Pagosa Springs is a municipality that is the county seat of, and the only incorporated municipality in, Archuleta County, Colorado, United States. On the 16th (Sun), take in the natural beauty of The Springs Resort & Spa, then hike along Piedra River Trail, and then admire the sheer force of Treasure Falls.
For maps, ratings, photos, and tourist information, read our Pagosa Springs day trip planning tool .
San Juan, Puerto Rico to Pagosa Springs is an approximately 14.5-hour flight. Traveling from San Juan to Pagosa Springs, you'll gain 3 hours due to the time zone difference. While traveling from San Juan, expect slightly colder days and much colder nights in Pagosa Springs, ranging from highs of 31°C to lows of 7°C. Finish your sightseeing early on the 16th (Sun) so you can drive to Mesa Verde National Park.
Whereas most national parks are primarily devoted to showcasing unique and special landscapes, Mesa Verde National Park focuses on ancient human habitation.
On the 17th (Mon), don't miss a visit to Park Point, explore the ancient world of Far View Sites, then explore the ancient world of Spruce Tree House, then contemplate the long history of Balcony House, and finally steep yourself in history at Cliff Palace. Get ready for a full day of sightseeing on the next day: see the interesting displays at Chapin Mesa Archeological Museum, stroll through Petroglyph Point Hike, and then explore the ancient world of Long House.
To see photos, more things to do, ratings, and tourist information, read Mesa Verde National Park trip planner .
Traveling by car from Pagosa Springs to Mesa Verde National Park takes 3 hours. Alternatively, you can do a combination of shuttle and car; or do a combination of shuttle and bus. Traveling from Pagosa Springs in June, you will find days in Mesa Verde National Park are a bit warmer (37°C), and nights are about the same (9°C). Finish your sightseeing early on the 18th (Tue) so you can drive to Ouray.
Ouray is a Home Rule Municipality that is the county seat and the most populous city of Ouray County, Colorado, United States. Kick off your visit on the 19th (Wed): contemplate the long history of Yankee Girl Mine, stroll through Yankee Boy Basin, then take in the dramatic scenery at Box Canyon Waterfall & Park, and finally admire the sheer force of Bear Creek Falls.
To find where to stay, more things to do, photos, and tourist information, read our Ouray online trip planner .
Getting from Mesa Verde National Park to Ouray by car takes about 3.5 hours. Other options: do a combination of taxi, bus, and car; or do a combination of taxi and bus. When traveling from Mesa Verde National Park in June, plan for slightly colder days and about the same nights in Ouray: temperatures range from 26°C by day to 11°C at night. Wrap up your sightseeing on the 19th (Wed) early enough to drive to Bryce Canyon National Park.
Kick off your visit on the 20th (Thu): hike along Queen's Garden Trail, then explore the stunning scenery at Sunset Point, and then hike along Navajo Loop Trail.
For traveler tips, more things to do, photos, and more tourist information, use the Bryce Canyon National Park trip itinerary builder site .
You can drive from Ouray to Bryce Canyon National Park in 7.5 hours. Other options are to do a combination of shuttle, flight, and car; or do a combination of car, flight, and bus. Traveling from Ouray in June, you will find days in Bryce Canyon National Park are a bit warmer (30°C), and nights are little chillier (5°C). Wrap up your sightseeing on the 20th (Thu) early enough to drive to Zion National Park.
Kick off your visit on the 21st (Fri): cruise along Zion-Mt. Carmel Highway, explore and take pictures at Observation Point, and then explore the stunning scenery at Zion's Main Canyon.
To find where to stay, more things to do, photos, and tourist information, you can read our Zion National Park trip builder tool .
Getting from Bryce Canyon National Park to Zion National Park by car takes about 3 hours. Traveling from Bryce Canyon National Park in June, expect Zion National Park to be somewhat warmer, temps between 40°C and 11°C. Finish up your sightseeing early on the 21st (Fri) so you can travel back home.


(DUBOIS CO.) - The Dubois County Sheriff's Department is warning residents about a new scam involving the Dubois County Courthouse.
The victim received a call from a number with the Caller ID of listed as the Dubois County Courthouse. The caller informed the victim they were at fault for not appearing for jury duty and they owed a fine.
The victim was advised by the caller to pay the fine over the phone using a prepaid card. Police said the victim did comply and will likely never recover their money.
"We would like to remind everyone of the ongoing scammers, they are getting more clever and more dangerous," the department wrote in a press release. "Please remember that no government agency will demand collection of money over the phone, threaten incarceration for non-payment, or tell you that they will send the police to your home to arrest you if you do not make an immediate payment over the phone."
According to police, when in doubt, hang up and contact your local law enforcement agency.


Home » eBooks for Libraries » Friday Reads: Back to School!
Stock up your digital shelves with our Back to School e-Book sale! Running now through September 30, select e-Books will be discounted 25% off (with our regular lending terms). Click here to download the spreadsheet of all available titles with exact price changes.


A single Italian spinone card suitable for Valentines day or for when you want to let someone know that you love them. The original pen drawing has been printed on a 300gsm 6×6 inch card. A white envelope is included.


Meet our new apprentice, Kendra!
Hello, my name is Kendra Guiguin. I am trainee at Connect International English Academy and I will be here for 2 months. I am 18 years old and I come from Angers which is a lovely city in the north west of France. Our specialty in Angers is the Quernon d'Ardoise which is made with nougatine, caramelised almonds and hazelnuts all covered with blue chocolate.
I study in Angers on a 2-year course at Campus Sacré Coeur La Salle, I am studying to work as a personal assistant.
I really like watching a lot of series (in English of course!) like Game of Thrones, Lost in Space or The Crown. I also enjoy movies, most recently Avengers. I also take pictures of landscapes or houses with different architecture, so I can take a lot of pictures here in Wales.
I have studied English for a long time and I am very happy to improve it in Wales. Here at Connect International English Academy I am deeply immersed in the English language, so this period will be a great experience for me.
At the school please do not hesitate to ask me anything, I will be delighted to help you and I look forward to meeting you.
Montage Kendra 2Being immersed in language is the best way to learn English so don't hesitate to join us!


Highlights of the 2015 EuroPhilantopics event in Brussels. Jointly organised by BOZAR, DAFNE, EFC, EVPA and NEF, EuroPhilantopics is the annual event for foundations and EU institutions to come together and consider the challenges facing people and communities in the next 5-10 years. This year the theme was trust and how it can be levered to pave the way to a fairer society.


FTSE 250 exploration and production outfit Energean Oil & Gas (LON:ENOG) has announced the appointment of Iman Hill as its new Chief Operating Officer. Ms Hill is a petroleum engineer with 30 years experience including senior roles in companies such as BG and Shell.
Shares in Energean rose by 2.92% to 603.10p (as of 14:20 BST).


So far as history is concerned the doctrine of "hereditary total depravity" appears to have originated about the fourth century this side of Christ. Its greatest exponent and advocate was a man who later came to be designated as "Saint" Augustine. The doctrine was borrowed from heathen philosophy, and has been transmitted from century to century until today it is firmly entrenched as one of the fundamental teachings of nearly all the so-called "orthodox" creeds.
Simply stated, the doctrine is that all men are born in sin because of Adam's sin. Adam's guilt is transmitted to all his posterity. When Adam sinned he lost his original righteousness; this brought about a corruption of his entire nature, and thus, all who partake of Adam partake of his nature and come into the world "positively" averse to all good and inclined to all evil. By birth one possesses not only the guilt of Adam's sin, but also a corrupted nature which makes it impossible for him to do good or think good until this inherited corruption is removed.
Hereditary sin is distinguished from "actual sin." The former is inherited, while the latter is that which one commits himself. It should be sufficient answer to these wild speculations to note that the Bible makes no such distinction, knows nothing of "inherited" sin, and is as silent as the tomb on all such philosophical meanderings.
Wild and incredible misapplications of scripture are often used to support this theory. For example, Proverbs 23:7 is copied with Genesis 6:5 as follows: "For as he thinketh in his heart, so is he." And "God saw that the wickedness of man was great in the earth, and that every imagination of the thoughts of his heart was only evil continually." By joining these two verses, an effort is made to show that man's life is based on the way he thinks in this heart, and since all his thoughts are only evil continually, he is consequently totally depraved.
To answer this misapplication, one need only look at the passage in Genesis 6:5, and consider to whom it referred. The reference there is to the wicked antediluvians, who had refused to follow the way of God and had multiplied iniquity. "And God saw that the wickedness of man was great in the earth, and that every imagination of the thoughts of his heart was only evil continually. And it repented the Lord that he had made man on the earth, and it grieved him a his heart." But even then the Lord found one man who was not wicked, but who walked before God as a perfect man. That was Noah. Furthermore, God pleaded with the rest of the race through the preaching of Noah to turn from their evil ways. Their wickedness was such that they could turn from it and renounce it; their evil ways could have turned to righteous ways. A man's course is determined by his thinking, to be sure, but he has the power to determine what his thinking shall be.
Another passage often used to support the theory is Ecclesiastes 8:11, where it is stated that "the heart of he sons of men is fully set in them to do evil." It is argued that this passage shows it is impossible for men to do good; their hearts are "set" to do evil. Therefore, man is totally depraved.
But let us consider the verse. The word "set" shows that this condition is a result of man's own choice. Man himself has "set" his heart to do evil. Furthermore, a reading of the passage will show exactly why it was that this "set" had taken place — "Because sentence against an evil work is not executed speedily, therefore the heart of the sons of men is fully set in them to do evil." The writer is not talking about the condition of men's hearts at birth; mankind is not born with a heart fully set to do evil. But as he grows up, and begins to realize that he can sin and not be immediately punished for it, his heart becomes hardened, and he "sets" his heart to do evil.
Study in connection with this the words used to describe the attitude of Ezra. "For Ezra had set his heart to seek the law of Jehovah, and to do it, and to teach in Israel statutes and ordinances." (Ezra 7:10). Ezra had "set" his heart in one direction, just as others had "set" their hearts in an opposite direction. Neither was born with his "set"; but each developed it himself.
Another favorite passage of those teaching inherited depravity is Job 25:4. "How can he be clean that is born of woman?" But they do not read with understanding. For if they did, they would realize that these are the words of Bildad, who is described for us as a forger of lies! To take the language of one who is a forger of lies and try to make his words set forth the truth of God is certainly going a long way to prove a point. Bildad also asks, "How then can a man be justified with God?" Are we to suppose from that question that no man can be justified with God? If we answer that a man can be justified, then we can also answer that one can be clean who is "born of woman."
The doctrine of inherited total depravity is not true. It is a deception of Satan, a working of error. Men need to study the Bible that they may know the truth, render obedience to it, and be saved from the guilt of their own sins — not from some inherited taint from Adam.
A study of God's word will reveal that for a man to be saved from the guilt of sin, he must have faith in his heart (Rom. 10:9-10); repentance from past sins. (Acts 2:38; 17:30); make the good confession with his lips (Matt. 10:32-32; Rom. 10:10); and be buried through baptism into the death of Christ (Rom. 6:1-4). If one does these things, he has the promise of God that all his sins are forgiven, all guilt removed, and that he is a child of God. If then one will live as a faithful, consecrated member of the family of God, the promise of God is certain and sure: heaven will be the home eternal of such a person. Will you not do that which God commands, that you may live forever with him?


text:
Will the GenZe scooter disrupt your commute?
Barbara Grady
Friday, September 4, 2015 - 3:00am
American cities are rethinking transportation, as urbanites rethink cities and how to get around in them.
Cars are not so appealing anymore; they are isolating, expensive, a bother to park, and they pollute. Meanwhile, cities have to be redesigned to make room for more people while reducing smog and CO2.
Cities from Portland to Boston, Oakland to New Orleans are encouraging the use of public transportation, bikes and shared vehicles while increasing parking fees.
Many have "smart city" blueprints on the drafting board where four-wheeled, gasoline powered cars are out of the picture, replaced by a system of light rail complemented by shared electric vehicles (EVs) available on-demand for commuters.
It's that last mile between train and office that cities want to solve, along with millennials' inclination to ditch cars in favor of bikes or shared rides, as well as a general desire to reduce carbon footprints that is creating a new market.
Within this changing urban transportation marketplace GenZe, a U.S. subsidiary of Indian transportation conglomerate Mahindra Group, developed what it sees as the urban commuter vehicle for U.S. cities of the future — the near future, that is.
GenZe — named for "next generation" and "zero emissions" — has created an electric scooter that has certain amenities for urban commuters. It's a one-person lightweight motorcycle with storage for a briefcase or groceries, and equipped with smart-vehicle logistics apps for drivers to find out how to get places, which routes have traffic, how their battery is doing and so on.
The GenZe 2.0 is in production, and GenZe plans to ship its first scooters in October.
GenZe, based in Fremont, California, on the edges of Silicon Valley, touts its scooter as a Valley-engineered and Michigan-made EV that answers commute headaches and the need — and desire — for zero emissions vehicles. It already sells an electric powered bicycle — the GenZe e-bike — but that, it says, was just a precursor.
"We went out and traveled the country to various cities, urban centers. We talked to people asking how do you get from point A to B, how do get to work or school? And we asked what are your pain points in those commutes," said Yesim Erez, GenZe's head of marketing, describing the road trip led by Terry Duncan, the product's designer, three years ago.
"We learned so much from that exercise. We learned that people don't want to be stuck in traffic, that sometimes it is easier for people to bicycle or train than take car.
"We also learned that people sometimes are inconvenienced by those choices. The bus or train doesn't go everywhere. Your office might be a mile away from the train stop. And not everybody is in shape to take a bicycle or they don't want to arrive at a meeting sweaty."
Moreover, she said, "They may want to take a briefcase or gym bag to work or stop on the way home for groceries," which are not easily done on a traditional bicycle or even by train.
Thus they came up with the GenZe 2.0, a two-wheeled EV that looks like a cross between a scooter and a motorcycle.

Daniyel Turner of GenZe's marketing team showing the GenZe 2.0 at a party in Oakland, California.

They're not for the highway — their top speed is 30 miles per hour, so the GenZe 2.0 differs from other new EV motorcycles on the market such as the Empulse TT made by Brammo or Zero Motorcycles' Zero SF 12.5, which can go about 95 miles per hour. But those more brawny motorcycles also sell for $19,999 and $14,000.
The GenZe is only $2,999.
Also, GenZe's battery's range is only about 30 to 40 miles miles compared with 110 miles of the big EV motorcyles for the highway.
But the kicker is that GenZe 2.0's battery snaps out and can be carried into an office or coffee shop for charging. Thus there's no need to park the GenZe 2.0 at a charging station. The Lithium-Ion battery, contained in a battery pack, can be plugged into standard electrical outlets.
And it doesn't take gasoline, of course.
What's all this mean?
Like the Nissan Leaf, the Tesla sedan and the Proterra EV bus, the GenZe 2.0 motorcycle is a product filling a newly emerging space of EV transportation that begins to tackle the pollution problems of the urban core and the greenhouse gas problems of the globe. Like the Gogoro EV scooter in Taiwan, it may have to nudge this market along.
Consultant and mobilty designer Dan Sturges told GreenBiz this summer that the four-wheeled, gasoline powered car for solo driving commuters driven by a solo commuter is a scenario of the past that soon will disappear.
"Nearly 50 percent of our trips in urban areas are less than three miles, and 28 percent are one mile or less. Our cars are over-engineered for nearly every trip we take in them. It's overkill. It's like killing a roach with a shotgun. We could not do anything about this before the auto tech revolution, but now we can," he said in an interview with GreenBiz.
In smart cities discussions spawned by the 100 Resilient Cities movement and others, cities are talking about multi-modality transportation, about building infrastructurs and kiosks and systems so that city workers or residents can take trains for parts of their commutes and then hop on a shared vehicle motor scooter or bike or the rest of their trip, the last half mile to the office or meeting or home. They envision zero emissions trains and vehicles, bicycles and walkways.
GenZe aims to tap into that desire and is in discussion with several cities, including Oakland, and state agencies about pairing up to create city kiosks where potential drivers could rent a GenZe to get to a meeting, say, or find one at the end of a train commute.
Learn more about EVs and smart cities and see a GenZe 2.0 EV scooter at VERGE 2015 Oct. 26-29 in San Jose, California.
GreenBiz
@barbaragrady
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GM revs up all-electric, driverless answer to ride-hailing services
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Abundant Life Church Case Study

redpajama_set_name: RedPajamaCommonCrawl


Singapore, a gleaming metropolis of soaring skyscrapers, manicured gardens, and people in suits; where shopping malls are supersize, electronics are truly king, and chewing gum is illegal. I have passed through the city many times, but never considered it as more than a brief stop on my way somewhere else. Now I have a three-day visa run and am determined to get a glimpse into life beyond the shiny facade. I catch a bumboat to Pulau Ubin, a small island that is home to one of the last remaining kampoengs (traditional villages in Singapore).
For devout Hindus a ritualistic dip in the holy waters of Varanasi is said to purify the soul, but as pollution levels of the River Ganges rise, spiritual renewal may come at a price.
Determined to remember their life outside of cancer, a young family hit the road for an epic six-week, 10,000 km trip across Australia, chasing dreams, building memories and finding solace in the wide open spaces of the outback.


We're happy you are thinking about taking a bike ride with us, we promise to deliver everything you are hoping for.
If you can include the tour you wish to take and the date that you prefer in the subject, that will help us get back to you as quickly as possible, or if you have any questions, ask away.
The tours are by advance reservation only…let us know what you are looking for.
SORRY OUR CONTACT LINK JUST WENT DOWN TODAY: PLEASE EMAIL US DIRECTLY AT INFO@CONFEDERACYOFCRUISERS.COM WHILE WE INSTALL A NEW ONE.
504-400 5468 works for those without email access, but as we are often out on the streets, email is the best method for contacting us, we will always get back to you regardless.
We do our best to answer all emails within 24 hours, if you do not hear back from us, check your spam mailbox.
Thanks, We look forward to rolling through New Orleans with you.


Lastly, you'll need a desire for your apprenticeship to become a full-time job.
No related crypto jobs in North Miami Beach, FL at this time. Try a broader search like "Florida" to find blockchain jobs near North Miami Beach!


If you're walking around Battery Park soon make sure to check out the globe-trotting, eco-conscious art installation "Cool Globes: Hot Ideas for a Cooler Planet". The eco-initiative, created by well-known Chicago environmentalist Wendy Abrams, has been traveling the world in hopes of bringing attention to community and individual participation when it comes to combating climate change.
Although undeniably pretty to look at, the 12 globes are more than just eye-catching eco-art. Since its creation in 2007, the exhibit has traveled the world, using the colorful orbs to spread the message of community involvement when it comes to impeding climate change.
The Cool Globes exhibit will be on display at North End Avenue and Warren Street until Nov. 20th.
You fool! Confusing Ecuador's flag with Colombia's! JARDON YOU FOOL!
If you're walking around Battery Park soon make sure to check out the globe-trotting, eco-conscious art installation, "Cool Globes: Hot Ideas for a Cooler Planet".
The eco-initiative, created by well-known Chicago environmentalist Wendy Abrams, travels the world in hopes of bringing attention to community and individual participation when it comes to combating climate change.
The eco installation will be on display until November 20th.


It appears you don't have a PDF plugin for this browser. Please use the link below to download 2018-federal-form-8717.pdf, and you can print it directly from your computer.
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We last updated the User Fee for Employee Plan Determination Letter Request in February 2019, so this is the latest version of Form 8717, fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 8717 directly from TaxFormFinder. You can print other Federal tax forms here.
TaxFormFinder has an additional 774 Federal income tax forms that you may need, plus all federal income tax forms. These related forms may also be needed with the Federal Form 8717.
The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 8717 from the Internal Revenue Service in February 2019.


Welcome to my blog. If you don't know already, my name is Carly Markham and I have been writing this blog since 2012. I am 27 years old and I have recently moved to a lovely little village in South Derbyshire with my Fiance Sam and my three children, Gracie (8), Zach (6) and Elsie (4). The children are regular helpers on the blog and are the stars over on my Youtube channel.
I guess the niche of my blog is simply my life. I don't write about a particular subject although it started mainly as a parenting blog, It has evolved with me over the years. There are many things I am passionate about including travel, photography, music, festivals and theatre and they all feature on my blog. I will also be writing a lot of home/interior posts over the next few years while I am working my way through a house renovation. My blog is not just a hobby anymore, it is my job and I am incredibly proud of the work that I do.
I love to write and I really enjoy being a part of the blogging community. I have made so many amazing friends over the past six years and have met many inspiring people. I have worked with some of the best brands and PR's in the business and I am always actively looking for more fun projects to be involved in.
If you are interested in working with me on any blog/social media content then please view my Work With Me/Contact page for more information on what I have to offer.


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The RBF is pleased to announce that its Peacebuilding program guidelines are now available. Formerly known as the Peace and Security program, the Peacebuilding program's framework is based on a thorough review process, and is grounded in the theme of conflict transformation. The revised program aims to advance just and durable peace by supporting innovative and collaborative approaches and policies for conflict prevention, management, and transformation at the multilateral, regional, and national levels; strengthening constituencies and political will for conflict transformation and durable peace; and exploring solutions to emerging transnational threats and drivers of conflict.
The Fund's Peacebuilding program aspires to strengthen local constituencies for peace and to connect them with policymaking on the regional and international levels. It aims to understand the conditions that lead to violence and the processes that support durable peace in order to identify innovative solutions to the most pressing drivers of insecurity. The program's grantmaking focuses on conflicts that have a disproportionate influence on international peace and security. It works closely with the Fund's Pivotal Place programs, especially in the Western Balkans, and with the Global Governance portfolio of the Democratic Practice program. The Fund places particular importance on elevating the role of women and young leaders in international peacebuilding and conflict transformation efforts.


Skulls Embellished Two Tone Suedette Heels For £20!
Put a spring in your step with these two-tone suedette heels. Embrace the seventies in these chunky heels, featuring quirky skull detailing. Team yours with a classic little black dress, to let these statement shoes do the talking!


I, Reene, hereby establish the Association of Mergist Wikipedians (AMW).
The AMW believes that while some information is notable and encyclopedic and therefore has a place on Wikipedia, much of it is not notable enough to warrant its own article and is therefore best merged. In this sense we are similar to Inclusionists, as we believe in the preservation of information and knowledge, but share traits with Deletionists as we disagree with the rampant creation of new articles for topics that could easily be covered elsewhere.
Naturally, as tastes and beliefs vary, our members may tend toward either Inclusionism or Deletionism as their beliefs suit them. However, we as Mergists for the most part tend toward the middle and prefer balance over views that are radical and blanket in nature.
All you have to do to become a Mergist is add your name to the list below.
Wikipedia is not a dictionary - an entry that consists of just a definition does not belong here, but it might belong in a larger concept article or in Wiktionary.
Avoid redundancy - adding to existing articles should be considered before creating entirely new ones.
Please see Association of Mergist Wikipedians/Members. Feel free to add yourself.
The current General Secretary is Neutrality.
If you request a revote, please do it here.
New pages - Little mini-articles are pouring in every day that need our attention.
Articles to be merged - Hundreds of articles that have been tagged for merging. Some are easy; some are a little more of a challenge. An extra bonus: it auto-updates!!
Duplicate articles - A smaller group of articles that need merging. This one doesn't auto-update, but there's room for discussion.
Stubs - There are thousands of stubs that can be merged by the truly devoted mergist.
WikiProject Integration - Project to support mergist activities.
Below are links to VfD and VfU pages that AMW members ought to investigate. The idea is that these are votes which AMW members should be aware of, so we can read the articles and discussions and then weigh in appropriately. Anyone may add to this list, but please include a very brief description of who/what the article is about (though the presence of this summary does not mean that AMW members should fail to read the article itself).


The majority of cancer patients with delirium were admitted to the hospital (80%), whereas only 49% of those without delirium were admitted; patients with delirium were also much more likely to be admitted to the ICU.
Advanced cancer patients with delirium were also likely to die earlier, surviving for a median time of between 1 and 4 months after their visit to the emergency department, compared with a median survival time of over 10 months for patients without delirium.
Although around half of the patients had advanced directives, these did not seem to have any effect on the rates of hospitalization or survival.
According to a new study published by Elsayem et al in The Oncologist, patients with advanced cancer who are diagnosed with delirium when presenting to emergency departments are more likely to be hospitalized and more likely to die earlier than patients without delirium. This shows the importance of accurately diagnosing delirium in patients with advanced cancer, said lead author Ahmed Elsayem, MD, a provider in the MD Anderson Emergency Center and Professor in the Department of Emergency Medicine at The University of Texas MD Anderson Cancer Center, even though delirium can easily be missed in busy emergency departments.
In patients with advanced cancer, delirium can be caused by various different factors. "Advanced cancer itself is a major cause, and other problems such as medications or infection are triggers that can precipitate the full-blown syndrome," explained Dr. Elsayem. Previous studies have shown that delirium is associated with poor survival in advanced cancer patients being treated in intensive care units (ICUs) or receiving palliative care in hospices, but no one had investigated whether the same was true for those reporting to emergency departments.
"To the best [of] our knowledge this is the first study to show the poor survival of advanced cancer patients in the emergency department setting," said Dr. Elsayem.
This study follows on from an earlier study conducted by Elsayem and his colleagues (published in Cancer), in which they assessed the frequency of delirium in advanced cancer patients visiting the emergency department at MD Anderson. They tested for delirium using two separate questionnaires, classifying patients as suffering from delirium if at least one of the questionnaires gave a positive result.
Questioning 243 patients in total, they found that 44, or 18%, were suffering with delirium according to at least one of the questionnaires.
In the current study, they investigated the proportion of these cancer patients with and without delirium who were subsequently admitted to the hospital or ICU and recorded how long they lived after their visit to the emergency department. They also looked at whether possessing advanced directives influenced the rates of hospitalization and survival.
They discovered that the majority of cancer patients with delirium were admitted to the hospital (80%), whereas only 49% of those without delirium were admitted; patients with delirium were also much more likely to be admitted to the ICU. Advanced cancer patients with delirium were also likely to die earlier, surviving for a median time of between 1 and 4 months after their visit to the emergency department, compared with a median survival time of over 10 months for patients without delirium. Although about half of the patients had advanced directives, these did not seem to have any effect on the rates of hospitalization or survival.
Given the major influence delirium appears to have on survival, as well as the distress it can cause for patients and their family members, Dr. Elsayem explained that prompt diagnosis and management in hospital emergency departments is essential. In many cases, delirium in advanced cancer patients can be resolved by simply stopping or modifying their medication and treating any associated infections. "Treating the triggers if known—such as stopping medications—is the main treatment for an episode of delirium," said Dr. Elsayem.
He also suggested that further research needs to be done on this topic, including similar studies on delirium in advanced cancer patients in other emergency departments and with larger groups of patients.


Thousands of sick and disabled people have requested an audio-recording of medical assessments for sickness benefit, Employment and Support Allowance (ESA), official figures show.
Figures released by the Department for Work and Pensions (DWP) reveal that between December 2012 and February 2014, a total of 4,060 audio-recorded face-to-face Work Capability Assessments (WCA) were requested. The busiest month came in January 2014, when 500 people requested to have their WCA audio-recorded.
However, DWP figures also show that of the 4,060 requests to audio-record a WCA, only 2,670 were successfully completed – averaging between 150 to 200 a month.
On average, approximately 70 were cancelled each month, totalling 1,080 between December 2012 and February 2014. The DWP says 330 individuals were awaiting an audio-recorded WCA in February 2014.
For every 10,000 WCAs completed, the DWP received only 66 requests for audio recordings (0.66%).
The ratio of recordings requested to all assessments completed was highest in January 2014 (1.14%) and lowest in January 2013 (0.36%).
The ratio of completed audio recording to all assessments completed was on average 0.42% and the ratio of cleared (completed + cancelled) audio recordings to all assessments was on average 0.59%.
There is no legal right to record a face to face benefit assessment, says the DWP. And the department has no legal obligation to provide recording equipment.
According to the DWP, the current policy for audio recording of face-to-face assessments is that DWP has asked Atos Healthcare, and its successor Maximus, to accommodate requests as much as reasonably possible.
The DWP said they are releasing these statistics "as a contribution to the debate on audio-recording face-to-face WCAs".