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Effect of a brief intervention for alcohol and illicit drug use on trauma recidivism in a cohort of trauma patients
Sergio Cordovilla-Guardia ,
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing
* E-mail: cordovilla@unex.es
Affiliation Nursing Department, Nursing and Occupational Therapy College, University of Extremadura, Cáceres, Spain
Enrique Fernández-Mondéjar,
Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing
Affiliations Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, Granada, Spain, Instituto de Investigación Biosanitaria IBS, Granada, Spain
Raquel Vilar-López,
Roles Conceptualization, Data curation, Methodology, Writing – original draft, Writing – review & editing
Affiliations Department of Personality, Evaluation and Psychological Treatment. University of Granada, Granada, Spain, Addictive Disorders Network, RTA Instituto de Salud Carlos III, Spanish Ministry, Spain, Mind, Brain and Behavior Research Centre, University of Granada, Granada, Spain
Juan F. Navas,
Roles Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing
Affiliations Mind, Brain and Behavior Research Centre, University of Granada, Granada, Spain, Department of Experimental Psychology. University of Granada, Granada, Spain
Mónica Portillo-Santamaría,
Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing
Affiliation Servicio de Salud Mental, Hospital de la Ribera, Valencia, Spain
Sergio Rico-Martín,
Roles Conceptualization, Formal analysis, Resources, Validation, Writing – original draft, Writing – review & editing
Pablo Lardelli-Claret
Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing
Affiliations Instituto de Investigación Biosanitaria IBS, Granada, Spain, Department of Preventive Medicine and Public Health, School of Medicine, University of Granada, Granada, Spain. CIBER of Epidemiology and Public Health. Spain
Sergio Cordovilla-Guardia,
Sergio Cordovilla-Guardia Enrique Fernández-Mondéjar ... Pablo Lardelli-Claret
Estimate the effectiveness of brief interventions in reducing trauma recidivism in hospitalized trauma patients who screened positive for alcohol and/or illicit drug use.
Dynamic cohort study based on registry data from 1818 patients included in a screening and brief intervention program for alcohol and illicit drug use for hospitalized trauma patients. Three subcohorts emerged from the data analysis: patients who screened negative, those who screened positive and were offered brief intervention, and those who screened positive and were not offered brief intervention. Follow-up lasted from 10 to 52 months. Trauma-free survival, adjusted hazard rate ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated, and complier average causal effect (CACE) analysis was used.
We found a higher cumulative risk of trauma recidivism in the subcohort who screened positive. In this subcohort, an aHRR of 0.63 (95% CI: 0.41–0.95) was obtained for the group offered brief intervention compared to the group not offered intervention. CACE analysis yielded an estimated 52% reduction in trauma recidivism associated with the brief intervention.
The brief intervention offered during hospitalization in trauma patients positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism.
Citation: Cordovilla-Guardia S, Fernández-Mondéjar E, Vilar-López R, Navas JF, Portillo-Santamaría M, Rico-Martín S, et al. (2017) Effect of a brief intervention for alcohol and illicit drug use on trauma recidivism in a cohort of trauma patients. PLoS ONE 12(8): e0182441. https://doi.org/10.1371/journal.pone.0182441
Editor: Kent E. Vrana, Pennsylvania State University College of Medicine, UNITED STATES
Received: December 16, 2016; Accepted: July 18, 2017; Published: August 16, 2017
Copyright: © 2017 Cordovilla-Guardia et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by the Dirección General de Tráfico, Spain [grant number: 0100DGT22389] http://www.dgt.es/ (EFM); and the Consejería de Salud, Junta de Andalucía, Spain [grant number: PI-0691-2013] http://www.juntadeandalucia.es/salud/sites/csalud/portal/index.jsp (RVL). JFN is funded by an individual research grant from the Spanish Ministry of Education, Culture and Sport (FPU13/00669) http://www.mecd.gob.es/portada-mecd/. The study sponsors had no role in the design of the study; the collection, analysis, or interpretation of data; the writing of the report; or the decision to submit the article for publication.
Traumatic injury related to alcohol and illicit drug use remains an important public health challenge [1,2]. Among other health problems, the use of these substances is frequently associated with trauma recidivism [3–7]. The use of screening, brief intervention, and referral to treatment (SBIRT) programs in trauma centers [8] is spreading as an evidence-based measure which may enhance the impact of preventive efforts in this population [9]. Brief intervention (BI) is a counseling approach based on the principles of motivational interviewing [10], a collaborative person-centered form of guidance intended to elicit and strengthen motivation for change [11]. Brief interventions usually consist of one to four individual interviews lasting 7.5 to 60 minutes each [12,13], and are usually conducted by psychologists, nurses or doctors with specific training [12], although they can be successfully implemented by other health care practitioners [14]. Considerable evidence documents the usefulness of BI to combat problematic alcohol use in primary care [12], general hospitals [13] and trauma centers [13,15]. Admission to trauma centers offers a potential "teachable moment" because patients may have perceptions of vulnerability about their health and therefore may be particularly receptive to screening and counseling [16]. Numerous studies have reported the short-term effectiveness of a single BI session in reducing alcohol consumption when the session takes place during admission in these clinical settings [15,17–19], especially when BI is combined with a telephone booster after discharge [15,17,18,20,21]. However, the results were relatively modest after 12 months of follow-up. There is also evidence of the effectiveness of BI in reducing illegal drug consumption [22] or both alcohol and illicit drug use [23].
In light of this evidence, the American College of Surgeons passed a resolution in 2005 requiring level I trauma centers in the USA to have a mechanism for screening injured patients for alcohol-use disorder and providing an intervention to patients who screen positive [24]. This mandate greatly increased the dissemination of SBIRT programs [25]. In 2011, encouraged by this expansion, we implemented a project based on SBIRT (the MOTIVA project) targeted for patients hospitalized at our center for trauma related to alcohol and illicit drug use [26].
Unfortunately, the well-documented effect of BI in reducing alcohol or illicit drug consumption has not been accompanied by similar evidence of reductions in health events theoretically related to substance use. Thus far, the effect of BI on injury recurrence remains unclear. Gentilello et al. [27] tested the effect of brief alcohol intervention in a trauma center to reduce recidivisms. They found a 47% reduction in injuries requiring emergency department care or trauma center admission during the first year. An almost identical reduction in inpatient hospital readmissions (48%) was found in patients in the intervention group with up to 3 years of follow-up. However, neither of these estimates reached statistical significance. A similar reduction (41%) was found in a later metaanalysis [28] that combined the results from three studies [20,29,30] which considered trauma recidivism as a secondary outcome. However, the heterogeneity between studies regarding major design factors such as age of participants (adolescents 13 to 17 years old [29], older adolescents aged 18–19 years [30] or with no reported age range [20]) and length of follow-up (6 months [30] or 12 months [20,29]) raise questions concerning the validity of this estimate. More recently, Woolard et al., (2013) [31] evaluated the effect of BI for patients seen in the emergency department for alcohol and marijuana use after 12 months of follow-up. Although they found a decrease in binge drinking and conjoint use, the anticipated reductions in injury rates were not found.
Undoubtedly, methodological drawbacks shared by most previous studies [20,29–31] make it hard to offer valid evidence of the effectiveness of BI. For example, short follow-up periods (no more than 12 months) provide no information on the longer-term effects of BI, and the self-reported nature of the main outcome (recidivism) raises the possibility of differential misclassification bias.
In an effort to overcome these limitations we designed the present study to evaluate the effectiveness of BI in patients hospitalized for trauma who screened positive for alcohol and/or illicit drug use. Our main objective was to study the effect of BI on reductions in trauma recidivism after 10 to 52 months of follow-up. This research was accordingly designed to test two hypotheses:
The recidivism rate in patients who screened negative for alcohol or illicit drug use is lower than in patients who tested positive and did not receive BI.
In the subgroup of patients who screened positive for alcohol or illicit drug use, the recidivism rate in those who receive BI is lower than in patients who did not receive BI.
The MOTIVA project
This retrospective, region-wide, dynamic cohort study was based on data obtained from the MOTIVA project, with passive and active follow-up lasting from 10 to 52 months and was approved by the Granada Provincial Research Ethics Committee (CEI-Granada).
The MOTIVA project was a SBIRT-based program implemented in November 2011 at University Hospital of Granada (UHG). This center is a public tertiary-care hospital located in Andalusia, an autonomous region in southern Spain, and as part of the public health national system it covers a population of more than 600,000 inhabitants. The MOTIVA project was active during the 31 nonconsecutive months during which it received financial support from the Regional Andalusian Government and the Spanish National Traffic Directorate: November 2011 to October 2012, June 2013 to November 2013, and June 2014 to June 2015. The reference population for this project was all patients aged 16 to 70 years who were hospitalized for traumatic injuries. The MOTIVA project comprised the following activities:
a) Screening for alcohol and drugs. Of all 1818 patients aged 16 to 70 years who were hospitalized for trauma during the study periods (Fig 1), 1187 (65.3%) could be screened for alcohol and drug use; 609 patients were not screened and 22 refused screening. Informed consent was requested for alcohol and drug testing. In sedated patients or unable to collaborate, samples were collected at admission and consent to access the results of the screening was solicited when the patient´s clinical situation was resolved. When this was not possible, the consent was requested to the relatives. Alcohol consumption was screened by blood testing, and was considered positive when the blood alcohol level was higher than 0.3 g/L. For patients from whom a blood sample could not be obtained, the Alcohol Use Disorders Identification Test (AUDIT-C) was used, and the result was considered positive for patients who were admitted for problem drinking [32]. An AUDIT-C score of 4 or more in men and 3 or more in women was considered positive. Screening for other drugs (cannabis, cocaine, amphetamines, methamphetamines, benzodiazepines, opiates, methadone, barbiturates or tricyclic antidepressants) was done with urine testing by fluorescence immunoassay. Reviews of the patients' medical records were used to rule out patients who tested positive for benzodiazepines and opioids as a result of emergency treatment of their injury. Overall, 555 patients (46.8% of those screened) tested positive for alcohol or drugs. For the purpose of this study, we excluded from the cohort screened patients who met the following exclusion criteria: nonresidents in Andalusia, non-Spanish speaking, post-traumatic brain injury, mental disorders, spinal cord injury, and death during hospital stay. Two additional exclusion criteria were used for positive patients: positive screening result due to prescribed use of benzodiazepines, opioids, barbiturates or tricyclic antidepressants, and drug dependence under treatment. Therefore the final cohort comprised 867 patients, classified in two subcohorts: negative for alcohol and drugs (NAD: 548 patients) and positive for alcohol and/or drugs (PAD: 319 patients).
Fig 1. Flowchart of the distribution of patients.
† Patients between 16 and 70 years old admitted. ‡ Active follow-up by telephone interview (NAD: n = 91, BI accepted: n = 151, BI offered: n = 113). NAD: Negative for alcohol and/or drugs. PAD: Positive for alcohol and/or drugs. BI: Brief Intervention. No withdrawals in BI rejected group.
b) Brief intervention. Patients included in the PAD subcohort were candidates to receive BI. The convalescence period just before hospital discharge was considered the best window of opportunity for the interview, but some patients were discharged without receiving the BI, mainly those with a short hospital stay. Therefore BI was not offered to 132 (41.4%) eligible patients (NBI). In the remaining group of 187 for whom BI was offered (OBI), 25 (13.4%) patients who agreed to be screened declined the BI (BID group). Therefore a final total of 162 patients accepted and received the BI (BIA group).
The BI consisted of an interview (30 to 45 min) based on motivational interviewing principles [10]. All interviews consisted of six components.
Introduction starting with communication of the screening results and explanation of the aim of the intervention. We sought a positive response indicating the patient's willingness to participate in the intervention, through the expression of interest and concern with an empathic therapeutic approach and efforts to encourage confidence.
Exploration of the motivation for consumption and review of potential negative consequences, to favor discovery of the pros and cons of current substance use.
Personalized normative feedback about the patient's pattern of alcohol/drug use and risks, and resolution of ambivalence with nonconfrontational responses to resistance.
Discussion of possible future situations that might arise from the patient's current consumption of alcohol and/or drugs versus a change in consumption behavior.
When the level of motivation to change allowed: negotiation of consumption goals, identifying and anticipating potential barriers and establishing strategies to overcome them, favoring self-efficacy.
Final summary in which the patient was asked to state his or her conclusions, and any remaining questions were answered.
In all cases the patients were informed about community resources for problems with alcohol and illicit drug use. Patients were contacted by telephone 3 months after hospital discharge for a 10–15 min booster session to increase motivation to pursue their goals. The telephone booster session was performed in 123 (75.9%) patients of the BIA group. All interventions were conducted by a nurse or psychologist with the same specific training in BI. This training consisted of instruction, demonstrations and active learning exercises [33] provided by a clinical psychologist with extensive experience in motivational interviewing.
c) Registry of participants. A specially designed registry of all screened patients included information about the screening test results and BI implementation. The following additional information obtained prospectively from the medical record during the hospital stay was also included the registry: age, sex, mechanism of injury, Injury Severity Score (ISS) [34], diagnosis of psychiatric comorbidity, days of hospitalization and hospital mortality.
In order to complete the information regarding past trauma history (PTHx) of the patients included in the study, the Andalusian Regional Health Service Database (Diraya®) [35] was also consulted. This database, in operation since 1999, includes the patients' medical history and records of any health care received at more than 1500 centers operated by the Andalusian Public Health Service.
The three resulting subcohorts (548 NAD patients, 132 NBI patients and 187 OBI patients) were followed up with two procedures: passive follow-up and active follow-up.
Passive follow-up.
During the period from March to June 2016 the digital medical records (from the Diraya® database) of patients from all three subcohorts were reviewed to search for trauma recidivism up until March 1, 2016. Trauma recidivism was defined as the occurrence of a new traumatic injury requiring medical care at any center belonging to the regional public health system. The nurses who conducted this review were blinded to exposure status, and collected information on the occurrence of a new trauma, date, injury mechanism and ISS. To detect deaths during follow-up, those that occurred in any health care facility were also searched for in the Diraya® database. In addition, we consulted the database of the Provincial Institute of Forensic Medicine and funeral service records for the same period.
Active follow-up.
For purposes of comparison with passive follow-up data, active telephone follow-up was used for all PAD patients and a random sample of 91 NAD patients. To estimate the sample size we assumed an expected recidivism of 22% [36] and loss to follow-up less than 5%. In the telephone interview we ask each patient about the same variables as were used in passive follow-up, plus information about withdrawal from the cohort due to change of residence to another region outside Andalusia (2 in the BIA group and 1 in the NBI group) or change to private health insurance (1 patient in the NAD group).
Definition of study variables
For exposure we defined three main subgroups of patients: NAD, OBI and NBI. Patients who screened as PAD were subclassified into the following categories: consumers of alcohol (only alcohol detected), cannabis (only cannabis), cocaine-amphetamine (positive for amphetamine, methamphetamine and/or cocaine) and polydrugs (including any combination of two or more of the above groups). Exposure to heroin and methadone, when detected, was always accompanied by exposure to at least one other substance in this study, so all patients who screened positive for these two drugs were included in the polydrugs group. Patients in the OBI subcohort were classified according to whether they accepted (BIA group) or declined BI (BID group).
Cohen's kappa index was used to estimate concordance between the percentages of recidivists (any new trauma) found by active and passive follow-up method. On the basis of the passive follow-up, we defined two outcome variables for each patient:
Number of traumatic injuries during follow-up. This variable allowed us to estimate the incidence rate of trauma in each subcohort.
Time from hospital discharge up to the first new trauma, withdrawal or the end of follow-up with no new injury (March 1, 2016).
As potential confounders we recorded the following at baseline: age, length of hospital stay (continuous), sex (male or female), mechanism of injury (traffic, sports, assault, falls on the same level, falls from a height, cuts or bruises, and other mechanisms), injury severity categorized into three levels according to ISS (mild: 1 to 8, moderate: 9 to 15, and severe: ≥16), and PTHx classified into three levels (nonrecidivist: first-time trauma patient, single recidivist: only one previous trauma, and multirecidivist: patients with more than one previous trauma).
A descriptive analysis is reported here of the patients' baseline characteristics and outcomes in each subcohort. To evaluate the effect of BI on trauma recidivisms, two complementary strategies were used: intention-to-treat (ITT) analysis (comparison of the OBI and NBI groups) and per-protocol (PP) analysis (comparison of BIA and NBI groups). The Kaplan–Meier product-limit method and the log-rank test were used to estimate and compare curves for survival without new trauma events in each subcohort. Cox proportional hazards regression was used to obtain adjusted hazard rate ratios (HRR) to estimate the strength of association between each exposure level and the incidence of first traumatic events, including all baseline characteristics as covariates. For the total number of trauma events during the entire follow-up period for each patient as the dependent variable, a Poisson regression model was used to obtain the corresponding adjusted incidence rate ratios (IRR). Likelihood ratio tests (lrtest) were used to examine the potential statistical interaction between BI and PTHx.
Additionally, to compare the OBI and NBI groups, complier average causal effect (CACE) analysis [37] was used to obtain adjusted IRR estimates in the hypothetical subgroup of patients who would have agreed to receive the intervention if it had been offered.
All data analyses were done with Stata Statistical Software, Release 14 (StataCorp. 2015, College Station, TX, USA).
Of the 1187 patients screened, 555 (46.8%) were positive. After the exclusion criteria for BI were applied, we obtained a cohort of 867 patients (548 NAD patients, 319 PAD patients). Differences in the baseline characteristics between groups (Table 1) were observed for age (higher median age in the NAD group), sex (higher proportion of females in the NAD group) and PHTx (much higher frequency of nonrecidivism in the NAD group). When we compared the NBI and OBI groups, the main difference, as expected, was in length of hospital stay, which was much longer in the OBI group. The proportions of mild injuries and polydrug use were lower in the OBI group, whereas cannabis use was more frequent.
Table 1. Baseline characteristics of the groups.
The concordance for recidivism between passive and active follow-up was high (Table 2). However, active follow-up detected a lower number of new injuries in the OBI group (55 vs. 62 with passive follow-up).
Table 2. Analysis of concordance between passive and active follow-up of first trauma.
According to data from passive follow-up, the incidence rate of trauma recidivism was 8.7 per 100 patient-years in the NAD subcohort, 14.1 per 100 patient-years in the OBI subcohort, 13.0 per 100 patient-years in the BIA subcohort and 25.4 per 100 patient-years in the NBI subcohort. Subsequent trauma after discharge took place a median of 16 months earlier in the NBI group than in the OBI group (Table 3); however, there were no significant differences between groups in the mechanism, severity of injury or percentage of hospitalized trauma patients.
Table 3. Characteristics of the first new trauma in each patient during follow-up†.
Kaplan–Meier curves (Fig 2) showed a significantly greater cumulative risk of recidivism in the two PAD subcohorts (OBI and NBI) compared to the NAD group. In the PAD subcohort, longer trauma-free survival was observed for the OBI group than the NBI group (Fig 3).
Fig 2. Kaplan–Meier curves of trauma-free survival in follow-up patients.
NAD: Negative for alcohol and/or drugs. OBI: Offered brief intervention group. NBI: Not offered brief intervention group.
Fig 3. Kaplan–Meier curves of trauma-free survival in follow-up patients positive for substances.
Hall–Wellner bands represent 95% confidence intervals. OBI: Offered brief intervention group. NBI: Not offered brief intervention group. Adjusted hazard ratio using Cox proportional hazards regression model with covariables age, sex, mechanism of injury, Injury Severity Score, days of hospitalization, substance detected and past trauma history. NBI as the reference group.
The results of multivariate regression analysis for the entire cohort are shown in Table 4. According to the Cox proportional model with the NAD group as the reference, the adjusted HRR was 1.31 (95% CI: 0.96–1.78) for the OBI group and 2.14 (95% CI: 1.53–2.98) for the NBI group. Other variables related with recidivism were age (inversely associated) and PTHx (positively associated). The corresponding values for adjusted IRR were similar. There was no evidence of interaction between BI and PTHx on the risk of trauma recidivism (p = 0.754 in the lrtest).
Table 4. Multivariate regression models for the entire cohort (NAD + PAD).
When the analysis was restricted to PAD patients (Table 5) the adjusted HRR was 0.63 (95% CI: 0.41–0.95) for the OBI group compared to the NBI group. This lower risk of recidivism increased to 0.55 (95% CI: 0.36–0.85) in the per-protocol analysis (i.e., when we compared the NBI and BIA groups). The corresponding adjusted IRR values were 0.61 (95% CI: 0.43–0.86) for the OBI group and 0.45 (95% CI: 0.3–0.66) for the BIA group. The CACE analysis yielded an adjusted IRR of 0.48 (95% CI: 0.24–0.98). The pattern of association for the remaining baseline variables was not substantially different from that obtained for the entire cohort; only lower age and PTHx were significantly associated with trauma recidivism.
Table 5. Multivariate regression models for the PAD subcohort.
Our results strongly support the two hypotheses posed in the Introduction: trauma patients who tested positive for alcohol or illicit drug use had a higher rate of recidivism than those who tested negative, and among positive patients the recidivism rate was lower in those who received the BI. This latter result strongly supports the effect of BI in reducing the frequency of trauma recidivism in patients who screen positive for alcohol and/or other drug use. In the present study the more conservative (intention-to-treat) estimate yielded a 39% relative decrease, which rose to 52% decrease according to the CACE analysis. In addition, the first trauma after hospital discharge occurred 16 months earlier in the NBI group (who had less severe injuries at baseline) than in the OBI group. This emphasizes the benefit of the BI.
Given that in our setting almost half of trauma patients are admitted under the influence of alcohol and/or illicit drugs [38], the potential impact on public health of the implementation of SBIRT programs in trauma centers in Spain is enormous. In a cost-benefit analysis [39] with a similar estimated trauma risk reduction, screening and brief intervention for alcohol problems in trauma patients was found to be cost-effective (savings of USD3.81 for every USD1.00 spent), and the authors suggested that it should be routinely implemented. We note that the although the authors of that study only analyzed the impact of interventions on direct medical costs, we concur that the potential cost savings can be considered an additional advantage to the gains in other important indirect social benefits–which admittedly may be harder to quantify.
Our results are similar to those obtained in previous studies [27,28]; nevertheless, to our knowledge ours is the first long-term follow-up study (almost 5 years in some cases) of a patient cohort designed to measure the impact of BI on trauma recidivism. Previous efforts have focused on the decrease in alcohol and drug consumption as the primary outcome, and considered a reduction in recidivism as a secondary outcome [20,29–31]. It is important to take into account that the reduction in alcohol and illicit drug use resulting from BI may not be the only mediator between BI and the reduction in trauma recidivism: BI may also have a positive influence on other variables causally related to trauma, such as impulsive behavior [40–46] or trauma risk perception related to substance use. This perceived risk is particularly low in our social context, especially among consumers of substances other than alcohol, such as cannabis and cocaine [38]. According to the authors of the DRUID project (DRiving Under the Influence of Drugs) carried out in 18 European countries [47], the greater likelihood observed in some countries of detecting drivers under the influence of illicit drugs and medicines compared to drivers exposed to alcohol may be explained by the lower efforts and resources devoted to campaigns for accident prevention related to the consumption of these substances. These indirect mediators may explain why, although BI produces good short-term results in reducing alcohol consumption, these effects are diminished after 12 months [13,23], whereas the influence of the intervention in reducing the risk of trauma recidivism appears to be sustained in the long-term [27]. On the other hand, the effectiveness of screening and BI for drug use is being questioned by some studies [22,48]; however, our results show that the usefulness of these interventions goes beyond the reduction of consumption.
Although Gentilello et al. [27] used a health information system similar to ours to detect new traumas beyond 12 months, their design was sensitive only to injuries that resulted in hospitalization or death, whereas we were able to detect any trauma which received medical care regardless of whether it led to hospitalization.
A key element in our BI method was the addition of a booster phone call after 3 months in order to help patients to maintain the changes they resolved to make during hospitalization [26]. However, all previous studies also used a phone booster during the first month after hospital discharge [15,17,18,20,21]. We believe that a later booster session may help to enhance the effects of BI on recidivism by acting after physical recovery in most patients, i.e. when their motivation to abstain or limit substance use tends to decrease [26].
Regarding the other variables we investigated and their relation to recidivism, alcohol and illicit drug use and previous trauma history were the most important markers, confirming evidence from previous studies [3–7,49,50]. We tested the possibility that the effect of BI on the risk of recidivism might be modified by PHTx, but the interaction term between these two variables in the model was not significant. If the effectiveness of BI does not depend on a patient's past trauma history, this variable may be useful to identify subgroups of high-risk patients for whom SBIRT programs should be prioritized [51,52], especially in situations when the lack of resources prevents the use of these programs for all patients who screen positive for alcohol or illicit drug use in the hospital emergency department.
We are aware that the main limitation of our study is the nonrandom assignment of our patients to the BI or no BI groups. Ethical reasons prevented this option, because when the MOTIVA project was implemented there was strong evidence supporting the effectiveness of SBIRT programs in reducing alcohol consumption. However, despite this evidence, it is noteworthy that this project is the only SBIRT-based initiative implemented in Spain thus far. In all cases, whether the patient received the BI or not was dependent only on the availability of an SBIRT interviewer, which in turn was related with the length of the patient's hospital stay. A shorter stay may lead to less compliance with staff, which can lead to greater rejection of medical advice. Because variable "days of hospitalization", along with the main baseline characteristics of the patients, was included in our multivariate models, we are confident that the adjusted association we found between BI and recidivism reflects a causal effect, although we cannot completely rule out alternative noncausal explanations.
Another possible drawback of our study is selection bias due to incomplete and differential follow-up. For example, patients may have been injured and received care in a different public health service area or may have switched to a private health insurance plan unconnected with the public health information network. We made an effort to complement follow-up through public health digital medical records with active follow-up by telephone. However, because of the high correlation between these two data sources and the low number of patients we detected as losses to follow-up, we are confident that this source of bias very likely had a low impact on our results.
The results of this study suggest that a BI for hospitalized trauma patients who screened positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism. Although trauma recidivism in patients who received the brief motivational intervention was greater than in patients who screened negative for alcohol and/or illicit drug use on admission, the significant decrease compared to patients who screened positive and did not receive the intervention supports the need to implement screening and BI programs in trauma centers. Further research will be needed to explore how brief interventions influence factors other than the cessation of or reduction in alcohol and illicit drug use, such as impulsivity or trauma risk perception related to substance use, and to determine whether a positive effect on these factors might explain why decreased trauma recidivism appears to be maintained over time.
S1 Data File.
(DTA)
We thank the Fundación para la Investigación Biosanitaria de Andalucía Oriental (FIBAO), Matilde Sanchez and the rest of the trauma unit professionals, JM Salmeron, Inmaculada Romero and all the collegues of the Intensive Care Unit of University Hospital of Granada, Spain for their contribution to the development of the SBIRT program, and K. Shashok for improving the use of English in the manuscript.
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14. Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behavior. Applications of motivational interviewing. New York: Guilford press; 2008.
15. Field C, Walters S, Marti CN, Jun J, Foreman M, Brown C. A multisite randomized controlled trial of brief intervention to reduce drinking in the trauma care setting: how brief is brief? Ann Surg. 2014;259: 873–80. pmid:24263324
16. Woodruff SI, Clapp JD, Eisenberg K, McCabe C, Hohman M, Shillington AM, et al. Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the Life Shift/Shift Gears study. Addict Sci Clin Pract. 2014;9: 8. pmid:24886786
17. Sommers MS, Lyons MS, Fargo JD, Sommers BD, McDonald CC, Shope JT, et al. Emergency department-based brief intervention to reduce risky driving and hazardous/harmful drinking in young adults: a randomized controlled trial. Alcohol Clin Exp Res. 2013;37: 1753–62. pmid:23802878
18. D'Onofrio G, Fiellin DA, Pantalon M V, Chawarski MC, Owens PH, Degutis LC, et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Ann Emerg Med. 2012;60: 181–92. pmid:22459448
19. Nilsen P, Baird J, Mello MJ, Nirenberg T, Woolard R, Bendtsen P, et al. A systematic review of emergency care brief alcohol interventions for injury patients. J Subst Abuse Treat. 2008;35: 184–201. pmid:18083321
20. Longabaugh R, Woolard RE, Nirenberg TD, Minugh AP, Becker B, Clifford PR, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. J Stud Alcohol. 2001;62: 806–16. pmid:11838918
21. Soderstrom C a, DiClemente CC, Dischinger PC, Hebel JR, McDuff DR, Auman KM, et al. A controlled trial of brief intervention versus brief advice for at-risk drinking trauma center patients. J Trauma. 2007;62: 1102–11–2. pmid:17495708
22. Bogenschutz MP, Donovan DM, Mandler RN, Perl HI, Forcehimes AA, Crandall C, et al. Brief intervention for patients with problematic drug use presenting in emergency departments: a randomized clinical trial. JAMA Intern Med. 2014;174: 1736–45. pmid:25179753
23. Klimas J, Field C-A, Cullen W, O'Gorman CS, Glynn LG, Keenan E, et al. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: Cochrane Review. Syst Rev. 2013;2: 3. pmid:23311684
24. American College of Surgeons Committee on Trauma. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons Committee on Trauma; 2006.
25. Zatzick D, Donovan DM, Jurkovich G, Gentilello L, Dunn C, Russo J, et al. Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial. Addiction. 2014;109: 754–65. pmid:24450612
26. Dunn C, Ostafin B. Brief interventions for hospitalized trauma patients. J Trauma. 2005;59: S88-93-100.
27. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, Daranciang E, Dunn CW, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg. 1999;230: 473–80–3.
28. Havard A, Shakeshaft A, Sanson-Fisher R. Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction. 2008;103: 368–76–8. pmid:18190671
29. Spirito A, Monti PM, Barnett NP, Colby SM, Sindelar H, Rohsenow DJ, et al. A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department. J Pediatr. 2004;145: 396–402. pmid:15343198
30. Monti PM, Colby SM, Barnett NP, Spirito A, Rohsenow DJ, Myers M, et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consult Clin Psychol. UNITED STATES; 1999;67: 989–94. http://dx.doi.org/10.1037/0022 pmid:10596521
31. Woolard R, Baird J, Longabaugh R, Nirenberg T, Lee CS, Mello MJ, et al. Project reduce: reducing alcohol and marijuana misuse: effects of a brief intervention in the emergency department. Addict Behav. 2013;38: 1732–9. pmid:23261491
32. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31: 1208–17. pmid:17451397
33. Madson MB, Loignon AC, Lane C. Training in motivational interviewing: a systematic review. J Subst Abuse Treat. Elsevier Inc.; 2009;36: 101–9. pmid:18657936
34. Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW. The Injury Severity Score revisited. J Trauma. 1988;28: 69–77. pmid:3123707
35. González Cocina E, Pérez Torres F. La historia clínica electrónica. Revisión y análisis de la actualidad. Diraya: la historia de salud electrónica de Andalucía. Rev Española Cardiol. Elsevier; 2007;7: 37–46.
36. Dixon SD, Como JJ, Banerjee A, Claridge J a. Trauma recidivists: surprisingly better outcomes than initially injured trauma patients. Am J Surg. Elsevier Inc; 2014;207: 427–31; discussion 431. pmid:24439159
37. Imbens GW, Rubin DB. Causal Inference for Statistics, Social, and Biomedical Sciences: An Introduction. Cambridge: Cambridge University Press; 2015. https://doi.org/10.1017/CBO9781139025751
38. Cordovilla-Guardia S, Guerrero-López F, Maldonado A, Vilar-López R, Salmerón JM, Romero I, et al. Trauma risk perception related to alcohol, cannabis, and cocaine intake. Eur J Trauma Emerg Surg. 2014;40: 693–9. pmid:26814784
39. Gentilello LM, Ebel BE, Wickizer TM, Salkever DS, Rivara FP. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. United States; 2005;241: 541–50.
40. Pearson MR, Murphy EM, Doane AN. Impulsivity-like traits and risky driving behaviors among college students. Accid Anal Prev. England; 2013;53: 142–8. pmid:23428428
41. Moan IS, Norström T, Storvoll EE. Alcohol use and drunk driving: the modifying effect of impulsivity. J Stud Alcohol Drugs. United States; 2013;74: 114–9. pmid:23200156
42. Jakubczyk A, Klimkiewicz A, Wnorowska A, Mika K, Bugaj M, Podgórska A, et al. Impulsivity, risky behaviors and accidents in alcohol-dependent patients. Accid Anal Prev. England; 2013;51: 150–5. pmid:23246707
43. Richer I, Bergeron J. Driving under the influence of cannabis: links with dangerous driving, psychological predictors, and accident involvement. Accid Anal Prev. England; 2009;41: 299–307. pmid:19245889
44. Coghlan M, Macdonald S. The role of substance use and psychosocial characteristics in explaining unintentional injuries. Accid Anal Prev. England; 2010;42: 476–9. pmid:20159069
45. Torres A, Catena A, Megías A, Maldonado A, Cándido A, Verdejo-García A, et al. Emotional and non-emotional pathways to impulsive behavior and addiction. Front Hum Neurosci. 2013;7: 43. pmid:23441001
46. Paaver M, Eensoo D, Kaasik K, Vaht M, Mäestu J, Harro J. Preventing risky driving: A novel and efficient brief intervention focusing on acknowledgment of personal risk factors. Accid Anal Prev. Elsevier Ltd; 2013;50: 430–7. pmid:22694918
47. Horst S, Markus S, Raschid U, Kerstin A. DRUID Final Report: Work performed, main results and recommendations [Internet]. 2012 [cited 1 Nov 2016]. Available: http://www.druid-project.eu/Druid/EN/Dissemination/downloads_and_links/Final_Report.html?nn=613804
48. Saitz R, Palfai TPA, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, et al. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA. 2014;312: 502–13. pmid:25096690
49. Claassen CA, Larkin GL, Hodges G, Field C. Criminal correlates of injury-related emergency department recidivism. J Emerg Med. 2007;32: 141–147. pmid:17307623
50. Worrell SS, Koepsell TD, Sabath DR, Gentilello LM, Mock CN, Nathens AB. The risk of reinjury in relation to time since first injury: a retrospective population-based study. J Trauma. 2006;60: 379–84. pmid:16508499
51. Cochran G, Field C, Foreman M, Ylioja T, Brown CVR. Effects of brief intervention on subgroups of injured patients who drink at risk levels. Inj Prev. 2016;22: 221–5. pmid:26124071
52. Cochran G, Field C, Caetano R. Injury-related consequences of alcohol misuse among injured patients who received screening and brief intervention for alcohol: a latent class analysis. Subst Abus. 2014;35: 153–62. pmid:24821352
Alcohol consumption
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Traumatic injury risk factors
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Public and occupational health
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Home News and Editorial Mobvoi AI recorder — A new device from an established name
Mobvoi AI recorder — A new device from an established name
Phil Tann
It's not often we see a big sidestep from manufacturers looking to branch out. Mobvoi, makers of the Ticwatch devices and Earbuds Gesture have done exactly that. The Mobvoi AI recorder is something a bit different and could be very useful in both personal and corporate life.
Where this particular recorder stands out against other digital recorders is the automatic transcription capability from your recordings. This is specific to English and Mandarin at the moment with more languages on the way. While it's not perfect — 94% accuracy according to Mobvoi — the transcriptions can be made available in various formats through the subscription service that costs US$69.99 per year after the first 12 months.
There are plenty of other great features to make this a useful device including dual-mic noise cancelling and AGC (automatic gain control) that reduces background noise. To transfer your recordings you've got access to Wi-Fi, Bluetooth or a hardwired connection. To put into context the speeds of transfer, an hour recording will transfer via Wi-Fi in under one minute.
It carries a battery life of over 40 hours, storage for 500 hours of recording and 200 hours of online cloud storage included for free. It can easily be carried on your belt, lanyard, by hand or mounted to a metal surface for recording making it extremely versatile in daily use options.
The Mobvoi AI Recorder will be available on July 15 via Mobvoi.com and Amazon for USD $99.99
AI Recorder
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http://www.philtann.com
Phil is an Android enthusiast who spends most of his time reading up on U.S. Android news so he can get the low down on what could possibly hit Australian shores. Coming from a background in IT & T sales, he's in the perfect position to give an educated view on hardware and software.

redpajama_set_name: RedPajamaCommonCrawl


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Software and Entrepreneurship with Seth Godin
By Adam Conrad
Article Thursday, November 29 2018
Seth Godin is a successful writer and speaker who has been involved in the software development industry for decades. In this episode, we sat down with Seth to learn about the best ways to apply our skills for the betterment of society and how to maximize our effectiveness as software engineers, starting with our choices in college.
In college, Seth advises us to go wide, not deep. This may seem counterintuitive in a world where specialization seems to be the dominant path towards high salaries and defensible careers. At school, however, we are too young and inexperienced to focus on specialties. Instead, we advises we cast a wide net to expose ourselves to lots of people, lots of collaboration, and lots of different ways to think critically. Those are the foundations for future specialization, but we can't reach that point until we've seen the vast landscape of possibilities which can only come from a broad education.
Myths in the CS curriculum
Computer science is not the best way to become a programmer. The best way to be a programmer is to program a lot. The problem with the modern computer science curriculum is that it assumes theory as the foundation for practical applications of computer science.
While these problems are important and influential in modern computing, they do not apply to the 99% of developers who are developing web or mobile applications. Knowing how to create and analyze bubble sort does not translate to modern software development, and so it seems like there's a mismatch between theory and practice.
Software engineering is different than software. Software is more than just code and the practice of creating that code. Software is the systems of that code and the people who make it. Once you realize this you will make real progress instead of a series of hacking together janky software.
Yoyodyne and Software in the 90s
Before Godin was an author, he helped create an email marketing company called Yoyodyne. Acquired in 1998 by Yahoo!, Godin learned quite a few things about managing engineers and how software companies have scaled over the past few decades.
The internet was not designed to scale in the 1990s. For Yoyodyne, it simply wasn't feasible to support all of the emails they wanted to send. "100,000 emails could melt a server," says Seth. Today, instead of worrying about server administration and "the building falling down" as Seth puts it, developers can use tools like to AWS to handle all of this so you can instead focus on delivering great products for your customers.
On managing engineers
In addition to learning about how to scale a business in the 90s, Seth learned quite a bit about scaling engineering teams as well.
Colocating your software people with the rest of the company was as vital then as it is today. Even with the development of tools like Slack and remote meeting software, Seth still believes in the power of in-person collaboration. And while there are plenty of successful remote-first companies, he's not sure if that can be replicated across the entire software industry.
Seth also advises to be disciplined enough to get the spec right the first time. Today lots of people tend to intuit specifications instead of trying to get them right at the beginning of a product life cycle. As Seth points out, "buildings and cars are run on a spec and we aren't changing them, we should do the same thing with software".
Freelancers vs entrepreneurs
One distinction that seems to be hard for software developers to make is how to slot themselves in defining their work as freelancing or software entrepreneurship. Seth points out that entrepreneurs make money when they sleep because other people do every job, while freelancers make money when they work with their own two hands.
When freelancers try to scale, they hire others to become entrepreneurs and that seems to be too difficult. Instead, if you're a programmer and you want to become an effective entrepreneur, you need to stop programming.
In a similar vein, if you're the boss, the only thing you can complain about is yourself. Especially in software where people desperately need you and you have the most powerful tools at your disposal, you can give so much back to the world with your intelligence instead of squandering it in a "cubical farm" as Godin puts it.
"Software engineers should be getting pleasure from getting software to do things that matter." – Seth Godin
On "What To Do When It's Your Turn"
"I don't write a book because I need to…but because I have to," says Seth. His thesis is there are far more artists in the world than we believe there are, and that if every page in What To Do When It's Your Turn inspires those artists to express themselves, it's a journey worth pursuing.
Seth also points out that "people are afraid of being called out as a failure or a fraud." This is why people love meetings, so they can pass their accountability to others. Instead, Seth says people should stay in small teams because they have no meetings as they're too busy collaborating and making things to deal with meetings in the first place.
Finite vs infinite games
In discussing his book, Seth has introduced the concept of finite versus infinite games as a way of explaining how to think about adding value as a software developer.
Finite games are those that have rules, an end state, and a clear winner. Think of it like eating a slice of pie: there are only so many slices left, and the winner eats the largest slices of pie. As a practical example, Chevrolet and Ford will win battle it out for the market share game of the automotive industry.
Infinite games, on the other hand, offer abundance where more players contributing to the game create more winners. Think of this game as creating a bigger pie and continuing to grow it at a rate faster than it can be eaten. Wikipedia is an example of an infinite game: it is the result of 10s of millions of hours of donated time and can be as big as we want it to be. As a result, it will never end, there is no winner, and all you can do is pay it forward and help other people pay it forward.
"When we can create infinite games out of software our careers thrive and our heart sings" says Seth. Infinite games are the Holy Grail of software, according to Seth. He believes that if we put the effort in to create things that are more valuable as more people use it, we can create a better world for everyone.
altMBA takeaways
In helping software entrepreneurs create infinite games, Seth created the altMBA as a massively open online course (MOOC). Seth learned quite a few things about MOOCs in the development of the altMBA:
Software engineers were the earliest users of MOOCs. That means this audience was accustomed to MOOCs as a platform.
The dropout rate was close to 99%. When it gets hard and there's no social pressure, people drop out.
They can be really long. A 12+ week course is difficult to captivate an audience when there is no social pressure, grading system, and there is work to be done at your day job.
With those lessons, Seth decided to create a MOOC where no one drops out, it's not free (to create social pressure), and it is condensed into a super intensive, four week course. As a result, people discover really fast that most things are trivial compared to what is learned in altMBA, like learning how to see, how to speak on what you see, and how to spot change.
Final takeaways
In creating infinite games, Seth advises to avoid networks that have already been conquered. We are in the very early days of server farms like AWS, but Seth says "you can't out-Amazon Amazon or out-Uber Uber." In other words, the number of networks we can use is compounding daily, so don't focus on the ones that have already been conquered.
Finally, Seth encourages the people who are listening to this podcast to go and build the future, because we are the ones best equipped to make that happen.
Adam Conrad
Adam is a Boston-based designer, developer, UX consultant at Anon Consulting. He runs a UI and UX engineering publication over at UserInterfacing.


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How Do You Say 'My Love Forever And Always' In Italian?
Yo Kass answered
The phrase 'my love, forever and always' is probably best translated into Italian as mio amore, per sempre. Most Italians would use the same word, sempre, to convey both 'forever' and 'always' - and the word amore is Italian for 'love'.
If you were looking for other words to express the abundant nature of your love, you might use the expression amore senza fine which means 'endless love', or finchè la morte non ci separi - which is the equivalent of 'until death do us part'.
You could also use the phrase noi due, verso l'infinto e oltre' which means 'us two, to infinity and beyond' and is a play on a phrase popularized by the 1995 Disney/Pixar animated comedy Toy Story.
Italian culture is well known for its romance and passion, with everyone from William Shakespeare's Romeo and Juliet through to the 1953 Hollywood classic Roman Holiday relying on it as a theme.
It's for this reason that people often use Italian phrases that capture this spirit as a dedication to a love interest. The phrase mio amore, per sempre would be an appropriate tribute engraved on a ring or other type of jewellery, or even as part of a tattoo!
Suhail Ajmal answered
'Il Mio Amore Per sempre' is the translation of 'My Love Forever' in Italian. You can also find an online translator from English to Italian on the Internet for more information.
ray of light answered
In Italian you say "per sempre" which means forever, and "sempre" which means always.
Bill Vanore answered
Tutto il mio amore, sempre per te.
Aisha answered
The translation of the above phrase in Italian is as under:
"Il Mio Amore Per sempre E Sempre"
How Do You Say 'Lovely' In Italian?
Italian is a very lovely and sophisticated language. Internet has made it easy to learn and use Italian...
How Do You Say 'I Love You, Friend' In Italian?
Ti amo amico is "I love you friend" if the friend is male Ti amo amica is "I love you friend" if the...
How Do I Say I Love You Forever And Always In French To My Girlfriend?
The Spanish translation of "I love you forever is >>> je vous aime à jamais...
How Do You Say, 'Forever Love' And 'Believe In Love' In Italian?
In Italian "forever Love" is written as "per sempre amore"and Believe In Love is written as "Credi nell'amore"For...
How Do You Say 'My Love' To An Italian Woman?
Or you could say, Mio Amore. My Darling....
How Do You Say " I Love Italian Food" In Italian?
"MI PIACE IL CIBO ITALIANO "is the correct answer to your question....
How Do I Say I Love You Forever And Always In Japanese?
Love that lasts forever - Itsukushima Suzuki ai...
How Do You Say 'Good Morning, My Love' In Italian?
The Italian translation of 'good morning, my love' is buongiorno amore mio. Although the Italian...
How do I say I love you always and forever in French?
'Je t'aime pour toujours.' There's also Je t'aime de tout mon coeur (I love you with all...
What Is I Love You Forever And Ever In Nihongo?
How Do You Write 'Always In My Heart' In Italian?
How Does "Friends Forever Translate Into Italian?
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I Am Allergic To Anchovies But Love To Cook Italian Food, How Can I Still Get An 'Anchovy' Flavour Without Killing Myself?
What Does The Chinese Symbol For Happiness Look Like?
What Do You Do When You Can't Sleep?
Do you hang up on cold calls without saying anything? : )
How To Get Periods Regularly? What Are Tips To Maintain Regular Periods?
What is hummus and where does it come from?
How to say you love her , if she is an actress and you are a simple man?
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Thank you for your active participation in the Discovery Educator Network. Discovery Education and 3M are excited to offer the Discovery Education Science Techbook™ to 300 DEN STARs for the rest of the 2014-2015 school year (ending June 30, 2015).
You can sign-up and access this promotion by logging into Discovery Education and clicking on the DEN Community tab. Look for the Science Techbook Promotion icon underneath the DEN STAR Links section. Click the button and complete the steps on the Event Form. Don't see the icon? We've already met our limit of educators for this promotion. Please keep an eye out for more opportunities.
This offer is a part of 3M's ongoing support of initiatives designed to engage more students in STEM nationwide. We encourage you to check out more great ways to support STEM instruction in your classroom by going to the Science of Everyday Life and Young Scientist Challenge websites for resources for teachers, students, and parents.
Latoya Judd is one of my ROCK STARS in Durham. NC!!!!!
Discovery's Science Tech book is an amazing tool to use in every classroom. I was able to use the resources to further my student's learning experiences in each branch of science. It would be amazing to have this tool again available for my 5th grade science students.


Longchamp, a brand that captures the elegant and practical French style. We carry many of their items, including their simple "Le Pliage" series of bags.
Tumi is an international lifestyle brand that can be used during travel or on business. We carry a wide range of their products, including travel goods, business bags, casual items, women's bags and other small goods.
* Miles can be earned when shopping.
* ANA coupons, Diamond coupons, ANA travel tickets can be used.
This is a small handbag made of nylon satin from the Le Pliage® Néo series.
It comes with a removable shoulder strap so you can sling it on your shoulder.
The Le Pliage Néo line is a more urban version of the Le Pliage line, and captures a modern spirit.
The material and details are cutting-edge.
With shoes that will add to your "couture" rhythm, you will look absolutely charming.
Tumi's "T-Pass® Business Class Briefpack" is both a business briefcase and backpack that is light, functional and can be used in various scenes.
Made of abrasion resistant FXT ballistics nylon, it is tough enough to be used in your daily life.
It has space for all of the items that are necessary for business, including a cushioned PC compartment and a document storage space.


Ihr seid keine Atheisten. Ihr seid wie ich. Dumm.
Ich versichere Ihnen, daß dies keine Verleumdung ist !
Gott ist nur ein von Menschen erdachtes Wort. Wo soll den jener Gott sein? Über uns? 10.000 Meter über uns geht gar nichts mehr. Kein Sauerstoff. Und das braucht nun einmal ein denkendes Wesen.
Gott ist nur ein anderes Wort für Schizophrenie.
Daran sind millionen Menschen erkrankt. Unheilbar.
Weil es eine dumme Wischiwaschistory ist.
I find myself at this time in the city of Los Angeles, California (USA), in need of human and spiritual help for the work that we have in Columbia. There we are working with families who have been displaced by violence with very limited financial resources. We have a labor of rehabilitation with young people and children who are drug addicts, alcoholics and delinquents. We have at this time 25 missions throughout Columbia though our labor is stronger in the state of Santander and North Santander. We have at the head of this pastoral labor presbyters, Deacons, sub-Deacons, and seminary students (aspiring to Ordained Ministry). Also we need help for a group of our students who are realizing their theological studies and who are preparing themselves to serve our work in Colombia.
I have brought with me some photographs of this labor in Colombia and I hope to find through you, with God's help, some means to take help to our country. It is important to clarify that I do not speak English, but here I am able to find a good translator (If you have someone who speaks Spanish, that would be even better!).
I hope to find myself with you and with your help.
Atheisten: Denn sie wissen nicht, was sie glauben.
Ich find eure Seite ziemlich total scheiße.


If you are the owner of any website and have a great engagement on your Facebook page then you should use that visibility wisely. All the content, image, link, business slogan or discussion you post on Facebook are not visible to the audience visiting your website. By adding a custom feed from your Facebook page to WordPress page not only increase your website engagement but also improve the SEO and Facebook like. So, in this tutorial, we add a custom facebook feed in WordPress by using a plugin.
Step 1: To increase the WordPress capability we always use plugins, so here we are also going to install a plugin called Custom Facebook Feed plugin, just install and activate it. If you want to display image in your feed & shared then you have to go for a premium version of this plugin.
You can also use another free plugin: Facebook Feed WD Plugin that's free version gives you the capability to show custom facebook feed in WordPress including images.
Step 2: After activating the plugin go to Facebook Feed » Settings page to configure the plugin settings.
Then you need to use 123654123654123 as your page ID.
Step 4: The second thing is generating the access token which is recommended by the plugin to work in a proper manner. For adding the accesses token go to Facebook developers page and click on the create new app button.
Step 5: After step 4 you will get a pop-up asking for various information to create an app. Enter the display name for an app, an email address and select the category for your app then click on the 'Create App ID' button to continue.
Step 6: After creating an app you will redirect to the app's dashboard, here click a link on the top right side of the window called Tools & Support.
Step 7: Token and support page will open with lots of tests and debug app for Facebook apps. You just need to click on 'Access token tool'.
Step 8: The link Access Token Tool will redirect you to the page where you will find your app's Access Token or APP Token code.
[custom-Facebook-feed id=abcaccount], where abcaccount is your Facebook page name.
Step 10: If the feeds do not look well on your website page then you can customize it according to your website space. Go to Facebook Feed » Customize page where you can edit the feed height, width, padding and background color. You can also use your own custom CSS.
We hope this article will help you in adding a custom facebook feed on your WordPress website to make it more interactive.


text:
WTA Awards: Barty is Player of the Year, Raducanu named newcomer of the Year
Australia's world number one Ashleigh Barty was crowned WTA Player of the Year for the second time and US Open champion Emma Raducanu won the Newcomer of the Year award, the governing body of the women's tennis said on Tuesday.
Barty, who also earned the accolade in 2019, won a tour-leading five WTA titles this year. She won her second career Grand Slam title at The Championships, Wimbledon, and successfully defended her title at the Miami Open
The Australian also won the titles in Melbourne, Stuttgart, and Cincinnati. She also won the Porsche Race to the WTA Finals and secured the year-end World No 1 ranking for the third consecutive year.
The 19-year-old Raducanu scripted history in 2021 with her US Open title, where she became the first qualifier to win a Grand Slam. She did not drop a set throughout all 10 of her matches.
Raducanu made her Grand Slam main-draw debut at Wimbledon this year and reached the last 16 to become the youngest British woman to reach this stage at the All-England Club. Her other notable results this season include a finals appearance at the Chicago WTA 125 and the quarterfinals at the Transylvania Open.
The British teenager started the year ranked No 343 and finishes the season at a career-best No 19.
The Czech Republic's Barbora Krejcikova and Katerina Siniakova were named doubles team of the Year for the second time, having also been recognized with this honor in 2018.
This season, the Czech duo captured their third Grand Slam trophy as a team at Roland Garros, won additional titles at the Gippsland Trophy (Melbourne) and Mutua Madrid Open, before rounding off the year by lifting the WTA Finals Martina Navratilova Doubles Trophy at the AKRON WTA Finals Guadalajara.
While both held the No 1 doubles ranking this season, Siniakova finishes the year as the WTA doubles year-end No.1.
Meanwhile, Barbora Krejcikova took the WTA prize for the Most Improved Player of the Year following a stellar season in which she won the French Open singles crown. The Czech won the first three singles titles of her career this season. She made her Top 50 debut this year and climbed as high as World No 3.
Carla Suarez Navarro was named the Comeback Player of the Year award. The 33-year-old was di'gnosed with Hodgkin's Lymphoma in September, 2020 and after winning her battle against cancer, she decided to end her career on her own terms and returned to the tour in 2021 for her final farewell.
The Spaniard played Roland Garros, where she took Sloane Stephens to three sets in the opening round, and Wimbledon, where she had another three-set battle against eventual champion Ashleigh Barty in the first round. She also represented Spain at the Billie Jean King Cup finals.


CBS Corp CEO Leslie Moonves, who was given the additional title of executive chairman this week, is planning more original content and looking at taking some of his network's shows off the air and putting them exclusively on its subscription-based CBS All Access service, to compete with the growing popularity of Netflix Inc and Hulu.
It is a bold but not sudden move for the traditional television executive running a network known for its older viewers, who approached the digital TV revolution gingerly but is now pushing his company to its forefront.
The network's push to ramp up its online All Access service - which offers its shows on PCs, tablets and smartphones for $5.99 a month - comes as media companies are rethinking their business models and their relationships with streaming video providers, treating them more like competitors than allies.
Advertising is still important for CBS - home of the Super Bowl this year - but the focus is shifting to new revenue streams.
"When I started this job 20 years ago, advertising was everything to this company," Moonves told Reuters in an interview in his Los Angeles office on Monday, as he prepared to travel to the San Francisco Bay Area for the big game. "Advertising will still remain important, but it's not nearly as important as some of these new ways of getting revenue, such as interactive."
Moonves is also considering putting shows on All Access from the CW Network, its joint venture with Time Warner Inc's Warner Bros, which produced the offbeat hits "Crazy Ex-Girlfriend" and "Jane the Virgin." Ultimately, Moonves said he wants the service to include content from its Showtime subsidiary, best known for "Homeland" and "Dexter," and possibly shows from other partners.
He would not say which CBS shows - which include hits such as "The Big Bang Theory" and "The Good Wife" - would be candidates for exclusive distribution on the All Access service, but suggested it would be original content and shows that have an avid fan base but not necessarily high ratings.
CBS already said last year that its new "Star Trek" series, scheduled for 2017, would premiere on the network then switch exclusively to All Access.
Moonves said CBS could have sold "Star Trek" to Netflix, Amazon.com Inc or Hulu for "a pretty nice profit," but instead is betting that it will attract more mobile-savvy viewers willing to pay for subscriptions, which he hopes will be more valuable in the long term.
"Star Trek" is for All Access what "House of Cards" was to Netflix, he said.
Moonves now has complete control at CBS to push his digital agenda. Two days after Moonves spoke to Reuters, longtime CBS chairman and majority owner Sumner Redstone stepped aside and Moonves was handed the chairman role, with the blessing of Redstone's daughter Shari.
The day after that Redstone also stepped aside at his other majority-owned media company Viacom, and his role went to CEO Philippe Dauman, over the objections of Shari.
Moonves, who splits his time between Beverly Hills and New York and describes himself as an "old school media guy," has spent most of his career in television, developing hits such as "Friends" and "Everybody loves Raymond."
When Redstone split CBS from Viacom 10 years ago, investors saw the mainstream broadcaster as the slow-moving company catering to an older audience, compared to the young, scrappy Viacom, whose networks include Nickelodeon and MTV. But CBS shares have easily outperformed those of Viacom over the last five years.
Mario Gabelli, the second-largest shareholder of Viacom and CBS, wants to see Viacom take a page out of Moonves' digital strategy playbook. "It's going to be tough to get into the digital world and over-the-top," he told Reuters.
Digital success has helped Moonves gain favour with Shari Redstone, who is vice-chair of the boards of CBS and Viacom, and nominated Moonves for the CBS executive chairman role.
"Les and I get together frequently and he is always asking me what companies I am investing in and what I am seeing," said Shari Redstone, whose firm, Advancit Capital, invests in early-stage companies in technology and media. "He is fascinated with everything."
The 66-year-old Moonves may not be a millennial but he is more familiar than most of his generation with the latest technology. Delivery service Postmates and route-finder Waze are two of his favourite apps. Every few months he visits Silicon Valley to see what is new, and said he would be open to a seat on the board of a media technology company one day.
It is unclear how exactly the CBS All Access service, which launched 18 months ago, is doing. The network will not disclose how many subscribers the service has, but Jefferies analyst John Janedis estimates it is around 500,000. That is a fraction of Netflix's tens of millions of viewers.
Moonves believes his relative success in the digital realm may be down to the scepticism he brings from a pre-smartphone era, and not just saying yes to new ideas.
"I am the old-fashioned guy," he said. "My job at the company is to be Dr. No."
Looking back, he is glad CBS said no to buying a stake in online streaming service Hulu, saying his team convinced him it did not make sense and that CBS would be better off controlling its own content.
"It was bold in the sense that they were not afraid of being perceived as a Luddite of a company," said Pivotal Research analyst Brian Wieser. "It was the right decision because it did not limit their strategic choices in what could be a fast-changing business."
Moonves admits he was worried about losing ratings, upsetting the network's affiliates and cannibalising its business with the launch of All Access, but is now fully behind it.
"We are investing in the future of All Access, which we think is an important part of our future," he said.


A Commercial Paralegal is required to join a local authority based in East of England. This is a great opportunity for a paralegal to undertake a role within a small, supportive team where you can expand your knowledge and skillset.
The successful paralegal will have experience running own caseloads, however this is not essential. Our client is looking for enthusiastic, hardworking candidates with excellent attention to detail.
This local authority are ideally looking for someone on a part time basis and will be able to offer flexibility in terms of working hours.
We encourage interested applicants to apply immediately to be considered for short listing. Alternatively should you require further information or wish to discuss your suitability before applying please contact Leah Edgar in our Manchester office for a confidential discussion. Sellick Partnership is a market-leading professional services recruitment specialist operating across the UK. Over the years we have built up an enviable relationship with employers and our expert team of consultants boast up-to-date market knowledge and a strong reputation making Sellick Partnership best placed to help you.


text:
using System;
namespace Problem5BooleanVariable
{
    class Problem5BooleanVariable
    {
        static void Main()
        {
            string tR = Console.ReadLine();

            if (tR == "True")
            {
                Console.WriteLine("Yes");
            }
            else
            {
                Console.WriteLine("No");
            }
        }
    }
}

redpajama_set_name: RedPajamaGithub


Hiya crafty peeps! It's been a busy week over at Some Odd Girl and since my blog was hopping with the new clear release on Tuesday I decided to share this new digi on a different day so it wouldn't miss out on it's own little spotlight...please meet Lady Bug Tia- isn't she just too freakin' adorable?!? Nothing screams springtime to me like ladybugs- I remember being young and counting the number of black spots because that showed how old they were :) I colored her with my Copics, naturally lol, and paired her with some paper from Doodlebug designs. For the card base I actually took a black chipboard page from a Cosmo Cricket mini album and I plan on tying two of the pages together with some red and white baker's twine from Doodlebug designs- it just would have been hard to photograph them already tied together. I love using pieces of chipboard albums for all different kinds of projects since you can find them in all sorts of different shapes and finishes- I'm all about multipurpose items, lol! Make sure you pop on over to the Some Odd Girl store to check out this and all the other images that have been released this week, both clear and digi :) Thanks for stopping in to visit!
Gosh Katie, this is so cute! I love that little lady bug Tia! Thanks for joining us at Oddball Art Stamps challenge!
This card is precious. I love the colors and the image. Thanks so much for joining us at Aud Sentiments for our friend challenge.
Your shaped card is darling!


Sympathy cards are hard to make. I prefer to make them when I don't need them so I will have a variety of cards to choose from. My stack of Sympathy cards was getting low so I decided to create a few.
This is one of the designs I came up with. It is simple and classic. I don't like fussy sympathy cards.
I used watercolor paper and painted fall colors on the wet paper. Then I splattered it with some Cherry Cobbler ink. I used the Seasonal Layers Thinlits to cut out the leaf. Then I slid the watercolor paper behind the leaf cut out. I used dimensionls to raise the top layer and it gave the card some nice dimension. A sentiment and a tiny bit of splatter finished my card.
What is your favorite type of sympathy card? Please share.
Such a pretty and simple card.
I like sympathy card that just evoke that the person cares just like this one.


Calving season can be a stressful time for cattle producers and the new prescription rules may add to that stress. Producers used to be able to purchase antibiotics to treat their livestock over the counter, but now they must have a prescription from a licensed veterinarian. These changes came into effect on Dec. 1, and apply to all medically important antibiotics, including penicillin.
Isabella Oxsengendler has spent her entire life around dogs, starting with her first at the age of three — which is why no one was surprised when she became a professional dog trainer.
The Calgary Public Library started the Locked Library events to engage the public with the literature and the library itself. Similar to the experiences at the Locked Room, teams are given challenges and puzzles to complete.
Airdrie's sixth annual firefighter Rooftop Campout for Muscular Dystrophy represents so much more than raising awareness and funds for Muscular Dystrophy Canada (MDC).


text:
Маражо̀ () е на̀носен остров, разположен в устието на река Амазонка в Бразилия. Той е част от щата Пара. С обща площ от 47 573 km² Маражо е най-големият остров в света, изцяло заобиколен от прясна вода. Въпреки че североизточната брегова линия на острова гледа към Атлантическия океан, количеството вода от Амазонка, вливащо се в океана, е толкова голямо, че превръща водата около острова в сладководна. Южно от острова е разположен град Белем, който е и столица на щата Пара. Маражо е почти изцяло разположен върху линията на екватора. Населението на острова е около 250 000 души.

Има алувиален произход и като цяло е блатиста низина, обрасла с ценни тропически гори. Основен поминък на населението е дърводобивът. Главното селище на острова се нарича Соре (Soure).

Острови в Атлантическия океан

redpajama_set_name: RedPajamaWikipedia


STAND Engineering Consulting and Trade Ltd. is a pioneer structural engineering and design firm based in Ankara, Turkey, utilizing cutting-edge technologies to deliver exceptional and complex engineering projects that demand the highest level of skills and expertise. We are specialists who create preliminary, concept and shop drawings to bring a project to life.
We have developed our own substantial library of engineering software, enabling us to optimize our structural engineering solutions with experience and efficiency. Now we proudly share our knowledge and experience in software development by presenting applications that are tailored to fullfill your needs.
Our vast portfolio includes structural analysis and design of low, medium and high-rise Reinforced Concrete and Steel structures, for commercial, residential, governmental, medical, institutional, industrial, tourism and transportation projects. We also provide structural analysis and rehabilitation services for existing structures to encompass seismic design and strengthening.
Betriebssystem: Win64 Sprache: English FDN is an effective utility to find nodes in your analytical model that are too close to each other but not connected.


As of April 1, most of the amendments proposed by the 2012 General Assembly have received sufficient votes to become part of the Book of Order. In fact, with only a few exception the amendments have passed with overwhelming majorities (in the 95% range).
It may well be that our Presbytery's vote on these last two proposed amendments will be significant. Council has recommended an affirmative vote on both. If you'd like to offer an opinion, you might want to do so on the Presbytery's blog site.
Is Love a Legacy that you will leave?
How are you about Hugging?
My sneakers remind me of my spiritual life.
© Copyright 2019 Presbytery of Western Colorado. All Rights Reserved.


Joined today, as I feel I need some help.
My second wife and I split up and divorced in the late 90's with our son and daughter living with her. I lost contact with both children as my wife was very, very difficult (long story).
My daughter from this marriage contacted me 3 days ago, out of the blue, sending me a message on Facebook messenger. She is now in her mid 20's with a young daughter.
We have chatted over the last three days, using Messenger, the first day almost constantly, then by arrangement the following two evenings.
I find myself feeling very nervous in the run up to our chats, I'm afraid that she might stop contact, but it's in my nature to commit fully to something no matter the consequences.


text:
from __future__ import print_function

import os
import sys

from django.core.management.base import BaseCommand, CommandError
from optparse import make_option

class Command(BaseCommand):

    help = "Init the static site project"

    args = '[directory]'

    option_list = (
        make_option(
            '--title', '-t', dest='title', default='Default site',
            help='Site title [Default: "%default"]'),
        make_option(
            '--domain', '-d', dest='domain', default='example.com',
            help='Domain name [Default: "%default"]'),
        make_option(
            '--languages', '-l', dest='languages', default='he,en',
            help='Supported languages. [Default: "%default"]'),
        make_option(
            '--timezone', '-z', dest='timezone', default='America/Chicago',
            help='Time Zone. [Default: "%default"]'),
    ) + BaseCommand.option_list

    def handle(self, *args, **options):

        if len(args) != 1:
            raise CommandError('init takes one argument: directory name')

        directory = args[0]

        from django.conf.global_settings import LANGUAGES

        the_langs = dict(LANGUAGES)

        langs = options.pop('languages').split(',')

        # we need to keep ordering, for the default language
        try:
            languages = [(l, the_langs[l]) for l in langs]
        except KeyError, e:
            print("Invalid language specified:", e, end=". ")
            print("Valid languages are:")
            for name, desc in LANGUAGES:
                print(name, '(' + desc + ')')
            sys.exit(1)

        os.makedirs(directory)
        print("Initializing project structure in", directory)

        extra = {
            'build': 'build',
            'default_lang': langs[0],
            'languages': languages,
            'extensions': ('py', ),
            'domain': options['domain'],
            'timezone': options['timezone'],
            'title': options['title'],
            'files': (),
            'template': os.path.abspath(
                os.path.join(
                    os.path.dirname(__file__),
                    os.pardir, os.pardir, os.pardir, 'project_template')),
        }
        extra.update(options)

        from django.core.management import call_command
        call_command('startproject', 'conf', directory, **extra)

        print("\n\tdomain:", options['domain'])
        print("\ttimezone:", options['timezone'])
        print("\ttitle:", options['title'])
        print("\tlanguages:", ', '.join(langs))