text:
Call for Reviewers
Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement
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Quality improvement report
Ahmed Salem1,2,
http://orcid.org/0000-0002-5573-4023Hossam Elamir3,
Huda Alfoudri4,
Mohammed Shamsah4,
Shams Abdelraheem5,
Ibtissam Abdo3,
Mohammad Galal3,
Lamiaa Ali3,6
1Anaesthesia and Intensive Care Department, Sabah Al Ahmad Urology Centre, Ministry of Health, Sabah, Kuwait
2Anaesthesia and Intensive Care Department, Faculty of Medicine, Banha University, Benha, Egypt
3Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
4Anaesthesia, Critical Care and Pain Management Department, Adan Hospital, Ministry of Health, Hadiya, Kuwait
5Critical Care Department, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
6Public Health Department, Fayoum University Faculty of Medicine, Fayoum, Egypt
Correspondence to Dr Hossam Elamir; dr_hossam_elamir{at}hotmail.com
Background The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training.
Methods Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm.
Results A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval.
Conclusions A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
http://dx.doi.org/10.1136/bmjoq-2020-001130
Since the influenza pandemic in 1918, no rapidly spreading disease has caused as much public health concern and profound global impact as the novel coronavirus disease 2019 (COVID-19) pandemic.1 2 COVID-19 is a disease caused by a Betacoronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).3 4 By 30th June 2020, there were 10 187 304 confirmed positive cases and 503 872 reported deaths globally and 45 524 cases and 350 deaths in Kuwait.5 Given the complexity of the situation, the novelty of the disease and its heavy death and economic toll, clinicians have been urged to share and integrate what they know about COVID-19 management.2 6 7 However, the exponential growth of available information has had its drawbacks. Low-quality studies and/or contradicting information have been globally circulated.
Our hospital is one of the biggest hospitals in Kuwait, with a total capacity of 847 beds. It serves more than one million people.8 With the emergence of the COVID-19 disease, the Intensive Care Unit (ICU) of the hospital increased its capacity from 40 to 111 beds. The hospital also used many satellite locations outside the main ICU, as Intermediate Care Units or High Dependency Units. The surge in capacity has necessitated the rapid redeployment and recruitment of a large number of healthcare providers. Due to its emergency response, the hospital has become one of the biggest COVID-19 treatment centres in the country.
The expanded ICU faces many challenges, including a large number of redeployed non-intensive care physicians and nurses who have joined work in the ICU, newly recruited intensivists from other hospitals who are not familiar with the local guidelines and critical care physicians and nurses whose cognitive capacities have been overwhelmed by the new stressors, layout changes and drained resources. This situation is exacerbated by the lack of standardised protocols for disease management2 3 and has created an environment where substandard care can flourish, primarily due to variations in practice.
For the past two decades, research has shown that non-compliance with clinical practice guidelines is the third leading cause of preventable patient deaths and is responsible for one-third of wasted healthcare expenditure.9 Clinical algorithms are considered a highly effective means of handling clinicians' limited cognitive capacity when overwhelmed by a dramatic increase in new clinical information in a short time.9 Considering the current struggle to manage the COVID-19 pandemic and warnings of a second wave,10 this paper aims to propose a comprehensive improvement project for standardising the care provided to hospitalised patients with COVID-19 using a clinical algorithm-based toolkit. This aim can be achieved by addressing the following secondary objectives:
To share the toolkit with others so they can be prepared for the second wave.
To invite other institutions to join in the implementation of the comprehensive project.
To seek professional feedback as part of our multiple Plan-Do-Study-Act (PDSA) cycles.
Although this paper does not include the implementation of an intervention, it follows the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines as a framework for reporting.11
Our hospital is an 847-bed government hospital in Kuwait, which mainly provides secondary care services and some tertiary services (ie, cardiac surgeries and heart transplants). Though elective admissions and ambulatory care visits have been substantially reduced since the emergence of the COVID-19 crisis, the hospital has not been exclusively dedicated to COVID-19 management. One hundred and seventy-four beds in the wards, plus 70 beds in the ICUs have been allocated to patients with COVID-19. Our Anaesthesia, Critical Care and Pain Management Department is one of the best structured and best equipped nationally. Moreover, the hospital has established the first and biggest Extracorporeal Membrane Oxygenation (ECMO) service in the country.
A group of experts in anaesthesia, critical care, public health and healthcare quality worked together and adopted a logical system design approach to produce a toolkit to support the management of patients with COVID-19. The authors conducted a review of the literature in search of a best practice framework for developing clinical algorithms that is reasonably practical without compromising the robustness of the method, as researchers have recommended.12 Taking into account these two criteria, we selected Horabin and Lewis' (1980) framework and not Mozena and colleagues' framework (1996).13 14 We followed a structured seven-step approach in developing the toolkit algorithms and a five-step method in writing them.13 Then, we applied Rosenfeld et al's five points to each algorithm.12
The seven steps of developing a set of algorithms are: (1) identifying the performance requirement that involves problem solving or decision-making (ie, management of hospitalised patients with COVID-19), (2) defining the problems that need to be addressed (eg, management of oxygen therapy, mechanical ventilation, haemodynamic stabilisation), (3) defining the responsibility to solve the problems (eg, non-intensive care physicians, consultant intensivists), (4) deciding how to use the algorithms (ie, for teaching and guiding care), (5) drafting the first version, (6) testing and revising until reaching graphic appropriateness and (7) testing and revising until learning or performance effectiveness is attained. The first six steps have been completed and are discussed in this paper. The final step will be the subject of future research following full toolkit implementation and evaluation.13
The five-step method for writing the algorithms began with: (1) describing the starting point (eg, in online supplemental appendix 1, patients allocation according to modified early warning signs (MEWS)); then (2) describing the outputs or specific solutions (eg, in online supplemental appendix 1, O₂ nasal cannula up to 6 L/min, O₂ mask (up to 10 L/min) or mechanical ventilation); next, (3) connecting the starting point and the outcome using a case example to develop the decisions; and (4) checking the connecting decisions with experts to conclude whether they are complete or not; finally, (5) repeatedly testing the algorithms until users arrive at consistent decisions.13
[bmjoq-2020-001130supp001.pdf]
MS Visio 2016 was used to draw the algorithms, which were manually drafted by the first author. As per Rosenfeld and colleagues' five-point recommendations, graphical representations were limited to three shapes, the logical flow was maintained by reducing clutter, counselling and decision nodes were inserted before any significant patient-preference-dependent decision must be made, each decision node was branched to at least two exit arrows, and finally, arrow crossing was avoided.12 MS Excel 2016 was used to create data-collection spreadsheets. MS 365 Forms (online platform) was used to create and host the data-collection online forms.
This paper does not include human subjects as it presents a tool without implementation. No confidential information of any type has been used or disclosed. Hence, ethical approval was not required. It was not appropriate or possible to involve patients or the public in the different phases of this research.
Considering the short time window available to the team, a critical review type of literature review was conducted.15 The team sought to identify the most significant findings by reviewing a number of published articles, guidelines and books; listened to hours of clinical webinars. Moreover, the team were guided by their knowledge and experiences to propose clinical algorithms that address the main issues that have emerged during the management of patients with COVID-19.
A set of seven clinical algorithms, plus one illustrative layout diagram, has been developed. The algorithm set addresses the following issues: patients allocation according to MEWS, oxygen escalation therapy (figure 1), management of airway during intubation of patients with COVID-19, mechanical ventilation (figure 2), haemodynamic management of patients with COVID-19 (figure 3), immune suppression therapy in patients with COVID-19, anti-coagulant/anti-thrombotic therapy in patients with COVID-19 (figure 4) and weaning of mechanical ventilation (figure 5). Whenever possible, the algorithms include the reference parameters, an abbreviation list and any auxiliary information needed for better understanding and implementation. Online supplemental appendix 1 presents the complete set of algorithms with its references for standalone use and better readability and printing purposes. The set is augmented by documentation forms (online supplemental appendix 2), data-collection online forms and spreadsheets (online supplemental appendix 3) and an indicators' reference sheet (online supplemental appendix 4) to guide implementation and performance measurement.
Oxygen escalation therapy.29 30
Mechanical ventilation.8 31–33
Haemodynamic management of patients with COVID-19.34–36
Anti-coagulant/anti-thrombotic therapy in patients with COVID-19.37–39
Weaning of mechanical ventilation.33
In accordance with best-practices, the algorithms are composed of three main shapes: 'rounded rectangles to describe a clinical state at entry or completion of a decision sequence, diamond-shaped or hexagonal decision nodes to indicate branch points leading to alternate pathways, and rectangles to indicate diagnostic and therapeutic actions' (p. S46).12 From the manual sketching of the first algorithm on 24th May 2020 to the approval of the eight-algorithm set (V.3.9) on 7th October 2020, the set underwent many stages of sketching, drafting, reviewing, provisionally approving, adding and deleting and refining before it was finalised. These activities are reflected in the algorithm version number (3.9), where the unit digit (3) indicates the number of major changes introduced to the set (ie, addition or deletion of an algorithm) and the tenth digit (9) indicates the number of minor refinements (eg, addition or deletion of a step, addition of an abbreviation list, graphical rearrangement). Online supplemental appendix 5 presents a table summarising these changes.
To facilitate implementation and monitoring, the set of algorithms has been augmented with supplementary documentation forms (online supplemental appendix 2), data-collection online forms and spreadsheets (online supplemental appendix 3) and an indicators' reference sheet (online supplemental appendix 4). These supplementary tools are designed to be used to document, audit and monitor certain findings in a frequency that reflects compliance with the critical steps of the algorithm and guides decision-making. The indicators' reference sheet defines which measures are process measures and which are outcome measures.
Feedback was obtained from groups and individuals who work in different organisations, including more than 80 senior and junior ICU physicians, nurses and respiratory therapists. The feedback was intended to explore and evaluate the clinicians' reaction and learning guided by the new Kirkpatrick evaluation model.16 Two members of the research team, representing the clinical and quality professions, used verbal feedback, individual and focus group interviews and observation as evaluation tools and methods. These tools and methods have aided in exploring the clinicians' satisfaction and engagement, and the algorithms' content relevance as characteristics which demonstrate the degree of favourable clinicians' reaction to the proposed algorithms.16 Moreover, an online introduction to the algorithms and on-job training have been offered to practising clinicians. The two-member evaluation team explored, on a very limited scale, the degree of acquiring the intended knowledge, skills, attitudes, confidence and commitment based on the participation in the training events.16 The feedback has assisted in selecting the algorithms colour theme, changing the algorithms boxes location to reduce clutter, adding explanatory elements such as the abbreviation lists and testing the feasibility of the use of the algorithms within the work context. The collective feedback showed a positive reaction towards content relevance with less positive satisfaction and weaker engagement. However, the clinicians exhibited some 'buy-in' when they had seen that their comments were considered in the subsequent revisions. Regarding the training events, the highest positive feedback was knowledge and skills, while attitudes, confidence and commitment were challenging.
Our hospital is working to improve the quality of care provided to all patients, including patients with COVID-19. To this end, the hospital has recently proposed a protocol for safely transporting critically-ill patients with COVID-19, which was published in a high impact peer-reviewed journal.17 While the first protocol focusses on one problem and introduces a table that fits the non-branching linear procedure of patient transportation;13 this paper proposes a complete toolkit, with a set of clinical algorithms that fits the complex problems and the necessity of making clinical decisions. Although our organisation is a large government secondary-care hospital, the proposed algorithms can be used in other settings that provide inpatient, low-acuity and critical levels of care, including private centres, university hospitals and smaller or larger hospitals.
The research team, which represents a professional panel, relied on its members' judgement to select best-practice clinical guidelines to improve clinicians' decision‐making. To obtain the full potential of these guidelines, they were translated into clinical algorithms.9 Whether for teaching clinical decision making, or guiding clinical diagnosis and management, a clinical algorithm is defined as a graphical set of sequentially-detailed, explicit steps and instructions, which guide healthcare providers on how to perform a procedure appropriately.18–20
"All models are wrong; the practical question is how wrong do they have to be to not be useful". This quote is attributed to the British mathematician and professor of statistics, G. Box.21 If this is applied to a more generic entity, a model; it can also be applied to a more specific one, an algorithm. Every patient is unique, and it is impossible to reflect the full complexity of reality and account for every single clinical eventuality. As modelling is intended to reflect the necessary details to understand the modelled subject in some way,22 the proposed set of algorithms is intended to be a guiding tool for clinicians during their attempts to diagnose and manage patients with COVID-19.
Since their introduction in the early 1970s, clinical algorithms have had a substantial impact on healthcare delivery and research.19 23 Recent literature shows that what was theoretically valid in the 1970s and 1980s has been practically demonstrated in the 2010s. A study published in 2017 showed that a referral algorithm, described as a 'simple educational intervention', can effectively reduce the burden of inappropriate referrals and improve service use and cost-efficiency.24 Reflecting on hospital practice, this toolkit may reduce the number of patients with COVID-19 who are admitted to limited-capacity ICUs by following the patient allocation algorithm (figure 1). Moreover, it has been demonstrated that an algorithm-guided, standardised approach to evaluating patients can save resources without sacrificing patient outcomes or diagnostic accuracy.25 This is of high importance when looking at current hospital practices of frequently ordering unnecessary follow-up investigations. On the other hand, incidences of late intervention have been reported. Given the fact that most of the interventions in this set of algorithms are supported by clear parameters/findings, which indicate when to initiate, we expect that the interventions will be activated earlier.26
In addition, the benefit of using this toolkit is not limited to increased efficiency in resource utilisation or appropriate referrals. Our hospital has recruited and reallocated many non-intensive care clinicians to manage patients with COVID-19. Communication during consultation and handover between new, less-trained clinicians and senior, more-experienced clinicians must be standardised to permit the provision of high-quality, uninterrupted clinical care. The algorithm-based supplementary documentation forms will create a shared mental model where attendance, punctuality, attention, summarisation and provision of anticipatory guidance can be improved.27
While the above-mentioned benefits align with high-quality care (eg, efficiency, appropriateness and continuity of care), it is worth noting that this initiative also corresponds with the assertions of renowned quality experts; Staines and colleagues during this global pandemic. To avoid the hibernation of quality/patient safety programmes and use the skillset of quality/patient safety experts, Staines and colleagues introduced what can be viewed as a contemporary manifesto for quality activities during a pandemic, such as COVID-19.6 The initiative presented in this paper fulfils many of the recommendations that they advocate, such as working to improve care through clinical decision support; gathering, filtering, summarising and briefing experience and evidence; organising just-in-time audits of key relevant practices; strengthening the capacities of the learning system and emphasising the importance of capturing crisis-related improvement opportunities and innovations; and contributing to data analysis, representation and interpretation of variation.6
Few, yet important, concerns have been raised regarding calls to develop and use clinical algorithms. Since their early appearance in the literature, clinical algorithms have faced similar objections. The main objections are that algorithms will create unable-to-think robotic clinicians with less individual autonomy, and that they are inapplicable to specific patients.20 28 In fact, algorithms are frameworks used to facilitate thinking about clinical encounters in a branching logic, which allows individualisation of management and care once the patient is thoroughly examined.14 19 28
From a behavioural psychology perspective, communicating the results of performance monitoring is a cornerstone in changing behaviour. Therefore, an evaluation method must indicate whether or not a behaviour was performed as required.20 The algorithm set has been augmented with documentation forms to facilitate implementation by requiring the documentation of certain findings in a frequency that reflects compliance with the algorithm and guides the decision making (online supplemental appendix 2). The documentation forms, in turn, facilitate auditing and performance measurement, as they supply the data needed to monitor critical steps in the spreadsheets (online supplemental appendix 3). This will help to evaluate the effectiveness and timeliness of the care provided, and eventually inform clinicians about how appropriate their decisions were concerning a clinical problem.
Given that one universal and essential characteristic of the current pandemic is coping with a flood of redeployed clinicians and the need for rapid training and learning, a self-paced, free and open-access online training is available to train individual and group clinicians on why and how to use the algorithms and what benefits they may expect. This training, which fits in various staff circumstances and time zones, includes a post-activity feedback assessment and practice exercises to evaluate the usefulness of the training. Moreover, the training entitles participants to claim continuing education credits, which may motivate more clinicians to engage in such educational activity.
The research team members are planning to monitor and report on the current performance in their respective organisations. Benefitting from the easy access to the shared same data-collection online forms, the team can provide a fast performance report to practising clinicians with the added option of benchmarking. After having a foundation of local acceptance, the team intends to seek support from the national clinical bodies and the Quality and Accreditation Directorate in the Ministry of Health, Kuwait, to integrate the indicators list into the current National Indicators Programme. Moreover, the publication of this work as a peer-reviewed article will add some weight to the toolkit and eventually substantiate the research team's call for adopting best practices.
This paper has several strengths which distinguish it. Excluding papers that describe non-branching linear procedures using a table or a list, there are no previous papers on the management of patients with COVID-19 that fit the standard definition of an algorithm. In addition, the comprehensiveness of the algorithms and the inclusion of the whole management spectrum of patients with COVID-19 are unprecedented. Moreover, this initiative was brought about by critical care physicians, not quality professionals, in response to their awareness of the variation in practice. This will ensure better clinician buy-in to the improvement project.
The scientific contents of the algorithms are up-to-date and universally-accepted best-practices. However, the parameters, drug doses and management thresholds can be revised, customised or modified without destroying the main structure of the algorithms. Furthermore, the algorithms were developed and written following a best-practice, logical system approach and method.13 Finally, the algorithm set, together with the supplementary documentation forms (online supplemental appendix 2), data-collection online forms and spreadsheets (online supplemental appendix 3) and indicators' reference sheet (online supplemental appendix 4) create a unique essential toolkit that is needed in this incomparable challenging situation.
However, some limitations are also present. Although the algorithm set was piloted during its development and writing processes, it was not tested on a larger scale to verify its value in standardising care. The piloting involved few supporting clinicians; which gives a biassed result. Acknowledging the time constrains and the stressing work environment, wider piloting was not possible at that moment. Moreover, the feedback, which has been sought, was verbal and did not follow a structured scheme each time. A qualitative approach to analysing the feedback, if feasible, would have added more insights.
Being an early report proposing a toolkit, the effects of standardisation on clinical outcomes and quality of care have yet to be established. Moreover, the impact of the intervention on behaviour has not been assessed. However, the benefits of using algorithms in changing clinical outcomes and behaviour are supported in the literature. The authors also acknowledge that the shapes used in the algorithms are not standard flowchart elements. Also, more details were needed in some of the shapes. This should be of no concern, as the algorithm set is meant to be used in a clinical context where the shapes of algorithm elements are not rigorously standardised. This decision is also supported in the literature.12
Practice implications
To understand and methodically predict the clinical outcomes of current COVID-19 management practices, clinical processes must first be stabilised and standardised, which is the aim of these algorithms.14 The initiative of translating narrative clinical guidelines to more-comprehensible, graphically-represented algorithms may inspire other professional bodies and guideline panels to do the same. Moreover, after demonstrating its effectiveness following implementation, this toolkit will enhance healthcare institutions' readiness and resilience to manage the second COVID-19 wave that looms on the horizon. Furthermore, although the authors' organisation is a large government secondary-care hospital, the proposed algorithms can be used in other settings that provide inpatient, low-acuity and critical levels of care, including private centres, university hospitals and smaller or larger hospitals.
The data-collection online forms and spreadsheets together with the indicators' reference sheet should allow easy measurement of performance and benchmarks between different healthcare institutions that decide to use the toolkit. Indicating compliance with clinical guidelines, this measurement is at the core of the science of improvement.9 14 Expecting successful control of the current pandemic, the authors believe that these clinical algorithms could be used as a decision support tool in managing patients with non-COVID ailments. The algorithms for intubation (with some modifications), weaning and haemodynamic management apply to all ICU patients, while mechanical ventilation algorithm applies to any ARDS (acute respiratory distress syndrome) patient.
Reality can be chaotic to the extent that one may prefer the abstraction of models or algorithms to make sense of reality. It is true that 'a picture is worth a thousand words'. The considerably large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly set of algorithms. Research has demonstrated the many benefits of using decision support tools, such as clinical algorithms. We hope that this toolkit will improve the quality of care provided to patients with COVID-19 by acting as a training and guiding tool. We also hope that the timely sharing of this toolkit will help prepare other institutions to meet the present and future challenges of COVID-19 and similar pandemics. While inviting other institutions to join in the second phase of this research by adopting this toolkit, we advocate that all professional bodies and guideline panels support their clinical guidelines with algorithms.
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. Evaluation of fluid responsiveness during COVID-19 pandemic: what are the remaining choices? J Anesth 2020;34:758–64.doi:10.1007/s00540-020-02801-ypmid:http://www.ncbi.nlm.nih.gov/pubmed/32451626
Vieillard-Baron A,
Balik M
. 5 minutes echo exam during a pandemic, 2020. Available: https://esicm-tv.org/webinar11_live_32-haemodynamic-management-of-covid-19-septic-shock.html [Accessed 21 Jun 2020].
Therapeutics. Boston, MA, USA: : Brigham and Women's Hospital, 2020. Available: https://5eed4dd82e59e4d21bd0003d-covid-protocols.netlify.app/ [Accessed 21 Jun 2020].
Barnes GD,
Burnett A,
Allen A, et al
. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis 2020;50:72–81.doi:10.1007/s11239-020-02138-zpmid:http://www.ncbi.nlm.nih.gov/pubmed/32440883
Atallah B,
Mallah SI,
AlMahmeed W
. Anticoagulation in COVID-19. Eur Heart J Cardiovasc Pharmacother 2020;6:260–1.doi:10.1093/ehjcvp/pvaa036pmid:http://www.ncbi.nlm.nih.gov/pubmed/32352517
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Data supplement 1
Contributors AS reviewed the published literature and drafted the algorithms manually. HA, MS and SA revised and approved the algorithms. HE drew the algorithms using MS Visio, wrote the manuscript and created the data-collection online forms and spreadsheets. IA, MG and LA drafted the documentation forms and HE finalised them. IA and LA drafted the indicators reference sheet and HE and AS finalised it. AS, IA, MG and LA revised the final version of the documentation forms, indicators reference sheet and data-collection online forms and spreadsheets. All authors critically revised the manuscript, gave final approval of the version to be published and are accountable for all aspects of the work. HE is the guarantor of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
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Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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text:
Mariah Carey >
Mariah Carey's beau wants to marry her
By Bang Showbiz in Lifestyle / Showbiz on 24 June 2015
Follow Mariah Carey
Mariah Carey James Packer Nick Cannon Miranda Kerr
Mariah Carey's new beau James Packer wants to marry her as soon as her divorce from Nick Cannon is finalised.
Mariah Carey's new beau James Packer wants to marry her.
The '#Beautiful' hitmaker, who split from Nick Cannon last summer after six years of marriage, and the Australian billionaire have only been dating since last week, but they are reportedly already talking about exchanging vows.
A source close to the 45-year-old singer told gossip website TMZ.com James wants to marry her sooner rather than later, and she is very open to the idea.
The 'Fantasy' hitmaker is still legally married to Nick, with whom she has four-year-old twins Monroe and Moroccan, but their divorce is expected to be finalised in the near future.
The couple, who were introduced by mutual friend Brett Ratner, are currently holidaying with her children on a lavish yacht near Sardinia, where James has been blaring Mariah's music for everyone in the area to hear.
The 47-year-old businessman, who has an estimated fortune of $4.7billion, fell for the singer after attending her concert in Las Vegas in early May and has been pursuing her ever since.
He was previously linked to top model Miranda Kerr, 32, following his split from second ex-wife Erica in 2013.
While Mariah has clearly moved on, Nick recently admitted he would never rule out the idea of them getting back together.
Speaking in April, he said: ''It's one of those things, I'm a hopeless romantic too. Through this learning process, you never say never.
''To me one thing I know, that will always be the love of my life, always be my family and that's never going to change.''
Mariah Carey to be inducted into Songwriters Hall of Fame
Mariah Carey jokes about her record-breaking achievement
Mariah Carey is sued by former nanny
Mariah Carey remakes All I Want For Christmas Is You video for anniversary
Mariah Carey vows to make Christmas special for her kids
Mariah Carey's All I Want for Christmas Is You tops Billboard Hot 100 after 25 years
Mariah Carey's All I Want For Christmas Is You finally lands US No1
Mariah Carey and Amazon Music team up for Christmas documentary
Mariah Carey wants to make Christmas 'great' for her kids
Mariah Carey confirmed as face of Walkers
Mariah Carey's daughter takes her shopping at Target
Mariah Carey swims with dolphins
Mariah Carey offered £9M to be face of Walkers
Mariah Carey's tough childhood
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redpajama_set_name: RedPajamaCommonCrawl


Villa surrounded by nature with 3 bedrooms and 3 bathrooms including a Polynesian bathroom.
The living room is large with an American style kitchen.
The villa is sold fully equipped, furnished and tastefully decorated.
Large laundry room of 12 m² with washing machine.
8 meters long bean pool in front of the 25 m² covered terrace with splendid views of the landscaped garden.
In a subdivision without walls and plant fences instead, located in a very quiet countryside environment.
Only 3.5 km from Black Mountain Golf Course ranked No. 1 in Thailand several times and the local water park.
Possibility to have a tenant for 1 year.
Thai Bali Villa is located in soi 116, only 6 km. from town/ 2 km. from beach. Many facilities such as Western kitchen style, jacuzzi, washing machine, microwave, internet access, cable tv, common swimming pool, parking, security 24/7.


text:
Company News »
Arctic Cat Reports Fiscal 2015 Third Quarter Results
Published on January 28, 2015, 11:31 GMT
Arctic Cat Inc. (NASDAQ:ACAT) today reported net earnings of $7.5 million, or $0.57 per diluted share, on net sales of $193.7 million for the fiscal 2015 third quarter ended December 31, 2014. Arctic Cat's adjusted earnings totaled $0.68 per diluted share, excluding executive transition costs of $0.11 per diluted share, in the 2015 third quarter. In the prior-year quarter, Arctic Cat reported net earnings of $12.1 million, or $0.89 per diluted share, on net sales of $225.8 million.
Commented Christopher Metz, Arctic Cat's president and chief executive officer: "Since I joined the company as CEO in December, I have learned a great deal about Arctic Cat's strengths, opportunities and challenges. My short time here has reinforced my belief that Arctic Cat is an iconic brand in a growing industry, with significant potential to improve its top- and bottom-line results. We currently are developing our strategic growth plans. However, I can say with confidence that we will seek to spur growth through additional OEM partnerships and small bolt-on acquisitions that enable us to quickly expand our expertise and capabilities, and drive even faster product innovation. We also will assist our dealers in aggressively reducing non-current inventory and providing marketing support, which in turn will accelerate wholesale and retail growth of new, innovative products. Overall, I am excited about the company's long-term future."
Operating Review
Arctic Cat's fiscal 2015 third-quarter net sales were down 14 percent to $193.7 million versus the prior-year quarter. The company continued to see strong retail growth in sales of its WildcatTM recreational off-highway vehicle (ROV) line and gained further market share in this category. Snowmobile sales in the quarter were negatively impacted by the timing of shipments to Arctic Cat's OEM partner that moved to the fiscal 2015 first and second quarters. Following strong snowmobile retail sales and market share gains in fiscal 2014, Arctic Cat will have higher snowmobile sales to its dealers for the current full fiscal year.
Gross profit margin in the 2015 third quarter rose slightly to 18.0 percent compared to 17.8 percent in the prior-year quarter, primarily due to improved product mix.
Operating profit in the 2015 third quarter was $5.9 million versus $18.4 million in the same quarter last year. Contributing to the decline was the impact of unfavorable Canadian currency exchange, as approximately 30 percent of Arctic Cat's annual sales are to Canada, and increased general and administrative expenses, including executive management transition and legal costs. The company also continued to increase investment in research and development to ensure a strong pipeline of new products and technologies.
Arctic Cat ended the 2015 third quarter with a strong balance sheet. The company had cash and short-term investments totaling $67.5 million at quarter end, up from $62.5 million in the year-ago quarter, and no long-term debt.
For the nine months ended December 31, 2014, Arctic Cat's net earnings were $26.4 million, or $2.02 per diluted share, compared to $41.0 million, or $2.99 per diluted share, in the prior-year period. Arctic Cat's adjusted earnings totaled $2.47 per diluted share, excluding an executive severance charge of $0.08 per diluted share in the 2015 first quarter, a warranty expense charge of $0.26 per diluted share recorded in the fiscal 2015 second quarter, and executive transition costs of $0.11 per diluted share in the 2015 third quarter. Year to date, the company's net sales increased 3 percent to $599.9 million versus net sales of $585.1 million in the year-ago first nine months.
Business Line Results
ATVs/Side-by-Sides – Sales of Arctic Cat's all-terrain vehicles (ATVs) and side-by-sides totaled $83.9 million, up 7 percent compared to prior-year sales of $78.2 million. Contributing to sales was growth in Wildcat ROVs, while core ATV sales were down. During the quarter, the company continued its efforts to lower core ATV inventory at its North America dealers.
"We are very pleased that retail sales of our side-by-side Wildcat ROVs grew at twice the industry average in calendar 2014," said Metz. "Dealer and consumer response to our expanding Wildcat line is enthusiastic and we expect further gains in the ROV segment, driven by new products and technologies." In early February, Arctic Cat plans to introduce a new Prowler ROV for the 2016 model year.
Arctic Cat unveiled 15 new 2015 models of ATVs and ROVs. Adding to its expanding line of side-by-sides, in mid-September Arctic Cat introduced three Wildcat Sport models on a new 60-inch wide chassis. The new chassis' width offers consumers a mid-sized option between the original Wildcat and the recently introduced Wildcat Trail model, with its narrower 50-inch stance. Arctic Cat also debuted the Wildcat Trail Limited EPS, which is a more fully featured version of the Wildcat Trail with its 50-inch wide chassis, and the Prowler XT side-by-side recreation model. In addition, new 2015 model year ATVs included the all-new XR line designed for the sport utility segment and the TRV(R) 1000 XT EPS, with its two-person seating for the touring category.
Snowmobiles - Snowmobile sales in the fiscal 2015 third quarter totaled $81.5 million versus $118.1 million in the prior-year quarter, primarily due to the timing of OEM shipments, which moved to the 2015 first and second quarters.
Commented Metz: "We are very pleased with our continued OEM snowmobile partnership. Sales of Arctic Cat's snowmobiles and the parts, garments and accessories business have grown under this partnership and contributed to our operating income. We see long-term potential from this and other future OEM and strategic alliances."
For the 2015 model year, Arctic Cat introduced 15 new snowmobiles, including the expanded model offering of Arctic Cat's first designed and built 2-stroke snowmobile engine, the 6000 C-TEC2. Since its introduction, sales of this powerful, lightweight and fuel-efficient engine have more than doubled for fiscal 2015. The 6000 C-TEC2 engine contributed to SuperTrax Magazine naming Arctic Cat's ZR 6000 LXR as the winner of its Best-in-Class 600.
Parts, Garments & Accessories – Sales of parts, garments and accessories (PG&A) in the fiscal 2015 third quarter were $28.3 million versus $29.5 million in the prior-year quarter. All areas of the company's PG&A business performed well in the quarter with the exception of snow-related parts, which were impacted by the lack of snow. Year to date, Arctic Cat's ATVROV accessories sales have increased 14 percent.
Fiscal 2015 Full-Year Outlook
Commented Metz: "Fiscal 2015 is a challenging year of transition where we are resetting our strategic priorities to deliver improved long-term performance. At this time, we are lowering our fiscal 2015 full-year outlook for sales and earnings, as we work through existing challenges. As we stated in the 2015 second quarter, one of our biggest challenges is rightsizing our core North America ATV dealer inventory levels. Bold actions are necessary to return to growth."
To accelerate the company's core ATV inventory reduction plan, Arctic Cat will take a $7 million charge in the 2015 fourth quarter that will enable it to reduce dealers' non-current inventory at a much faster pace than previously planned. Additionally, the company expects lower international sales in fiscal 2015, including sales to Russia, due to macroeconomic headwinds and reflecting the increased unfavorable Canadian currency exchange, as approximately 30 percent of Arctic Cat's annual sales are to Canada.
Added Metz: "Looking ahead, an improved dealer inventory position will allow us to launch more new products and increase sales. In addition, our strong cash position gives us the flexibility to make investments to grow the business through innovative products, strategic and OEM partnerships, and bolt-on acquisitions. We believe the company has terrific opportunities to return to growth and create shareholder value."
For the fiscal year ending March 31, 2015, Arctic Cat now estimates fiscal 2015 full-year sales in the range of $705 million to $715 million and net earnings of $0.36 to $0.44 per diluted share. Arctic Cat's fiscal 2015 outlook includes: executive severance charge of $0.08 per diluted share recorded in the first quarter; warranty expense charge of $0.26 per diluted share recorded in the second quarter; executive transition costs of $0.11 per diluted share in the 2015 third quarter and about $0.03 per diluted share in the 2015 fourth quarter; estimated dealer inventory reduction of $0.40 per diluted share; and the anticipated unfavorable Canadian currency impact of up to $0.80 per diluted share for the fiscal 2015 full year. Excluding the impact of the recall, severance, inventory reduction and executive transition costs, the company anticipates fiscal 2015 earnings in the range of $1.24 to $1.32 per diluted share, as adjusted. The new earnings guidance excludes any new CFO transition costs that could be incurred in fiscal 2015. Previously, Arctic Cat anticipated full-year net earnings of $1.55 to $1.65 per diluted share on net sales in the range of $745 million to $755 million.
A conference call is scheduled for 10 a.m. CT (11 a.m. ET) today. To listen to the live call, dial 1-800-768-6563, passcode 5885056. The webcast may be accessed through the investor relations section of www.arcticcat.com/corporate. In addition, a telephone replay will be available through February 4, 2015, by dialing 1-888-203-1112, passcode 5885056.
Arctic Cat Inc. designs, engineers, manufactures and markets all-terrain vehicles (ATVs), side-by-sides and snowmobiles under the Arctic Cat(R) brand name, as well as related parts, garments and accessories. Its common stock is traded on the Nasdaq Global Select Market under the ticker symbol "ACAT." More information about Arctic Cat and its products is available at www.arcticcat.com.
The Private Securities Litigation Reform Act of 1995 provides a safe harbor for certain forward-looking statements. The Company's Annual Report, as well as the Report on Form 10-K, its Quarterly Reports on Form 10-Q and other filings with the Securities and Exchange Commission, the Company's press releases and oral statements made with the approval of an authorized executive officer, contain forward-looking statements that reflect the Company's current views with respect to future events and financial performance. These forward-looking statements are subject to certain risks and uncertainties that could cause actual results to differ materially from historical results or those anticipated. The words "aim," "believe," "expect," "anticipate," "intend," "estimate" and other expressions that indicate future events and trends identify forward-looking statements including statements related to our fiscal 2015 outlook, business strategy, expected product introductions and demand. Actual future results and trends may differ materially from historical results or those anticipated depending on a variety of factors, including, but not limited to: product mix and volume; competitive pressure on sales, pricing and sales incentives; increase in material or production cost which cannot be recouped in product pricing; unexpected delays in the introduction of new products; changes in the sourcing of engines; interruption of dealer floorplan financing; warranty expenses and product recalls; foreign currency exchange rate fluctuations; product liability claims and other legal proceedings in excess of reserves or insured amounts; environmental and product safety regulatory activity; effects of the weather; general economic conditions and political changes; interest rate changes; consumer demand and confidence; and those set forth in the Company's Annual Report on Form 10-K for the year ended March 31, 2014, under heading "Item 1A. Risk Factors." The Company does not undertake any obligation to publicly update or revise any forward-looking statement, whether as a result of new information, future events or otherwise.
(000s omitted, except per share amounts)
Three Months Ended Nine Months Ended
December 31, December 31,
Snowmobile & ATV Units $ 165,453 $ 196,295 $ 512,813 $ 503,285
Parts, Garments & Accessories 28,282 29,495 87,040 81,798
Total Net Sales 193,735 225,790 599,853 585,083
Snowmobile & ATV Units 140,158 166,994 422,923 402,650
Total Cost of Goods Sold 158,822 185,577 479,058 454,036
Gross Profit 34,913 40,213 120,795 131,047
Selling & Marketing 11,757 9,726 30,812 28,836
Research & Development 6,496 5,723 18,463 17,291
General & Administrative 10,797 6,372 36,026 21,802
Total Operating Expenses 29,050 21,821 85,301 67,929
Operating Profit 5,863 18,392 35,494 63,118
Interest Income 8 6 18 22
Interest Expense (97 ) (96 ) (346 ) (136 )
Total Other Expense (89 ) (90 ) (328 ) (114 )
Earnings Before Income Taxes 5,774 18,302 35,166 63,004
Income Tax Expense (Benefit) (1,713 ) 6,182 8,721 22,051
Net Earnings $ 7,487 $ 12,120 $ 26,445 $ 40,953
Net Earnings Per Share
Outstanding:
Basic 12,941 13,420 12,920 13,338
Diluted 13,062 13,657 13,072 13,698
Selected Balance Sheet Data: 2014 2013
Cash and Short-term Investments $ 67,492 $ 62,536
Accounts Receivable, net 59,102 74,123
Inventories 144,577 137,189
Total Assets 352,013 340,642
Short-term Bank Borrowings 0 0
Long-term Debt 0 0
Shareholders' Equity 206,196 211,914
Product Line Data: 2014 2013 Change 2014 2013 Change
Snowmobiles $ 81,523 $ 118,061 -31 % $ 295,466 $ 276,060 7 %
All-Terrain Vehicles 83,930 78,234 7 % 217,347 227,225 -4 %
Parts, Garments & Accessories 28,282 29,495 -4 % 87,040 81,798 6 %
Total Sales $ 193,735 $ 225,790 -14 % $ 599,853 $ 585,083 3 %
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by chrissythehyphenated | January 12, 2017 · 6:58 pm
Spicer talks about Acosta's behavior
Sean Spicer: I Told CNN's Jim Acosta If He Behaves Like That Again I'll Have Him Removed [1:28]
Comments Off on Spicer talks about Acosta's behavior
Radio talk-show host Larry Elder says Obama's legacy is Donald J. Trump.
Video of Elder's interview on Hannity is worth watching.
Comments Off on Obama's Legacy
Filed under Barack Obama, Donald Trump
Mattis hearing
Before Mattis can join the Cabinet, Congress must approve a one-time exception to a law requiring a military officer to be out of uniform for at least seven years before leading the Pentagon. Even some of Trump's strongest critics say Mattis merits the exception — and the Senate voted decisively today to approve the waiver on a 81-17 vote. It goes next to the House.
Jan 12, 2017: Gillibrand tried desperately to make Mattis look like a sexist homophobe.
http://www.foxnews.com/politics/2017/01/12/defense-secretary-nominee-mattis-warns-world-order-under-historic-threat.html
Comments Off on Mattis hearing
Filed under Armed Forces, Defense, James Mattis, U.S. Senate
by bluebird of bitterness | January 12, 2017 · 4:25 pm
Columbia University distributes microaggression whistles to students
From The Babylon Bee.
Sources confirmed Monday that school officials at Columbia University have instituted a new program to help students alert professors and other undergrads to potential microaggressions, with each pupil at the prestigious university being given a whistle to blow whenever they witness a microagression or begin to feel microaggressed against themselves.
Columbia students are reportedly encouraged to blow their whistle and flail their arms wildly about in the air whenever they hear triggering phrases such as "Where are you from?" "Nice weather today," or "Hello."
University president Lee Bollinger stated the initiative is already paying dividends, with numerous reports of near-constant loud whistle blasts constantly being heard in common areas, dorm rooms, bathrooms, dining halls, and classrooms.
"One of our history professors warmly greeted his class and asked how their weekend was," Bollinger said, "without realizing he was microaggressing students who are uncomfortable with the Gregorian calendar. So they were able to slam him with ear-shattering whistle blasts for the rest of the class period."
"Our university is now a constant cacophony of whistle blasts. Progress!" he added.
Filed under Funny Stuff
Tagged as The Babylon Bee
Excerpts from the National Review editorial posted yesterday
The president is leaving the same way he came in: with a great deal of vague and fruity talk about "hope and change," very little of genuine interest, and an undercurrent of bitterness communicating his unshakeable belief that the American people just simply are not up to the task of fully appreciating History's unique gift to them in the person of Barack Obama.
And he is so terribly disappointed in us! Having just endured the electorate's rejection of his party and his mode of politics with the election of Donald Trump, and grimly considering the likely dismantling of much of his executive-order legacy, President Obama gave a speech about how our democracy has failed and why.
You'll be something less than shocked to learn that his belief is that Americans are so beguiled and befouled by racism and prejudice that we failed to cultivate the sacred spark the Promethean president handed down to us.
Oh, and we watch too much Fox News and read too many Facebook posts from that right-wing uncle of myth and lore, which deprives us of a "common baseline of facts."
Last night was billed as a forward-looking speech, but it was in no small part an evening of recriminations.
He said those who resist his agenda are racists.
He said those who disagree with him about climate change are un-American.
He proposed adopting new norms in media and political discourse that would suffocate criticism of his party, its policies, and its philosophy.
He proposed rewriting campaign-finance laws and redrawing congressional districts to make it easier to elect Democrats.
All this from the man whose administration weaponized the IRS for political purposes and whose executive usurpations were repeatedly thrown out by the courts.
For a man who rose to national attention on the basis of his oratory, he has had relatively little to say. He brought no new ideas or insights to the office, only a pointlessly grandiose sense of his own specialness.
Barack Obama is a man who stood astride History muttering "You're welcome, you ingrates."
Comments Off on No, You Didn't
by Pistol Pete | January 12, 2017 · 12:31 pm
Media Poke Honey Badger… Get Bit
After eight years of fawning, butt-kissing, and constant tongue baths, the media have resumed their adversarial role to the new president. Following up on scurrilous, unsubstantiated smears the press were drooling over the opportunity to savagely attack The Donald and treat him like meat before ravening hyenas. They found out an unfortunate fact of life. Prod a dangerous creature and you could wind up having a real bad day.
The Media Is Outraged That Trump Criticized CNN. They Must Have Forgotten When Obama Did The Same To Fox News
The media was furious after Donald Trump refused to take a question from a CNN reporter at his first press conference as president-elect Wednesday
The press was incensed, but why did Barack Obama not generate the same outrage when he repeatedly criticized Fox News and questioned its legitimacy over the last eight years?
YOU'VE SEEN THIS:
CNN's Sciutto Calls Colleague Jim Acosta 'Brave' After Trump Press Conference Diss
THESE BOTTOM-FEEDING SCUM THINK IT'S FUNNY TO DISRESPECT REPUBLICANS. IT'S GREAT SPORT.
Sciutto discussed the ordeal soon afterward and jumped to his colleague's defense, calling Acosta "brave" for what he did.
"If I could just add this: a lot of charges were leveled at CNN, including my brave colleague there, Jim Acosta," Sciutto said.
Killing CNN
Yesterday, Trump made it crystal-clear to CNN that they have crossed the red line – you know, the one Obama dared the Russians to cross in Syria. They crossed it, and Obama whimpered. Trump is done with red lines. He is building a wall, and CNN is closed out of Trump's news conferences. He flatly refused to allow them to exercise the pretense of journalism by refusing to permit them to level questions at him during his presser.
NY Magazine: Trump 'Owns the Press' at First Press Conference
But observed as spectacle, Trump came away with a resounding victory. That's because Trump won even before he stepped before the microphone, by making the media the story. Last night, BuzzFeed published a salacious 35-page oppo-research dossier on Trump that alleged Russia possessed sexual and financial dirt on Trump that could be used to blackmail him.
Journalists receive oppo research frequently during political campaigns, but publish only what they can verify. By amending this standard for Trump, BuzzFeed handed him an opening to play the victim. Trump thrives in a world where facts are fungible.
"We are now fully immersed in the anonymous, the unverified, and the unverifiable. And he hasn't even taken office. Trumpism sure is fast."
IN A CHANGE OF PROTOCOL I'M RETURNING TO THE OLD FORMAT, POSTING DIFFERENT THINGS IN THE COMMENT SECTION SO THE HAPPY WANDERERS CAN BROWSE AT THEIR LEISURE.
Filed under Barack Obama, Donald Trump, Media Bias, News Media
by Pistol Pete | January 12, 2017 · 8:38 am
The Confirmation Follies
There's so much going on it feels like I just flushed a coven of quail and don't know which one to shoot at.
Moonbat Interrupts Tillerson Confirmation Hearing: "Rex Tillerson, I Reject You. I Reject You. My Home Was Destroyed By Hurricane Sandy"
Apparently Tillerson has access to the government's super secret weather machine and used it to make Hurricane Sandy.
Code Pink Removed From Tillerson Hearing Before It Begins
IF YOU HAVE AN ERECTION LASTING MORE THAN 4 HOURS, IMAGINE MAKING LOVE TO MEDEA BENJAMIN. YOU SHOULD DEFLATE FASTER THAN A BALLOON WITH A HOLE IN IT.
Cory Booker Lays Groundwork for 2020 Run at Jeff Sessions Hearings
There may as well have been a banner hanging in the grand marble meeting room that housed Jeff Sessions' hearings for attorney general: Booker 2020.
But Booker, swarmed by far more cameras than any other witness of the day when he entered the room, used the afternoon to take a splashy stand and lay groundwork for a potential 2020 presidential run.
Senate Showdown: The Real Reason Cory Booker Testified Against Jeff Sessions
"Sen. Cory Booker will use his testimony to cement support among the Democratic activist/populist wings of the party as he considers a 2020 presidential run," Schweitzer, who has helped confirm over 20 nominees at the Senate, said.
Senator Who Attacked Jeff Sessions Caught in BOMBSHELL Scandal
FIND A DEMOCRAT THAT DOESN'T TAKE KICKBACKS. JUST TRY IT.
Senator Cory Booker is embroiled in a Newark Watershed Conservation and Development Corporation (NWCDC) scandal involving allegations of massive kickbacks, Politico reports. Yesterday, Donald Bernard Sr., who was the senior projects manager at the company that ran Newark's water infrastructure under the direction of then-mayor of Newark, New Jersey Cory Booker, pled guilty in federal court to accepting nearly $1 million in bribes from contractors.
Cory Booker Has No Idea What The Hell An Attorney General Does
Rex Tillerson Fends Off Little Marco Rubio at Confirmation Hearing – January 11, 2017
THE LITTLE PRICK CALLED TRUMP 'UNFIT TO LEAD,' THEN A MONTH LATER HE ENDORSED HIM.
Louisiana Rep Says Being Made to Wait to Testify Last At Sessions Hearings Is Like Being on 'Back of the Bus'
AN ASPIRING RACE HUSTLER WHO IS A COUPLE I.Q. POINTS HIGHER THAN THE PEOPLE WHO BLINDLY VOTE FOR HIM BECAUSE HE BE BLACK…KINDA LIKE THEM
Sen. Tim Scott Obliterates Twitter Troll Who Called Him A "House N***a" With One Perfect Word
Sen. Tim Scott (R-S.C.) picked up a nasty troll.
However, Scott's one word response was perfect!
Tillerson Pledges Support for Israel
"Israel is, has always been, and remains our most important ally in the region," Tillerson said. "They're important to our national security."
Comments Off on The Confirmation Follies
Filed under Cory Booker, Israel, Jeff Sessions, Marco Rubio, Race Relations, Rex Tillerson, Tim Scott, U.S. Senate


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text:
Cadmus meaning
kăd'məs
A Phoenician prince who killed a dragon and sowed its teeth, from which sprang up an army of men who fought one another until only five survived. With these five men Cadmus founded the city of Thebes.
A Phoenician prince and founder of Thebes: he kills a dragon and sows its teeth, from which many armed men rise, fighting each other, until only five are left to help him build the city.
(Greek mythology) A Phoenician prince, son of king Agenor of Tyre. Was sent by his royal parents to seek and return his sister Europa after being abducted from Phoenicia by Zeus. Credited with founding Greek city of Thebes and inventing Greek alphabet.
Origin of cadmus
Greek Kadmos of Phoenician origin qdm in Semitic roots
CADMUS, in Greek legend, son of Agenor, king of Phoenicia and brother of Europa.
The first of these historians was probably Cadmus of Miletus (who lived, if at all, in the early part of the 6th century), the earliest writer of prose, author of a work on the founding of his native city and the colonization of Ionia (so Suidas); Pherecydes of Leros, who died about 400, is generally considered the last.
According to the usual tradition, he was born at Thebes - originally the local centre of his worship in Greece - and was the son of Zeus, the fertilizing rain god, and Semele, the daughter of Cadmus, a personification of earth.
and married Autonoe, daughter of Cadmus, by whom he had several children, among others, the unfortunate Actaeon.
Cadmus >>
Words near cadmus in the Dictionary
cadmium-yellows
cadmiuria
cadmoindite
cadmoselite
cadralazine


text:
module Replication
  module StrandMethods

    def self.extended(strand_class)
      strand_class.class_eval do
        include InstanceMethods
      end
    end

    module InstanceMethods
      def replicate
        origin.new(pairs)
      end
    end
  end
end

redpajama_set_name: RedPajamaGithub


text:
The Worshipful Company of Musicians is one of the Livery Companies of the City of London. Its history dates back to at least 1350. Originally a specialist guild for musicians, its role became an anachronism in the 18th century, when the centre of music making in London moved from the City to the West End, and for more than a century it was a general guild for figures in the City, with no specific musical role.  In the late 19th century, the musical element was revived, and the modern Company promotes all aspects of the art and science of music.

History
The guild is believed to have been in existence at least as early as 1350, but the earliest official charter known was granted by King Edward IV to his minstrels in 1469. In 1500, the Fellowship of Minstrels was granted incorporation as the Musicians' Company by the Lord Mayor of the City of London, and the Company was given the right to regulate all musicians within the City. In earlier centuries, minstrels had held an honourable position in mediaeval society, but by the 15th century they were less highly regarded, and the protection of a guild was much needed. The guild received a Royal Charter in 1604, transforming it into the Worshipful Company of Musicians, with the influence and prestige of other City livery companies. It was granted control over all music-making in and within three miles of London, except for Westminster and Southwark. Nevertheless, the musicians employed by the court and powerful aristocratic families resisted the new Company's authority, and in 1632 Charles I revoked the 1604 charter. In 1637 the Westminster Musicians Guild attempted to assert control of the City's musicians, and the Company fought hard to retain its privileges, operating without a charter from 1632 to 1950.

By the middle of the 18th century most public music-making had moved from the City to the newly built West End of London, and the Worshipful Company had become an anachronism. To maintain its membership and existence, the Company began admitting non-musicians, principally leading City businessmen, and, like many of the Livery Companies, it lost its original specialist identity. In 1870, with the election of the music publisher William Chappell, the Company began to revive its interest in music. A modest number of musicians were admitted to membership, and the non-musicians in the Company agreed to an increasing emphasis on musical philanthropy as its primary activity.

Despite the lack of an official charter since 1632, the Company held tercentenary celebrations at the beginning of the twentieth century, under the direction of Colonel Thomas Bradney Shaw-Hellier commandant of the Royal Military School of Music. Masters of the Company who have been composers or otherwise connected with music include: Frederick Bridge, 1892; Herbert Sullivan, 1926; Hugh Allen, 1937; Herbert Howells, 1959; Jack Westrup, 1971; and Lennox Berkeley, 1976.

In 1949 the Company successfully petitioned the City authorities for permission to apply to King George VI for a new charter of incorporation. The new charter was granted in 1950.

Present-day activities
The Company no longer has the power to regulate music within the City. It supports musicians and musical education, awarding prizes, scholarships and medals, among which are the Collard Fellowship, the Cobbett Prize for chamber music, the Santley medal for singers. and more than thirty other annual awards in honour of, among others, Harriet Cohen, Harry Mortimer, John Christie, and Priaulx Rainier. Its Yeomen Programme is a young artists' scheme for musicians who have won one of its awards.

The Company now has more than 390 liverymen and its affairs are managed by a Master, Senior Warden and Junior Warden, elected annually, and the Court of Assistants. The Company ranks fiftieth in the order of precedence for Livery Companies.  Its motto is Preserve Harmony.

Awards
 Honorary Freedom (first presented de facto in 1876 and de jure in 1904).
 Gold Medal (awarded from 1903 as Special Presentations to the Silver Medal; since 2008 the award has been formally called the Gold Medal).
 Honorary Fellowship (awarded since 2004; recognising "performers, composers and others within the profession" but outside the Company).
 The Prince's Prize (first presented in 2004; for "the most promising young instrumentalist or singer amongst the Company's Award winners")
 Popular Music Awards (founded in 2016).
 Walter Willson Cobbett Medal (founded in 1924; recognising services to chamber music).
 Sir Charles Santley Memorial Gift (founded in 1956; recognising vocalists, composers of vocal music or researchers into singing).
 Choral Director's Lifetime Achievement (founded in 2018 to "honour those choral directors who have made a significant contribution to choral singing in the United Kingdom".)
 John Henry Iles Medal (founded in 1947; "awarded annually in recognition of a significant contribution to the brass band movement").
 Harry Mortimer Medal (founded in 1995; "in recognition of services for the teaching of young people in the brass band movement").
 Jazz Young Musician Medal (founded in 1991).
 Jazz Lifetime Achievement Award (founded in 1991).
 Silver Swan (founded in 2004; recognising "senior Livery members who have given special service to the Company").

Notes

External links
 The Musicians' Company
The Musicians' Company Archive website - dedicated to the presentation of Archived Materials and Company Treasures

Musicians
Music organisations based in the United Kingdom

redpajama_set_name: RedPajamaWikipedia


When this Pokémon card was first released, I have to admit I was not too high on it. I just did not like how in order for it to be effective, one of your Pokémon had to be knocked out. Otherwise it would only yield you a less than modest 4 card hand. A 4 card hand is fairly weak unless you have a Claydol out already. In those 4 cards, you may draw a couple Pokémon or energy which you will play down immediately. If you do not draw another supporter or draw card in those 4 cards, you will be stuck with a 2 to 3 card hand and become reliant on a topdeck.
However, I now feel that this card is reasonably strong at the moment. With the advent of fast decks such as Beedrill, Machamp, and Luxray/Infernape, your Pokémon are going to be KO'd quickly and often. It is necessary to have some sort of recover against those decks, and this card is perfect for that. If you can get a brand new 8 card hand early in the game, it will significantly increase your chances of making a comeback.
Besides being effective versus speed decks, it can also be incredible helpful versus power locking decks. Any deck that plays Mesprit LA or Power Spray will be difficult to deal with when you are reliant on Claydol's "Cosmic Power" for drawing cards. A deck using Palkia G Lv. X will try to shut off your powers for several turns in a row. Without the ability to use Claydol, they have a great opportunity to simply take over the game. If you fall behind against a deck like that, it is hard to come back. Cynthia's Feelings is great against a deck like this because it gives you a chance to keep up with them. If you can get a new 8 card hand while they are trying to power lock you, that can basically nullify their strategy and keep you in the game.
I would recommend playing in the neighborhood of 3 copies of this card in most decks. It reminds me a bit of the card Copycat which I used to play 3 of in nearly every deck.
If you have any thoughts about this card, please comment! We want to hear from you.
This card seemed great way back when in kingdra, also in AMU. I think that cynthia is great in flygon and maybe even decks coming out in supreme victors.
I use at least one in every SP deck I run because usually you should be able to notice when your opponent is about to KO and you can grab it with Cyrus!
That's a superb idea Rokman, I gotta try that out.
If you don't have any Claydols, or only have one, Cynthia is an excellent alternative or supplement. 4 Cynthias and 4 Professor Rowans in a deck give pretty good draw power. You will almost always have at least one in your hand. Even if you need to give up a card or two when you play it, the cards you give up are still going back into your hand, so you can get them again later in the game(hopefully).
I run 2 in beedrill, and try to run at least 1 in every deck I play. It is definately underrated and overlooked because most of the time it doesn't do a whole lot. But netting 8 fresh cards is game braking. It reminds me alot of holon scientist, which was bashed alot but a tech 1 won me so many games, and not playing 1 cost me quite a few back in the day. Same type of deal to me. If your claydol gets smoked, running this in a BTS deck can get you that other dol back down instnatly, instead of scooping your cards up.
This is the one card in all of my decks that I will NEVER cut. Luxury Ball is more likely to go than Cynthia's. This one card creates way too much recovery in a tight spot.
It is also incredible defense against Power Sprays which I don't think I mentioned. Jeremy and I were testing today and Cynthia's bailed me out so hard when he would Spray my Claydols. It's great to just hold it in your hand waiting for them to go for a KO directly followed by a Power Spray in efforts to bind you down.
Yes. If there is an issue in a lot of decks these days, it is the lack of non-power related draw support. Taking out Cynthia's really kills you against Power Lock.
I think this has some nice potential even without the boost from a knockout. Say you have a bad hand, use this refresh it to four cards, play anything you can, and use Claydol to increase your low hand size.
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Homepage. This page: Old photos of the pre-war 8hp Ford sidevalve.
Firstly, another period Ford photo from Les' extensive photo collection, this time of a late 1930s sidevalve Ford. Judging by the non-beaded edge to the wings, I think this is a 1937/39 7Y, fitted with the 8hp version of Ford's sidevalve motor. It was in effect the 'bargain basement' car in Ford's model range, taking over from the earlier 8hp Model Y. Buyers could choose from a standard saloon, a De Luxe, and a small 5cwt van. Australian buyers could also opt for a tourer or roadster version, perhaps more suited to their climate. All 7Y Fords were powered by the four cylinder all-iron 933cc 'Eight' sidevalve engine, with thermo-syphon cooling, coupled to a three speed 'box. The car shown below is a De Luxe version of the 7Y 'Eight', and looks to be fitted with a wireless. In 1939 the 7Y was replaced by the E04A Anglia.
2. Another 7Y De Luxe saloon.
Next is a photo from my own collection. It shows a 7Y Eight from the front this time, along with some ladies of mixed vintage. The dip in the bumper is a throwback to the long-rad Model Y. Again this is a De Luxe model, sporting an opening windscreen with a chrome-plated surround. It also has a factory-option single fog lamp, fitted to the nearside only. GPJ 223 was registered in Surrey.
3. A base model 7Y Ford?
This photo shows another Ford 7Y, registration DUR 578, a Hertfordshire series first used in 1938. A note on the back suggests that the driver is a Mr Harold Westcott, and the location is given as Smethwick, Staffordshire. This looks like it could be a base model Ford 8, note the single screen wiper (those shown above have two), and the lack of shiny trim around the bonnet side vent. This one has however been upgraded with pop-up semaphores, or "trafficators", mounted externally just ahead of the doors.
4. Ford 7Y registration ELE 89.
Graham emailed these photos over, hoping that his Grandfather's car could be identified. The car's registration was ELE 89, a London issue used from October 1937 onwards. As more photos came to light and were sent over, it became clear that the Ford was a 7Y De Luxe saloon. The first picture shows his Grandfather in the middle of repainting the little 8hp Ford - note the windows masked over, the partially-repainted side of the car, and the door, minus doorhandle, being rubbed down.
He also has a faded purchase receipt for this pre-war Ford 8, which read: "43 Butler Avenue, Harrow. Received the sum from Mr Leach 31 Warham Road Wealdstone the sum of 90 GBP for Ford Reg No ELE 89 as seen tried & approved. George Bennett pp P Bennett". Unfortunately it isn't dated. A look in a price guide for April 1939 gives a valuation for the 7Y of around this figure, suggesting a purchase shortly before the war.
The following photographs again show ELE 89, this time on a camping trip, parked with a pre-war caravan which presumably they'd rented. This front view of the 7Y Ford confirms it as a De Luxe model (twin wipers, opening screen etc). The small circular badge alongside the AA item on the grille is '8' (for Ford 8). Also interesting is the while paint applied to the running boards (a feature found on early 7Ys only), and the wing edges. This ties in with a London-registered car being used during the hours of black-out during WW2. No headlamp mask is fitted, so perhaps this photo was taken shortly after the war. The caravan is parked on quite a slope, judging by how extended the corner steadies are. Note the old-style Calor Gas bottle.
Graham also turned up this photograph of the car and caravan together.
And finally in this set, a rear view of ELE, again parked at the campsite. Note the enclosed spare wheel cover, and other caravans in the background. Thanks again to Graham for allowing these great photo to be shown here.
5. A different 7Y on a family's picnic.
Three ladies are in shot with this next Ford 7Y. Registered EWA 381, this car first hit the road late in 1937, or early 1938. The single wiper and lack of trim around the bonnet vents, confirms this as a "base" model 7Y. The picnic dates to the post-war era, as evidenced by the E493A Prefect parked in the background.
6. More food, and another 7Y.
Picnics continue to feature in many of the old photos that turn up. Here, another family is shown tucking into their food (and cigarettes) alongside a black 7Y Deluxe. While the car is pre-war, the scene looks to be from the 1950s, if the style of the car parked alongside the Ford (it looks like a 1954-on Morris Oxford Series 2) is anything to go by. The location is Wells, in Somerset.
7. Holidaying with a pre-war Ford in the 1960s.
This side-on view of a pre-war Ford 8 was provided by Steve Greenaway (thanks). His father borrowed the Ford in the 1960s to use on a family holiday. By this point in time, the Ford was beginning to show its age. Eagle-eyed Ford aficionados will spot that the rear wing has the correct, non-beaded, edge, while the front wing - presumably a replacement from a later model - does have a beaded edge, and also a non-original headlamp bolted to it. Giveaways that this is a 7Y rather than a more common 103E Pop, include the rear wraparound corner bumpers, and the spare wheel sited on the rear panel beneath a metal cover. Pops don't have running boards or ring-type bonnet catches either.
It was a sunny day when the car was caught on film, parked outside The New Inn. Great photo, thanks Steve!
8. More picnic fun with a 7Y Eight.
Nick kindly sent over this old family photo, it features a Ford 7Y Eight captured - as many photos on this page were - on a picnic.
"I had been struggling a bit to identify this Ford, which I remember from my early youth. I nearly convinced myself by comparing pictures elsewhere that it must have been a Ford Popular 103E. But its owner at the time of this photograph, which probably dates from about 1955, was my uncle and he was a motor-fitter all his working life. He never referred to it as anything other than a "Ford Eight", and he must have been good at knowing which model was which."
"Long story shortened etc., I found pictures of other Model 7Y cars on your website, and my uncle's clearly was a Model 7Y with its very solid bumper bar and not the successor E04A Anglia from about the same time, or the 103E. The registration was HPU 910 (small-boy photographic memory kicks in) and that is consistent with it being registered in Essex just before the start of the Second World War."
"My family told me that when the war led to severe shortages of petrol for domestic use, the price of cars fell dramatically, and so owners (and maybe speculators) would jack them up and leave them on blocks so that the tyres would not become mis-shapen, hoping to bring them back into use whenever petrol became available again. My uncle worked at a Vauxhall agent and it was his custom to run a big car, I think a Vauxhall 12 or 14 (but I was then too young to remember much about it), until he got married to my aunt, the woman in the Ford picture. Then the pressure of running a household must have been the reason he downsized and started to own much-less prestigious cars; I remember that he talked about having to cut the running costs."
"Working at a garage, he probably picked up this old Ford for a song, already 15 years old maybe; there's obvious collision damage or similar on the front wing, which he must have got repaired, because I do not recall any of his cars showing damage. It's got a spotlight, though, so this must have been a DeLuxe."
"By coincidence, the picture on your website of Model 7Y registered EWA 381 shows it parked next to an E493A Prefect, which was the next Ford my uncle owned (registration VNO 334). Then you go on to say "More food, and another 7Y". Just look at the picnic paraphernalia in my picture: My aunt is sitting on a reversible waterproof groundsheet, effectively a thin blanket with a rubberised membrane on the underside. This was dual-purpose and also used for many years to help secure the load on a roof-rack, waterproof side out, for obvious reasons. And everybody had storage tins labelled "Cake" in those days. But it's the collapsible windbreak around the methylated-spirit stove that I like particularly; three sheets of metal secured into this open-sided cube using four wing-nuts, and the whole brew-kit fitted for transport into that box with the teapot and saucepan on it. I don't think they ever went anywhere without it all."
Marvellous memories you have of the Ford and rides out in it, Nick. Great stuff. HPU dates to the car to mid-1939 - unlike other examples featured, the wipers are mounted below the screen.
Photos of a 7Y bombed during WW2, can be found on this page.
Period advertising for the 7Y Ford.
"I have just returned from travelling abroad in an 18-months-old Ford 'Eight'. We travelled from Dieppe to Monte Carlo in the over-all time of 29.5 miles, including all stops."
During those continuous hours of driving the car ran perfectly. It never once boiled, even though it was driven in the heat of the day. Coming back we travelled 650 miles without any stops, except for meals."
"I must congratulate you on producing a car which, though so cheap, can perform in a manner that would do credit to the most expensive car in the world."


text:
Residents to vote on blueprint for Kessingland's future in referendum
Andrew Papworth
Published: 8:00 AM November 3, 2016
Kessingland Parish Council chairman Liam Martin. - Credit: Nick Butcher
Residents are to vote on the future of a popular seaside tourist resort as a referendum is held on a vision to provide more affordable housing and better job prospects there over the next 20 years.
Parish councillors have spent the last four years drawing up the Kessingland Neighbourhood Plan amid fears young people are leaving to take up job opportunities and cheaper homes elsewhere. It has devised a blueprint for three areas of new housing development, including one which would be kept exclusively for those with a connection to the village in order to encourage them to stay.
And there would also be a new children's centre, along with a new 60-bed care home - both of which were approved by Waveney District Council's planning committee last month.
Kessingland Parish Council chairman Liam Martin said: 'We're trying to get as many people out there to vote.'
The idea of new zones for housing development is to try and give residents some say over where new homes could go, instead of developers having free reign across the village. The care home and nursery are designed to provide facilities for two important sections of the community, with a growing elderly population and young families struggling to find nearby childcare.
The poll will take place on Thursday, November 24, with polling stations around the village open between 7am and 10pm.
Before then people will be able to view the plans on the parish council's website.
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They will also be able to attend an open day at the Marram Green community facility on Saturday, November 19, between 10am and 4pm, toask any questions they might have about the plan.
What do you think? Email andrew.papworth@archant.co.uk