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Clinical Associate Professor, Medicine - Primary Care and Population Health
Dr. Jonathan Shaw received a B.A. in Philosophy from Yale University in 1999 and an MD from Harvard Medical School in 2006. While completing his internship and residency in family medicine at the Oregon Health and Science University from 2006-2009, he obtained additional training as a visiting scholar in Mbabane, Swaziland via the Baylor International Pediatric AIDS Initiative. He has also provided maternal and infant care in rural Guatemala. After completing residency he has practiced in community health settings, serving primarily immigrant populations, both in Oregon and now East Palo Alto. He moved to the Bay Area in 2011, joining Stanford's Center for Primary Care & Outcomes Research / VA Palo Alto, as a Health Services Research Fellow. His work and evaluation efforts during fellowship included homeless veterans outreach, and leading an interdisciplinary team (ImPACT) working to improve care coordination for the VA Palo Alto's most medically complex veterans. His research interests include psycho-social determinants of health, women's health, the impact of health policies on vulnerable and under-served populations, and research to improve primary care delivery.
Administrative Appointments
Faculty Affiliate, Center for Health Policy / Primary Care & Outcomes Research (2014 - Present)
Medical Staff (Family Medicine), Ravenswood Family Health Center, East Palo Alto (2014 - Present)
Clinical Lead - Prevention Quality Indicators Module, AHRQ Quality Indicators Enhancement Project (2015 - 2017)
Faculty Affiliate, Evaluation Sciences Unit, Division of Primary Care and Population Health (2015 - 2018)
Community Co-Chair, Community Advisory Board, Stanford Center for Clinical Research (2015 - Present)
Research Affiliate, Center for Innovation to Implementation (Ci2i), VA Palo Alto (2016 - Present)
Research Affiliate, VA Women's Health Evaluation Initiative (2017 - Present)
Director of Community Partnership, Division of Primary Care and Population Health (2018 - Present)
Medical Director, Evaluation Sciences Unit (ESU), Division of Primary Care & Population Health (2019 - Present)
Boards, Advisory Committees, Professional Organizations
Community Co-Chair, Community Advisory Board (CAB), Stanford Center for Clinical Research (2015 - Present)
BA, Yale University, Philosophy (1999)
MD, Harvard School of Medicine, MD (2006)
Residency, Oregon Health Sciences University, Family Medicine (2009)
MS, Stanford University, Department of Health Research & Policy, Health Services Research (2014)
Fellowship, Stanford CHP/PCOR and VA Palo Alto HSR&D, Health Services Research (2014)
Community and International Work
Medical Staff (50% FTE) at Ravenswood Family Health Clinc, 1885 Bay Rd, East Palo Alto
East Palo Alto / East Menlo Park
Opportunities for Student Involvement
Divisional Director of Community Partnership Activities
Liasion between Division of Primary Care and multiple local community clinics and organizations
Partnering Organization(s)
Mayview, Opportunity Center (PHCC), Ravenswood FHC, Redwood City School District Community Schools
ImPACT: Intensive Management Patient Alligned Care Team, VA Palo Alto
Case Management of high cost, high need VA Patients
VA Palo Alto
Medically Complex Veterans
jgshaw@stanford.edu
University - Academic staff Department:&nbspMed/Primary Care and Population Health Position: Clinical Associate Professor
1265 Welch Road
MSOB, 3rd floor (X338)
Division of Primary Care and Population Health
Stanford, California 94305
Clinical Contact (Ravenswood Family Health Center, East Palo Alto) Rosa Gomez, RN Nurse Manager, Ravenswood FHC
Jon Shaw
Primary care, psycho-social determinants of health & care, maternal-child health
Graduate and Fellowship Programs
Health Services Research (Masters Program)
Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA Zulman, D. M., Haverfield, M. C., Shaw, J. G., Brown-Johnson, C. G., Schwartz, R., Tierney, A. A., Zionts, D. L., Safaeinili, N., Fischer, M., Thadaney Israni, S., Asch, S. M., Verghese, A. 2020; 323 (1): 70–81
Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.
View details for DOI 10.1001/jama.2019.19003
What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection. BMJ open Brown-Johnson, C., Schwartz, R., Maitra, A., Haverfield, M. C., Tierney, A., Shaw, J. G., Zionts, D. L., Safaeinili, N., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019; 9 (11): e030831
OBJECTIVE: We sought to investigate the concept and practices of 'clinician presence', exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts.DESIGN: In 2017-2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services.SETTING: Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre.PARTICIPANTS: Participants were 55% men and 45% women; 40% were non-white.RESULTS: Qualitative analyses yielded a definition of presence as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals/patients. For both medical and non-medical professionals, creating presence requires managing and considering time and environmental factors; for physicians in particular, this includes managing and integrating technology. Listening was described as central to creating the state of being present. Within a clinic, presence might manifest as a physician listening without interrupting, focusing intentionally on the patient, taking brief re-centering breaks throughout a clinic day, and informing patients when attention must be redirected to administrative or technological demands.CONCLUSIONS: Clinician presence involves learning to step back, pause, and be prepared to receive a patient's story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.
View details for DOI 10.1136/bmjopen-2019-030831
Improving contraceptive choice for military servicewomen: better provision serves both women and deployment planning BMJ SEXUAL & REPRODUCTIVE HEALTH Shaw, J. G., Shaw, K. A. 2019; 45 (2): 86–87
View details for DOI 10.1136/bmjsrh-2018-200238
Long-acting Reversible Contraception (LARC) Provision by Family Physicians: Low But on the Rise. Journal of the American Board of Family Medicine : JABFM Chelvakumar, M., Jabbarpour, Y., Coffman, M., Jetty, A., Glazer Shaw, J. 2019; 32 (1): 10–12
Although the fraction of family physicians (FPs) providing Long Acting Reversible Contraceptive (LARC) services increased between 2014 and 2017, the most recent estimates show that less than a quarter of family physicians include provision of LARC in their practice. Increasing the number of FPs providing LARC will help increase patients' access to the most effective forms of birth control currently available.
View details for DOI 10.3122/jabfm.2019.01.180215
Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. American journal of medical quality : the official journal of the American College of Medical Quality Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J. N., Chang, S., Mahoney, M. 2018: 1062860618802365
A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.
Social Isolation and Medicare Spending: Among Older Adults, Objective Isolation Increases Expenditures While Loneliness Does Not Journal of Aging and Health Shaw, J. G., Farid, M., Noel-Miller, C., Joseph, N., Houser, A., Asch, S. M., Bhattacharya, J., Flowers, L. 2017; 29 (7): 1119-1143
Evaluate objective isolation and loneliness' impact on Medicare spending and outcomes.We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to 3-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality.Objective isolation predicts greater spending, $1,644(p<0.001) per beneficiary annually, whereas loneliness predicts reduced spending, -$768(p<0.001). Increased spending concentrated in inpatient and nursing-home (SNF) care; despite more healthcare, objectively isolated beneficiaries had 31%(p<0.001) greater risk of death. Loneliness did not predict SNF use nor mortality, but predicted slightly less inpatient and outpatient care.Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.
Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119
To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.
View details for DOI 10.1097/AOG.0000000000000542
Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. Journal of general internal medicine Haverfield, M. C., Tierney, A., Schwartz, R., Bass, M. B., Brown-Johnson, C., Zionts, D. L., Safaeinili, N., Fischer, M., Shaw, J. G., Thadaney, S., Piccininni, G., Lorenz, K. A., Asch, S. M., Verghese, A., Zulman, D. M. 2020
Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
View details for DOI 10.1007/s11606-019-05525-2
Post-traumatic stress disorder in pregnancy: Does treatment impact the risk of preterm birth? Panelli, D. M., Chan, C., Shaw, J. G., Herrero, T., Lyell, D. J., Phibbs, C. S. MOSBY-ELSEVIER. 2020: S328
View details for DOI 10.1016/j.ajog.2019.11.520
The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations LEARNING HEALTH SYSTEMS Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2019
View details for DOI 10.1002/lrh2.10210
"They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions. Patient education and counseling Zulman, D. M., Slightam, C. A., Brandt, K., Lewis, E. T., Asch, S. M., Shaw, J. G. 2019
OBJECTIVE: To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions.METHODS: We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions.RESULTS: Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health.CONCLUSION: This study presents a novel taxonomy of condition interactions from the patient perspective.PRACTICE IMPLICATIONS: Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.
View details for DOI 10.1016/j.pec.2019.11.020
CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system LEARNING HEALTH SYSTEMS Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2019
Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation. Learning health systems Brown-Johnson, C., Shaw, J. G., Safaeinili, N., Chan, G. K., Mahoney, M., Asch, S., Winget, M. 2019; 3 (3): e10188
Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.
High-Need Patients' Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program. Journal of general internal medicine Hsu, K. Y., Slightam, C., Shaw, J. G., Tierney, A., Hummel, D. L., Goldstein, M. K., Chang, E. T., Boothroyd, D., Zulman, D. M. 2019
BACKGROUND: Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients' personal goals and factors associated with goal progress.OBJECTIVE: To describe high-need patients' goals, and to identify factors associated with their goal progress DESIGN: Retrospective cohort study PARTICIPANTS: A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.MAIN MEASURES: Two independent reviewers examined patients' goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.RESULTS: The majority (n=72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1-0.9; p=0.03) and those living alone (aOR 0.4; 95% CI 0.1-1.0; p=0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p=0.02).CONCLUSIONS: Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.
View details for DOI 10.1007/s11606-019-05010-w
Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields Journal of General Internal Medicine Schwartz, R., Haverfield, M. C., Brown-Johnson, C., Maitra, A., Tierney, A., Bharadwaj, S., Shaw, J. G., Azimpour, F., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019
While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.
View details for DOI 10.1007/s11606-019-04913-y
Obstetric Outcomes in U.S. Veterans: Emerging Knowledge, Considerations, and Gaps. Seminars in reproductive medicine Hugin, M., Shaw, J. G. 2019
In the post-9/11 era, the number of young women serving, and deploying, in the military grew rapidly; as they exit service, there is tremendous increase in reproductive-aged women Veterans. Here, we review the limited but growing research regarding Veterans' pregnancy and obstetric outcomes. U.S. women Veterans returning from deployment carry a high burden of physical and mental health conditions, and often trauma. As poor mental health is known to predict poorer maternal and infant sequelae, there are unique concerns around perinatal outcomes in Veterans. Accordingly, there is new attention to their reproductive risks and needs-evidenced by recent research and programmatic efforts within the VA. Emerging research suggests that the unique health profiles of pregnant Veterans, including prevalent posttraumatic stress disorder, predict increased risk of preterm birth, preeclampsia, and gestational diabetes. In the most contemporary large study, relying on California birth data, Veterans who relied on VA for their health care coverage were high risk, with increased rates of preeclampsia and Cesarean delivery. Additionally, Veterans' infants (compared with non-Veterans') were more likely to require NICU care. Additional research is needed to explore upstream factors leading to these poorer outcomes. Current effort to coordinate VA and non-VA care for Veteran mothers is warranted.
View details for DOI 10.1055/s-0039-1692128
Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Contraception Cahill, E. P., Henkel, A., Shaw, J. G., Shaw, K. A. 2019
Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Cahill EP, Henkel AG, Shaw JG, Shaw KA OBJECTIVE: To understand effect of adjunct misoprostol with overnight osmotic dilators for dilation and evacuation for cervical preparation after 16 weeks gestation on procedure time and dilation, complication rate, and side effects.We searched PubMed, ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, dilators and reviewed reference lists of published reports. Randomized controlled trials of cervical preparation for second trimester D&E using overnight osmotic dilators comparing adjunct misoprostol to placebo were included. Weighted mean and standard deviation (SD) and pooled binary outcomes were compared with two sample t-test or chi-square respectively.Among 84 articles identified, three met inclusion criteria of randomized controlled trials comparing adjunct misoprostol to placebo with overnight osmotic dilators prior to second trimester abortion with 457 total subjects at 16-24 weeks gestation (misoprostol n=228; placebo n=229). In the meta-analysis, misoprostol as compared to placebo did not significantly decrease mean procedure times (8.5 + 4.6 vs 9.6 + 5.8 minutes, p=0.78) or need for manual dilation (18% vs 28%, p=0.23). There was no difference in total complications (p=0.61), major complications (hemorrhage, uterine perforation, hospitalization, p=0.44), or cervical lacerations (p=0.87).Current limited evidence suggests that use of adjunctive misoprostol with osmotic dilators after 16 weeks does not affect procedure time or need for manual dilation. Further research is needed to determine if adjunctive misoprostol affects major complications and blood loss.Adjunctive misoprostol does not affect procedure time or need for manual dilation in mid to late second trimester abortion. Further research is needed to determine the effect of adjunctive misoprostol on major complications and blood loss.
View details for DOI 10.1016/j.contraception.2019.09.005
Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data. Health services research Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018
OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.
FOSTERING PATIENT-PROVIDER CONNECTION DURING CLINICAL ENCOUNTERS: INSIGHTS FROM NON-MEDICAL PROFESSIONALS Schwartz, R., Brown-Johnson, C., Haverfield, M. C., Tierney, A. A., Bharadwaj, S., Zionts, D. L., Romero, I., Piccininni, G., Shaw, J. G., Thadaney, S., Azimpour, F., Verghese, A., Zulman, D. M. SPRINGER. 2018: S200
THE PREVALENCE OF PELVIC FLOOR DISORDERS IN ACTIVE DUTY FEMALE SOLDIERS: DATA FROM THE STANFORD MILITARY DATA REPOSITORY Rogo-Gupta, L., Nelson, D., Young-Lin, N., Shaw, J., Kurina, L. WILEY. 2018: S567–S568
Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Frayne, S. M., Phibbs, C. S., Saechao, F., Friedman, S. A., Shaw, J. G., Romodan, Y., Berg, E., Lee, J., Ananth, L., Iqbal, S., Hayes, P., Haskell, S. Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs. Washington DC. 2018
https://www.womenshealth.va.gov/WOMENSHEALTH/docs/WHS_Sourcebook_Vol-IV_508c.pdf
Deployment and Preterm Birth Among US Army Soldiers. American journal of epidemiology Shaw, J. G., Nelson, D. A., Shaw, K. A., Woolaway-Bickel, K., Phibbs, C. S., Kurina, L. M. 2018; 187 (4): 687–95
With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.
Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017. Seminars in reproductive medicine Katon, J. G., Zephyrin, L., Meoli, A., Hulugalle, A., Bosch, J., Callegari, L., Galvan, I. V., Gray, K. E., Haeger, K. O., Hoffmire, C., Levis, S., Ma, E. W., Mccabe, J. E., Nillni, Y. I., Pineles, S. L., Reddy, S. M., Savitz, D. A., Shaw, J. G., Patton, E. W. 2018; 36 (6): 315–22
The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.
Contraception in US servicewomen: emerging knowledge, considerations, and needs CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Harrington, L. A., Shaw, K. A., Shaw, J. G. 2017; 29 (6): 431–36
We describe current literature regarding contraceptive use among women serving in the military. We explore the state of contraceptive use by female servicewomen, gaps in knowledge, special considerations, and evidence of unmet needs.Recent data on US servicewomen show that overall rates of contraceptive use remain low. Data highlight disparities and suggest barriers to contraceptive uptake persist, with contraceptive use being lower around the time of deployment. Methods that do not require daily use or prescription refills, such as long-acting reversible contraception (LARC) - intrauterine devices and contraceptive implants - may be distinctly well suited for service and deployment. Two contemporary studies document growing popularity of LARC methods among female members of the military, possibly driven by a surge in contraceptive implant use. Nonetheless, LARC appears to remain underutilized.Despite no-cost provision, the importance of preventing unplanned pregnancy, and the potential benefits of cycle control during service, emerging data about the US military suggest barriers to and underutilization of contraception, particularly LARC. Research is needed to explore preferences and tailor contraceptive counseling to servicewomen. Existing and future work can inform efforts to standardize military provider training and ensure all servicewomen are appropriately counseled and have timely access to any method they may choose.
Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen. Obstetrics and gynecology Erickson, A. K., Nelson, D. A., Shaw, J. G., Loftus, P. D., Kurina, L. M., Shaw, K. A. 2017; 129 (5): 800-809
To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake.This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression.Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, β=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, β=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001).Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.
Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194
Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.
View details for DOI 10.1111/ppe.12349
Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175
Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings.clinicaltrials.gov Identifier: NCT02932228.
View details for DOI 10.1001/jamainternmed.2016.8021
Interpretation of epidemiologic studies very often lacked adequate consideration of confounding. Journal of clinical epidemiology Hemkens, L. G., Ewald, H., Naudet, F., Ladanie, A., Shaw, J. G., Sajeev, G., Ioannidis, J. P. 2017
Confounding bias is a most pervasive threat to validity of observational epidemiologic research. We assessed whether authors of observational epidemiologic studies consider confounding bias when interpreting the findings.We randomly selected 120 cohort or case-control studies published in 2011 and 2012 by the general medical, epidemiologic, and specialty journals with the highest impact factors. We used Web of Science to assess citation metrics through January 2017.Sixty-eight studies (56.7%, 95% confidence interval: 47.8-65.5%) mentioned "confounding" in the Abstract or Discussion sections, another 20 (16.7%; 10.0-23.3%) alluded to it, and there was no mention or allusion at all in 32 studies (26.7%; 18.8-34.6%). Authors often acknowledged that for specific confounders, there was no adjustment (34 studies; 28.3%) or deem it possible or likely that confounding affected their main findings (29 studies; 24.2%). However, only two studies (1.7%; 0-4.0%) specifically used the words "caution" or "cautious" for the interpretation because of confounding-related reasons and eventually only four studies (3.3%; 0.1-6.5%) had limitations related to confounding or any other bias in their Conclusions. Studies mentioning that the findings were possibly or likely affected by confounding were more frequently cited than studies with a statement that findings were unlikely affected (median 6.3 vs. 4.0 citations per year, P = 0.04).Many observational studies lack satisfactory discussion of confounding bias. Even when confounding bias is mentioned, authors are typically confident that it is rather irrelevant to their findings and they rarely call for cautious interpretation. More careful acknowledgment of possible impact of confounding is not associated with lower citation impact.
Medicare Spends More on Socially Isolated Older Adults Flowers, L., Houser, A., Noel-Miller, C., Shaw, J., Bhattacharya, J., Schoemaker, L., Farid, M. AARP Public Policy Institute. Washington, DC. 2017 ; Insight on the Issues (125): 1–15
Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial CONTRACEPTION Shaw, K. A., Shaw, J. G., Hugin, M., Velasquez, G., Hopkins, F. W., Blumenthal, P. D. 2015; 91 (4): 313-319
The objective was to investigate mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19weeks of gestation, with the aim of improving procedure access, convenience and comfort.This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7weeks of gestation randomized to receive either one set of osmotic dilators plus mifepristone the day prior to procedure (mifepristone group) or two sets of osmotic dilators (placed 18-24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects.Mean gestational age was similar between groups (20weeks); more nulliparous subjects were randomized to the mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means -56s, with confidence interval (95% CI -4:09 to +2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was >3cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a "better than expected" experience.Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety.Use of mifepristone for cervical preparation before surgical abortion after 19weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.
Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869
We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.
Gestational Diabetes and Hypertensive Disorders of Pregnancy Among Women Veterans Deployed in Service of Operations in Afghanistan and Iraq JOURNAL OF WOMENS HEALTH Katon, J., Mattocks, K., Zephyrin, L., Reiber, G., Yano, E. M., Callegari, L., Schwarz, E. B., Goulet, J., Shaw, J., Brandt, C., Haskell, S. 2014; 23 (10): 792-800
View details for DOI 10.1089/jwh.2013.4681
To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis. journal of urology Richardson, M. L., Elliott, C. S., Shaw, J. G., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 190 (4): 1306-1312
OBJECTIVES: To compare the cost-effectiveness of three strategies for use of a mid-urethral sling (MUS) to prevent occult stress urinary incontinence (SUI) in those undergoing abdominal sacrocolpopexy (ASC). METHODS: Using decision-analysis modeling, we compared cost-effectiveness over a 1 year post-operative time period of three treatment approaches: 1) ASC alone with deferred option for MUS; 2) ASC with universal concomitant MUS; and 3) preoperative urodynamic study (UDS) for selective MUS. Using published data, we modeled probabilities of SUI after ASC with or without MUS, the predictive value of UDS to detect occult SUI, and the likelihood of complications after MUS. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost effectiveness ratio (ICER) per quality-adjusted life years (QALY) gained. In addition to base-case analysis, one-way sensitivity analyses were performed. RESULTS: In our model, universally performing MUS at the time of ASC was the most cost-effective approach, with an incremental cost per QALY gained of $2867 when compared to performing ASC alone. Preoperative UDS was more costly and less effective than universally performing intraoperative MUS. The cost-effectiveness of ASC + MUS was robust to sensitivity analysis, with a cost-effectiveness ratio consistently below $20,000 per QALY. CONCLUSIONS: Universal concomitant MUS is the most cost-effective prophylaxis strategy for occult SUI in women undergoing ASC. The use of pre-operative UDS to guide MUS placement at the time of ASC is not cost-effective.
View details for DOI 10.1016/j.juro.2013.03.046
Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review. Obstetrics and gynecology Shaw, K. A., Topp, N. J., Shaw, J. G., Blumenthal, P. D. 2013; 121 (6): 1335-1347
To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13-24 weeks).We searched MEDLINE (1966-2012), ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports.Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester.Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone-misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7-8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3-7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone-misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1-2 hours longer for a 12- to 24-hour interval compared with a 36-48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols.Shortening the mifepristone-misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.
View details for DOI 10.1097/AOG.0b013e3182932f37
Attitudes of preclinical and clinical medical students toward interactions with the pharmaceutical industry ACADEMIC MEDICINE Hyman, P. L., Hochman, M. E., Shaw, J. G., Steinman, M. A. 2007; 82 (1): 94-99
Medical school is a critical time for physicians in training to learn the professional norms of interacting with the pharmaceutical industry, yet little is known about how students' attitudes vary during the course of training. This study sought to determine students' opinions about pharmaceutical industry interactions with medical students and whether these opinions differ between preclinical and clinical students.The authors surveyed medical students at Harvard Medical School (HMS) from November 2003 through January 2004 using a six-question survey. The authors then analyzed how responses differed among the classes.Out of 723 questionnaires, 418 were returned--an overall response rate of 58%. A total of 107 (26%) students believed that it is appropriate for medical students to accept gifts from pharmaceutical companies, and 76 (18%) agreed that the medical school curriculum should include events sponsored by the pharmaceutical industry. Many students--253 (61%)--reported that they do not feel adequately educated about pharmaceutical industry-medical professionals' interactions. Preclinical and clinical students had similar opinions for the majority of their responses. Finally, students who reported feeling better educated about pharmaceutical industry interactions tended to be less skeptical of the industry and more likely to view interactions with the industry as appropriate.Students' opinions about interactions with the pharmaceutical industry were similar between preclinical and clinical students, suggesting that the current medical school experience may have limited impact on students' views about interactions with the pharmaceutical industry.


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These are the latest cases and convictions from Blackpool Magistrates' Court - December 16, 2019
Gazette Reporter
Here is the latest round-up of cases from Blackpool Magistrates' Court.
Lewis Rudge, 25, drink-driving, no insurance and no licence
Blackpool Magistrates' Court
A drunken learner driver swerved across the road, smashing into a bus shelter before coming to rest against the gatepost of a house.
Lewis Rudge panicked and lost control after police signalled him to stop by putting on their vehicle's blue lights.
Rudge, a carpet fitter, 25, of Castle Avenue, Poulton, pleaded guilty to driving with excess alcohol, without insurance, and not in accord with his provisional licence.
His partner, Leanne Hilton, a 31-year-old mother-of-two, of Tower Close, Thornton, pleaded guilty to permitting Rudge to drive without insurance.
Rudge was banned from the road for 14 months, fined £200 with £85 costs and ordered to pay £32 victims' surcharge.
Hilton was fined £120 with £85 costs, ordered to pay £32 victims' surcharge and had six motoring penalty points put on her licence by Blackpool magistrates.
Prosecutor Pam Smith said police saw Rudge driving an Audi A3 on Devonshire Road, on November 20 at 1.40am.
His speed was fluctuating and he could not maintain a middle path so police put on their car's blue lights to stop him.
Rudge carried on, veering over the road, colliding with a bus shelter damaging the mental frame, and smashing glass panels before crossing the verge and footpath and coming to rest against a gatepost. Hilton was in the front seat.
A breath test showed 41 microgrammes of alcohol in Rudge's body - 35 is the limit.
Rudge said he was driving the car because his partner was over the limit.
Brother of Manchester Arena bomber has murder trial delayed
Gerry Coyle, defending, said: "These two are lucky to be alive. This could have been catastrophic."
The defence said Rudge had driven because his partner did not feel well and he had panicked when he saw the police's lights behind him because of his inexperience as a learner driver.
Hilton had had two insurance policies and if she had not been over the alcohol limit as a supervising driver then Rudge would have been covered by the insurance.
Juris Irbe, 36, drink-driving
A man was more than twice the legal alcohol limit when he was found by police asleep in his car after a night at the casino.
Juris Irbe, a 36-year-old, of Hopwood Close, St Annes, who is employed as a production worker, pleaded guilty to being in charge of a motor vehicle while over the limit.
He was fined £360 with £85 costs, ordered to pay £36 victims' surcharge and had 10 motoring penalty points put on his driving licence by Blackpool magistrates.Prosecutor Pam Smith said on November 21 at 9.42am police saw a Renault Clio parked in Harrington Avenue with its engine running and Irbe slumped over the steering wheel.
An officer knocked on the window and Irbe woke up but then went back to sleep.
A breath test showed 77 microgrammes of alcohol in his body - 35 is the legal limit for driving.
Irbe said he had been drinking at a casino and could not remember much after that.
Trevor Colebourne, defending, said his client decided to go back to his car to sleep and he started the heater because it was cold.
Jack Starkey, 29, animal abuse offences
A dad-of-two was caught badger baiting – the blood sport in which the animal is ripped apart by dogs – in a country park near Manchester.
Two dog walkers alerted police when they came across Jack Starkey, 29, and three other men digging a badger out of its sett. They then let a dog attack it.
The badger was found badly bitten and had to be put down.
Starkey, of Bold Street, Fleetwood, admitted his part in what RSPCA prosecutor Carmel Wilde said was "gaining a thrill from a blood sport in which a badger is killed".
Three dogs owned by Starkey, including a black Patterdale terrier, have been taken off him.
Starkey pleaded guilty to attempting to kill the badger on January 3. He also admitted interfering with badger setts and causing suffering to the Patterdale dog by failing to have its wounds treated.
The dog walkers were in the woods when they found two vans and a car – and the men covered in mud near a large hole in the ground.
The walkers called police and a local animal welfare group, which found the badly injured badger.
The RSPCA went to Starkey's home and matched DNA from the badger with his dog, the court was told.
Magistrates heard Starkey was a "novice" at badger baiting and what he did was a one-off.
He was given an 18 week suspended jail term and ordered to pay £1,115 costs. He must do 100 hours unpaid work and rehabilitation.
Blackpool superclub Home & HQ confirms shock closure
B&M warehouse closure plan puts 128 Blackpool jobs at risk
Couple are fined over mass pub brawl in Blackpool

redpajama_set_name: RedPajamaCommonCrawl


Trailer for Sale - $40 less than husband wants for it - TODAY ONLY!
My husband has been posting his trailer for sale for about 2 weeks for $125.I want it gone - BADLY!!!
Here's the deal - if you come here before he gets home tonight - around 6:30, I WILL SELL IT FOR $40 LESS THAN HE IS!!!!
I will sell you the trailer, which is a Toyota truck bed welded strongly onto a trailer, with 5-prong universal hitch (working tail-lights).
Email for directions, sorry I don't have a picture!
No need to reply. You are completely mad! I love it. Fantastic. I wish more folks on craigslist had your sense of humor. Your ad is legend. It should go on the "best of craigslist" site! I hope y'all sell the trailer.


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Lucifer season 7 review: Is it as good as the others?
Samuel September 6, 2022 4 min read
If you're an avid fan of the show, then you're probably wondering what the hype is all about. Season 7 of Lucifer arrived on Netflix on June 25th and has since not looked back. So what is the fuss all about? In this blog post, we'll be taking a look at the storyline, the trailer, and the actors involved in the show. We'll also be giving our opinion on whether season 7 is as good as the others and whether it's been cancelled or renewed for a season 8. So without further ado, let's get into it!
First look at Lucifer season 7
It's the season finale of Lucifer season 7, and fans are eager to find out how the season turns out. So far, the season has been based on the DC Comics character of the same name. The season starts with Lucifer being released from Hell and trying to find a way back home. Along the way, he meets new characters including Chicago PD detective Liv Moore (Lauren German). The season concludes with a showdown between Lucifer and Amenadiel. Will Lucifer finally return to his throne or will Amenadiel take it? The season is full of action and twists, so make sure to tune in to find out!
What is the Storyline of Season 7 of Lucifer?
The season 7 of Lucifer is finally here, and fans are hooked! The season is packed with action, drama, and twists and turns that will leave you guessing who's good and bad. Lucifer is out to prove himself and win back his throne from the Holy Angel Amenadiel. Along the way, he'll team up with new allies in order to take down his enemies. Will he be able to restore Heaven on earth again? Find out in the season 7 of Lucifer!
Lucifer Season 6 ending explained
Legions of fans are eagerly waiting for the final season of Fox's hit show Lucifer. And with good reason, as the season has been chock-full of action and excitement from start to finish. Let's take a look at the key talking points: 1. In the final season, Lucifer starts working for a mysterious organization known as The Devil's Hand. This new job brings him into direct conflict with his former allies, especially Amenadiel and Maze. 2. The season culminates in a massive battle between Lucifer and Amenadiel that will determine the fate of humanity – whoever prevails will be in charge of this world for eternity! 3. So far, Lucifer has been widely praised by fans for its compelling story line and exciting twists – so make sure you tune in next week to find out who wins!
What is the Trailer for Lucifer Season 7?
Are you ready for the return of Lucifer? The show is set to air on October 3rd, and the trailer for the season promises to be action-packed. Tom Ellis (Lucifer) has teased that his character is "back in action," and we can't wait to see what happens. There's been a lot of talk about the return of Maze, and it looks like she will be playing a big role this season. So mark the date in your calendar and join the legions of Lucifer fans anxiously waiting for the next season to air.
Where to watch Lucifer
It's the final season of Lucifer and the fans are in for a treat. Season 7 is chock full of action, mystery, and humor, and it's definitely worth checking out. Lucifer is available on lots of different platforms, so whether you're a fan of the show or just curious, there's no reason not to give it a watch. The acting is top-notch, the writing is engaging, and the references to pop culture icons are a fun bonus. So, what are you waiting for? Go watch Lucifer season 7 now!
Actors in Lucifer
Season 7 of Lucifer is already drawing rave reviews. The plotlines are exciting and the twists will keep you hooked all season long. If you're a fan of the show, don't miss out on this season – it's worth your time! Each actor brings their own unique energy to the show, which makes it exciting to watch. The cast is also amazing and full of talented actors. So, if you're looking for a good show to watch, don't miss out on Lucifer season 7!
Lucifer Season 7 Cancelled or Renewal Status :
It's the final season of Lucifer, and the season finale has us on the edge of our seats. Will the Devil finally get his due on the show? Will Lucifer finally overcome his demons and be saved? Let us know what you think in the comments below! As for the rest of the season, I thought "The Crash" was the best so far. There are still plenty of twists and turns to come as we journey down into Hell with Lucifer. So, stay tuned!
So, did you like Lucifer season 7? After reading the blog, the answer is probably yes! The storyline is interesting and the cast looks fantastic. However, the final verdict is still out as the season has not aired yet. So, stay tuned for more updates on the season and let us know what you think in the comments below.
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60 Metascore
Tuesday TV: You Betcha, Fargo's Terrific
There's no place quite like the twisted heartland of FX's Fargo (Tuesday, 10/9c), a marvelous 10-episode variation on themes established in the quirky 1996 Oscar winning film. Once again, warm and neighborly small-town decency gives way to a bitter chill that has less to do with the snowy Minnesota plains than with the dark crevasses of human depravity.
The Tuesday Playlist: That's a Wrap For Voice Blind Auditions, Cougar Town
The curtain comes down on the best part of TV's hottest singing competition, as the "blind auditions" portion of NBC's The Voice reaches its final act (Tuesday, 8/7c) with the selection of the last members of the four coaches' teams. Any fears that the show would lose its oomph this season with new bodies in the hot seats were quickly put to rest when Usher eased onto his swiveling throne with charismatic grace, adopting a signature "one leg up" posture that was parodied last weekend on Saturday Night Live, while Shakira proved a worthy adversary to the boys' club with her feisty attitude, passion and humor.
Tue, Apr 9, 2013
Ask Matt: How Scandal-ous, Smash's Crash, PBS Is Hot, Middle Graduation, More
Send questions and comments to askmatt@tvguidemagazine.com and follow me on Twitter! Question: [SPOILER ALERT for anyone who's fallen behind on Scandal] I'm a loyal reader of your column, and always enjoy hearing your well-thought-out and articulate opinions on TV's hottest topics. I'm writing to you for the first time now because I wanted to know your take on the latest installments of Scandal. I saw in your last column the tag line "Scandal is the new Revenge," and I agree Scandal has been far more gripping lately than Revenge.
The Tuesday Playlist: Second Act for Smash, Kiss and Tell on New Girl?
Someone should make a musical about the remaking of Smash between its first and second seasons. Let's call it Phantom of the Rewrite. Or maybe The (New) Producers, seeing how NBC replaced the original creator/showrunner in hopes of calming this elaborate backstage drama's own behind-the-scenes creative turmoil, which manifested on screen in turgid and oft-ridiculed soap opera between the splashy production numbers (which are still mostly terrific). Smash 2.0 (Tuesday, 9/8c) wastes no time addressing, while slyly commenting on, the show's problem spots, many involving Debra Messing's character, insecure lyricist-librettist Julia Houston. Her dull husband, cloddish son and needy lover? History. Her hideous scarves? Mocked. Also soon to be gone. Along with reviled characters like the scheming, lurking Ellis and Karen's cheating ex, Dev.
Tue, Feb 5, 2013
The Tuesday Playlist: Finales, a Salute to Primetime Soaps, White Collar, The Taste
It's another ridiculously busy night of TV, with premieres and finales jousting for attention amid other distractions. It's just as well that CBS' top-rated lineup is taking a breather with repeats. First, the farewells, going head to head. Once again, NBC sends away its reliably tear-jerking Parenthood (10/9c) earlier in the TV year than we'd like, but a limited run of 15 episodes beats the alternative. Shows like this don't tend to repeat well, and if a shorter run makes business sense — while freeing up the time period in the back half of the season for something else (in this case, a retooled Smash in two weeks) — then so be it. This fourth season has been Parenthood's strongest and most emotionally charged to date, especially in the storyline involving Kristina's breast cancer ordeal, providing Monica Potter and Peter Krause (as husband Adam) with their strongest dramatic material to date. Emmy voters, wake up and take note.
Matt's Picks: January 17-20
How I Met Your Mother (Monday, 8/7c, CBS)Finding humor in tragedy is always a tricky business, and that's the challenge facing Mother as the gang accompanies Marshall back to his Minnesota home for his father's funeral. Ted and Barney task themselves with doing whatever it takes to coax a smile or a laugh from their grieving buddy. But Marshall is distracted by an unexpected meeting with the bully who terrorized him through high school. The joke being that the bully is played by the diminutive Danny Strong (Buffy the Vampire Slayer). Elsewhere, Monday is a big night for new shows on TV, with the premieres of two remakes of British series — Being Human on Syfy and Skins on MTV — plus Harry's Law on NBC and the launch of Piers Morgan's talk show (with Oprah as the first guest) on CNN...


Texas nurses are concerned by the policy of separating children from their families upon entry into the United States.
The effects of separation at a young age are traumatic and can have long-lasting health consequences including an increased risk of PTSD, autoimmune diseases, cardiovascular disease and cancer. The long-term health of children is best supported by keeping them with their families and ceasing their separation from parents at the border.
The Code of Ethics for Nurses stresses a dedication to preserving the rights of vulnerable groups, including children. Protecting the health of the children affected should be a top priority.
We call on our elected officials at all levels to take action immediately to stop the policy of separation, before even more children are irreversibly harmed.


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Scientific Info
Rome is a unique, exciting city!
Imagine a magic landscape, rich of history and timeless masterpieces everywhere. Imagine to plan your event in the best location of the world, where progress meets art and history… this is Rome.
A modern and cosmopolitan city, the most beautiful of the world. Rome is today the capital of the congresses, the favourite choice for international events, thanks to its modern exhibition and conference venues and charming hotels. Rome is a movie set: stunning renaissance squares, medieval churches, monuments, parks, everything invites you to discover the most beautiful city in the world.
Rome is very well connected to the rest of the world: getting to Rome is possible and easy by any kind of transport.
DISTANCES (from the main European cities)
How to get to Rome
Leonardo da Vinci Airport, Fiumicino
It is the main airport in Rome and it is linked to the city by different trains, fast trains and trains calling at some stations. The fast train goes from Fiumicino to the Termini station in 30 minutes. At the Termini station, departure and arrival are on track 22.
Ciampino Airport
It is the second airport in Rome, mainly used for charter flights. It is linked to the city centre by a bus of the regional lines Cotral, departing every 30 minutes, and by the subway, line 1, from the Anagnina station.
Termini station
This is the most important Italian station, with all national and international lines. It is connected to Fiumicino airport by train. It is well connected to the underground and to the city bus network.
It has been recently completely restored and it has been enriched by a large shopping centre, a huge bookshop and it is used as a cultural and artistic events location.
How to move around
There are more than 200 lines of public buses, orange and blue, in service from
5.30 am to midnight.
There are also the Fast Lines or Express Lines (green) travelling for long distances, the Exact lines with departure on schedule, the Electric Lines for the transportation in the city centre, the Night lines for transportation from midnight to 5.30 a.m. and lines for disabled people.
BY SUBWAY
In Rome there are three lines, A, B and C, working from 5.30 am to 11.30 p.m. (Saturday till 00.30), meeting at Termini station.
BY TAXY
Cabs in Rome are white or yellow and can be found all over the city, in special parking lots.
The climate in June
The City of Rome enjoys favourable climatic conditions because of its geographic location. Rome also enjoys one of the most optimal number of hours of daylight in Europe
Tours and place of interest
Having been the center of one of the world's greatest civilizations ever, Rome has exerted a huge influence over the world in its millennium long history. With wonderful palaces, ancient churches and basilicas, grand Roman monuments, ornate statues and graceful fountains, Rome has an immensely rich historical heritage and cosmopolitan atmosphere
The Colosseum
The Colosseum is the largest and most famous amphitheater in the Roman world.
The Colosseum was capable of holding some 50,000 spectators, and today is a major tourist attraction in Rome with thousands of tourists to view what is left of the interior arena.
The Roman Forum
Located in the small valley between the Palatine and Capitoline Hills, the Roman Forum was for centuries the teeming heart of ancient Rome. The Forum today is a sprawling ruin of architectural fragments and includes the Arches of Septimius Severus and Titus, the Temple of Antoninus Pius and Faustina and the Temple of Saturn.
The center of the Catholic world and a major tourist attraction is the St. Peter's Basilica. The Basilica stands on the traditional site where Peter, the apostole who is considered the first pope, was crucified and buried. Many famous artists worked on the complex and its sourroundings: Michelangelo designed the dome while Bernini designed the great St. Peter's Square.
Castel Sant'Angelo began life as the mausoleum of the Emperor Hadrian, built between 135 and 139 AD. The building was used as a prison until 1870, but now houses a museum. Among the most well known tourist attractions in Rome, film buffs will recognise is a setting from "Angels and Demon".
The Navona Square
Piazza Navona is one of the most famous of Rome's many squares and it was established towards the end of the 15th century. Today, the square features no less than three magnificent fountains and is an immensely popular place to sip a cappuccino, shop and watch street performers.
A truly monumental stairway of 135 steps, the Spanish Steps were built between 1721-1725 in order to link the Bourbon Spanish embassy to the Holy See with the French church, Trinità dei Monti. At the foot of the Spanish Steps is the Piazza di Spagna and the Fontana della Barcaccia,a sober fountain designed by Gian Lorenzo Bernini.
The Trevi Fountain
Designed by Italian architect Nicola Salvi, the Trevi Fountain features a mythological sculptural composition of Neptune, god of the sea, flanked by two Tritons. It is the largest Baroque fountain in the city and one of the most famous fountains in the world. The fountain has appeared in several notable films, including Federico Fellini's "La Dolce Vita".
Founded by Pope Julius II in the 6th century, the Vatican Museums inside the Vatican City boasts some of the world's most important relics. Attractions of the Museums includes the spiral staircase, the Raphael Rooms and the exquisitely decorated Sistine Chapel. Under the patronage of Pope Julius II, Michelangelo painted the chapel ceiling. Today the ceiling, and especially the Last Judgment, are widely believed to be Michelangelo's crowning achievements in painting.
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#ifndef __XLAT_TABLES_PRIVATE_H__
#define __XLAT_TABLES_PRIVATE_H__

void print_mmap(void);
void init_xlation_table(uintptr_t base_va, uint64_t *table,
			int level, uintptr_t *max_va,
			unsigned long long *max_pa);

#endif /* __XLAT_TABLES_PRIVATE_H__ */

redpajama_set_name: RedPajamaGithub


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The Worldwide Popular Revolt Against Proportionality in Self-Defense Law
Renée Lettow Lerner, George Washington University Law SchoolFollow
This article examines popular dissatisfaction with the proportionality standard in self-defense law, which holds that the prevention of harm cannot be achieved by causing harm that is disproportionate. Legal elites, such as prosecutors, judges, and legal scholars, have long championed versions of this standard. But there is an increasingly widespread movement in the United States and Europe to modify elite notions of proportionality.
Common to these movements is the desire to replace complicated balancing tests with clearer rules, which would limit the discretion of prosecutors and judges, and to permit use of deadly force against attackers in more situations. Fueling the movements is the belief that government is not able or willing to adequately protect its citizens. While these reform movements are occurring in many countries, the article focuses on three places in particular: Florida, Britain, and Belgium. For each place, the author discusses events that led to dissatisfaction with existing rules, political debates surrounding reform, and detailed legislative action. Efforts in Florida and Britain show an approach to reform that centers on presumptions that deadly force may be used in certain situations, such as a forcible entry into a home. Efforts in Belgium show another approach, which is in effect an expansion of provocation doctrine: anyone who exceeds the bounds of proportionality because of emotion (fear, anxiety, or panic) caused by attack or threat of attack is not criminally liable. The paper then analyzes the two types of efforts. The author concludes that emotions caused by attack are proper grounds for mitigation, but not for complete exoneration. Reforms that emphasize presumptions may be justified, particularly presumptions about the use of force against those who forcibly intrude into the home.
http://ssrn.com/abstract=961468
Renee Lettow Lerner, The Worldwide Popular Revolt Against Proportionality in Self-Defense Law, 2 J.L. Econ. & Pol'y 331 (2006).


going to bake for all the parties and dinners coming up.
great conversation piece that would be, huh?
she has a free chapbook and goodies for everyone who wants them, as well.
everyone, too – have the tissues ready for this one!
time to time – so don't miss the fun!
To JOIN THE CHAT simply sign up here – http://groups. Yahoo.com/subscribe/authorislandchat and make sure you are set to INDIVIDUAL EMAILS – that way,you'll be in on the action from the get go, but be warned – it could get crazy! If you can't make the chat, make sure you are set to DAILY DIGEST or WEB ONLY for this group, so it won't fill your inbox, but you can still check out the chat later.


Graphic Plotter is a useful program to draw different type of math.
It is written in Visual Basic 6 (ca. 18.1.2000), and consequently requires the Visual Basic runtimes in order to work.
You may well already have not these on your system, so I have included the files.
The files are compressed in .zip.
After you have downloaded graphic_plotter.zip, extract all the contents into the folder where you want it installed, z.B. c:\graphic_plotter for example.
If you have not to Visual Basic Runtime files on PC. you should be unzipped Vbrun60.zip, comctl32.zip and executed BEFORE running graphPlot.
Once all the files are in place, you can run GraphPlot_2001.exe.


Are you wondering what the perfect Mother's Day gift is? Check out this gift card holder I created using my Cricut, American Crafts Cardstock and my Xyron Creative Station. This post contains affiliate links. At no extra cost to you, I receive a small commision. Thank you for your support.
I still don't know what to get my mom or what to even tell my husband to get me for Mother's Day. A gift card is a great idea because it gives moms a chance to go out, alone, and buy something for themselves that they normally wouldn't. Make this gift card holder to make the gift card a little more personalized.
You can't just give a gift card in an envelope, at least I can't. I have to make a cute gift card holder made out of cardstock and cut with my Cricut.
Begin by cutting out your Cricut card with the Design Space file above. It's all sized for you, you just need the American Crafts cardstock to go along with it. This amazing cardstock is by Jen Hadfield of Tatertots & Jello. She is amazing and has done awesome things in her career and her diving into the scrapbooking world is something I've loved watching. After you've cut all your pieces, it's time to assemble. Use the gated images and the buckles and then run those through the Xyron Creative Station. Place those over the floral cut pieces. Use your Xyron Mega Runner and place adhesive on the back side of the floral cardstock and secure that to the cardstock that has the notches cut in it. Place the buckles over the cut areas but leave the slits exposed so that the buckle straps will slide right in. You're going to adhere your gift card holder to the inside of the card. The smaller green piece is where you can glue the gift card or write your Mother's Day message. Use the butterfly 3-D stickers on the buckle of the card and add some ephemera to the outside of the envelope.


Here we go again. Just months after an unidentified object temporarily shut down an airport in China, another UFO briefly halted operations at a different Chinese airport.
According to initial sketchy reports in ShanghaiDaily.com and the People's Daily Online, the UFO forced the Baotou airport in China's Inner Mongolia province to prevent three planes from landing for almost an hour Saturday night.
Whatever the unknown object was — and mind you, nobody is claiming aliens or interdimensional beings here — it was reported hovering near the airport. As strictly a safety response, officials wouldn't allow aircraft to land and directed two of them to land at neighboring airports (where, presumably, the UFO had no interest).
Be the first to comment on "Another UFO Shuts Down Another Airport in China"


The rehab centers near Dayton, WA play a significant role in addiction treatment from drugs like Valium and Vicodin and also alcohol dependency.
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Regain your sobriety – Search the best detox hospitals near Dayton, WA right here. We have information about alcoholics anonymous, outpatient drug addiction programs, detox facilities and much more.
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Essential at any celebration, Awfully Chocolate offers the widest range of chocolate birthday cakes in Singapore. And because we understand birthday cakes mark such special occasions, at Awfully Chocolate all cakes are baked fresh daily, using premium ingredients.
Don't forget to include a personalised cake message when you purchase your favourite chocolate birthday cake online!


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YouTube - Nieuport 17
Climb Rate:
Le Rhone 9J rotary
110 h.p.
1- .303 cal.
750 fpm
The origins of the Nieuport 17 can be traced back to the introduction of aeronautics in France. A Frenchman, Clement Ader, received the first ever contract to built a military aircraft in 1892. Although he could not get the aircraft to fly, it set a precedent for the use of an airplane as a military weapon.
By 1907 the United States had put forth its own requirements for a military aircraft. Germany patented the first fixed machine gun to be used on an aircraft in 1910. The first recorded use of a weapon being fired from an aircraft was in the United States on August 20, 1910.
The first British dedicated fighter aircraft took flight on November 3, 1912. During the civil war in Mexico, in November of 1913, the first recorded air to air combat took place with pistols being fired between aircraft.
The Nieuport 17 that first flew in 1916 was the second model of the Nieuport Fighting Scouts, and a vast improvement over its predecessor. The aircraft had a more powerful engine, greater wing area, and a stronger fuselage structure. Controls were actuated by wire rather than ropes.
Pilots appreciated the Nieuport 17 for its great maneuverability, speed, and climb rate. An improved gun mount made loading of the machine gun easier. Eventually a synchronized machine gun that could be fired through the propeller arc was mounted on the aircraft.
The Nieuport 17 became the preferred aircraft of a number of World War I flying aces. Eventually it became the predominant French World War I fighter aircraft before more modern aircraft replaced it.
In addition to France, a number of Allied nations flew the Nieuport 17. It was built under license in Italy and Russia.
Some 3,600 Nieuport 17 aircraft were produced in all.
The Proctor Enterprises Nieuport 17 shown above is built from their kit. With a wingspan of 54 in. and length of 37 in. it requires from .48 to .70 engines or their electric motor equivalent for power. All up weight is about 5 1/2 lbs.
Balsa USA has a Nieuport 17 kit with construction from wood. It has a wingspan of 80 in. with a length of 61 in. A 1.20 four cycle engine can power the 14 lb. model.
Balsa USA has a Nieuport 17 kit with a wingspan of 107 in. and length of 82 in. For power you will need from 40 cc to 50 cc engines. Weight is around 28 lbs.
Arizona Model Aircrafters has Nieuport 17 museum quality kits with wingspans of 28 in., 55 in., 82 in. and 110 in.
There is a Nieuport 17 by 3 Sea Bees Models. Wingspan is 66 in. and length is 46 in. Power can come from .46 to .60 two cycle or .60 to .80 four cycle engines. The model can also be easily converted to electric motor power. Weight is around 8 1/2 lbs.
The Dare Nieuport 17 by Brodak has a wingspan of 69 in. and length is 48 in. A .53 to .64 four cycle engine is recommended as power for the 6 3/4 lb. model.
You can find plans for a gas powered Nieuport 17 at the AMA Plans Service. It has a 54 in. wingspan. Plan number is 15529.
One thought on "Nieuport 17"
WARNING! – COMMENT MODERATION IS IN USE. COMMENTS NOT REGARDING THE NIEUPORT 17 OR CONTAINING LINKS OR ADVERTISING WILL NOT APPEAR AND ARE AUTOMATICALLY DELETED. PLEASE DO NOT SUBMIT YOUR COMMENT TWICE — IF APPROVED IT WILL APPEAR SHORTLY.


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Yes, Virginia, there is a deep state. And it's at State
Image via kwese.com
By DrJohn
Over the last 18 months, democrats have been fond of saying that the walls are closing in on Donald Trump. So much so, that David Rutz of the Washington Free Beacon put together a hilarious montage of it:
Well, the walls are closing in. On Bruce Ohr and the deep state. The conspiracy is being ripped from the clutches of the FBI and the DOJ and pushed into the light of day. Yesterday Devin Nunes has some very interesting things to say. He asserted that exculpatory evidence was left out of the FISA app on Carter Page:
House Intelligence Committee Chairman Devin Nunes claimed Monday that the FBI and Justice Department failed to include exculpatory evidence in surveillance warrant applications against former Trump campaign adviser Carter Page.
"There is exculpatory evidence that we have seen, of classified documents that need to be declassified," Nunes said in an interview with Fox News' Sean Hannity.
"Exculpatory in nature in what way? Exculpatory in what way?" Hannity asked.
"In that the Carter Page FISA when the judges should have been presented with this exculpatory evidence that the FBI and DOJ had," Nunes replied.
Then he went on to leave a teaser:
Nunes also told Hannity that the committee is interested in learning more about Justice Department official Bruce Ohr's role in the Trump-Russia investigation.
Ohr, the former associate deputy attorney general, met with Steele before and after the 2016 presidential election. The post-election meetings were held after the FBI ended its relationship with Steele because of the former British spy's contacts with the media.
As Nunes noted, though the FBI severed ties with Steele, Ohr provided information from his 12 meetings with Steele back to the FBI. Ohr's wife, Nellie Ohr, also worked during the campaign for Fusion GPS, the opposition research firm that hired Steele in June 2016.
"Bruce Ohr is going to become more and more important in this investigation, and I think people should pay close attention to it," Nunes told Hannity.
Today John Solomon provided much insight into what Nunes was hinting at- the obama DOJ was weaponized in the 2016 election in an effort to destroy Donald Trump. One of the chief conspirators was Bruce Ohr.
But a close review of these new documents shows just how closely Associate Deputy Attorney General Bruce Ohr, who reported to Obama-era Deputy AG Sally Yates, maintained contact with Fusion — and, in particular, its primary source, former British spy Christopher Steele — before, during and after the election.
Ohr was the conduit between Christopher Steele, Fusion GPS, his wife Nellie Ohr and the FBI. Ohr and wife Nellie ( a Fusion GPS employee) met with Steele on July 30, 2016.
Ohr scheduled a call with Steele over Skype a few days later. But then the two men met in Washington on July 30, 2016, at the Mayflower Hotel.
Ohr brought his wife, Nellie, who was working at Fusion GPS on the Trump-Russia research project.
"Great to see you and Nellie this morning Bruce," Steele wrote shortly after their breakfast meeting. "Let's keep in touch on the substantive issues/s (sic). Glenn is happy to speak to you on this if it would help."
The very next day Peter Strzok opened a counterintelligence investigation into Donald Trump.
Ohr continued to use Steele as a source even after he was terminated by the FBI for unauthorized disclosures to the media in early November 2016. In violation of its own rules, the FBI continued to use Steele as a source, again with Ohr as the conduit.
Ohr's notes from that meeting indicate that FBI officials told him they "may go back to Chris" — an apparent reference to Steele — just 20 days after dismissing him.
In all, Ohr's notes, emails and texts identify more than 60 contacts with Steele and/or Simpson, some dating to 2002 in London. But the vast majority occurred during the 2016-2017 timeframe that gave birth to one of the most controversial counterintelligence probes in American history.
(documents at the link)
Now we are left to question how much of Steele's "theories" were used in the ongoing FISA app's used to spy on the Trump staff with Carter Page as the pigeon. It seems reasonable to think that without Steele's continued input no further FISA warrants would have been granted.
Yes, Virginia, there is a deep state- and it's at the State Department.
Personally, I think Trump already knows all this. I think that up to now he's been content to allow liberals to mouth off and stake out positions that he can (and certainly will) use to beat them over the head. You can bet that the FISA app will be declassified before election day. Nunes said that it makes the FBI look very bad.
Without any doubt.
This entry was posted in Uncategorized and tagged 2016 election, American Intelligence, Bruce Ohr, Deep State, Donald Trump, Politics, scandals. Bookmark the permalink.
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