text:
Research ArticleOriginal Research
Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach
Shaylee Peckens, Megan M. Adelman, Amie M. Ashcraft, Jun Xiang, Brittany Sheppard and Dana E. King
Shaylee Peckens
the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
Megan M. Adelman
Amie M. Ashcraft
Jun Xiang
Brittany Sheppard
Dana E. King
Background: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient.
Methods: To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149).
Results: Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms.
Conclusion: An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States.1 Age-adjusted mortality has not changed significantly since the 1990s.2 Geographically, states clustered along the Ohio and Mississippi Rivers seem to suffer disproportionately compared with their national counterparts.2 In addition, COPD is estimated to account for over $49 billion in direct costs in 2020 with the majority of the cost burden from hospitalization secondary to exacerbations and other concomitant chronic conditions.3 Multiple studies predict COPD's prevalence will continue to rise, with 1 estimate predicting an annual increase of 4.8% per year due to the growing older adult population and the increasing prevalence of tobacco use in various areas globally.4
Nationally, West Virginia (WV) ranks among the highest in the nation in poor physical and mental health secondary to limited health care access and services, socioeconomic barriers, and high rates of chronic disease states.5 Based on data from the WV Behavioral Risk factor Surveillance System, WV had the highest rates of COPD across the United States (13.9%).5 One of the major drivers to COPD development is tobacco use. Nearly 25% of West Virginians currently smoke, ranking them as the second highest in the nation.5 Only about 55% of these current smokers have previously tried to quit smoking in the past year.5 In addition, WV continuously ranks as one of the poorest states in the nation with ∼19% of the population considered to be at or below the poverty line; this economic burden limits the ability for patients to pay and access health care.5 This—among other barriers, such as a lack of access to care and cost of COPD inhaler treatment—impacts the success of outpatient COPD management.
Pharmacological treatment regimens should be individualized to the patient, and are often guided by cost, drug availability, ease of use, and patient benefit. It can be difficult for providers to manage a complicated COPD case during a standard 15-to-20-minute primary care provider (PCP) office visit—especially in conjunction with other chronic conditions and acute concerns. Many PCPs have transitioned to the "team-based" care approach with the widely accepted implementation of the patient center medical home concept, and it has been demonstrated to improve health, enhance the care experience, and reduce costs in primary care settings. Previous literature has demonstrated the impact of a holistic, team approach for COPD management and beneficial outcomes on patient outcomes.6,7 Studies by Koff and colleagues6 and Liang and colleagues7 demonstrated multidisciplinary care resulted in improved symptoms and quality of life while also decreasing overall health care expenditure compared with standard of care (ie, primary care provider only). This study evaluated the effectiveness of a team-based approach to improving patients' COPD management in a rural primary care clinic in Appalachia.
We conducted a retrospective chart review to assess the impact of our multidisciplinary primary care COPD clinic on selected patient outcomes with approval from the West Virginia University Institutional Review Board. Patients referred to the clinic and having at least 1 visit from February 2015 to February 2019 were included for analysis. Outcome measures include the number of hospitalizations, urgent care visits, and emergency department (ED) utilization (pre- and post-clinic intervention) as well as improvement in symptoms as measured by subjective reporting (as assessed by the COPD Assessment Test [CAT] score, further explanation provided below), rates of smoking cessation, and cigarette use.
Clinic Setting and Procedures
The Department of Family Medicine (DFM) clinic is located in Morgantown, WV—a town of approximately 30,000 in Appalachia. The department is a National Committee for Quality Assurance−certified patient-centered medical home and is staffed by 18 physicians, 18 residents, 28 nurses and medical assistants, 1 dietitian and certified tobacco treatment specialist (CTTS), 1 clinical psychologist and psychology intern, 1 licensed clinical social worker, and 2 pharmacists.
The multidisciplinary COPD clinic was implemented within the DFM in early 2015 to reduce COPD admissions and readmissions. The clinic provides consultation with a team composed of a registered dietitian/CTTS, nurse, PharmD, clinical psychologist, family medicine resident, and a Board-certified family medicine attending physician. The multidisciplinary primary care COPD clinic occurs 1 half-day per week (Friday afternoons) in the DFM office space.
Patients are referred to the clinic by their PCP if they meet 1 of the following criteria: 1) newly diagnosed COPD or asthma based on pulmonary function testing; 2) need for tobacco cessation counseling and/or therapy; or 3) recent admission or readmission to the hospital for COPD, asthma, or related pulmonary illness; or 4) medication review. Patients see team members individually during their appointment in the following order: nursing, dietician/CTTS, psychology, pharmacy, and family medicine. Between each patient/provider interaction, the team regroups for a brief huddle to discuss findings, review treatment options, and manage treatment strategies. Patients' appointments with the full team last approximately 45 to 70 minutes.
At the beginning of each clinic visit, the nurse administers the Fagerström Test for Nicotine Dependence and the COPD Assessment Test (both described below) and informs the patient of the focus of the visit. Then the nurse obtains background information on recent hospitalizations or acute visits, vital signs, medications taken, laboratory results (including pulmonary function tests, computed tomography lung cancer screening, etc.), immunization status, tobacco use (cigarettes, cigars, electronic-cigarettes, snuff, smokeless tobacco, etc.) and any other illicit substances, and interest in quitting (as applicable). The dietitian/CTTS then sees the patient to discuss tobacco use and uses motivational interviewing to discuss options for cessation. The CTTS specifically focuses on lifestyle changes to aid with tobacco cessation (eg, increasing water intake, meditation, oral fixation, etc.). She determines and recommends aids to assist with cessation including telephone followup by a team member, referral to the state's 1-800-QUITNOW line, and referral to a free 7-week tobacco cessation class offered at the same clinic. The dietitian/CTTS evaluates unexplained weight loss and recommends supplemental nutrition as indicated, and counsels regarding exercise behaviors to promote exercise tolerance and respiratory capacity. The clinical psychologist then meets with the patient about any prior psychiatric history, barriers to tobacco cessation, and behavioral modification to increase tobacco cessation success. Strategies include but are not limited to schedule modification, journaling, set intentions, etc. The clinical psychologist also reviews barriers for medication adherence if a patient is not taking therapy as prescribed.
The pharmacist reviews the patient's current medication regimen and reconciles as necessary, assesses disease-state burden based on patient-reported symptoms and quality of life, and recommends appropriate changes in therapy. The pharmacist also addresses barriers that could contribute to suboptimal therapy results, including assessing appropriate inhaler administration technique, therapy nonadherence, and medication affordability; recommends appropriate vaccinations; and assists with medication options for tobacco cessation. Then a final huddle with all team members is completed to discuss finalized medication plan, patient barriers, and specific goals. Finally, the resident and attending physicians meet with the patient, confirm history, conduct physical examination, discuss the recommended plan, and arrange for follow-up. Two attending physicians are kept consistent and rotate through the clinic; residents participate as part of their family medicine subspecialty rotation and are variable based on the month.
Followup is determined on an individualized basis. If no changes are made or a patient seems well controlled following hospitalization, they will be referred back to their PCP for future appointments. If further treatment and adjustments are warranted, they will be scheduled for a follow-up appointment within 4 to 6 weeks. The pharmacist or the nurse will contact the patient between appointments, as necessary and based on specific patient needs, to ensure the patient was able to afford and obtain new therapy, tobacco cessation followup, and other clinical issues. As a patient progresses through 2 to 3 follow-up visits to the multidisciplinary primary care COPD clinic, the team will assess whether the patient is ready to be returned back to his PCP for further care or whether consultation with a pulmonary specialist is warranted.
Measures and Data Collection
Patient data and outcomes were manually collected via chart review of electronic medical record (EMR). Data are included for patients first seen at the COPD specialty clinic between February 1, 2015 and February 28, 2019 to allow assessment of outcomes 6 months after the initial COPD clinic visit. The primary outcomes of the study evaluated frequency of hospitalizations, ED visits, and urgent care visits pre and post enrollment within the COPD specialty clinic. Secondary outcomes evaluated CAT scores and tobacco use pre/post clinic encounters.
Hospital Admissions, ED Visits, and Urgent Care Visits
Only hospitalizations and urgent care or ED visits which were due to respiratory conditions or complaints—examples include pneumonia, COPD exacerbations, etc.—were included for evaluation. These endpoints were collected via documentation in the EMR in encounter types and externally scanned documents (for hospitalizations which were outside of the system). Patients who also had respiratory complications during hospitalization (ie, not the primary complaint) were also included for analysis, which included hospital-acquired pneumonia or exacerbation following infection. During appointments, patients were asked about any recent hospitalizations, urgent care visits, and ED visits, which was documented at each encounter appointment. Visits and hospitalizations within the health care system were automatically documented within the EMR (during the hospitalization), while those outside of the system had to be reported by the patient or appropriate documentation uploaded by the nursing staff. If a patient had multiple follow-up appointments with the COPD clinic but a hospitalization occurred between appointments, that hospitalization was counted as a postintervention hospitalization.
Fagerström Test for Nicotine Dependence
At every appointment, patients manually completed a Fagerström Test for Nicotine Dependence.8,9 This instrument is standard for assessing the intensity of a patient's physical dependence on nicotine using 6 items that evaluate the number of cigarettes smoked, the compulsion to use nicotine, and nicotine dependence. Patients receive a total score of 0 to 10, and higher scores indicate more intense physical dependence on nicotine.
Symptom improvement was evaluated based on patient-reported surveys, collected as part of standard of care during individual encounters. At each clinic appointment, patients completed a CAT during their rooming to assess the burden of their symptoms and the impact on the patients' daily life.10⇓⇓⇓–14 The score is included in the provider's note in the objective section to help monitor disease state management. This questionnaire evaluates cough, phlegm, chest tightness, breathlessness, activity limitations at home, confidence leaving home, sleep, and energy. Patients receive a total score from 0 to 40, with lowers scores indicating fewer symptoms and higher quality of life. Patients who had ≥ 2 appointments as part of the consult were evaluated based on change in score.
COPD Staging
COPD staging and classification was based on the 2018 Global Initiative for Chronic Obstructive Lung Disease guidelines.15 This classification system evaluates a patient's pulmonary function testing, specifically FEV1, individual CAT score, and recent history of COPD exacerbation or hospitalization. Patients were classified based on stage (1 to 4) and grade (A to D).
Smoking Status and Smokeless Tobacco Use
Patients were classified as smokers and nonsmokers based on their self-reported use of cigarettes. Clinic patients classified as smokers reported their average number of cigarettes/cigars smoked per day. Patients were also classified as smokeless tobacco users (currently used, formerly used, or never used) based on their self-reported use of smokeless tobacco products. End tobacco use status was collected via electronic documentation in the EMR as of September 2019. Tobacco use was assessed during every encounter, as appropriate, and use was updated in the EMR.
SAS (version 9.4, 2013, SAS Institute, Inc. Cary, NC) was used to conduct the statistical analyses for this study. Descriptive analyses were performed for demographic and clinical characteristics while paired t-test compared the differences in CAT scores and cigarette use between the first and most recent visits. Differences in total hospital admissions, ED visits, and urgent care visits were also evaluated using paired t-test. McNemar's test assessed the difference in tobacco status between the first and most recent visits. Tests with a 2-sided P < .05 were considered statistically significant.
Patient Demographic and Clinical Characteristics
Since its inception in 2015, a total of 149 patients, ages 38 to 93 years, were seen at the specialty clinic (Table 1). The mean age of patients was 60.2 ± 10.3 years. Of the total sample, 83 (56%) were male and 83 (56%) of had private insurance. Patients had on average 1.75 appointments per consult (range, 1 to 6; standard deviation (SD), 1.06). At the first clinic visit, patients' mean Fagerström Test for Nicotine Dependence score was 5.1 ± 2.3, and the mean CAT score was 23.3 ± 8.4. The majority of patients received a COPD grade of B (n = 81; 62.3%), followed by D (n = 40; 30.8%), A (n = 8; 6.1%), and C (n = 1; 0.8%). Most patients were classified at a Gold Stage of 2 (n = 52; 47.3%). Most patients were tobacco users (n = 93; 62.4%) and smoked an average of 17.3 cigarettes per day. Finally, the vast majority had never used smokeless tobacco (n = 125; 86.8%).
Patient Demographic and Clinical Characteristics at First Chronic Obstructive Pulmonary Disease (COPD) Specialty Clinic Visit (n = 149)
Primary Outcomes: Hospital Admissions, ED Visits, and Urgent Care Visits
There were significant changes in hospital admissions and ED visits for COPD specialty clinic patients (Table 2). Clinic patients had significantly fewer hospital admissions 6 months after their first clinic visit (0.09 ± 0.4) than at 6 months before their first visit (0.3 ± 0.6), (t (147) = 5.0, P < .0001). Clinic patients also had significantly fewer hospital admissions 1 year after their first clinic visit (0.2 ± 0.7) than at 1 year before their first visit (0.4 ± 0.8), (t (148) = 4.1, P < .0001). There was also a significant change in the number of ED visits. Patients at the COPD specialty clinic had significantly fewer ED visits 6 months after their first clinic visit (0.1 ± 0.4) than 6 months before their first clinic visit (0.4 ± 0.7), (t (148) = 5.5, P < .0001). Clinic patients had significantly fewer ED visits 1 year after their first clinic visit (0.2 ± 0.7) than 1 year before (0.5 ± 0.9), t (148) = 4.3, P < .0001. There was no difference between pre and post urgent care visits.
Comparisons of the Difference in Total Hospital Admissions, Emergency Department (ED) Visits, and Urgent Care Visits before and after the First Chronic Obstructive Pulmonary Disease (COPD) Specialty Clinic Visit
Secondary Outcomes: Nicotine Dependence Score, CAT Score, and Tobacco Use Behavior
There were significant changes in CAT Scores and in the number of cigarettes smoked per day by COPD specialty clinic patients (Table 3). Clinic patients had significantly lower CAT scores at their most recent clinic visit (20.5 ± 8.1) compared with their first specialty clinic visit (23.7 ± 7.5), (t(55) = 3.3; P = .002). They also reported smoking significantly fewer cigarettes per day at their most recent clinic visit (13.8 ± 11.0) compared with their first visit (17.3 ± 11.2), (t(50) = 2.3; P = .03). The percentage of self-identified tobacco users also decreased between their first specialty clinic visit (61.1%) to their most recent visit (52.1%), χ2 (1) = 11.27; P = .0008.
Comparison of Mean Difference Nicotine Dependency Scores, Common Admission Test (CAT) Scores, and Cigarette Use/Day before and after the Most Recent Chronic Obstructive Pulmonary Disease (COPD) Clinic Visit
This study demonstrates the benefit of a multidisciplinary team approach to mitigate complications of COPD and avoid future hospitalizations in a rural primary care setting. Patients referred to the clinic experienced fewer COPD symptoms, smoked less, and had a 50% reduction in hospitalizations the following year. In light of the huge cost of COPD in the United States annually—an expected $49 billion in 2020—identifying primary care interventions that can provide prevention of complications is critical.16
The current study's findings are consistent with previous literature demonstrating positive benefits from a multidisciplinary approach to care in COPD management. However, only a few trials directly demonstrated reduced hospitalization or rehospitalization; most have concentrated on other outcome measurements including quality of life and symptom improvement.6,7,17⇓–19 The recent evidence of the integrated care management approach further supports the benefit of a multidisciplinary team to reduce ED visits and hospital admissions.20 The streamlined unified meaningfully managed interdisciplinary team (SUMMIT) trial protocol shows further interest in the multidisciplinary approach to care in an urban homelessness setting; results of the trial are not yet available.21 In contrast, the current study demonstrated reduced COPD hospitalization rates in a primary care rural clinic setting.
The current study also demonstrated a significant improvement in CAT scores as well as increased tobacco cessation rates and decreased cigarette use. Success rates for tobacco cessation in this study may be due to the multiple encounters reinforcing the cessation message including counseling by the certified cessation specialist, the pharmacist, the psychologist, and the physicians. Patients may have also adjusted behaviors exclusively during this limited, intensive intervention, knowing they were being proactively monitored and observed (Hawthorne effect); future studies could assess long-term impact of an interdisciplinary care on outcomes such as sustained tobacco cessation. In addition, some of these outcomes, for example, those included in Table 3, have few data points, and therefore the results should be interpreted with caution.
Members of the multidisciplinary team are not always consistent in the studies cited. Most contained at least a physician, nursing and/or care manager, and respiratory/tobacco cessation specialist. The inclusion of a physical therapist, pharmacist, psychologist, dietitian, exercise specialists, and social workers varied by study and location.7,17,22,23 There is no consensus agreement regarding the ideal makeup of a COPD team despite the multiple studies that have been conducted. Regardless of the disciplines involved, teams should establish interdependence among the members where the treatment plan and patient-specific goals combines the expertise of the individual disciplines involved. The current study site has 6 core disciplines consistently represented—medicine, pharmacy, dietitian, tobacco cessation, psychology, and nursing—a combination that has worked well for our workflow and the site's currently available space. For practice sites interested in starting a multidisciplinary clinic, targeted strategies to identify disciplinary buy-in, evaluate gaps in care, develop an implementation plan, and discuss a clinic workflow are critical first steps for success.24,25
COPD's morbidity and mortality have significant implications in the rural setting. Based on a report from the Centers for Disease Control and Prevention, death due to respiratory illness is significantly higher in rural populations compared with urban settings.26 The report hypothesizes this trend is due to health care access barriers including preventative and screening services, treatment delays, and lack of emergency services. Implementing strategies to bridge this gap are needed. Utilization of intensive interdisciplinary clinics may provide benefit and broadened scope in areas where physician resources may be limited.
This study has several limitations including the length of followup. The clinic has been in operation since 2015, so sustained improvement cannot be ascertained longer term. In addition, most patients had 3 visits to the COPD clinic and were then returned to the care of their PCP; outcomes regarding those referred for specialty care were too few for analysis. In addition, the study data were limited to chart review and patient reporting. Hospitalization rates were accurately documented if within our health care system; however, if a patient was admitted to an outside facility, documentation was based on patient-reports or if the institution notified our clinic. This was also viewed with the Fagerström score reporting; despite this being incorporated in the procedure of rooming a patient, it was inconsistently documented in the EMR. As a result, some data were missing, and we evaluated the difference from first visit to most recent encounter instead of changes between visits. We also recognize the limitations of using the CAT score to measure symptom improvement—primarily the subjectivity of the rating score and difficulty some patients experience in ranking symptoms on a Likert scale (ie, what constitutes a ranking of 2 vs 3 for coughing). However, the CAT score is a validated tool for assessment of COPD symptoms and included in the guidelines as recommended assessment for staging and monitoring.15 Finally, tobacco cessation and cigarette use was also self reported and not verified via carbon monoxide or other measurement. This may be a consideration in future evaluation to verify cessation rates.
The implications of these findings may improve important COPD-related outcomes including readmission hospitalizations. While causality cannot be established in this study, the results are promising and further investigation is warranted. The team-based model should be considered in other practice settings to help reduce admissions and disease management. Further research is needed to evaluate the long-term implementation of the team-approach, establish an objective method to measure patient symptoms, and determine an effective strategy to spread the approach throughout primary care.
The authors would sincerely like to thank the faculty, residents, nurses, clinic staff, and students for their hard work and dedication to this effort; in particular, Kara Kozul, Kelsey Samek, and Judy Siebart.
This article was externally peer reviewed.
Conflict of interest: None.
Funding: None.
To see this article online, please go to: http://jabfm.org/content/33/6/978.full.
Received for publication April 27, 2020.
Revision received June 25, 2020.
Accepted for publication June 29, 2020.
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Shaylee Peckens, Megan M. Adelman, Amie M. Ashcraft, Jun Xiang, Brittany Sheppard, Dana E. King
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Rockobit: Kelly Johnson
Kelly Johnson, guitarist with rock legends Girlschool, has died at the age of 49.
Enfield-born Johnson joined the band as they morphed from Painted Lady into Girlschool, turning what had been a bit of fun into a serious proposition. Taken under the wing of Motorhead following the release of 1979 debut single Take It All Way. The patronage of Lemmy and the boys saw them develop a formidable live reputation, and, in the split 1980 EP The St Valentine's Day Masacre, a significant, if specialist, market for their records.
Johnson quit in 1983, as the band embarked on something of a lean period, becoming one of those acts seemingly on permanent tour, trading more off past glories than current inspiration, and even trying out new names and some stunt casting (She Devils, with Toyah on lead vocals and Strange Girls). But it was Johnson's return in 1993 that gave the band a new life. While never recapturing quiet the peak of their early 80s heyday, they moved beyond filling a role as their own tribute band.
Kelly had spent the time between her stints in Girlschool living in LA - she spent a couple of years in a band with former Go-Go Kathy Valentine. Her taste wasn't restricted to heavy rock - she cited Elastica as a favourite band, for example - but it's the genre she'll always be associated most strongly with.
Johnson's time with Girlschool came to an end in 2000 when she quit the music industry altogether; shortly afterwards, she was diagnosed with cancer of the spine. The last six years, she had fought the disease; sadly, she lost her battle sometime yesterday.
More from No Rock on girlschool, kelly johnson, obit, obituary
Kelly Johnson
Classic rock guitarist, never given the respect she deserved.
Thanks for all those great gigs!
BertrandCherbourg said...
I am an "old" french fan of Girlschool of 41 year old... I felt in love with Kelly when I was 14!!!!
My music period when I was young man was the "NWOBHM", Judas Priest, Saxon, Iron Maiden, Motörhead and of course, Girlschool!
It's very strange and hard for me because I don't knew that Kelly was ill... The presse doesn't speak a lot about metal music...
R.I.P. dear girl... always in our minds!

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#atozchallenge: D is for Denni Johnson
Q: Denni's got quite the role in this trilogy as the One of All Sacred. What's her origin?
A: She was a relatively new character alongside Caren and Poe, but she didn't really have much of a role until about a quarter of the way into The Phoenix Effect. A proto-Denni popped up in True Faith in a similar role but with vastly different motives and personality. Both versions were pre-teens. When writing the trilogy it made more sense for her to be a teenager and a little closer in age to Caren.
Q: Why the One of All Sacred, anyway? Where did that idea come from?
A: In a way that came from a subplot in TF. I was fascinated by the idea of Chosen One plotlines at the time, especially ones with mundane origins that ascend to deity level, either by a ritual or by outside forces. It was still a subplot in TPE, but by the time of the trilogy reboot it became a major plot point — so much so that her awakening is Chapter 1 of A Division of Souls. She's one of the major drivers of the plot of the trilogy. [More about the One of All Sacred on 4/18 when we hit 'O' on the A to Z Challenge!]
Q: Like her sister, she's got a Mendaihu name as well. An extended version of it is given in A Division of Souls. What's the story behind that?
A: She gives her Mendaihu name as Denysia Shalei si Emmadha si Dhumélis. In Anjshé, the 'si' is a conjunction — in this sense she's merely giving multiple clan names that her Trisandi soul is tied to. [Pronunciation: shah-LEY, ey-MADH-ah, and dhoo-MEY-lees. The 'dh' is a 'd' sound with a very slight lisp.] All three clans are highly regarded on Trisanda as strong in both spirit and in deed. She purposely gave all three names at the Moulding Warehouse to prove a single point: she wasn't going to take her role as the One of All Sacred lightly, not if she claimed to be from such an honored lineage.
And yes, this is a lineage for her entire family. Caren almost never claims all three names as she rarely sees need for it.
Q: That's Jena Malone in that picture. Is she the basis for Denni?
A: Yes, she is. I wrote TPE around the same time the movie Contact, where she played the young Ellie Arroway. Spunky, smart and self-reliant, yet still relies on the connection of others. The trilogy version has her somewhat older (maybe her role in Donnie Darko, which was out about the same time I started ADoS).
Q: For a fifteen-year-old girl, she certainly has a hell of a lot of responsibility, doesn't she?
A: Well, sure, why not? She shares much the same daily responsibilities as her older sister Caren, especially since they're living on their own. Her parents made sure she was self-reliant, as both they and Caren were ARU agents, and they didn't want her to completely depend on the help of others. But they also taught her that there's no fault in asking for it, either. Whenever she's performing her duties as the One of All Sacred, she always has that in the back of her mind, and that's why she nearly always encourages community but also reminds her followers to think for themselves instead of following her blindly.
That's not to say that she immediately becomes a Magical Girl and her real life is conveniently forgotten whenever she's doing her magic as the One. Now that she's known as the One by pretty much everyone on Earth, she of course feels a bit self-conscious, not to mention feeling a bit weird about still needing to attend school. She wants to do her best as the One, but she also wants to continue being teenaged Denni. I actually touch on this theme in The Persistence of Memories as well as The Balance of Light.
In short: she's willing to take all the responsibility that comes with being a deity, but she refuses to let it go to her head.
Q: What is her relationship with Amna Ehramanis?
A: She's her best bud, they've known each other since they were five. Like all lifelong friends, they've gone through all kinds of ups and downs, scrapes and japes, and they're still BFFs. Denni always plays the straight character to Amna's wackiness. As to why Amna becomes her devoted Protector once she's fully awakened, well…there are a few reasons for that, which are revealed in TPoM and TBoL. 😉
A: Like Caren, she's a music fiend and constantly streams stuff from her sister's collection. She's a voracious reader. She's a decent student and gets excellent marks, but she'll admit she doesn't see the point in trying to be top student. She loves hanging out with Caren's fellow agents at the ARU, and thinks of them as an extended family. In particular she looks upon Alec Poe as a big brother. She's had a few school crushes here and there, but nothing serious, and she's okay with that. There's a fifteen-year difference between Caren and Denni, which might lead some to think she was an unplanned pregnancy, but she's actually not. Aram and Celine deliberately chose to have another child after the previous Season of Embodiment. (As to whether they knew her fate at that time is not known.)
And yes, she too has a theme song, Lamb's "Small". This is what she thinks about when she's up in her nonspace.
Posted in Mendaihu Universe FAQTagged ados, atozchallenge, Bridgetown, Denni Johnson, Mendaihu, mu, tbol, tpom, trilogy
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3 thoughts on "#atozchallenge: D is for Denni Johnson"
stephie5741	 April 6, 201612:24 am	 Reply
She sounds like a fascinating character!
http://stephie5741.blogspot.com
Jon Chaisson	 April 6, 20162:36 am	 Reply
Thanks! Yes, she's one of my favorites. Her entire role is to keep everyone in line, and it's a lot harder than it looks. 😉
Nilanjana Bose	 April 6, 201610:19 am	 Reply
Well done on keeping up to date with your post for D. Great job!
Nilanjana


text:
Grace Kelly Might Make An Appearance In 'The Crown' Season 4
'The Crown' Recreates Famous Princess Diana Moment In Rare Look At Season 4
Olivia Colman's Glam Squad Used This Anti-Aging Face Tool Before The Golden Globes
You Can Now Stay In The Castle Where 'The Crown' Is Filmed
All The Hidden Meanings In The Hairstyles On 'The Crown' Season Three
Calling All Fans Of 'The Crown', This Is The Instagram Account You Need To Follow
5 Filming Locations From 'The Crown' You Can Visit In Real Life
Princess Anne Is Officially Our Favourite Royal After This Iconic Donald Trump Snub
The First Pictures Of Baby Prince William On 'The Crown' Season 4 Have Leaked
A New Podcast Series Has Arrived For 'The Crown' Devotees
Helena Bonham Carter Once Had A Sleepover With The Queen
Princess Anne's Hair Took Hours To Style On Set For 'The Crown'
Before The Kardashians, The Royal Family Made Their Own Reality TV Show
Buckingham Palace Reveals The History Behind The Opening Scene Of 'The Crown' Season 3
Princess Diana's Famous "Three People In A Relationship" Line Is Featured In Season 3 Of 'The Crown'
But this time, it wasn't Princess Diana who said it - by Chelsea Tromans
While the previous seasons of The Crown have largely been about Queen Elizabeth, it's Prince Charles' storyline that has us speeding our way through all 10 episodes of season three, which have been uploaded in one go on Netflix for our binging pleasure.
Watch Below: The Crown Season 3 Promo
We'll have to wait until season four before Princess Diana (played by Emma Corrin) comes onto the scene, but for now, Prince Charles' (Josh O'Connor) and Camilla Parker-Bowles' (Emerald Fennell) blossoming relationship has us hooked.
One scene in episode nine that has sparked our attention is when Princess Anne (played by Erin Doherty) utters one of Princess Diana's famous quotes. Speaking of her brother Charles' intention to propose to Camilla, she says he'd better be prepared for there to "always be three in the marriage."
The real Princes Diana famously described her marriage with Prince Charles as such in a TV interview. "There were three of us in this marriage," she said. "So it was a bit crowded".
In the context of The Crown, Princess Anne is referring to Camilla's relationship with ex-boyfriend (and eventual husband) Andrew Parker-Bowles.
According to The Sun, a source claims that Prince Charles' staff are 'paranoid' about how The Crown will portray the affair. "Charles's staff are deeply paranoid about The Crown," the insider said. "They are trying to make him a popular king-in-waiting."
"The next few seasons are going to be increasingly focused on the Prince of Wales's behaviour, especially around his marriage to Diana and affair with Camilla. The timing couldn't be any more disastrous in terms of Charles's bid for popularity," the source added.
Chelsea Tromans
Chelsea Tromans is a fashion, beauty and lifestyle editor whose words can be found on BEAUTYcrew, marie claire, Women's Health, WHO, Daily Addict, and The Joye…just to name a few. She's a night owl who's trying to train herself to be a morning person (coffee helps!) and she recently traded in her hectic Sydney life for a quieter pace in Brisbane.


> >> Is it possible to use rsync to a folder on a remote computer?
> >> If so what's the syntax?
> > user at server:folder/folder/..
i had similar issues with fat filesystems on target.
a USB drive with a FAT filesystem, I use the -rlt options. "


text:
Democratic Socialist Movement (DSM)
Contact DSM
Newspaper of the DSM
Socialist Democracy May Day 2005
OBASANJO�S ANTI-CORRUPTION POSTURING WILL NOT HALT TREASURY LOOTING
Some Nigerians may take Obasanjo�s regime as being serious with its current anti-corruption posture, particularly with a handful of government officials publicly exposed and sacked for being corrupt and some arraigned in the court of law for possible prosecution on corruption charges.
The list of the scapegoats in the latest anti-corruption publicity stunt by Obasanjo, the grand master of corruption himself, includes Tafa Balogun, (ex-Inspector General of Police forced to retire over N13 billion illegally acquired wealth), Mrs. Bola Osomo, former Housing Minister dismissed over federal government property sale scandal, Professor Fabian Osuji and Chief Adolphus Wabara, former Education Minister and Senate President respectively, who lost their positions on corruption charges involving N55 million senate bribery to increase budgetary allocation to education ministry.
Before now, the regime had equally arraigned in court, some of its top notchers including the deceased former Internal Affairs Minister, Sunday Afolabi and two dismissed ministers over National Identity Card scam worth $242 million. However, nothing is heard any longer on the case after the demise of the principal culprit, Sunday Afolabi who had been earlier reported to have confessed that substantial part of the stolen money was used to "capture" southwest Nigeria from the Alliance for Democracy (AD) for Peoples� Democratic Party (PDP).
As expected, the press is awash with praises by government officials at all levels who are themselves corrupt for the anti-corruption stance of Obasanjo in an effort to make mountain out of a mole hill and deceive the public when in actual fact mega corruption with due process continues in the system, in the corridors of power unabated. The whole national drama is a public relations stunt to deceive the international community, the much touted foreign investors and Transparency International, the organisation that last year rated Nigeria the third most corrupt nation in the world!
PRIVATISATION IS MEGA CORRUPTION
Privatisation is the main thrust of the regime�s neo-liberal economic policies since its inception in 1999, apart from devaluation, commercialisation and cut in government expenditure on social services. All anti-poor economic policies determined by IMF/World Bank.
By its design, privatisation programme is to transfer ownership of public properties and investment to mega rich privileged private individuals and corporate bodies at give away prices. The beneficiaries of the unwholesome transactions are mostly government officials, their fronts and foreign partners. The Bureau of Public Enterprises (BPE) and National Council of Privatisation (NCP) are the government�s octopus bodies perfected to dispose public property to private hands. And in recent time, the past activities of the bureau under El-Rufai, have been called to question even from the unexpected quarters, the National Assembly with respect to the privatisation scandal in Nitel -Pentascope deal, Ajaokuta Steel debt buy back, Sheraton Hotels which ran into billions of naira. This makes Osomo�s scandal a child�s play. Yet today, El-Rufai is the apple of the presidency�s eye.
The same regime has conveniently looked the other way against all cries that the former Works Minister, Tony Anenih should be probed for squandering over N300 billion meant for federal road construction and maintenance. With nothing to justify the huge sum, the former minister, rather than being probed got promoted as the chairman of the ruling party�s (PDP) board of trustee and a close confidant of the president.
In the recent exposure of the fraudulent sales of 207 choice properties of federal government at Ikoyi, Lagos, five of the beneficiaries were direct relations (brothers, sisters and in-laws) of Stella Obasanjo among other top government officials including serving ministers, governors and senators acquiring properties worth several millions of naira without questioning the source of their stupendous wealth.
The Ikoyi house sale scandal is a vivid example of what privatisation means in the true sense of it - legalized stealing of public wealth. Quoting The Guardian of Sunday April 17, 2005, page 10, one of the affected occupants of the sold houses, a woman who resides at 25, Ilabere Street, Ikoyi has an agonizing tale to tell: "I am one of the victims. My house was sold. My husband, a Colonel, is still in service. As far back as 3rd of February, some guys came to inspect our house. They said that my house has been sold along with my neighbour�s house. They said they have documents from the ministry of Housing to back up their claims. They didn�t allow me to read the letter���I asked him who bought the house? He said it is a directive from the presidency, that an official in the presidency bought the two houses".
The cancellation of the deal by the president was not a self righteous step but a pre-emptive one, hurriedly taken to forestall embarrassment the deal would have caused him with the involvement of his household. Stella Obasanjo has her fingers in many blue chip companies using fronts. Her business involvement and that of Gbenga Obasanjo, the president son in COJA and other shady deals remain unprobed.
The major face of corruption in the government is the privatisation programme where government officials rush to buy under-valued public property with stolen public money. These properties/establishments are, in most cases, resold at exorbitant prices, while workers and residents are thrown out in order to maximize profit.
Obasanjo�s regime has made over N10 trillion, mainly from oil in its six years, yet there is no visible development in infrastructure or standard of living of the poor masses except the increasing body weight of Mr. President. The lot of the people is unemployment, mass retrenchment, insecurity of life and property. So, while government makes more money than ever before in the history of the country, life has become more miserable for the poor working masses.
According to the United Nations Industrial Organisation (UNIDO), about $107 billion of Nigerian money is held in private accounts in Europe and the US. With the country�s fictitious foreign debt quoted at $35billion, the World Bank says the country is now poorer in terms of income levels than Bangladesh.
Also quoting the Department For International Development (DFID), over 70% Nigerians live on $1 daily. Between 80 and 90 million Nigerians are living in absolute poverty while 29 percent of the country�s children are under weight. Yet, government embarks on wasteful spending on White Elephant projects such as 8th All African Games (COJA) which gulped N3 billion on official figures. Mr. President has spent, as at the time of going to press, 512 days outside Nigeria at a cost yet to be determined. Before the end of this year, another twenty one government establishments, including Nigerian Ports Authority, NIGERDOC, NEPA etc. are to be sold off, as usual cheaply, to corrupt government officials and their business associates. The attendant effect will be mass retrenchment of workers in those establishments adding to misery in the land. The regime is united in corruption against the poor working masses.
OBASANJO FIDDLES AS THE NATION ROTS: CAN HE FIGHT CORRUPTION?
The tough image against corruption being depicted by Obasanjo is a mere political bravado. Nobody should be deceived. The regime itself is a child of corruption. The elections that brought Obasanjo and PDP to power was a monumental fraud. Apart from collecting money from dubious characters including 419, fraudulent politicians and government officials to execute the elections, Obasanjo�s election in his home state, Ogun, has been declared an electoral fraud by a court of law. He had also become accomplice to several electoral fraud in different states. Anambra State saga is a quick reminder where Ngige and Uba confessed to Obasanjo how the gubernatorial election in Anambra State was rigged. What did he do? In his (Obasanjo) word, "I was horrified and told both of them (Ngige and Uba) to leave my residence".
It is not a hidden fact that before Obasanjo was sworn-in in May 1999, Obasanjo Otta Farm Project had completely been abandoned. Where then did the resources that revamp the farm to a state where according to Fani Kayode, now monthly generates N30 million as profit, come from?
Presently, the Minister of Finance, Ngozi Iweala earns a whooping sum of $247,000 (not paid in naira!) per annum. On top of this, her accommodation, feeding, transportation, telephone, education and health care expenses of herself and family are completely borne by the government. This takes place in a country where the minimum wage is N5,500 and where tens of millions are jobless and without any social security payment.
If the regime is serious about fighting corruption, all it requires is simple. All the political/ public office holders should first declare their assets with periodic assessment; earn average wages of skilled workers; adequate funding of social services and amenities like education, health, transportation, security, electricity etc. But the regime will never do this. On the contrary, what obtains is a situation where public office holders earn fabulous salaries and allowances, with some receiving their salaries in dollars, inflating contracts, etc combined with policy of privatisation and commercialisation of public utilities that allows few rich who have stolen or via their fronts, acquiring to themselves these properties at give away prices at the expense of the poor majority. In this kind of situation, crusade against corruption is a farce.
CAN THE SUFFERING END?
Under this capitalist regime, with its anti-workers neo-liberal policies, the suffering of the workers and poor masses will continue. Things will get worse with more pains and pangs for the Nigerian people. The coming period will witness more stealing of public fund by government officials at all levels to prosecute year 2007 election. With the anti-people programmes of the regime, more jobs cuts, grinding poverty, starvation and homelessness will be the lots of the poor working masses.
The only way forward is for the masses to rely on their own strength, mobilise, organise and build a movement that will struggle against the system with the vision of replacing this unjust government with a working class-based government that will nationalise the commanding height of the economy so that working people can begin to democratically plan the economy for common good. This can be achieved when workers, youth, farmers, poor masses organise into working class party with socialist perspective, programmes and ideas.


text:
Fue la edición N° 93 de la FA Community Shield, disputada por el Chelsea como ganador de la Premier League 2014/15 y el Arsenal, campeón de la FA Cup 2014-15 el 2 de agosto de 2015.

El ganador fue el Arsenal, que venció 1-0 al Chelsea con gol de Alex Oxlade-Chamberlain. Consiguiendo su título 14° de Community Shield.

Equipos participantes

Partido

2015
Fútbol en 2015
Deporte en Reino Unido en 2015
Arsenal Football Club

redpajama_set_name: RedPajamaWikipedia


After a failed attempt to make gluten free orange and almond cupcakes, I needed to make something simple – using just the ingredients in my cupboard – to restore my confidence. And nothing could be simpler than this recipe. The combination of roasted hazelnuts, oats and golden syrup is delicious. It kept very well, so I ate it for nearly week as breakfast.
Preheat oven to 180C. Grease and line a 16x26cm slice pan with baking paper.
Place rolled oats, hazelnuts and flour in a large bowl and mix.
Place butter, golden syrup and raw caster sugar in a small saucepan over a low heat and stir until melted and combined. Pour onto the dry ingredients and mix well. Spoon the mixture into the prepared pan. Use the back of a soup/dessert spoon to smooth the surface.
Bake for 20 – 25 minutes, or until golden and firm to the touch. Use a knife to score lines into the slice to make 16 pieces and allow to cool completely in the pan.
Remove from pan and cut with a sharp knife.
I do like to make fiddly treats. Something that you can really get your hands into. This roll/slice definitely falls into that category. I think it would have been helpful to have latex gloves on hand, but I made do baking paper and a spatula to shape the chocolate mixture in the log shape. I was very happy with the way this turned out and I think I will include it the little gift basket I put together for Christmas each year.
Using an electric mixer, beat butter and sugar until light and fluffy. Add egg yolks, one at a time, beating well after each addition.
Fold in cocoa, then stir in nougat, savioardi, white chocolate and hazelnuts until well combined.
Place a 30cm-long sheet of foil on a work surface and top with a sheet of baking paper. Spoon chocolate mixture along one long edge, leaving a 2cm border at both ends. Roll up foil to enclose chocolate mixture and form a log, then twist ends to seal.