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The Free Library > Business and Industry > Business > Health Services Research > April 1, 2012
The Free Library > Business and Industry > Health care industry > Health Services Research > April 1, 2012
The Free Library > Date > 2012 > April > 1 > Health Services Research
Location of cancer surgery for older veterans with cancer.
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Many older veterans who are eligible for care in the Veterans Health Administration (VHA) also receive care in the private sector through Medicare (Fleming et al. 1992; Weeks et al. 2002, 2003; Ashton et al. 2003; Hynes et al. 2007). Studies examining health care utilization among veterans with dual eligibility for VHA and Medicare services have shown an increasing proportion of veterans relying on Medicare for care (Wright et al. 1999; Shen et al. 2005). In 2003 and 2004, among veterans eligible for both VHA and Medicare services who were hospitalized, 63% received inpatient care from Medicare only, 26% received inpatient care from VHA only, and 11% received care from both Medicare and the VHA (Petersen et al. 2010).
Prior studies have found that up to 70% of VHA users hospitalized for acute myocardial infarction and 76% of patients hospitalized for stroke were admitted to non-VHA hospitals, which may reflect greater access to non-VHA hospitals during an acute illness, where proximity is important (Wright et al. 1999; Shen et al. 2008). Veterans also receive substantial elective care outside the VHA. In a recent study, West and colleagues reported that more than three-quarters of older veterans undergoing elective high-risk surgeries underwent surgery in non-VHA hospitals under Medicare (West, Weeks, and Wallace 2008). However, because they studied veterans eligible for VHA care rather than VHA users, it is not clear whether the high rates of elective surgery outside of the VHA among their population reflected a desire of regular VHA users to obtain certain services, such as high-risk surgery, outside the VHA or whether their VHA cohort primarily consisted of veterans who received very little or no care from the VHA. If VHA users are choosing to obtain care outside the VHA, it would suggest that the VHA is not meeting their needs, in which case this could be an area of focus to assure better access to care and better coordination of care for VHA users.
In this study, we attempted to differentiate between these two options using a more comprehensive approach to identifying veterans who were active users of the VHA system versus those who were not. We studied patients with lung cancer or colorectal cancer for this purpose.
VHA-Medicare File. The VHA-Medicare file contains administrative data for all Medicare-reimbursed care, including admissions to private sector hospitals, by veterans who are potentially eligible for VHA services (Hynes et al. 2007; West and Weeks 2007, 2009). The VHA-Medicare file allows for ascertainment of care covered under Medicare only and not care delivered in the VHA. We used VHA-Medicare data from 2000 to 2005.
VHA Administrative Data. We used VHA administrative data from the Patient Treatment File and the Outpatient Clinic File to ascertain outpatient visits and treatments received.
Veterans Affairs Central Cancer Registry (VACCR) data. Since 2001, the VACCR identifies all patients with cancer who were diagnosed and/or received their first course of treatment in a VHA facility (including surgery, radiation, or chemotherapy; 92% of colorectal cancer patients, and 90% of lung cancer patients were diagnosed at the VHA facility that reported their cancer). In addition, tumor registrars from each VA medical center actively track veterans they have identified with cancer, who are treated outside VHA facilities, and treatments received at non-VHA hospitals are included in the registry data. We linked VACCR data from 2001 to 2004 with VHA administrative data and Medicare data through 2005 to ascertain treatments received, including cancer surgery, both in the VHA and treatments received outside of the VHA and covered under Medicare.
Cohort Identification
We identified two patient cohorts.
VHA-Medicare Cohort. On the basis of the methods of West, Weeks, and Wallace (2008), we used the VHA-Medicare cohort (see www.virec.research. va.gov/DataSourcesName/VA-CMS/VACMSbackground.htm last accessed September 1, 2011) to identify all men and women aged > 65 years who had a Medicare claim for an inpatient admission with an ICD-9 diagnosis code for lung cancer (162.0-165.9) and an ICD-9 procedure code for lung lobectomy (32.4) or pneumonectomy (32.5) or who had an ICD-9 diagnosis code for colon cancer (153-153.9, 154.0) and an ICD-9 procedure code for colon resection (45.73-45.76) during 2000-2005. Of note, the VHA-Medicare cohort includes veterans who (1) have obtained health care services from the VHA since 1992, or (2) have enrolled in the VHA, or (3) are receiving compensation or pension benefits from the Department of Veterans Affairs. Veterans are never removed from the VHA cohort, even if they never use VHA services and become ineligible or die. As of 2008, the VHA cohort included 14,506,025 individuals.
VACCR Cohort. Our second cohort included patients from the VACCR aged [greater than or equal to] 65 years who were diagnosed or received their first course of treatment for lung or colon cancer in the VHA during 2001-2004. We used this VACCR cohort to assess location of surgery for patients included in the VACCR (who were diagnosed and/or received their first course of treatment in the VHA). We identified patients with stage I/II lung cancer or I/II/III colon cancer for whom resection is recommended.
To ascertain whether patients in our VHA-Medicare cohort were receiving regular care in the VHA, we identified face-to-face office visits with internists or nurse practitioners in the VHA during the year before surgery using codes from the Healthcare Common Procedure Coding System (Table $1) and assessed receipt of primary care and specialty care using VHA clinic codes (Table $2). We also counted the number of primary care visits in the year before cancer surgery to further ascertain whether patients were receiving regular care in the VHA prior to their cancer resection. By identifying the extent to which veterans in our cohort were active users of the VHA system in the year prior to their cancer surgery, we were able to differentiate between regular VHA users who received their surgery outside of the VHA versus potentially eligible veterans who never received care in the VHA.
For our VACCR cohort, we used the ICD-9 procedure codes described above to ascertain surgery. Location of surgery was classified based on source of payment and was categorized as in the VHA, contracted care delivered outside of the VHA, but paid for by the VHA, or outside of the VHA and covered by Medicare. As <1% of surgeries were contracted care delivered outside the VHA, and these surgeries were paid by the VHA, this category was considered care in the VHA. This analysis allowed us to determine how often patients who were already part of the VHA system (based on having their cancers diagnosed and/or receiving first course of treatment) were getting cancer surgery outside the VHA.
We also compared site of care by patient age, year of diagnosis, service connection, and distance from the patient's zip code to the diagnosing VHA facility using chi-square tests. Veterans with more severe service-connected disabilities are eligible for more benefits with lower out-of-pocket expenses and are more likely to rely on the VHA for their care than veterans in lower priority groups (Hynes et al. 2007).
The VHA-Medicare cohort included 44,847 veterans in the VHA-Medicare file who underwent lung cancer or colon cancer surgery outside the VHA between 2000 and 2005. The distribution of VHA face-to-face visits during the year before cancer surgery for these patients is presented in Table 1. Most patients (61.5% of colon cancer patients and 57.2% of lung cancer patients) had no visits in the VHA during the year before their cancer surgery, and very few had more than three visits with a primary care provider.
Among patients in the VACCR cohort (patients who were diagnosed in the VHA and/or received their first course of treatment in the VHA) who underwent colon or rectal cancer resection, 4.1% of colorectal cancer patients had surgery outside the VHA covered by Medicare, and 5.80/0 of lung cancer patients had surgery outside the VHA. Table 2 depicts the proportion of patients in the VACCR who had surgery outside the VHA covered by Medicare stratified by age, year, service-connected disability, and distance from the nearest VHA facility. The proportion of patients in the VACCR who received their cancer surgeries outside the VHA did not differ by patient age, year of diagnosis, service connection, or distance to VHA facility.
A recent study reported that 82% of veterans with lung cancer and 780/0 of veterans with colon cancer received their cancer resections outside the VHA (West, Weeks, and Wallace 2008). However, it has been unclear to what extent this reflects a choice to undergo cancer treatment outside the VHA among patients who are being cared for in the VHA, or whether it represents usual care for veterans who are not users of VHA care. It is important to know where dually eligible veterans receive care to understand if the VHA is meeting the needs of eligible veterans. In addition, as care in multiple systems may be poorly coordinated, understanding the extent and types of care obtained outside the VHA can help to identify opportunities for improving coordination and quality of care.
Among veterans who underwent lung or colon cancer surgery outside the VHA, we assessed visits in the VHA during the year before surgery and found that most of these veterans had no outpatient visits in the VHA during that time. In contrast, among patients identified by the VACCR, who had their cancers diagnosed and/or received their first course of treatment in the VHA, the vast majority received their cancer surgery in the VHA. These findings were similar despite proximity to VHA facilities or levels of service-connected disability among our veterans. Thus, our findings suggest that although most veterans have cancer surgery outside the VHA, nearly all VHA patients diagnosed with cancer in the VHA have their cancer surgery in the VHA.
Veterans who are eligible for Medicare have a choice of where to obtain health care services. Many factors including gender (Hoff and Rosenheck 2000; Weaver et al. 2003; Liu, Maciejewski, and Sales 2005), age (Wright et al. 1997; Hynes et al. 1998; Liu, Maciejewski, and Sales 2005), clinical condition for which care is sought (Petersen et al. 2010), residence in an urban or rural area (Mooney et al. 2000; Weeks et al. 2005), distance from a VHA facility (Burgess and DeFiore 1994; Lahiri and Xing 2004), VA priority status (Hynes et al. 2007), and requirements for copayments (Smith et al. 1996) have been shown to influence use of VHA care among veterans. Even though frequent use of non-VHA hospitals by veterans has been reported in a number of studies (Fleming et al. 1992; Wright et al. 1997; Wright et al. 1999; Weeks et al. 2004; Weeks et al. 2005; Hynes et al. 2007; West and Weeks 2007), many of these studies either focused on acute myocardial infarction or stroke (Wright et al. 1997; Wright et al. 1999; Weeks et al. 2006; Shen et al. 2008), where immediate access to the nearest hospital may be crucial, or studied patients in the VHA cohort (Hynes et al. 2007; West and Weeks 2007, 2009; West, Weeks, and Wallace 2008), which includes patients who are eligible for VHA services but who do not necessarily ever use them. Our findings suggest that high use of elective cancer surgery identified by others (West, Weeks, and Wallace 2008) probably represents use of non-VHA care by veterans who receive none or very little regular care from the VHA.
Our findings should be interpreted in light of some limitations. First, we focused only on patients aged 65 and older with lung or colon cancer who underwent surgical resection, and so the generalizability of our findings to younger patients and those with other conditions requires further study. Second, we used the VHA-Medicare cohort to identify patients who had their cancer surgery reimbursed by fee-for-service Medicare. As this cohort was defined based on having surgery in Medicare, it included only patients who underwent a cancer surgery reimbursed by Medicare, and thus did not include patients who may have been eligible for the VHA cohort, but underwent lung or colon resections in the VHA. To address this limitation, we complemented the analysis with data from the VACCR cohort (which includes patients who were diagnosed and/or received their first course of cancer treatment in the VHA), and we found that very few of these patients underwent cancer surgery outside the VHA. Third, we did not have information on veterans' income and priority group designation for receipt of services. We used service connection disability designations as a proxy for priority to receive VHA services. However, as a large proportion of our sample consisted of veterans with no service-connected disabilities, we did not find an association between the level of service connection and the location of care.
In conclusion, although large numbers of older veterans with lung or colon cancer undergo major cancer surgery outside the VHA, these are primarily patients who are not regular users of VHA care at the time of their cancer surgery. Moreover, those with cancers diagnosed in the VHA infrequently undergo resections of their cancers outside the VHA. Thus, the high frequency of non-VHA care used by veterans most probably reflects an overall choice to receive most or all of their care outside the VHA rather than a desire of veterans being cared for in the VHA system to receive certain high-complex treatments outside the VHA. Additional data collection from veterans receiving care outside the VHA could be useful to understand how the VHA can serve the needs of eligible veterans better. In addition, future studies investigating patterns of health care use among older veterans should examine the extent to which these veterans are utilizing other VHA services.
Joint Acknowledgment/Disclosure Statement: This work was funded by the Department of Veterans Affairs through the Office of Policy and Planning. The authors would like to thank David Izrael, Jeffrey Souza, Stephanie Segers, Larry Hughes (VA-Austin Data Center), John Quinn (VA-Austin Data Center), and Elizabeth Axelrod for expert programming assistance, and Garrett Kirk for research and administrative assistance. This analysis would not have been possible without the invaluable feedback we received from the VA Oncology Program Evaluation Team, especially members with extensive clinical oncology experience within the VA system, including Dr. Albert Muhleman (Cincinnati VAMC), Dr. Nirmala Bhoopalam (Hines, ILVAMC), Dr. Paulette Mehta (Central AR VHA), Dr. Dawn Provenzale (VA HSR&D Researcher in Durham, NC), Dr. Michael Kelley (Chief of Oncology, VHA), Dr. Robert Kerns (National Program Director for Pain Management, VHA), and the chief VACCR registrar, Raye Anne Dorn (VHA--DC VAMC).
A special acknowledgement goes to Marshall Amesquita and Barbara Stephens, Contracting Officer's Technical Representative, and the rest of our VA Oncology Program Evaluation Team: Stanlie Daniels (VHA), Heidi Martin (VHA), Diana Ordin (VHA), and Patricia Vandenberg (VHA OP&P). The views reflect those of the authors and not the Department of Veterans Affairs.
Ashton, C. M.,J. Souchek, N.J. Petersen, T.J. Menke, T. C. Collins, K. W. Kizer, S. M. Wright, and N. P. Wray. 2003. "Hospital Use and Survival among Veterans Affairs Beneficiaries." New England Journal of Medicine 349 (17): 1637-46.
Burgess, J. F. Jr, and D. A. DeFiore. 1994. "The Effect of Distance to VA Facilities on the Choice and Level of Utilization of VA Outpatient Services." Social Science and Medicine39 (1): 95-104.
Fleming, C., E. S. Fisher, C. H. Chang, T. A. Bubolz, and D.J. Malenka. 1992. "Studying Outcomes and Hospital Utilization in the Elderly. The Advantages of a Merged Data Base for Medicare and Veterans Affairs Hospitals." Medical Care 30 (5): 377-91.
Hoff, R. A., and R. A. Rosenheck. 2000. "Cross-system Service Use among Psychiatric Patients: Data from the Department of Veterans Affairs." The Journal of Behavioral Health Services & Research 27 (1): 98-106.
Hynes, D. M., L. A. Bastian, B. K. Rimer, R. Sloane, and J. R. Feussner. 1998. "Predictors of Mammography Use among Women Veterans." Journal of Womens Health 7 (2): 239-47.
Hynes, D. M., K. Koelling, K. Stroupe, N. Arnold, K. Mallin, M. W. Sohn, F. M. Weaver, L. Manheim, and L. Kok. 2007. "Veterans' Access to and Use of Medicare and Veterans Affairs Health Care." Medical Care 45 (3): 214-23.
Lahiri, K., and G. Xing. 2004. "An Econometric Analysis of Veterans Health Care Utilization Using Two-Part Models." Emprical Economics 29: 431-49.
Liu, C. F., M. L. Maciejewski, and A. E. Sales. 2005. "Changes in Characteristics of Veterans Using the VHA Health Care System between 1996 and 1999." Health Research Policy and Systems 3 (1): 5.
Mooney, C.,J. Zwanziger, C. S. Phibbs, and S. Schmitt. 2000. "Is Travel Distance a Barrier to Veterans' Use of VA Hospitals for Medical Surgical Care?" Social Science and Medicine 50 (12): 1743-55.
Petersen, L. A., M. M. Byrne, C. N. Daw, J. Hasche, B. Reis, and K. Pietz. 2010. "Relationship between Clinical Conditions and Use of Veterans Affairs Health Care among Medicare-Enrolled Veterans." Health Services Research 45 (3): 762-91.
Shen, Y., A. Hendricks, D. Li, J. Gardner, and L. Kazis. 2005. "VA-Medicare Dual Beneficiaries' Enrollment in Medicare HMOs: Access to VA, Availability of HMOs, and Favorable Selection." Medical Care Research and Review: MCRR 62 (4): 479-95.
Shen, Y., P. A. Findley, M. Maney, L. Pogach, S. Crystal, M. Rajan, and T. W. Findley. 2008. "Department of Veterans Affairs-Medicare Dual Beneficiaries with Stroke: Where Do They Get Care?" Journal of Rehabilitation Research and Development 45 (l): 43-51.
Smith, M. E., G. Sheldon, R. E. Klein, T. Feild, R. Feitz, D. Stockford, S. Krumhaus, and C. A1pert. 1996. "Data and Information Requirements for Determining Veterans' Access to Health Care." Medical Care 34 (3 Suppl): MS45-54.
Weaver, F., D. Hynes, W. Hopkinson, R. Wixson, S. Khuri, J. Daley, and W. G. Henderson. 2003. "Preoperative Risks and Outcomes of Hip and Knee Arthroplasty in the Veterans Health Administration." Journal of Arthroplasty 18 (6): 693-708.
Weeks, W. B., D. J. O'Rourke, L. B. Ryder, and M. M. Straw. 2002. "Veterans' Care Preference for Coronary Artery Bypass Grafting in a Rural Setting." Military Medicine 167 (7): 556-9.
--. 2003. "Veterans' System-of-Care Preferences for Percutaneous Transluminal Coronary Angioplasty in a Rural Setting." The Journal of Rural Health 19 (2): 105-8.
Weeks, W. B., L. E. Kazis, Y. Shen, Z. Cong, X. S. Ken, D. Miller, A. Lee, and J. B. Perlin. 2004. "Differences in Health-Related Quality of Life in Rural and Urban Veterans." American Journal of Public Health 94 (10): 1762-7.
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Weeks, W. B., D. M. Bott, D. A. Bazos, S. L. Campbell, R. Lombardo, M. J. Racz, E. L. Hannan, S. M. Wright, and E. S. Fisher. 2006. "Veterans Health Administration Patients' Use of the Private Sector for Coronary Revascularization in New York: Opportunities to Improve Outcomes by Directing Care to High-Performance Hospitals." Medical Care 44 (6): 519-26.
West, A. N., and W. B. Weeks. 2007. "Who Pays When VA Users Are Hospitalized in the Private Sector? Evidence from Three Data Sources." Medical Care 45 (10): 1003-7.
--. 2009. "Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care." Health Services Research 44 (5 Pt 1): 1718-34.
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Wright, S. M., J. Daley, E. S. Fisher, and G. E. Thibault. 1997. "Where Do Elderly Veterans Obtain Care for Acute Myocardial Infarction: Department of Veterans Affairs or Medicare?" Health Services Research 31 (6): 739-54.
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Additional supporting information may be found in the online version of this article:
Appendix SA 1: Author Matrix.
Table S1: Health Care Common Procedure Coding System (HCPCS) Codes for Face-to-Face-Office Visits.
Table S2: Clinic Stop Codes Used to Identify Primary Care and Specialty Care.
Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
Address correspondence to Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail: keating@hcp.med. harvard.edu. Elena M. Kouri, Ph.D., and Mary Beth Landrum, Ph.D., are with Department of Health Care Policy, Harvard Medical School, Boston, MA. Elizabeth B. Lamont, MD, MS, is with Department of Health Care Policy, Harvard Medical School, Boston, MA, and Division of Adult Oncology, Massachusetts General Hospital, Boston, MA. Sam Bozeman, MPH, is with Abt Associates Inc., Cambridge, MA. Barbara J. McNeil, MD, Ph.D., is with Department of Health Care Policy, Harvard Medical School, Boston, MA, and Department of Radiology, Brigham and Women's Hospital, Boston, MA. Nancy L. Keating, MD, MPH, is with Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, and the Department of Health Care Policy, Harvard Medical School, Boston, MA.
Table 1: Outpatient Visits to Veterans Health Administration (VHA)
Providers during the Year before Surgery among Patients Who Underwent
Cancer Surgery outside the VHA
Colon Cancer Lung Cancer
(N= 31,368), % (N= 13,4 79), %
No visits 61.5 57.2
Visits other than PCP 1.6 1.5
1-2 PCP visits 24.2 26.9
3+ PCP visits 12.7 14.4
PCP, primary care physician.
Table 2: Patient Characteristics and Location of Surgery for Patients in
Veterans Affairs Central Cancer Registry Cohorts
Colon Cancer (N = 4,017)
Out of VHA
N byMedicare p Value *
65-69 832 4.0 .97
70-74 1,098 4.3
80+ 990 3.9
2001 1,001 4.9 .53
2002 1,037 3.9
Service-connected disability ([dagger])
None 2,682 4.5 .11
<10% 190 5.3
100/-40% 573 3.1
[greater than or 556 3.3
equal to] 50%
Distance from VHA facility
<30 miles 2,313 3.9 .62
30-60 miles 738 4.7
>60 miles 966 4.0
Lung Cancer (N = 1,521)
% Surgery
N by Medicare p Value *
70-74 478 6.5
2001 360 6.9 .32
None 1,041 ,5.0 .16
<10% 63 9.5
<30 miles 716 4.9 .12
Notes.* Using the chi-square test.
([dagger]) Numbers do not sum to total because data about
service-connected disability were missing for 16 patients with
colon cancer and four patients with lung cancer. VHA, Veterans
Health Administration.
COPYRIGHT 2012 Health Research and Educational Trust
Kouri, Elena M.; Landrum, Mary Beth; Lamont, Elizabeth B.; Bozeman, Sam; McNeil, Barbara J.; Keating
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Mr. Hari Padmanabhan
Chairman, PanIIT Alumni Reach For India (IIT Kanpur)
Mr. Hari Padmanabhan is a serial entrepreneur, a global corporate board level executive, mentor and angel investor. He is currently Executive Chairman of the Encore Group. Previous to this, he was the Chief Strategic Advisor of 3i Infotech till May 2009 and was the Deputy Managing Director between 2003 and 2008. He has a Bachelor of Technology degree from IIT Kanpur & post graduate degree in Management from IIM Calcutta.
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Non-Executive Director and Non-Profit Promoter (IIT Bombay)
Mr. Ashank Desai is Founder and Chairman of Mastek, a top 10 software company in India. Additionally, he is the founder and former president of National Association of Software and Service Companies (NASSCOM) and vice president of the Asian Oceanian Computing Industry Organization (ASOCIO). Mr. Desai was previously a member of the Governing Council of IIMA. He has an M.Tech degree from IITB and has a postgraduate degree in Management from IIM Ahmedabad. Mr. Ashank Desai is also a Distinguished Alumni of IIT Bombay.
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Dr. Satyanarayana is a professor with the Department of Civil Engineering at IITM, which is also his alma mater. A faculty member at IIT Madras since 1991, he currently teaches in the Building Technology & Construction Management Division of the Institute. He is a board member of the Institute for Lean Construction Excellence, Vice-Chairman – Board of Advisors of The Glass Academy and Member of the Academic Advisory Group, Project Management Institute (PMI) India. He is currently the Director of IIT Tirupati.
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Mr. Arjun Malhotra serves as Chairman Emeritus of Headstrong's Board of Directors. Prior to Headstrong he was CEO and Chairman of TechSpan, which merged with Headstrong in 2003. A pioneer of the Indian IT industry, he founded TechSpan in 1998. A winner of the Silicon Valley Entrepreneurs Award, he has had a string of entrepreneurial successes. He co?founded the HCL Group in 1975, taking it from a six person garage operation to one of India's largest IT corporations. Mr. Arjun Malhotra is also a Distinguished Alumni of IIT Kharagpur.
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Ravi Venkatraman is based out of Chennai and was a former Chairman of PIAI and is PIAI GB Life member. He has served on PIAI EC from 2016-20. Further, he was Past President of IITMAA during which he had strengthened IITMAA secretariat and ushered in youngsters to take up key positions at the association. Ravi had a long professional career in Banking & IT where he served as CIO of Bank of Baroda, General Manager at IDBI Bank and retired after a long stint with Mphasis as a senior executive and Delivery Lead. Ravi is a 1971 batch alumnus from IIT Madras.
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Prof. Satish Agnihotri is now professor-in-charge (Rural Technology Action Groups RuTAG) and faculty member with CTARA(Center for Technology alternatives in Rural Areas) at IIT Bombay. Dr. Agnihotri is an IAS officer of Odisha cadre from 1980 batch. Dr. Satish B. Agnihotri retired as Secretary (Coordination & Public Grievances), Cabinet Secretariat. Prior to this he was Secretary, Ministry of New & Renewable Energy, Director General (Acquisition) in the Ministry of Defence, Additional Secretary in the Ministry of Agriculture discharging the role of Financial Advisor and Director General of Shipping during 2010-12. He also worked with UNICEF, Kolkata as Consultant on Child Nutrition and Health. He served on various boards including Coal India Limited.
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Phillip Sitter
Reporter573-761-0249573-761-0249[email protected]
Phillip Sitter is the News Tribune's reporter who covers Missouri's Senate, governor, executive government agencies, and MOSERS and MPERS. Previously, he covered local schools and school districts for the News Tribune for over 2 years since starting at the News Tribune in December 2016. Sitter's time at the News Tribune has been his first full-time job in journalism, although he studied at the University of Missouri's School of Journalism and contributed at the News Tribune in fall 2014 as a graduate student while on the Columbia Missourian's state government beat. He has also worked for MU's Bond Life Sciences Center. Sitter lives in Jefferson City and is originally from northwestern Illinois. He obtained his bachelor's degree in political science with a minor in Catholic social tradition from the University of Notre Dame in 2012 and lived in Washington, D.C., for a year after that while he began law school, before ultimately deciding that wasn't the career he wanted to pursue. He has also lived in London, United Kingdom, and New Orleans, Louisiana, for study-abroad and service opportunities. Follow him on Twitter at @pslifeisabeauty.
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MoDOT hit $38M pothole in 2020 With 2020 in its rearview mirror, the Missouri Department of Transportation last month released its report looking back at the year — including how the COVID-19 pandemic affected the agency and how the state's transportation infrastructure compares to the rest of the country. Jan. 5 2021 @ 12:05am
Algoa inmate's sentence among commutes, pardons by Parson Jason Norman, 45, an inmate at Algoa Correctional Center in Jefferson Center, was among the four people Gov. Dec. 24 2020 @ 12:05am
St. Thomas man among first Missouri elk season hunters All five of the hunters selected for permits to harvest bull elk in the first season of its kind in Missouri harvested a bull during the firearms portion this month, the Missouri Department of Conservation announced Tuesday. Dec. 23 2020 @ 12:05am
A+ program funding boost to help more than 800 State Tech students The $10.1 million Gov. Mike Parson announced this week would provide aid to Missouri's A+ scholarship program is not quite enough to cover all of the program's increased needs, but it will benefit students, including hundreds using the program at State Technical College of Missouri in Linn. Dec. 22 2020 @ 12:05am
Missouri's jobless rate dips again Missouri's unemployment rate decreased 0.2 percentage points between October and November, coming down to 4.4 percent. Dec. 17 2020 @ 12:05am
Missourians warned to not let guard down in latest report Though fewer counties around the state were reported to be in the red zone, the White House Coronavirus Task Force warned Missourians this week to not let their guards down. Dec. 9 2020 @ 9:10pm
Missouri's largest public retirement funds continue recovery Economic recovery from the COVID-19 pandemic slowed in July, August and September compared to the three months before, but most of the largest statewide public retirement funds in Missouri had still regained more than they lost in the spring's economic crash. Dec. 7 2020 @ 12:05am
COVID-19 liability, police reform among topics of 600 pre-filed legislative bills Missouri lawmakers had pre-filed 600 pieces of legislation between the state House and Senate for the spring session, as of Friday morning — the end of the first week of pre-filing, which opened Dec. Dec. 6 2020 @ 12:05am
Missouri Census committee turns in final report Missouri census committee turns in final reportMissourians fell a little short in counting themselves during this year's census compared to the previous one, but the committee tasked with encouraging participation reported this week that the count was successful. Dec. 5 2020 @ 12:05am
Report: Mid-Missouri drivers each lose $1,500+ a year due to bad roads Missouri Department of Transportation leaders said two reports released by nonprofits paint a picture of the state's roads and bridges that show Missouri needs to change its trend of under-investment in infrastructure. Dec. 3 2020 @ 10:59pm
Out-of-state workers to help staff hospitals Health care workers from other states will be brought in through a corporate partnership with state government and Missouri hospitals to assist with staffing as the COVID-19 pandemic continues to surge, Gov. Mike Parson and the Missouri Hospital Association's leader announced Wednesday evening. Dec. 2 2020 @ 7:58pm
Fate of COVID-19 liability bill uncertain A state Senate bill proposing expanded liability protections against civil lawsuits related to the COVID-19 pandemic did not move forward in the legislative process Tuesday following a hearing on it, amid the governor changing his mind about the bill. Dec. 1 2020 @ 11:02pm
Federal government recommends 'aggressive mitigation' of COVID-19 Every county in Missouri had moderate or high levels of community transmission of COVID-19 going into the Thanksgiving holiday weekend, with 97 percent of counties in the red zone, according to the federal government. Dec. 1 2020 @ 5:53pm
Advocates, Missouri Department of Corrections spar over handling of COVID-19 Advocates from organizations such as the Missouri NAACP on Tuesday called for the state Department of Corrections to do more to combat the spread of COVID-19 among the state's prison population and the staff who work with inmates, and to be more transparent about those efforts and results. Nov. 25 2020 @ 10:10am
Parson eases K-12 quarantine policy Gov. Mike Parson and his administration announced a new policy Thursday that elicited disapproving responses from teachers' unions. Nov. 12 2020 @ 10:50pm


UDP Picture Week is May 6-9 for all full year recital classes.
Pictures will be held DURING regular class times for all Mon, Tues, Wed & Thurs classes.
Saturday Ballet/Jazz Intro will have photos taken on Thursday May 9th, 5:30 – 5:45pm.
Urban Dance Projects offers dance lessons in acrobatic arts, ballet, contemporary, hip hop & diva style, jazz, kinder combo, lyrical, musical theatre, parent & tot, tap, and tiny tots.
Students age 2 year to adult who wish to benefit from the fun and fitness of dance are encouraged to explore the wide variety of dance classes offered. Classes are also offered for students interested in intensive dance training and exam preparation.
Urban Dance Projects is always looking for talented instructors to join our dynamic team. If you have a passion for working with children, a dance background along with recognized credentials and a desire to teach the art of dance then please submit your resume to udpadmin@urbandanceprojects.com. We look forward to meeting you!
Copyright © 2017 Urban Dance Projects. All Rights Reserved. Site customized and hosted by Electris Design.


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Italian and Portuguese
UCAS Code: R3R5
A levelAccess to HE DiplomaCambridge International Pre-U Certificate - PrincipalInternational Baccalaureate Diploma ProgrammeScottish Advanced HigherWelsh Baccalaureate - Advanced Skills Challenge Certificate (first teaching September 2015)UCAS Tariff
A-levelAccess to HE DiplomaCambridge International Pre-U Certificate - PrincipalInternational Baccalaureate Diploma ProgrammeScottish Advanced HigherWelsh Baccalaureate - Advanced Skills Challenge Certificate (first teaching September 2015)UCAS Tariff
A,B,B
ABB to include one of the named languages. Contextual Offers: please visit the course webpage for further details about our Access UCL scheme
M:28
Pass in Access to HE Diploma, with a minimum of 28 credits awarded with Merit in the Level 3 units. Please note, where subject specific requirements are stipulated at A level we may review your Access to HE syllabus to ensure you meet the subject specific requirements prior to a final decision being communicated.
Cambridge International Pre-U Certificate - Principal
D3,M1,M1
D3,M1,M1 in three Cambridge Pre-U Principal Subjects to include one of the named languages
A score of 16 points in three higher level subjects to include one of the named languages, with no score lower than 5. Contextual Offers: please visit the course webpage for further details about our Access UCL scheme
ABB at Advanced Highers to include one of the named languages (AB at Advanced Higher and BBB at Higher)
Successful completion of the WBQ Advanced Skills Challenge Certificate plus 2 GCE A-Levels at grades ABB, to include one of the named languages.
Full-time with time abroad | 2021
The four-year BA Italian and Portuguese is a joint honours programme split equally between your two languages. You will take modules not only in language (speaking, listening, reading, writing and translation) but also in cultural topics including literature, history, film, linguistics, politics and other relevant field designed to complement your language learning. With a wide variety of modules on offer, you will be able to tailor your modern languages degree to your areas of interest.
You will spend a Year Abroad in the third year, split between two countries where your languages are spoken.
Studying Italian at UCL you will experience innovative teaching in every area of study. Examples include language projects using e-learning, historical Italian cookery, dedicated visits to museums and galleries in London, hands-on access to UCL rare books collections (for example Dante incunables) and extra-curricular activities such as film club screenings.
We are one of the biggest Italian departments in the UK. We have leading experts in all periods of Italian literature, from Dante to the present day. But we're also famous in the world of Italian studies for the broad range of other courses we offer. Our students can explore interests as diverse and fascinating as Renaissance art, Italian history, modern and contemporary Italian art, linguistics and the structure of human language, cinema and documentary films, graphic novels, the Mafia....
Portuguese is taught in the Department of Spanish, Portuguese and Latin American Studies at UCL, allowing the study of Portuguese language and culture beyond Europe, with expertise ranging from Renaissance Portugal to Modernist Brazil and Lusophone Africa. Modules will include the study of literature, history and film.
UCL is ranked 3rd in the UK for Modern Languages in the 2018 QS World Rankings and offers outstanding opportunities to language students and graduates.
School of European Languages, Culture and Society
Iberian studies
Iberian studiesItalian studies
Iberian studiesLanguages and area studies
Very few graduates take this subject and so we can't say anything definitively about what graduates go on to do with these degrees - teaching, marketing and the arts and media were the most common jobs for graduates in Portuguese from 2015. That said, modern language grads usually have a range of opportunities available to them, both home and abroad. If you are interested in studying this subject, then it might be a good idea to go on open days and talk to tutors about what you might expect from the course and what previous graduates did.
This is one of the less common modern languages for students to take, but graduates from Italian courses have a lot of options available to them when they complete their degrees. About one in five graduates from 2015 got jobs overseas — often as English teachers — which is much higher than for most subjects, and higher than previous years. Nearly half of the rest went to work in London. Those who want to stay at home to work usually find jobs anywhere where good communication skills are a must — and in 2015, that included education, marketing and finance. But remember — whilst employers say they rate graduates who have more than one language, you need to have them as part of a whole package of good skills.
Russian and Portuguese
4.0 years | Full-time with time abroad | 2021
Swedish and Portuguese
Modern Languages and Translation Studies
Modern Languages with International Film
Italian and Beginners' Portuguese


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De Schmittentunnel is een 5.111m lange stratentunnel in Oostenrijk. De tunnel is gebouwd om het oude centrum van Zell am See te ontlasten van doorgaand autoverkeer. De tunnel bestaat uit één buis met een enkele rijstrook in beide richtingen. De werken aan de tunnel begonnen in 1993 en eindigden in 1996. De bouwkosten werden geschat op 700 miljoen schilling.

De tunnel begint ten zuiden van Zell am See naast het knooppunt van de Pinzgauer Straße (B311 naar Bruck) met de Mittersiller Straße (B168 naar Mittersill en Krimml). Vervolgens loopt hij door de bergflank ten Westen van de Zeller See en het centrum van Zell am See. De tunnel eindigt in de deelgemeente Thumersbach ten Noorden van het centrum. Hier vervolgt de Pinzgauer Straße zijn weg naar onder andere Saalfelden.

De Tunnel heeft één op- en afrit binnenin de tunnel en dat in zuidelijke richting net voor het centrum.

Tunnel in Oostenrijk
Bouwwerk in Salzburg

redpajama_set_name: RedPajamaWikipedia


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Commonwealth Games officials optimistic India will reverse 2022 boycott plans
Amlan Chakraborty
NEW DELHI (Reuters) - The likelihood of India boycotting the 2022 Commonwealth Games in Birmingham due to the absence of shooting as a medal sport appears to be fading, a senior official said on Thursday.
FILE PHOTO: Shooting - Gold Coast 2018 Commonwealth Games - Women's 50m Rifle 3 Positions - Finals - Belmont Shooting Centre - Brisbane, Australia - April 13, 2018. Tejaswini Sawant of India. REUTERS/Eddie Safarik/File Photo
The Indian Olympic Association (IOA) has threatened to boycott the Games as shooting — which supplied 16 of their 66 medals, including seven golds, at last year's Gold Coast Games — was dropped from the Birmingham program as it is an optional sport for host cities.
India finished third in the 2018 medals table but in the absence of shooting, they could slip to anywhere between fifth and eighth place in 2022, according to IOA estimates.
"We are committed to working together for finding a solution to this," Commonwealth Games Federation (CGF) president Louise Martin and IOA president Narinder Batra said in a joint statement after holding talks on Thursday.
"Following our discussions, the CGF are increasingly hopeful that the athletes of India will compete at the Birmingham 2022 Commonwealth Games."
Batra, however, did not announce any climb-down during a news conference with the visiting CGF officials.
"The decision we took for withdrawal, it stands, but we have to update our Executive Board (EB) after this discussion," said the IOA chief who also heads the International Hockey Federation (FIH).
"The discussions were good, our minds are open. You can't move forward if you stop talking to each other. The decision of withdrawal still stands, but let me go to the EB and to our general assembly. That's the process."
CGF chief executive David Grevemberg said the governing body would continue to engage with the IOA.
"With regards to solutions for 2022, what we've agreed now hearing these concerns is to actively work together with India to address and find some solutions," he said.
"This discussion in the past couple of months leading up to Birmingham 2022 has led to a lot of debate and a commitment by the members to review the sports program looking forward."
Reporting by Amlan Chakraborty in New Delhi; editing by Pritha Sarkar


It's spring - woot finally! Despite the snow and cold weather I'm in the mood to celebrate. The felicitations include things like cupcakes, cold Blue Moons laced with orange wedges, and seafood. Does anyone else fantasize about food when the weather changes? Lol I feel like a freak, but I do it every season. At any rate today I have some springy nail art for everyone. I chose to break out my severely underused Sugar Bubbles plates and two new polishes from Essie's Spring 2014 Collection, and created something slightly different from things I've done in the past. I hope you like it!


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Kravany (v minulosti Kravian, ) jsou obec na Slovensku v okrese Trebišov.

Symboly obce
Podle heraldického rejstříku má obec následující symboly, které byly přijaty 4. listopadu 2003. Znak je charakterizován zemědělskými nástroji a současně i zaměstnaneckým motivem, podle historického pečetidla obce z roku 1786.

Znak
V modrém štítě pětizubé hrábě bez středního zubu, překřížené dvěma dvouzubými vidlemi - vše zlaté.

Vlajka
Vlajka má podobu tří podélných pruhů žlutého, modrého, žlutého v poměru 3:2:3. Vlajka má poměr stran 2:3 a ukončena je třemi cípy, t. j. dvěma zástřihy, sahajícími do třetiny jejího listu.

Dějiny
V prvních dvou desetiletích 14. století byly Kravany ve vlastnictví šlechtice Petra, syna Petena, kterému jejich majetek zkonfiskoval král Karel Robert a v roce 1321 daroval šlechticům z rodu Bokša. Tento dokument je nejstarší zachovaný písemný doklad o vesnici Kravany. Obec byla ve 2. světové válce vypálená, po válce byla vesnice obnovena.

Reference

Externí odkazy

Obce v okrese Trebišov
Obce v regionu Dolní Zemplín


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Animal shelter warns of 'lost pet' scam, offers to return missing animal for money
LAKE COUNTY, Fla. - Pet owners who are looking for their lost pets should be extra cautious as a scam is going around.
According to the Lake County Animal Shelter, a scam is going around regarding lost posts.
Missing pet scam
A pet scam is going around where people claim to have found lost pets, then ask people to pay up without actually having found the pet.
They said that the scammer contacts pet owners who have posted on social media or national databases about their lost or missing pets. The scammer then claims to have found the pet and asks for a gift card in exchange for the return of the pet. However, the scammer does not have the pet and is most likely not even local.
Marc Ronco of Howey-in-the-Hills said he was targeted by the scheme after his dog, Daisy, disappeared from his yard Friday night.
"This person that texted me and said, 'I found your dog. I have your dog and I found her in Griffin Park,' which is the park that's in Howey," Ronco said.
Ronco said the texter refused to meet him though and would only send a link to a picture of a Maltese that clearly was not Daisy.
He said the person demanded a reward for 'finding' the animal, but said payment must be made in gift cards.
As he was texting with the person, Ronco arrived at the Lake County Animal Shelter to check for his dog there, and shelter staff, like Ronco, were immediately not buying the claims of the texter.
"I called the first number and said, 'Hey, this is the Lake County Animal Shelter and I'm calling about a pet you recently found,'" said shelter director Whitney Boylston. "They said, 'Yes?' and I said, 'Well, have you recently found a pet?' Click, hung up on me."
"Praying on them in this very desperate time in their lives, it's inexcusable," she said.
The shelter is urging those with lost pets to be careful and cautious. If you have lost a pet, please email the Lake County government at lostandfoundpets@lakecountyfl.gov so they can create a lost pet report for you.
You can also check petharbor.com regularly or visit the shelter in person.


World History and Civilization emphasizes events and developments in the past that greatly affected large numbers of people across broad areas and that significantly influenced peoples and places in subsequent eras. Key events related to people and places as well as transcultural interaction and exchanges are examined in this course. Students are expected to compare and contrast events and developments involving diverse peoples and civilizations in different regions of the world. They examine examples of continuity and change, universality and particularity, and unity and diversity among various peoples and cultures from the past to the present. Students are also expected to practice and process skills of historical thinking and research and apply content knowledge to the practice of thinking and inquiry skills and processes. There will be continuous and pervasive interactions of processes and content, skills and substance, in the teaching and learning of history.
At the high school level, Indiana's academic standards for social studies provide standards for specific courses that focus on one of the five content areas that make up the core of the social studies curriculum: history; government; geography; economics; and Individuals, society and culture (psychology, sociology, and anthropology). One of these content areas is the major focus of the course while the other areas play supporting roles or become completely integrated into the course content. Supporting content areas are indicated in parentheses. Each high school course continues to develop skills for thinking, inquiry and research, and participation in a democratic society.
Students analyze and explain trends and events of global significance, such as world wars, international controversies and challenges, and cross-cultural changes which have influenced our modern world.
Students conduct historical research that incorporates information literacy skills such as forming appropriate research questions; evaluating information by determining accuracy, relevance and comprehensiveness; interpreting a variety of primary and secondary sources; and presenting their findings with documentation.
Students examine the movement toward civilization, including those of North Africa, Southwest Asia, South Asia and East Asia from 8000 to 600 CE.
WH.2.2 Examine the development of Judaism and the civilization of Ancient Israel, including the origins of monotheism, the significance of the Exodus from Egypt, the Hebrew Bible and the Ten Commandments as the source of many moral and ethical traditions of Western civilization.
North Africa, and parts of Europe.
WH.2.6 Trace the changes that culminated in the end of the Republic and the formation of the Roman Empire.
WH.2.8 Analyze the causes, conditions, and consequences of the decline and fall of the western part of the Roman Empire.
WH.3.1 Analyze the impact of trade networks such as the Silk Road and Indian Ocean trade network.
WH.3.2 Explain the rise and achievements of the Byzantine Empire.
WH.3.3 Explain the division between the Eastern and Western branches of Christianity as a result of the Great Schism of 1054.
WH.3.4 Examine the origins, rise, and spread of Islam including the life of Muhammad, and Islam's division into the Sunnis and Shiites..
WH.3.5 Trace the spread of Islam and its impact throughout Southern Europe, Northern Africa and Asia.
WH.3.6 Explain the role of Christianity as a unifying force in medieval Europe.
WH.3.7 Describe the rise and achievements of Charlemagne and the birth of the Holy Roman Empire.
WH.3.8 Analyze the consequences of the fall of the Western Roman Empire and the development of feudalism and manorialism on Europe.
WH.3.9 Explain the cultural, political and religious causes of the Crusades and their consequences for Europe and Southwest Asia, including the growth in power of the monarchies in Europe.
WH.3.10 Describe the improvements in agriculture, the growth of towns, and the commercial revival during the Middle Ages.
WH.3.11 Examine the key achievements of civilizations in Africa prior to European contact.
WH.3.12 Compare and contrast the developments and achievements of the Maya, Aztec and Inca civilizations.
WH.3.13 Explain and understand the achievements of the Tang and Song Dynasties.
WH.3.14 Describe and explain the rise, expansion and decline of the Mongol Empire and its consequences for Eurasian peoples.
WH.3.15 Examine the development of feudalism in Japan and its impact on Japanese society and government.
Students explore the rise of Europe and its consequences for worldwide exploration and colonization—1300 to 1750 CE.
WH.4.1 Trace the origins and developments of the European Renaissance and its impact throughout Western Europe.
WH.4.2 Analyze the factors that led to the rise and spread of the Protestant Reformation, the Catholic Counter-Reformation, as well as reforming movements in other religions, including the wars of religion.
WH.4.3 Discuss the emergence, role, and impact of the citizen in nation-states.
WH.4.4 Explain the causes of the worldwide voyages of exploration.
WH.4.5 Explain consequences of the conquests and colonization as a result of the worldwide voyages of exploration including the transatlantic slave trade, Columbian Exchange, and the effects on native populations in the Americas.
WH.4.6 Examine the growth and development of the European economic system as a result of exploration and the growth of mercantilism.
WH.4.7 Trace the development of the gunpowder empires such as the Ottoman, Mughal, and Ming empires and their reaction to Western interaction.
WH.4.8 Trace the development and impact of absolute monarchies in Europe.
WH.4.9 Describe the progression of events in England that led to constitutional monarchy such as the Magna Carta, the English Civil War, and the Glorious Revolution of 1688.
WH.5.1 Explain the key developments of the Scientific Revolution and its impact on the world.
WH.5.2 Explain the key ideas of the Enlightenment in European history and describe its impact upon political and religious thought and culture in Europe and the Americas including the foundation of American government.
WH.5.3 Examine the key causes, events, and consequences of the French Revolution as well as the rise and fall of Napoleon.
WH.5.4 Trace events, explain the causes, and analyze the outcomes for the Latin American independence movements of the nineteenth century.
WH.5.5 Explain the reasons for the rise of nation-states and the effects of nationalism in Europe, North America and Asia.
WH.5.6 Explain the causes and conditions of the Industrial Revolution in England, Europe, and the United States.
WH.5.7 Examine the economic, social, and political changes caused by the Industrial Revolution and their impact on the development of political and economic theory.
WH.5.8 Analyze the causes and consequences of European imperialism upon the indigenous peoples of Africa, Asia and Oceania.
WH.5.9 Compare and contrast the responses of China and Japan to challenges by Western imperial powers.
WH.6.1 Trace and explain the long-term and immediate causes (including Nationalism, Imperialism, Militarism, and Alliances), major events and global consequences of World War I.
WH.6.2 Explain the causes and consequences of the Russian Revolutions of 1917 and the establishment of the Union of Soviet Socialist Republics.
WH.6.3 Examine the events and developments of the interwar period and their impact on the beginning of WWII including the impact of WWI on society, the Great Depression, and the rise of totalitarianism.
liberators, and perpetrators; and, summarize world responses including the Nuremberg Trials.
WH.6.6 Explain the causes and consequences of the Cold War and describe the role it played in ethnic or nationalistic conflicts in various parts of the world.
WH.6.7 Describe the paths to decolonization and independence from colonial rule in Asia, Africa, and the Middle East.
WH.6.8 Explain the origins of the modern State of Israel.
WH.6.10 Describe and analyze the global expansion of democracy and globalization in the late 20th century.
WH.6.11 Investigate current global issues such as terrorism, genocide, and environmental issues.
WH.7.1 Identify patterns of historical change and duration and construct a representation that illustrates continuity and change.
WH.7.2 Locate and analyze primary sources and secondary sources related to an event or issue of the past.
WH.7.3 Investigate and interpret multiple causation in analyzing historical actions and analyze cause-and-effect relationships.
WH.7.4 Explain issues and problems of the past by analyzing various interests and viewpoints of the participants involved.
WH.7.5 Use technology in the process of conducting historical research and to present products of historical research.
WH.7.6 Formulate and present a position or course of action on an issue by examining the underlying factors contributing to that issue and support that position.


After growing up in the gang lifestyle of the Los Angeles projects, 18-year-old Caine Lawson (Tyrin Turner) wants a way out. Everyone around him, including his unpredictable friend O-Dog (Larenz Tate), is trapped in their lives of crime and violence. With the help of his caring teacher (Charles Dutton) and supportive girlfriend (Jada Pinkett), Caine plans to leave the city for good. But in a series of tragic events, Caine realizes that escape will not be easy.


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Psychologist diagnoses Jessica Jones: Avoidant or Traumatized?
by Mary Ingram, LMFT | May 1, 2018 | Counseling News, Fun, Mental Health, Superhero Diagnoses | 0 comments
WARNING: TV Show Spoilers Included!
Purpose of Therapy:
Ms. Jessica Jones entered my office and threw herself down on the couch, arms crossed in her leather jacket, eyes glaring at the floor. When I welcome her to therapy she says "We can skip the bullshit introductions, okay? You're my 4th shrink; one taught me street signs for my trauma flashbacks, one hypnotized me into remembering more of my trauma, and one was court-mandated to teach me to throw a rubber ball to control the anger resulting from my trauma."
"So what's my job going to be?", I ask.
"My sister set this up because she thinks I have trouble with relationships," she lets out a long sigh. "Probably from my trauma."
After an hour-long interview with this surly woman, I learned that Ms. Jones had been engaging in casual sex for several months, and had abruptly cut off from her sister and former business associate. She spent most of her time drinking and working, which, according to her, "has worked just fine for me so far."
"Then why are you here?" I asked. Her sister had left a message on Ms. Jones' phone and one of my cards outside her door, appointment time written on the back.
Ms. Jones sends a darting, appraising glance my way, then she sighs and says "I met someone. Good guy, with a good kid. I don't want to F this up, if I can help it." She looks down and away from me, embarrassed and defiant.
Process of Therapy:
Working with Jessica Jones was anything but easy; it's hard to count the number of times she angrily shut down, missed sessions, hurled insults at me, or walked out in the middle of our sessions. This happened most often early on, during the phase of the therapeutic relationship when therapist and client are getting to know each other, and when the client is learning whether the therapist is trustworthy, safe, caring. Ms. Jones' behaviors early on are common in clients struggling with a few different things: Bipolar Disorders, Intermittent Explosive Disorder (IED), Post-Traumatic Stress Disorder (PTSD), Borderline Personality Disorder, and insecure attachment issues (leading specifically, in this case, to an Avoidant Attachment Style). Any one could fit, but I had a feeling one was really at the core.
"I don't know why we keep talking about my life; you just see me as a 'disorder' anyways; just fix me and let's be done."
"We both know that's not true, nor how it works. How do you really think I see you?" She aims a defiant stare at me, huffs irritably, and says "I don't know."
"Do you want to know?" I'm asking her to take a risk in our relationship: can she risk emotional vulnerability?
"I could care less what you think of me! Are we done?!" She stands up to leave. She pushes people away, and avoids risking closeness.
"Nope." I wait, smiling, patient, until she hurls herself back on the couch with a groan. I start again.
"Honestly? I see you as a good person, who has been through a TON of trauma…"
"…Yeah but I was still a jerk as a…"
"…kid, yes I know, I was getting to that. Before all the trauma, you were growing up in a family full of sometimes quiet, sometimes explosive, but ever present tension between your parents. You didn't consciously know it at the time, but you found out later they were on the brink of divorce before the car crash that killed your dad and brother. Kids are smart, sometimes too smart for their own good, and I bet you especially so. Do you know how that risk of divorce impacts a kid? How that tension in the household eats away at the kid's sense of stability, of trusting that their parents are okay, and the family is okay, which means everything is okay, including the kid? That all starts to fall apart. So a kid's sense of security in herself and in her world starts to crumble, and she has to find a way to cope with it. Being a "jerk", as you describe it, or being irritable, surly, pushing people away, keeping to yourself, starting to drink, listening to music that matches your sense of pain, anger, isolation…you add to that an excess of horrific trauma, and all of those traits, all of those ways of coping, become intensified. You're trying to cope. To survive. Physically and emotionally. Relationships are difficult because you don't trust people to be available and safe, and maybe you don't feel you deserve them in the first place. So you avoid them, and avoid and deny your need for closeness. That is your attachment style, Avoidant. Nothing is or ever was wrong with you, not even when you were a kid. The people you attached to, who were supposed to give you a sense of safety and security in yourself and in relationships, were too caught up in their own stuff to be able to provide security for you. So you learned to cope by avoiding and pushing away."
Jessica sat in silence, still staring at the ground, but with tears running down her face. "Am I on to something here?" I ask softly, checking in with her. She nods.
Trauma impacts people in different ways, ways that can be isolating, tragic, destructive, and compelling, eliciting from others the compassion for human suffering that each of us holds. Part of what makes the story of Jessica Jones so compelling, however, is not that her story is so tragic, her powers so extraordinary, or her reactions so dramatic.
While all of the above are true, what really draws people in is how human she is. How relatable it is to yearn to be loved and valued, but feel fearful of being rejected or abandoned. Every person has felt that at some point or another, in big ways or small, and every person has a different way of responding to either seek reassurance or protect themselves.
Every therapist (and most clients who have had good experiences in therapy) know that the key to improvement isn't JUST about the therapist's knowledge or JUST about the client's diligence; the real key for a client's success in therapy is the sense of safety and care within the therapeutic relationship. A relationship where they can feel accepted, even in their worst, most shameful or vulnerable moments. For people like Jessica, sometimes the hardest work to do is to walk in the door. From there, both client and therapist have to work, take risks, stretch themselves, to forge a trusting, safe relationship, a secure attachment, from which real growth and change can begin.
By Mary Ingram, LMFT of Thriveworks Philadephia
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Home » Counseling News » Psychologist diagnoses Jessica Jones: Avoidant or Traumatized?


1 Response to Do antidepressants work?
I have often asked myself this question. Never out loud and never where the voices in my head can hear me but I have asked it. The reply is always the same, if standing on your head in the dark at midnight every night for exactly three minutes worked to alleviate even some of the depression do it.


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Q: what new features come with a multidimensional database with SSAS 2017? I cant find anything on what new features come out with SSAS 2017 for a multidimensional database. the only thing i can find is updates with the Tabular.
any insight would be appreciated.

A: SSAS 2017 is primarily focused on new tabular features. There is a new compatibility level for tabular (1400) but no new compatibility level for multidimensional.
There are several discontinued and deprecated features, mainly for the multidimensional mode, and the default mode when installing is tabular now.

redpajama_set_name: RedPajamaStackExchange


President Donald Trump and the Trump Corporation filed suit Monday against House Democrats, led by House Oversight Committee Chairman Elijah Cummings (D-MD), to prevent the committee from issuing subpoenas seeking the President's financial records, both from his companies, and from an accounting firm hired to handle Trump finances.
This is likely the first of dozens of legal battles between Trump, his companies, and House Democrats. So far, the Dems have at least 85 separate investigation targets listed on their agenda, and that doesn't count their adjacent investigations into various Trump Administration endeavors or "potential Trump investigations" that might result from future appointments and policy decisions.
The post President Trump SUES House Democrats To Halt Demands For His Financial Records appeared first on Conservative Fighters.


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Impact-Driven Philanthropy
our grantmaking process
The Raikes Foundation makes grants in three core program areas: Education, Youth Homelessness, and Impact-Driven Philanthropy. We also make a limited number of community grants and grants for special projects. Proposals are by invitation only. We make the majority of our grants to organizations we have identified. We do not accept unsolicited proposals.
To be eligible for a grant, applicants must be classified as tax-exempt under section 501(c)(3) of the Internal Revenue Code and as public charities under section 509(a)(1), (2) or (3) of the Code. Public organizations designated under section 170(c) of the Code are also eligible. The Raikes Foundation does not make grants to individuals or to organizations outside the United States.
The Raikes Foundation does not fund: individuals; organizations that discriminate on the basis of age, race, national origin or citizenship, ethnicity, gender, disability, sexual orientation, political affiliation or religious belief; or religious purposes unless grant activities address the needs of the wider community without regard to religious beliefs.
"Even if our grants and strategies don't fully succeed, we only fail if we don't learn. "
– Jeff Raikes
List of Grants
Search Grants by Strategy
- Any -Community GivingEducationYouth HomelessnessExpanded Learning OpportunitiesSpecial InitiativesImpact Driven Philanthropy
Alliance for a Green Revolution in Africa General Operating Support 08/31/17 $1,000,000.00 Community Giving
Alliance for a Green Revolution in Africa General Operating Support 11/08/18 $10,000.00 Community Giving
Alliance For Education Alliance for Education/African American Male Achievement Program Seattle Public School Partnership 12/18/18 $14,500.00 Community Giving
American Bar Association Fund for Justice and Education Improving Under 18 Homeless Youth System Coordination – Lifting up Mainstream System Partners to End Youth Homelessness 08/24/18 $65,000.00 Youth Homelessness
American Bar Association Fund for Justice and Education National Homeless Youth Legal Network, Publication and Convening 12/01/17 $25,000.00 Youth Homelessness
American Civil Liberties Union Foundation Inc. General Operating Support 09/14/18 $50,000.00 Community Giving
American Enterprise Institute for Public Policy Research Elevating Completion: Research Paper Series & Convenings 09/28/17 $270,900.00 Education
Americas Promise-The Alliance For Youth "Education Leads Home" SXSW EDU Conference Campaign Launch 12/21/17 $12,500.00 Youth Homelessness
Americas Promise-The Alliance For Youth The State of Young People National Summit Sponsorship 04/05/19 $25,000.00 Education
Americas Promise-The Alliance For Youth Communication's Campaign to Advance Social, Emotional & Academic Development (SEAD) 05/01/19 $250,000.00 Education
Ashland Greenwood Public Schools Foundation General Operating Support 09/14/18 $2,500.00 Community Giving
Ashland Greenwood Public Schools Foundation Distinguished Teaching Award 05/04/18 $12,500.00 Community Giving
Association of Black Foundation Executives Inc. General Operating Support and Annual Membership 02/01/19 $2,500.00 Community Giving
Association of Public and Land-Grant Universities Research/Practice Partnership to Advance Equitable Learning Environments 12/22/17 $2,650,000.00 Education
Association of Public and Land-Grant Universities Plan to Develop a Research/Practice Partnership to Advance Equitable Learning Environments 08/29/17 $25,000.00 Education
Association of Public and Land-Grant Universities General Operating Support 12/01/17 $13,000.00 Education
Baseball Beyond Borders General Operating Support 02/10/17 $1,000.00 Community Giving
Bassuk Center on Homeless and Vulnerable Children & Youth Inc. Racial Equity and Homelessness Summit 12/21/17 $4,000.00 Youth Homelessness
Bassuk Center on Homeless and Vulnerable Children & Youth Inc. Racial Equity and Homelessness Summit 11/01/17 $25,000.00 Youth Homelessness
Bellwether Education Partners, Inc. CASEL's Diversity, Equity and Inclusion Field Facilitation and Assessment 10/08/18 $500.00 Education
Bellwether Education Partners, Inc. Diversity, Equity and Inclusion Field Facilitation and Assessment 04/26/19 $1,000.00 Education
Bishop Blanchet High School General Operating Support 08/21/19 $2,500.00 Community Giving
Boys and Girls Club of America (Atlanta) General Operating Support 11/02/18 $40,000.00 Expanded Learning Opportunities
Boys and Girls Club of America (New York) General Operating Support 10/27/17 $25,000.00 Community Giving
Boys and Girls Club of America (South Puget Sound) Teen Center Renovation Capital Campaign 08/24/18 $20,000.00 Community Giving
Building Changes Equity Training Participation 10/06/17 $4,100.00 Youth Homelessness
Building Changes Schoolhouse Washington (2020) 11/25/19 $428,000.00 Youth Homelessness
Building Changes Understanding and Addressing Barriers to Academic Success for Students of Color Experiencing Homelessness 12/11/17 $80,500.00 Youth Homelessness
Building Changes General Operating Support (Schoolhouse Washington) 08/09/19 $500.00 Youth Homelessness
Californians for Justice Fund Inc. General Operating Support 11/25/19 $650.00 Education
Campion Advocacy Fund Regional Homelessness Action Plan Communications 09/23/19 $80,000.00 Regional Homelessness
Candid IDPC Travel Stipend 2018 12/18/18 $1,000.00 IDPI 1 - Strengthen the Ecosystem of Donor Support
Carnegie Foundation For Advancement Teaching W Coast Office Education 2018 Summit on Improvement in Education 11/10/17 $15,000.00 Education
Cascade Public Media KCTS 9 General Operating Support 12/14/18 $2,500.00 Community Giving
Cascade Public Media General Operating Support (KCTS 9) 07/12/19 $2,500.00 Community Giving
Catalist Women General Operating Support 08/05/19 $100,000.00 Impact Driven Philanthropy
Center for Effective Philanthropy General Operating Support 09/10/18 $100,000.00 IDPI 1 - Strengthen the Ecosystem of Donor Support
Center on Budget Policy and Priorities General Operating Support 10/11/19 $1,050.00 Education
Chapin Hall Center for Children Voices of Youth Count Conference 08/16/18 $25,000.00 Youth Homelessness
Chapin Hall Center for Children No More Missed Opportunities: The Youth Homelessness Prevention Initiative 12/16/19 $250,000.00 Youth Homelessness
- Grant data provided in the table above reflects grants within the past three years.
- Grant data provided contains a blend of funding directly from the Raikes Foundation and/or through a Raikes Foundation Donor Advised Fund.
info@raikesfoundation.org
2157 N. Northlake Way #220 Seattle, WA 98103
Careers Reports and Filings


There are several methods to manage a website in different languages. We will list the possibilities and pick up the optimal ones to get working efficiently.
From my own experience, I've been using different plugins and different ways of providing translations to a website.
After adding credits, you can get back to your wordpress website under WPML activate the Gengo plugin and fill in the public and private keys.
It should work smoothly and your website is ready !
Go to your WPML translation management section and select the pages to translate.
Click on the Add to basket button and check the basket tab in order to access the Send to Gengo button.
Depending on the number of pages/articles it might take some time to upload into your Gengo account.
Once this step is done, you can check the status of your order under the tab : Current translation jobs.
That image shows the different sections of the page using Visual Composer.
Note on Gengo and others : a few bugs may occur if you are using Visual composer and other similar plugins, duplicates of sections can increase the price of your translations. In that case either contact Gengo or use a different system. If the cost is important to you, you would rather use a direct translator via freelancer.com and other networks.
The above image shows you the new translator called assistant, the screen-shot is in French but you can easily guess the meaning, do you ?
Now click on the Translate button and follow the instructions to add your translated text. You will see each fields to translate and you must click on a button to copy the original text inside a new textbox where the translation occurs.
Once this is done at 100%, you click on the button at the bottom to save the changes. A new page/post will be available in the corresponding language and depending on the way you configure your theme, a new link will be available to tell visitors about the new content in their preferred language.
For menus and footers there is a page where you can verify the status with WPML, open up the menu under WPML and Synchronize WP Menus.
It should appear on your translated pages.
Repeat the steps for all your menus.
That's it for now about WPML, any updates will be inserted right on this page. Working with WPML is quite nice as it allows the user to save time compared to any other plugins, we've tried to use Qtranslate which is a good one but when it comes to integrate with Visual Composer and other page builders, there is a serious advantage with the professional solution. Remember saving time is like saving money so think twice before going with one another solution.
Does a website in French perform as much as if it were in English ?
In other words, the same design, structure and appeal will generally be of different impact depending on the type of visitors so finally you would rather use different domains if not different names for your website in English version and in French (or any languages).
The services/products your are selling, the information you are giving away, the category of your content… all of these must be taken in consideration before you decide to go with one translation schema !
We hope this article has helped you and we welcome any type of constructive comments!


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October's final deadlines include contests in poetry, fiction, and nonfiction awarding publication to the winning book or chapbook. Each of these contests has a deadline of October 31 and offers a prize of $1,000 or more in addition to publication. Good luck, writers!
American Poetry Review Honickman First Book Prize: A prize of $3,000 and publication by American Poetry Review is given annually for a first poetry collection. The winning book is distributed by Copper Canyon Press through Consortium. Li-Young Lee will judge. Entry fee: $25.
Cloudbank Books Vern Rutsala Book Prize: A prize of $1,000 and publication by Cloudbank Books is given annually for a collection of poetry, flash fiction, or a combination of the two. Holly Karapetkova will judge. Entry fee: $25.
Comstock Review Jessie Bryce Niles Poetry Chapbook Contest: A prize of $1,000, publication by the Comstock Writers Group, and 50 author copies is given biennially for a poetry chapbook. Kathleen Bryce Niles-Overton will judge. Entry fee: $30.
Finishing Line Press Open Chapbook Competition: A prize of $1,000 and publication by Finishing Line Press is given annually for a poetry chapbook. All entries are considered for publication. Entry fee: $15.
Indiana Review Blue Light Books Prize: A prize of $2,000 and publication by Indiana University Press is given in alternating years for a collection of poetry or a collection of short fiction. The 2020 prize will be awarded in short fiction. The winner will also receive travel expenses to read at the 2020 Blue Light Reading in Bloomington, Indiana. Entry fee: $20.
Omnidawn Publishing Fabulist Fiction Chapbook Contest: A prize of $1,000, publication by Omnidawn Publishing, and 100 author copies is given annually for a work of fabulist fiction. Kellie Wells will judge. Entry fee: $18.
River Teeth Literary Nonfiction Prize: A prize of $1,000 and publication by University of New Mexico Press is given annually for a book of creative nonfiction. Bret Lott will judge. Entry fee: $27.
Persea Books: A prize of $1,000 and publication by Persea Books is given annually for a first poetry collection by a woman who is a U.S. citizen or permanent resident. The winner also receives a six-week, all-expenses-paid residency at the Civitella Ranieri Center in Umbria, Italy. Entry fee: $30.
Tupelo Press Sunken Garden Chapbook Prize: A prize of $1,000, publication by Tupelo Press, and 25 author copies is given annually for a poetry chapbook. Entry fee: $25.