect Dis. 2017;55:20–3.
Dekker ARJ, Verheij TJM, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Fam Pract. 2015 Aug;32(4):401–7.
Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38(5):349–54.
Kourlaba G, Gkrania-Klotsas E, Kourkouni E, Mavrogeorgos G, Zaoutis TE. Antibiotic prescribing and expenditures in outpatient adults in Greece, 2010 to 2013: evidence from real-world practice. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2016;21(26)
Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother. 2014;69(1):234–40.
Holloway KA, Ivanovska V, Wagner AK, Vialle-Valentin C, Ross-Degnan D. Prescribing for acute childhood infections in developing and transitional countries, 1990–2009. Paediatr Int Child Health. 2015;35(1):5–13.
Doubova SV, Perez-Cuevas R, Balandrán-Duarte DA, Rendón-Macías ME. Quality of care for children with upper respiratory infections at Mexican family medicine clinics. Bol Méd Hosp Infant México. 2015;72(4):235–41.
Rún Sigurðardóttir N, Nielsen ABS, Munck A, Bjerrum L. Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: comparison between Denmark and Iceland. Scand J Prim Health Care. 2015;33(4):269–74.
Bagger K, Nielsen ABS, Siersma V, Bjerrum L. Inappropriate antibiotic prescribing and demand for antibiotics in patients with upper respiratory tract infections is hardly different in female versus male patients as seen in primary care. Eur J Gen Pract. 2015;21(2):118–23.
Del Fiol Fde S, Lopes LC, Barberato-Filho S, de CB MC. Evaluation of the prescription and use of antibiotics in Brazilian children. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2013;17(3):332–7.
We thank those who facilitated the collection of data, i.e., the head authorities, local administration authorities and health authorities from the Ministry of Public Health. We also thank all the staff from the Health District 17D03 of Quito for support during field work.
There is no funding.
Pontificia Universidad Católica del Ecuador, Posgrado de Medicina Familiar, Avenida 12 de Octubre 1076, Vicente Ramón Roca, Quito, Ecuador
Xavier Sánchez Choez, María Luciana Armijos Acurio & Ruth E. Jimbo Sotomayor
Universidad Alcalá de Henares, Alcalá de Henares, Spain
Xavier Sánchez Choez & Ruth E. Jimbo Sotomayor
Xavier Sánchez Choez
María Luciana Armijos Acurio
Ruth E. Jimbo Sotomayor
XS and RJ designed the study and participated in the elaboration of the protocol, LA and XS analyzed results and wrote the manuscript; LA participated in statistical analysis and wrote the manuscript; XS and RJ participated in fields and bench work; LA corrected manuscript. All authors read and approved the final manuscript.
Correspondence to Xavier Sánchez Choez.
The study was approved by the Committee for Research Ethics on Human Beings – PUCE (authorization CEISH-222-2016, 09th November 2016).
The authors declare that they have no competing interest.
"Description of Variables", shows variables collected for the analysis of appropriateness and adequacy of antibiotic prescription. (DOCX 23 kb)
"Variables considered for the regression model", shows variables chosen for bivariate logistic regression model. (DOCX 21 kb)
Sánchez Choez, X., Armijos Acurio, M.L. & Jimbo Sotomayor, R.E. "Appropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in ambulatory health care centers in Ecuador". BMC Pharmacol Toxicol 19, 46 (2018). https://doi.org/10.1186/s40360-018-0237-y
Health systems and services
Anti-bacterial agents
Drug utilization


BigBrother Naija 2018 MIRACLE Wins the prize – No longer a doubt that the BBNaija Talent Show has proven to be an award-winning talent show and the largest – so far in Nigeria and across African. You may be wondering why the statement. Every housemate has one way or the other benefited in the show (apart from the money). The past BBnaija season 3 – today all are occupied doing what they love to do and it's paying them.
The Big Brother Naija helps in bringing out the real talent in them. See Teddy-A for instance, he never won any money but his career has become known all over the world.
Talk about Reco Swave, Yes he won the N1,000,000 as he his now known for what he loves doing – acting and music. Same all others.
N200,000 in place of their weekly wigger.


The present work assesses the radiation sensitivity of an affordable and performant COTS multicore processor for noncritical avionic applications. The target device is the Epiphany E16G301 multicore manufactured in 65 nm CMOS which integrates 16 processor cores. This device was selected due to its high performance, low power consumption, and affordability, allowing general public accessing to parallel computing. Additionally, the E16G301 is the coprocessor for parallel processing of the Parallella platform, which was considered by NASA researchers for onboard health management of the DragonEye UAS. The evaluation of the device is done using quantitative theory by means of radiation experiments with 14 MeV neutrons to emulate the effects of high-energy neutrons present at avionic altitudes. Static and dynamic cross sections are obtained to evaluate the intrinsic sensitivity of the device as well as its dynamic response. Results show that the failure rate of the E16G301 running a matrix multiplication as application reaches level D of the DO-178B/C guideline, being the device well suited for minor failure conditions of avionic applications.


text:
Az Egységes Oroszország pártot Vlagyimir Putyin, Dmitrij Anatoljevics Medvegyev és több más orosz politikus alapította 2001. december 1-én Oroszországban. A párt ideológiájának az orosz konzervativizmust, illetve egy, a jobboldalt és baloldalt egyaránt magába foglaló centrizmust hirdette. 2003 óta folyamatosan abszolút többséggel kormányozza az országot.

Parlamenti választások
 A 2003-as oroszországi parlamenti választáson a párt 37,6 százalékot kapott.
 A 2007-es oroszországi parlamenti választáson a párt 64,3 százalékot kapott, ezzel megszerezte a kétharmadot és ő lett a legerősebb párt Oroszországban.
 A 2011-es oroszországi parlamenti választáson a párt 49,3 százalékot kapott, ezzel ismét ő lett a legerősebb orosz párt Oroszországban.
 A 2016-os oroszországi parlamenti választáson a párt 54,2 százalékot kapott, ezzel ismét megszerezte a kétharmadot és ő lett a legerősebb orosz párt Oroszországban.
 2021-es oroszországi parlamenti választáson a párt 49,82 százalékot kapott, ezzel ismét kétharmadot szerzett.

Elnöki választások
 A 2004-es oroszországi elnökválasztást Vlagyimir Putyin nyerte 71,3 százalékkal, ezzel ő lett Oroszország elnöke.
 A 2008-as oroszországi elnökválasztást Dmitrij Anatoljevics Medvegyev nyerte 71,2 százalékkal, ezzel ő lett Oroszország új elnöke.
 A 2012-es oroszországi elnökválasztást Vlagyimir Putyin nyerte 63,6 százalékkal, ezzel ő lett Oroszország újra megválasztott elnöke.
 A 2018-as oroszországi elnökválasztást Vlagyimir Putyin nyerte 76,6 százalékkal, ezzel ő lett az Orosz Föderáció  újra megválasztott elnöke.

Jegyzetek

Oroszországi pártok
Euroszkeptikus pártok
Konzervatív pártok
Berendezkedésellenes pártok

redpajama_set_name: RedPajamaWikipedia


text:
Product: Aire
Product's album entitled Aire is a collaboration of songs based upon the life of Galileo. Adopting an approach of trying to tie the central themes together with their religious, scientific and humanitarian connotations permeating throughout is a difficult ask. The result is a somewhat sombre and melancholy affair which makes for an entirely vacuous experience and one of emotional disappointment. I thought I was in for another insipid affair as things begin very slowly with "City Of Gold" and although the tempo moves up a notch halfway through the song, we are introduced to a song writer of some talent but a singer needing something more inspiring to really make any impact on me. Vocally, Arman Christoff Boyles who is credited with all song writing duties just doesn't cut it as a singer to my ears as there are too many tracks where he sounds off key, too dissonant and simply unpleasant to listen to. Although the music itself broaches some level of competence that can be enjoyed, the overall feeling with this album is one of frustration in finding anything really memorable at all.
Featuring 17 songs ranging in lengths between 1:38 and 5:42 minutes, musically, there are some nice ideas here and there but overall, I found very little to encourage me to hit the repeat button. Being required to review a large amount of new material reinforces my concerns that too many bands fall into the same trap of writing music that takes far too long to relay its message or does so in a way that leaves little or no favourable impression on the listener. Snippets of sporadically reasonable music are not sufficient qualities to rescue the remainder from the quagmire.
This is exactly the opposite style of music that Iona and Karnataka delivered to critical acclaim recently with their albums of lively and uplifting songs, that despite their religious connotations, found favour with a new audience who were able to accept their songs for what they were, despite any subliminal or underlying messages. With all due respect to the songwriter's penchant for dark and gloomy phrasings, this would hardly be representative of an album you would play to a friend if you wanted to introduce them to the world of progressive rock. The songs just amble on with little directional impetus and could hardly elevate this band above the lowliest of the average.
With so much better music available from every corner of the globe, it would be hard for me to recommend this one to you unless you thought that insincerity and dishonesty were virtues worth admiring. For my ears at least, this album is really very droll and quite uninspiring.
Track Listings:
1. City Of Gold
2. Age Of Reason
3. Mighty Maze
4. Here Comes Tomorrow
5. Still Here
6. Value Of Gold
7. Wonderful Dreamers
8. Other Worlds
9. Everyday Business
10.Autumn
11.Beyond All Reason
12.Angels
13.Black Is The Day
14.Fall
15.The Calling
16.Last Word
17.Breathing
Reviewer: Greg Cummins
Related Link: Product's Web Site

redpajama_set_name: RedPajamaCommonCrawl


Mazda MX5 reinvents itself again.
Two new Mazdas which take their inspiration from the company's latest racing car are making their way to the company's showrooms.
Earlier this year a motorsport version of the MX-5 with no less than 275bhp at its disposal made its debut in the Britcar Production GTN Championship – taking on Porsche, Lotus and Ferrari racers in the process – and to celebrate the company's created the "Black Limited Version" of its 2 supermini, which promises to bring a darker and sportier edge to the range.
But it's the similar treatment to the open-top MX-5 which ought to get keen drivers excited, because while it doesn't have the race car's tuned engined it does get a similar paint scheme and added options thrown in.
The limited edition treatment, available to order now, costs £12,395 for the 2 supermini and £22,995 for the MX-5 roadster.
To lease an MX5 check out Mazda Car Leasing for the latest special offers or call 0844 561 7199 to get a contract hire quote.


text:
The World Factbook (1990)/Germany, Federal Republic of
< The World Factbook (1990)
The World Factbook (1990)
United States Central Intelligence Agency
Germany, Federal Republic of
pages 113–114
2134170The World Factbook (1990) — Germany, Federal Republic ofUnited States Central Intelligence Agency
Germany, Federal Republic of
(West Germany)
See regional map V
Total area: 248,580 km²; land area: 244,280 km²; includes West Berlin
Comparative area: slightly smaller than Oregon
Land boundaries: 4,256 km total; Austria 784 km, Belgium 167 km, Czechoslovakia 356 km, Denmark 68 km, France 451 km, GDR 1,381 km; Luxembourg 138 km, Netherlands 577 km, Switzerland 334 km
Maritime claims:
Continental shelf: 200 meters or to depth of exploitation
Exclusive fishing zone: 200 nm
Territorial sea: 3 nm (extends, at one point, to 16 nm in the Helgoländer Bucht)
Disputes: it is US policy that the final borders of Germany have not been established
Climate: temperate and marine; cool, cloudy, wet winters and summers; occasional warm, tropical foehn wind; high relative humidity
Terrain: lowlands in north, uplands in center, Bavarian Alps in south
Natural resources: iron ore, coal, potash, timber
Land use: 30% arable land; 1% permanent crops; 19% meadows and pastures; 30% forest and woodland; 20% other; includes 1% irrigated
Environment: air and water pollution
Note: West Berlin is an exclave (about 116 km by air or 176 km by road from FRG)
Population: 62,168,200 (July 1990), growth rate 0.5% (1990)
Birthrate: 11 births/1,000 population (1990)
Death rate: 11 deaths/1,000 population (1990)
Net migration rate: 5 migrants/1,000 population (1990)
Infant mortality rate: 6 deaths/1,000 live births (1990)
Life expectancy at birth: 73 years male, 81 years female (1990)
Total fertility rate: 1.4 children born/woman (1990)
Nationality: noun—German(s); adjective—German
Ethnic divisions: primarily German; Danish minority
Religion: 45% Roman Catholic, 44% Protestant, 11% other
Literacy: 99%
Labor force: 27,790,000; 41.6% industry, 35.4% services and other, 18.2% trade and transport, 4.8% agriculture (1987)
Organized labor: 9,300,000 total; 7,760,000 in German Trade Union Federation (DGB); union membership constitutes about 40% of union-eligible labor force, 34% of total labor force, and 35% of wage and salary earners (1986)
Long-form name: Federal Republic of Germany; abbreviated FRG
Type: federal republic
Capital: Bonn
Administrative divisions: 10 states (länder, singular—land); Baden-Württemberg, Bayern, Bremen, Hamburg, Hessen, Niedersachsen, Nordrhein-Westfalen, Rheinland-Pfalz, Saarland, Schleswig-Holstein
Constitution: 23 May 1949, provisional constitution known as Basic Law
Legal system: civil law system with indigenous concepts; judicial review of legislative acts in the Federal Constitutional Court; has not accepted compulsory ICJ jurisdiction
National holiday: NA
Executive branch: president, chancellor, Cabinet
Legislative branch: bicameral Parliament (Parlament) consists of an upper chamber or Federal Assembly (Bundesrat) and a lower chamber or National Assembly (Bundestag)
Judicial branch: Federal Constitutional Court (Bundesverfassungsgericht)
Leaders: Chief of State—President Dr. Richard von WEIZSÄCKER (since 1 July 1984);
Head of Government—Chancellor Dr. Helmut KOHL (since 4 October 1982)
Political parties and leaders: Christian Democratic Union (CDU), Helmut Kohl; Christian Social Union (CSU), Theo Waigel; Free Democratic Party (FDP), Otto Lambsdorff; Social Democratic Party (SPD), Hans-Jochen Vogel; National Democratic Party (NPD), Martin Mussgnug; Republikaner, Franz Schoerhuber; Communist Party (DKP), Herbert Mies; Green Party—Realos faction, Joschka Fischer; Green Party—Fundis faction, Jutta Ditfurth
Suffrage: universal at age 18
Elections: National Assembly—last held 25 January 1987 (next to be held by 18 January 1991); results SPD 37.0%, CDU 34.5%, CSU 9.8%, FDP 9.1%, Green Party 8.2%, others 1.4%; seats—(497 total, 22 are elected by the West Berlin House of Representatives and have limited voting rights) SPD 186, CDU 174, CSU 49, FDP 46, Green Party 42
Communists: about 40,000 members and supporters
Other political or pressure groups: expellee, refugee, and veterans groups
Member of: ADB, CCC, Council of Europe, DAC, EC, EIB, EMS, ESA, FAO, GATT, IAEA, IBRD, ICAC, ICAO, ICES, ICO, IDA, IDB—Inter-American Development Bank, IFAD, IEA, IFC, IHO, ILO, ILZSG, IMF, IMO, INTELSAT, INTERPOL, IPU, ITC, ITU, NATO, OAS (observer), OECD, UN, UNESCO, UPU, WEU, WHO, WIPO, WMO, WSG, WTO
Diplomatic representation: Ambassador Jeurgen RUHFUS; Chancery at 4645 Reservoir Road NW, Washington DC 20007; telephone (202) 298-4000; there are FRG Consulates General in Atlanta, Boston, Chicago, Detroit, Houston, Los Angeles, San Francisco, Seattle, and New York, and Consulates in Miami and New Orleans; US—Ambassador Vernon WALTERS; Embassy at Deichmanns Avenue, 5300 Bonn 2 (mailing address is APO New York 09080); telephone 49 (228) 3391; there are US Consulates General in Frankfurt, Hamburg, Munich, and Stuttgart
Flag: three equal horizontal bands of black (top), red, and yellow; similar to the flag of the GDR which has a coat of arms in the center
Overview: West Germany, a major economic power and a leading exporter, has a highly urbanized and skilled population that enjoys excellent living standards and comprehensive social welfare benefits. The FRG is poor in natural resources, coal being the most important mineral. The FRG's comparative advantage lies in the technologically advanced production stages. Thus manufacturing and services dominate economic activity, and raw materials and semimanufactures constitute a large proportion of imports. In 1988 manufacturing accounted for 35% of GDP, with other sectors contributing lesser amounts. The major economic problem in 1989 is persistent unemployment of over 8%. The FRG is well poised to take advantage of the increasing economic integration of the European Community. The dramatic opening of the boundary with East Germany in late 1989 poses new economic challenges that could tax even this powerful economy.
GDP: $945.7 billion, per capita $15,300; real growth rate 4.3% (1989 est.)
Inflation rate (consumer prices): 3.0% (1989)
Unemployment rate: 8.4% (1989)
Budget: revenues $539 billion; expenditures $563 billion, including capital expenditures of $11.5 billion (1988)
Exports: $323.4 billion (f.o.b., 1988); commodities—manufactures 86.6% (including machines and machine tools, chemicals, motor vehicles, iron and steel products), agricultural products 4.9%, raw materials 2.3%, fuels 1.3%; partners—EC 52.7% (France 12%, Netherlands 9%, Italy 9%, UK 9%, Belgium-Luxembourg 7%), other West Europe 18%, US 10%, Eastern Europe 4%, OPEC 3% (1987)
Imports: $250.6 billion (f.o.b., 1988); commodities—manufactures 68.5%, agricultural products 12.0%, fuels 9.7%, raw materials 7.1%; partners—EC 52.7% (France 12%, Netherlands 11%, Italy 10%, UK 7%, Belgium-Luxembourg 7%), other West Europe 15%, US 6%, Japan 6%, Eastern Europe 5%, OPEC 3% (1987)
External debt: $500 million (June 1988) Industrial production: growth rate 3.3% (1988)
Electricity: (including West Berlin) 110,075,000 kW capacity; 452,390 million kWh produced, 7,420 kWh per capita (1989)
Industries: among world's largest producers of iron, steel, coal, cement, chemicals, machinery, ships, vehicles, and machine tools; electronics, food and beverages
Agriculture: accounts for about 2% of GDP (including fishing and forestry); diversified crop and livestock farming; principal crops and livestock include potatoes, wheat, barley, sugar beets, fruit, cabbage, cattle, pigs, poultry; net importer of food; fish catch of 202,000 metric tons in 1987
Aid: donor—ODA and OOF commitments (1970-87), $60.0 billion
Currency: deutsche mark (plural—marks); 1 deutsche mark (DM) = 100 pfennige
Exchange rates: deutsche marks (DM) per US$1—1.6918 (January 1990), 1.8800 (1989), 1.7562 (1988), 1.7974 (1987), 2.1715 (1986), 2.9440 (1985)
Railroads: 31,443 km total; 27,421 km government owned, 1.435-meter standard gauge (12,491 km double track, 11,501 km electrified); 4,022 km nongovernment owned, including 3,598 km 1.435-meter standard gauge (214 km electrified) and 424 km 1.000-meter gauge (186 km electrified)
Highways: 466,305 km total; 169,568 km primary, includes 6,435 km autobahn, 32,460 km national highways (Bundesstrassen), 65,425 km state highways (Landesstrassen), 65,248 km county roads (Kreisstrassen); 296,737 km of secondary communal roads (Gemeindestrassen)
Inland waterways: 5,222 km, of which almost 70% are usable by craft of 1,000-metric ton capacity or larger; major rivers include the Rhine and Elbe; Kiel Canal is an important connection between the Baltic Sea and the North Sea
Pipelines: crude oil, 2,343 km; refined products, 3,446 km; natural gas, 95,414 km
Ports: maritime Bremerhaven, Brunsbuttel, Cuxhaven, Emden, Bremen, Hamburg, Kiel, Lübeck, Wilhelmshaven; inland 27 major
Merchant marine: 422 ships (1,000 GRT or over) totaling 3,436,568 GRT/4,297,520 DWT; includes 2 passenger, 7 short-sea passenger, 218 cargo, 4 refrigerated cargo, 95 container, 20 roll-on/roll-off cargo, 2 railcar carrier, 7 barge carrier, 2 multifunction large-load carrier, 12 petroleum, oils, and lubricants (POL) tanker, 21 chemical tanker, 15 liquefied gas, 5 combination ore/oil, 13 combination bulk
Civil air: 194 major transport aircraft
Airports: 466 total, 457 usable; 240 with permanent-surface runways; 3 with runways over 3,659 m; 41 with runways 2,440-3,659 m; 55 with runways 1,220-2,439 m
Telecommunications: highly developed, modern telecommunication service to all parts of the country; fully adequate in all respects; 40,300,000 telephones; stations—87 AM, 205 (376 relays) FM, 300 (6,400 relays) TV; 6 submarine coaxial cables; satellite earth stations operating in INTELSAT (12 Atlantic Ocean, 2 Indian Ocean), EUTELSAT, and domestic systems
Defense Forces
Branches: Army, Navy, Air Force
Military manpower: males 15-49, 16,006,352; 13,883,536 fit for military service; 326,666 reach military age (18) annually
Defense expenditures: 2.9% of GDP (1989 est.)
Retrieved from "https://en.wikisource.org/w/index.php?title=The_World_Factbook_(1990)/Germany,_Federal_Republic_of&oldid=6642485"


His career has been distinguished by his expertise in identifying the "Big Idea" that best addresses consumer needs, and then building cross-channel messaging platforms around those core concepts that resonate with customers.
Franklin has taught master's-level digital marketing and content strategy courses at Delaware's Wilmington University and Georgetown University's School for Continuing Studies. Students learn his method for melding brand insights together with audience demographics, behaviors, and psychographic data to create to create content that wins.
Franklin currently heads the Creative & Editorial Services team at Kaiser Permanente Mid-Atlantic, leading creative content marketing efforts that foster growth and maintain its member base of over 700,000.


text:
Pocognoli doubtful for West Ham clash
Irvine waits for news on defender
SEBASTIEN Pocognoli will be assessed by Albion's medical staff ahead of Tuesday's Barclays Premier League fixture with West Ham United.
The Belgium international suffered an injury after an accidental collision with team-mate Chris Brunt.
Alan Irvine believes the left-back has a dead leg, which could take a while to fully heal.
The Albion head coach said: "Seb has a dead leg, we think.
"He and Chris Brunt slid in at the same time and it seems he came off worse.
"All we can do now is assess him and see how he is.
"Dead legs can be a problem because you never know how quickly they will settle down.
"But we will keep our fingers crossed that he will recover in time for the West Ham game."
James Morrison missed Saturday's game with Arsenal due to illness.
Irvine added: "James came in train on Friday but clearly wasn't right.
"He did a light session and looked physically awful.
"Unfortunately it's been one thing after another since he went on international duty.
"He's had two illnesses, tooth ache and a sore knee. We will see how he is early this week."


text:
City lawsuit contends landlord leaving 56 of his homes in disrepair
Local // Houston
Bobby Blanchard
July 13, 2014 Updated: July 13, 2014 10 p.m.
1of2A sign states this lot is cleared as part of Mayor Annise Parker's 'Make Safe Saturday Initiative.' The city filed a lawsuit against landlord Richard Pfirman over 56 of his homes.Mayra Beltran/StaffShow MoreShow Less
2of2This abandoned house in the Lakewood neighborhood is one of the 56 involved in a lawsuit filed by the City of Houston against landlord Richard Pfirman.Mayra Beltran/StaffShow MoreShow Less
Soot lines the rim of a bathtub in an abandoned home in the Lakewood neighborhood in northeast Houston. The ceiling is caving in, holes dot the wall, rubble litters the floor and the back door is wide open. Poison ivy grows in an unruly backyard that hasn't been mowed in months.
Despite all of this, there are signs that someone is living in the house. A package of condoms lays on top of boots in a room's corner, a backpack sits on a sheet where it looks like someone slept recently and a plastic bag filled with coins has been left out.
Neighbors say the house has been that way for months now. And it's not alone - at least five other homes in the Lakewood neighborhood are in similar conditions. These homes are all the subject of a lawsuit the City of Houston filed earlier this summer against landlord Richard Pfirman, who owns more than 300 homes in Harris County. The city is suing him over the condition of 56 of his homes, a majority of which are vacant. The lawsuit says the city tried unsuccessfully on numerous occasions to work with Pfirman to avoid litigation.
"The interiors are gutted, and I believe there has been vagrant activities," said assistant city attorney Donna Edmundson. "They are just all around dangerous properties and they are dangerous to all the neighbors."
Edmundson said abandoned properties are a nuisance to the city not only because they hurt property values and attract crime, but they're also dangerous. Earlier this week, Houston firefighter Daniel Groover lost his life responding to a fire in a vacant home.
'Used to be nice, safe'
The suit against Pfirman was filed more than a month ago, but Edmundson said he has been evading service. Requests for comment to Pfirman's office were not returned, and neither was a phone call to the lawyer who represented him in a prior lawsuit.
The 56 properties range from being valued at just a few thousand dollars to nearly $100,000. Together, the properties are appraised at more than $1.7 million, according to the Harris County District Appraisal office.
In the Lakewood neighborhood, Estela Beaudreault can see one of Pfirman's vacant homes across the street from the porch of her lavender-painted home. She's lived there since 1976, when she said the area was a nice neighborhood and homes were not abandoned to rot. The legendary Lakewood Church, which has the largest congregation in the United States, was founded in the area.
"It used to be so pretty. It was such a nice, safe place to live, but it's not anymore," Beaudreault said, noting the empty homes have attracted transients and criminal activity.
Beaudreault's son Christian Milano, who runs a landscaping company, is remodeling the house that was last appraised at just $25,000, partly because of the surrounding abandoned homes in the neighborhood.
History of difficulty
"That looks horrible," Milano said, pointing across the street. "It makes me feel like I'm doing all of this for nothing. I want this house to have value, but as long as that's sitting over there like that, it's going to be tough."
Pfirman and the city have a history of butting heads. Edmundson said the city already has many liens against properties he owns and it has already taken him to court. In 2013, Pfirman was ordered to either fix or demolish 14 homes in Houston that had fallen in disrepair.
"We anticipated in our previous round with him at the courthouse, he would learn his lesson - that it would be a wake-up call for him," Edmundson said. "That wasn't the case."
Edmundson said the city could eventually demolish the properties if Pfirman does not increase their safety and living conditions. She estimated demolishing the properties would cost the city about $10,000 each, a bill Pfirman would have to pay.
"Unfortunately, Mr. Pfirman has been known to rent houses that are in the deplorable conditions to people," Edmundson said. "He makes deals with the expectations that the tenant is required to bring it up to code standards. And then you end up having folks that live in these dangerous homes. The bottom line is these people still deserve to live in safe homes."
George touts pandemic performance as primaries near in Fort Bend County
Thousands welcome back Houston's Dr. Martin Luther King Jr. Day parades,...
Man, 68, dies in north Harris County house fire
Harris County deputy sheriff dies of possible self-inflicted gunshot...


text:
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They say NBA 2K22 continues to exceed their expectations, and according to the NPD Group, it is the No. 1 selling game in the U.S. of all new releases for the 2021 calendar. In addition, the game also set a franchise record for the most experienced users in the shortest amount of time. This performance helps cement NBA 2K's legacy as the industry's premier basketball simulation experience, with over 8 million units sold worldwide to date.
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text:
Home Laura Perrins Americans' D-Day heroism still takes the breath away
Americans' D-Day heroism still takes the breath away
To mark today's 75th anniversary of D-Day, we are re-running this tribute from one year ago.
Today is the 74th anniversary of the 1944 D-Day landings. To mark it, I urge you to watch Ken Burns's epic series on America and World War II, simply titled The War. Each episode is more than two hours long.
The series meticulously documents WWII from the American viewpoint, recording the fierce battles both in the Pacific and Europe. They fought and died in this war, ordinary, young American men, on a volunteer basis, because their country asked them to.
The D-Day landings are particularly harrowing to watch, this desperate attempt to liberate Europe from the Nazis. It was a close-run thing. Some beaches were taken with relative ease, but not Omaha and Utah. The Americans were bogged down in Omaha, shells raining down upon their heads.
The American, British and Canadian troops took it only by defying orders and moving up the beach-head, as well as bringing their military boats very close in, risking their destruction, to shell the Germans. The success of the D-Day landings was not inevitable and defeating Hitler was not inevitable. Soldiers gave their lives to make it happen.
I watched this series with humility, imagining what it must have been like to stand on those landing boats knowing you were looking at almost certain death. I still don't quite understand how those American soldiers did succeed or indeed how those who survived could continue after the war. The shell-shock must have been profound.
Ten days after the landings, American bodies lay all over the beach. Those who survived tried to burn the corpses, but for days that followed more and more bodies were washed ashore. The English Channel continued to give up its dead.
The liberation of France that followed was no mere footnote either; the Germans made sure the Allies earned every mile. They did earn it, these young American men from small American towns liberating France, town by town, village by village.
They didn't have to do it, but they did. How many would do it now?
If you have Netflix you should make it your business to watch this series, lest we ever forget.
If you appreciated this article, perhaps you might consider making a donation to The Conservative Woman. Unlike most other websites, we receive no independent funding. Our editors are unpaid and work entirely voluntarily as do the majority of our contributors but there are inevitable costs associated with running a website. We receive no independent funding and depend on our readers to help us, either with regular or one-off payments. You can donate here. Thank you.
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Stark's Latest: Lester, Miller, Byrd, Kemp, Danks, Rios
By Steve Adams | July 28, 2014 at 3:43pm CDT
With roughly three days until the non-waiver trade deadline, here are some highlights from the latest Rumblings & Grumblings column by ESPN's Jayson Stark…
The Red Sox have contacted every contending team in each league and told them that Jon Lester is available for a two- to three-prospect package fronted by at least one upper-echelon prospect. One executive, however, tells Stark that the Sox simply can't get as much as the Rays would get if they moved David Price, which isn't surprising, given Lester's impending free agency and the remaining year of control that Price has.
Lester isn't the only player being shopped — Boston has firmly planted a "for sale" sign in the ground, and they're willing to move any impending free agents with the exception of Koji Uehara, whom they hope to re-sign. They're peddling Andrew Miller, Burke Badenhop, Stephen Drew, Jonny Gomes and Craig Breslow. The price for Miller is also exorbitant at this time, however, as officials from two interested clubs tell Stark that Boston has asked for one of the top prospects plus a lesser prospect.
The Giants have asked the Phillies about Marlon Byrd, but their main priority is second base. The Reds are reassessing their stance after losing eight of nine games, and the Royals have backed off of Byrd. The Mariners appears to be the most logical option, but Byrd still wants his $8MM 2016 vesting option guaranteed to approve a trade there.
Byrd tells Stark that he'd have to think long and hard if GM Ruben Amaro Jr. came to him and asked him to approve a trade to a team on his no-trade clause. While his hope was to retire a Phillie, he appreciates how aggressive Amaro was in signing him. "[Ruben] made it easy for me this offseason," he said. Still, given the odds that he'd want some form of perk to approve a trade, it's no longer certain that he gets dealt.
While the Red Sox and Mariners have been connected to Matt Kemp, officials from other clubs tell Stark they feel an offseason trade is much more likely than an in-season deal.
The White Sox have had scouts watching the Yankees' surplus of minor league catchers in recent weeks, fueling speculation that the Yanks would like to acquire John Danks.
Some officials believe the Yankees would like to find a right-handed hitting platoon partner to pair with Ichiro in Suzuki in right field. New York wants an option that doesn't have commitments beyond 2014, making names like Justin Ruggiano of the Cubs and Chris Denorfia of the Padres as possible targets. Earlier today it was reported that Denorfia could be moved soon.
The Royals have decided that Alex Rios isn't a good fit for their right field need. Because the team is unable to take on much additional salary (if any), they could wait until August to add a bat.
While Troy Tulowitzki's name has had a lot of buzz around it, club officials from interested teams tell Stark there's no indication he is available. Rather, the Rockies are open to moving bullpen arms Adam Ottavino, Rex Brothers, LaTroy Hawkins and Matt Belisle. However, the team would only move Hawkins if they're overwhelmed. That seems a bit odd, given his age, but Hawkins does have a cheap club option and has drawn praise in Denver for his mentoring of younger talent.
The D'Backs are telling clubs that they'd move Addison Reed, but they don't want to move Brad Ziegler. Arizona is also willing to move Aaron Hill and Oliver Perez. They'll listen on Martin Prado and Josh Collmenter, although they're more hesitant to deal them.
The chances of Cliff Lee being traded before August are almost nonexistent. Scouts who have seen him don't think he looks close to healthy, and the money he's owed is of course problematic.
Aaron Hill Adam Ottavino Addison Reed Alex Rios Andrew Miller Arizona Diamondbacks Boston Red Sox Brad Ziegler Burke Badenhop Chicago Cubs Chicago White Sox Chris Denorfia Cincinnati Reds Cliff Lee Colorado Rockies Craig Breslow John Danks Jon Lester Jonny Gomes Josh Collmenter Justin Ruggiano Kansas City Royals Koji Uehara LaTroy Hawkins Marlon Byrd Martin Prado Matt Belisle New York Yankees Newsstand Oliver Perez Philadelphia Phillies San Diego Padres San Francisco Giants Seattle Mariners Stephen Drew Texas Rangers Troy Tulowitzki
Latest On Yankees' Pursuit Of Starting Pitching
By charliewilmoth | July 27, 2014 at 6:46pm CDT
Here's the latest on the Yankees' search for starting pitchers, via CBS Sports' Jon Heyman. Heyman covers a long list of potential options, so be sure to click over to his article.
John Danks of the White Sox appears to be among the Yankees' top possibilities, Heyman writes. Heyman reported last week that the Yankees and White Sox were discussing a possible Danks deal. Danks, 29, has a 4.40 ERA with 6.3 K/9 and 3.2 BB/9 in 131 innings for Chicago this season. His contract, which will pay him $14.25MM in both 2015 and 2016, shouldn't be a huge obstacle, although Heyman notes that Danks' declining velocity (with a drop in his average fastball from 91.6 MPH in 2011 to 88.2 MPH this season) might be a concern.
The Yankees do not seem to be discussing an Ian Kennedy deal with the Padres.
New York isn't currently thinking hard about acquiring Cliff Lee from the Phillies, since he's currently working his way back from injury and should be able to clear waivers in August. The Yankees may not have the prospects necessary to acquire Cole Hamels, and he's "barely available" anyway. The Yankees are not believed to want A.J. Burnett to return.
The Yankees are more likely to consider signing Jon Lester in the offseason than to trade for him.
Chicago White Sox John Danks New York Yankees Newsstand Philadelphia Phillies
AL Central Links: Royals, Hanrahan, Lindor, Sox
By Steve Adams | July 23, 2014 at 8:29am CDT
Despite the fact that the Royals recently went through a stretch of 18 losses in 27 games, GM Dayton Moore tells Andy McCullough of the Kansas City Star that manager Ned Yost's job is safe. Perhaps more pertinent to MLBTR faithful is that Moore tells McCullough his 49-50 ball club will not be sellers at this year's deadline. Moore says that he doesn't blame the players, coaches or anyone but himself: "I look at myself, and what I can do, and what we can do as a baseball operations department to improve our team. … We're going to keep pushing until the standings say we're done."
Here's more from the AL Central…
The Royals scouted the Phillies twice this week already, tweets Jim Salisbury of CSNPhilly.com. Salisbury notes that Antonio Bastardo performed well in front of Kansas City evaluators, who are on the lookout for bullpen help.
Joel Hanrahan is a "long shot" to pitch in the Majors this season, reports Lynn Henning of the Detroit News (Twitter link). The Tigers, who signed Hanrahan for a guaranteed $1MM base salary in May, have been hopeful that he will eventually fortify their late-inning relief corps, but they've also been linked to numerous bullpen arms, suggesting that they may not be counting on much from the former Pirates All-Star.
Paul Hoynes of the Cleveland Plain Dealer writes that while it may have been a planned promotion, the timing of Francisco Lindor's promotion to Triple-A is "as subtle as a brick to the head." The Indians announced Lindor's promotion to Columbus shortly after Asdrubal Cabrera left Monday's contest with an injury, and while Lindor likely wouldn't be the immediate replacement, there's little doubt that he's seen as Cabrera's replacement next year. Hoynes also notes how poorly timed a DL stint would be for Cabrera, as it would hurt the team's chances to stay in the AL Central race while also costing them a potential trade chip.
The two White Sox players that are generating the most interest in trade are John Danks and Dayan Viciedo, tweets Chris Cotillo of SB Nation's MLB Daily Dish. The Yankees have reportedly had some discussions with the South Siders about acquiring Danks as of yesterday afternoon. Danks has a six-team no-trade clause, with only four contenders on the list, according to yesterday's report from MLB.com's Scott Merkin. He can block deals to the Orioles, A's, Nationals and Blue Jays.
Chicago White Sox Cleveland Indians Dayan Viciedo Detroit Tigers Joel Hanrahan John Danks Kansas City Royals Philadelphia Phillies
The Details Of John Danks' No-Trade Clause
By Jeff Todd | July 22, 2014 at 6:41pm CDT
White Sox starter John Danks is permitted to designate six clubs for no-trade protection under his five-year, $65MM extension. His list for 2014 includes the Athletics, Orioles, Nationals, and Blue Jays, MLB.com's Scott Merkin reports on Twitter.
Though Danks has reportedly drawn some interest, including from the Yankees, his contract certainly limits his appeal. As MLBTR's Steve Adams noted in breaking down the potentially available starters, Danks is due about $34MM through 2016. However, the 29-year-old lefty holds some value after working back from shoulder surgery, as he has shown the ability to produce over stretches. Through 124 innings on the year, Danks owns a 4.35 ERA with 6.3 K/9 against 3.3 BB/9. But he had lowered that mark to 3.99 before getting hit hard two days ago by the Astros.
Of course, it is far from clear that any of those four clubs would be interested in adding Danks (and, in particular, his contract), so the clause's impact on Danks' market may be limited. The A's and Nats appear to be set in their rotations, while the Jays are reportedly interested in adding a pure rental and the O's may likewise prefer not to take on that kind of commitment after promising $50MM to the struggling Ubaldo Jimenez before the season.
No-trade details have begun to emerge on several possible trade pieces around the league. Earlier today, we covered the teams to which A.J. Burnett and Cliff Lee can block trades (here and here).
Baltimore Orioles Chicago White Sox John Danks Newsstand Oakland Athletics Toronto Blue Jays Washington Nationals
Yankees, White Sox Have Discussed John Danks
The Yankees have checked in on White Sox left-hander John Danks, but talks are still in the early stages, reports Jon Heyman of CBS Sports. Chris Cotillo of MLB Daily Dish hears that the market for Danks has begun to pick up over the past three days. Nothing appears close at this time, though Heyman notes that the Sox are looking for prospects, so Danks likely would require more than just salary relief to acquire.
The 29-year-old Danks averaged 195 innings for the ChiSox from 2008-11, but a shoulder injury required surgery in 2012 and limited him to just 192 innings combined over 2012-13. He's been healthy all year in 2014, and while his fastball velocity is down to an average of 88.2 mph (per Fangraphs), he's been reasonably effective.
Danks' ERA spiked after a seven-run hiccup in his most recent start, but he had been a roll prior to that, posting a 2.69 ERA with a 42-to-20 K/BB ratio over his past 67 innings (10 starts). Overall, Danks has a 4.35 ERA with 6.3 K/9, 3.3 BB/9 and a 40.1 percent ground-ball rate in 124 innings this season.
While Danks has a fairly sizable chunk of money owed to him, that shouldn't be a huge issue for the Yankees. Danks is due $5.4MM through season's end and $14.25MM in both 2015 and 2016, making for a total commitment of roughly $33.9MM.
Chicago White Sox John Danks New York Yankees
Rosenthal's Latest: Milone, Phillies, White Sox
By Mark Polishuk | July 21, 2014 at 10:28am CDT
The Cubs have the prospect depth necessary to acquire David Price from the Rays, FOX Sports' Ken Rosenthal writes, and acquiring Price (and then extending him past 2015) is just the kind of big move Rosenthal feels the Cubs need to get them into contention sooner rather than later. Price is intrigued by the idea of playing in Chicago, friends of the southpaw say, and Cubs minor league pitching coordinator Derek Johnson was Price's pitching coach at Vanderbilt.
Here's some hot stove buzz from Rosenthal's latest piece…
The Athletics are getting calls about left-hander Tommy Milone, who lost his rotation job when Oakland acquired Jeff Samardzija and Jason Hammel from the Cubs. The 27-year-old Milone is controlled through 2017 and has a 3.84 ERA, 3.23 K/BB rate and 6.5 K/9 over 468 2/3 career innings, though his significant home/road splits could make some teams wary about his effectiveness outside of Oakland. The A's aren't too keen to move Milone since they value having rotation depth.
The Phillies are willing to eat some money on their major veteran contracts in order "to effectively buy prospects" in trades, though with teams so hesitant to move their young talent, Philadelphia might be better served by just pursuing salary relief.
Phillies closer Jonathan Papelbon "is generating little interest," sources tell Rosenthal.
Many of the would-be best trade chips on the White Sox aren't producing, which could make it tough for the Pale Hose to make deadline deals. Gordon Beckham and Alejandro De Aza, for instance, look more like non-tender candidates than valuable acquisitions in the view of one rival executive. John Danks might be the most attractive trade candidate on the Chicago roster, while the Sox might wait until the winter to explore dealing Alexei Ramirez when the trade market is more open.
The Blue Jays' search for offense could be mitigated by the impending returns of Edwin Encarnacion, Adam Lind and Brett Lawrie from the DL within the next week or two. Toronto GM Alex Anthopoulos said yesterday that he was still looking to add a bat before the trade deadline.
Eugenio Suarez has played well enough at shortstop that Tigers GM Dave Dombrowski doesn't think his team will look for an upgrade at the position before the deadline. Rosenthal notes that Suarez's presence could create a bit of a logjam next season when Jose Iglesias returns from injury.
The Tigers do have a need for more lineup balance, as the team is short on left-handed hitters.
With so little prospect depth, Rosenthal thinks the Yankees' best trade strategy would be to offer salary relief for large contracts. In hindsight, Rosenthal writes, the Yankees might've been better off trading Robinson Cano for prospects last summer, even though being a deadline seller is unheard of for the always-contending Yankees.
Alejandro De Aza Alexei Ramirez Chicago Cubs Chicago White Sox David Price Detroit Tigers Eugenio Suarez Gordon Beckham John Danks Jonathan Papelbon New York Yankees Newsstand Oakland Athletics Philadelphia Phillies Tampa Bay Rays Tommy Milone Toronto Blue Jays
Rosenthal On White Sox, Johnson, Cruz
By charliewilmoth | April 26, 2014 at 3:05pm CDT
Here's the latest from Ken Rosenthal, via a video at FOX Sports:
The White Sox might prefer not to trade John Danks, who they have signed to a reasonable contract through 2016. But Adam Dunn is set to become a free agent, and the team has plenty of potential replacements for Alexei Ramirez and Gordon Beckham, so Chicago could deal any of those players at the deadline.
Since Josh Johnson won't start more than seven games this season, the Padres have a $4MM option on him for 2015. Given Johnson's Tommy John surgery, though, it's unclear whether the Padres will be able to get enough out of Johnson in 2015 to make the option worthwhile.
Nelson Cruz of the Orioles has done a good job rebuilding his value after taking a one-year offer significantly below the cost of the qualifying offer he rejected last winter, Rosenthal says. Cruz is off to a fast start, hitting .300/.391/.588 in his first 92 plate appearances with Baltimore.
Adam Dunn Alexei Ramirez Baltimore Orioles Chicago White Sox Gordon Beckham John Danks Josh Johnson Nelson Cruz San Diego Padres
White Sox Looking To Trade Starter
By Steve Adams | December 9, 2013 at 12:26pm CDT
The White Sox are looking to move a starting pitcher, according to Jeff Passan of Yahoo Sports. While the Sox would love to unload John Danks' contract, they recognize how difficult that would be. Passan adds that Jose Quintana and Hector Santiago are both available. In order to move Chris Sale, the White Sox would need a package even bigger than the one that expected to be needed to land David Price, according to Passan (Twitter links).
Joel Sherman of the New York Post spoke with an executive that has been in regular contact with the Sox regarding Sale (Twitter link) and was told: "We have asked million times about Sale and never felt they would trade him." Likewise, Colleen Kane of the Chicago Tribune spoke with White Sox chairman Jerry Reinsdorf who said that while the only untradeable player he's seen in his time as chairman of the White Sox and Bulls was Michael Jordan, the team isn't looking to move Sale and sees him as a big part of its success going forward.
Quintana has been said to be off limits in trades, though reports last night indicated that the Padres have asked for Quintana in trades for Chase Headley. Quintana can be controlled through 2018 while Santiago is controllable through 2017. Santiago has been said to be easier to acquire than Quintana.
As for Danks, he is owed $42.75MM through the 2016 season — an average annual value of $14.25MM. Still just 28 years old, Danks underwent shoulder surgery in 2012 and has a 5.02 ERA over 192 innings over the past two seasons.
Chicago White Sox Chris Sale Hector Santiago John Danks Jose Quintana
Blue Jays Interested In Gordon Beckham
Blue Jays GM Alex Anthopoulos is no stranger to the trade market. Early reports have already pegged Hank Conger and Chris Iannetta as potential trade targets for Toronto, and now Scott Merkin and Gregor Chisholm of MLB.com report that the Jays are targeting White Sox second baseman Gordon Beckham as well.
Beckham, 27, hit .267/.322/.372 with a career-low five homers in a career-low 103 games this season. A broken hamate bone in his right hand cost him nearly two months of the 2013 campaign, which could have something to do with the decline in home runs. However, Beckham has never lived up to the hype that surrounded him after being selected with the eighth overall pick in the 2008 draft, slashing just .249/.314/.380 in 2,217 big league plate appearances.
Beckham is eligible for arbitration for the second time this offseason, and MLBTR contributor Matt Swartz projects a raise from $2.9MM to $3.5MM. He is under team control through the 2015 season.
Chisolm and Merkin go on to write that given the Jays' need to improve the rotation, it's possible that they could look to expand the deal to include a starting pitcher. The MLB.com duo notes that lefties Hector Santiago and John Danks are said to be available, also adding that the White Sox covet minor league right-handers Aaron Sanchez and Marcus Stroman. That pair of former first-round picks seems to me to be too steep an asking price for the players that the Blue Jays are targeting, but Merkin and Chisholm feel that Chicago GM Rick Hahn would need to be overwhelmed to part with Beckham.
Chicago White Sox Gordon Beckham Hector Santiago John Danks Toronto Blue Jays
Quick Hits: Commissioner, Rollins, Diamondbacks
By Mark Polishuk | September 26, 2013 at 11:45pm CDT
Now that Bud Selig has announced he will retire following the 2014 season, speculation has already begun about who will be Major League Baseball's next commissioner. ESPN's Jayson Stark thinks it would be "a monumental upset" if MLB doesn't go with an internal candidate, and the favorites are league executive vice-presidents Rob Manfred and Tim Brosnan, and MLB Advanced Media CEO Bob Bowman. Yahoo Sports' Jeff Passan hears that Manfred is the safest and most well-rounded pick, though some sources consider Brosnan to be the better candidate. Stark and Passan list such names as Tigers GM Dave Dombrowski, Mets GM Sandy Alderson, Indians president Mark Shapiro and Diamondbacks president Derrick Hall as other possible choices.
Here are some notes as Yankee Stadium says goodbye to Mariano Rivera…
Jimmy Rollins is confident that the Phillies already have the pieces they need to succeed thanks to their emerging youth, CSNPhilly.com's Corey Seidman writes. "That old window's closed," Rollins admitted. "This is a brand new thing. You've still got the pieces, but this is a brand new thing going forward. Obviously we would love to have that right-handed bat, but Darin Ruf has come up and done that so far. We're going to get Ryan [Howard] back, hopefully a healthy Ryan back on his legs and strong."
Diamondbacks GM Kevin Towers will recommend to ownership that manager Kirk Gibson be retained for next season, Towers told reporters (including MLB.com's Steve Gilbert). Gibson has a 289-277 record since taking over as Arizona's manager halfway through the 2010 season and he led the team to an NL West title in 2011. Both Gibson and Towers are only under contract through the end of the 2014 season.
While Brad Ziegler has enjoyed being the Diamondbacks' closer, he tells Nick Piecoro of the Arizona Republic that it doesn't matter if he's closing or in his usual set-up role next season. Ziegler has a 2.28 ERA and 12 saves over 71 IP and a league-best 76 games this season. He's going into his third and final year of arbitration eligibility though there has been talk that Arizona will try to work out a contract extension.
Jack Zduriencik's mistakes as the Mariners' general manager are recapped by Geoff Baker of the Seattle Times in a piece that chronicles the team's strategies and major transactions over the last several years. While Baker holds Zduriencik accountable for his own mistakes, he also points the finger at the club's upper management for the larger issues surrounding the Mariners' lack of recent success.
John Danks is "embarrassed" by his performance since signing a five-year, $65MM extension with the White Sox before the 2012 season, the southpaw tells MLB.com's Scott Merkin. "The goal is always to throw 200-plus innings, take the ball every day and give us a chance to win. I've got three years to make everyone believe it was worth it," Danks said. "That's part of my motivating factor. I want to be the productive player I'm expected to be."
"The Cubs are the last-place team poised to contend the soonest. The Astros are the one with the brightest future," Jim Callis writes for MLB.com in his analysis of both teams' young talent.
MLBTR's Zach Links contributed to this post
Arizona Diamondbacks Brad Ziegler Chicago Cubs Chicago White Sox Houston Astros Jack Zduriencik Jimmy Rollins John Danks Philadelphia Phillies Seattle Mariners


I wonder if you have been buried in snow like we were on Tuesday. I was to go to Toronto on Tuesday morning and made my way over to the station at 8:30, but found it snowing and drifting so greatly that I consulted the ticket agent and he advised me not to go, so I telephoned and our meeting was put off till yesterday, which was a beautiful day. I had intended to look round at stair carpets, just to satisfy my mind, for I fancy you do not care to have all the stair covered which matting. Will do, but I had no time. Hilda is going down to visit Mary Taylor next month and she can look. We are very busy at our Prov. Board planning for the Annual Meeting in May, which is to be held here; just fancy what we will have to go through. There will be just swarms of women. I am getting thoroughly tired of planning missionary meetings. We are now trying a new maid, a very decent widow, who is quite smart about her work, but not yet a very good cook, but we think she can learn. Yesterday we had the news that Miss Bessie McMurchy had left for Paris to be a nurse, so poor Mrs. Steele will be greatly upset, she was her right hand, Cor. Sec.
We have not had your letter yet. You will see by the Globe that Col. Logie is in Toronto, so they are quite busy at the office. How do the bed-rooms at the Manse compare with one at Bracebridge? Are they larger? Carpets are still selling off. Tom has just brought home that remarkable bulb, which grows without earth or water, he had it at the office, but when the flower opened, which is very like a jack-in-the-pulpit with a very long centre rising up, the odour cost such a commotion, that it was driven out, but it is certainly a great curiosity. No news just now. Must close to catch post. Hope you are keeping free from colds & comfortable and getting on nicely. Love from all.


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Q: Add drop down to widget if it is in a certain area Is there a way to programmatically add a dropdown selector to any widget added to a given widget area?
I have a header widget area and I'd like any widget added to it to have a dropdown box with the option to align the widget to the left right or centre.  This would then be used to print a css class which would align the widget...

A: Widget CSS Classes is probably your best friend. It has the ability to add CSS classes manually by just typing them in, or you can set up predefined items that will add classes automatically. It's quite handy.

redpajama_set_name: RedPajamaStackExchange


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