Friday, July 31, 2009
Sunday, July 5, 2009
Bleeding Disorders May Cause Menorrhagia and Postpartum Hemorrhage
"In those women who do have a bleeding disorder such as von Willebrand disease (VWD), there is an increased incidence of pathologic bleeding....The lack of a clinical tool for the objective assessment of abnormal reproductive tract bleeding and the lack of awareness of the potential of bleeding disorders to exacerbate or even cause abnormal bleeding leads to the underdiagnosis and suboptimal treatment of women with bleeding disorders."
Although menorrhagia or postpartum hemorrhage may result in considerable, clinically significant blood loss, congenital bleeding disorders exacerbating these conditions historically tend to be underdiagnosed, presumably because of lower awareness among obstetricians and gynecologists vs hematologists.
Clues suggesting the possibility of an underlying bleeding disorder include a family or personal history of bleeding events. Recognizing these clues should improve collaboration among obstetrician-gynecologists and hematologists, reduce diagnosis of "idiopathic" menorrhagia, and result in better management of reproductive tract bleeding events. Women who have these conditions should thereby have improved quality of life and school and work performance indicators.
Questions and Answers Addressed
1. What is menorrhagia?
Although menorrhagia is typically defined as more than 80 mL of blood loss per menstrual cycle, other indicative features are soaking through a pad or tampon within 1 hour, soaking through bed clothes, below normal ferritin levels, anemia, and pictorial blood assessment chart score of more than 100.
2. When should a gynecologist or obstetrician suspect a bleeding disorder and pursue a diagnosis?
Indicators suggesting an underlying bleeding disorder include menorrhagia since menarche, a family history of a bleeding disorder, or failed response to conventional management of menorrhagia.
Other indicators are a personal history of 1 or more of the following: epistaxis; notable bruising without injury; minor wound bleeding; bleeding of oral cavity or gastrointestinal tract without an obvious anatomic lesion; prolonged or excessive bleeding after dental extraction; unexpected postsurgical bleeding; hemorrhage from ovarian cysts or corpus luteum; hemorrhage requiring blood transfusion; and PPH, especially delayed PPH.
Even in the presence of gynecologic disease such as uterine fibroids, a bleeding disorder may contribute to menorrhagia.
3. What hematologic evaluations should be ordered, and when should they be repeated?
Platelet number and function and specific coagulation factor profile should be evaluated in consultation with a hematologist. Other tests should include complete blood cell count, activated partial thromboplastin time, prothrombin time, VW factor (VWF) measured with ristocetin cofactor activity and antigen, coagulation factor VIII, and fibrinogen.
If results of these tests are normal, women should undergo testing of platelet aggregation and platelet release. Although testing should not be delayed to coincide with menstruation, subsequent testing during menses should be considered if the first set of VWF levels is at the lower limit of normal.
Hormonal contraception should not be interrupted to permit testing.
4. How should menorrhagia be managed in women with bleeding disorders?
Tranexamic acid (1 - 1.5 g, 3 - 4 times/day) may be given before hematologic testing, although management is optimally started once the diagnosis is made. Nonsteroidal anti-inflammatory drugs should be avoided. Further management strategies differ based on whether future fertility and/or becoming pregnant soon are desired. A combination of therapies is often needed, and consultation with a hematologist is essential. Hemostatic treatment should start on the first or second day of menses.
5. How can PPH be prevented in women with bleeding disorders?
Hematology consultation and collaborative care are recommended. VWF levels should be determined. If the coagulation factor profile is not in the normal range by the third trimester, delivery should take place at a specialized center. If third-trimester VWF levels are 50 IU/dL or more, epidural analgesia/anesthesia may be considered safe for delivery; otherwise, appropriate hemostatic cover is required. Adequate venous access is needed during labor, and the third stage of labor should be actively managed.
6. What do we know about menorrhagia and RBDs?
Tranexamic acid and aminocaproic acid or desmopressin (DDAVP) is useful for the treatment of menorrhagia in combined factor V or factor VIII deficiency, but additional research is needed to determine its role in other RBDs. Patients should be treated with antifibrinolytic treatment and appropriate factor replacement when available.
"An awareness of bleeding disorders (such as VWD, RBDs, and platelet disorders) is an important asset for obstetricians and gynecologists," the consensus authors write. "These disorders remain underdiagnosed in women with menorrhagia and potentially in other cases of abnormal bleeding (such as PPH)....The authors of this consensus believe that these recommendations will aid obstetricians and gynecologists to better anticipate, prepare for, and manage cases of abnormal reproductive tract bleeding in women with bleeding disorders."
Clinical Context
RBDs are inherited autosomally, with prevalence ranging from 1 in 2 million for factor II and factor XIII deficiencies to 1 in 500,000 for factor XI and factor VII deficiencies. The number affected by RBDs around the world has reached approximately 7000, with the most common being factor XI deficiency. VWD affects menstruation and childbirth and may lead to unacceptable blood loss. Because of menses and childbirth, VWD is more likely to present in women vs men, although the prevalence is similar between the sexes.
This is a consensus panel review constructed by obstetricians and gynecologists with hematologists based on a 2007 meeting of the literature on VWD in women focusing on presentation, diagnosis, and treatment strategies.
Clinical Implications
• The prevalence of VWD in adult women with menorrhagia is 13%, increasing to 33% in adolescents, and diagnosis is made by assessing risk factors and performing hematologic evaluation.
• In women with VWD who desire fertility, medical management is recommended, and VWF level should be at least 50 IU/dL to prevent PPH.
Evidence-Based Catheter-Care Procedures May Reduce Bloodstream Infection Rate
Evidence-based catheter-care procedures regarding hand hygiene may significantly reduce the rate of catheter-related bloodstream infections (CRBSIs),
"...CRBSI are a well recognized problem in the intensive care unit (ICU)," write Walter Zingg, MD, from the University Hospitals of Geneva in Geneva, Switzerland, and colleagues. "A recent study, in the neonatal setting, found hand hygiene successful as a single intervention measure in reducing CRBSI when its promotion was guided by healthcare workers' perceptions and combined with organization at the workplace. On the basis of high incidence rates of CRBSI in previous surveys of the ICUs in our institution, we decided to conduct an interventional study using an educational campaign focusing on hand hygiene and catheter care."
"Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention," the study authors write. "Infection control efforts to improve the quality of hand hygiene and catheter care are essential elements for patient safety, not only for the reduction of CRBSI but also for other health care-associated infections."
Clinical Context
Risk factors for CRBSIs include long duration of CVC use, insertion site other than subclavian, overmanipulation of the CVC system, and heavy cutaneous colonization, as well as patient factors of illness severity and immunodeficiency. Strategies such as handwashing and the use of CVCs coated with antimicrobials have been examined as methods to reduce CRBSIs.
This is a study of the effect of an educational intervention on hand hygiene practice in ICUs and its impact on CRBSI rates and predictors of CRBSIs among patients in the ICU.
Clinical Implications
• Predictors of risk for CRBSIs in ICUs are hospitalization in a medical ICU, male sex, and baseline period.
• An educational intervention for ICU nurses and medical staff is associated with improved hand hygiene and reduced CRBSI rates.
Screening at 2 Months Identifies Most Women With Postpartum Depression
Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.
No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
The purpose of the study was to assess the feasibility of using electronically generated reminders to detect and refer at-risk women and to look at the prevalence and incidence of maternal depression assessed at well-child visits during the first 6 months after birth.
The study included 204 mothers and 413 electronic depression–screening cues. These prompts appeared automatically when the medical records of children 0 to 6 months old were opened and reminded medical staff to administer the 10-item Edinburgh Postpartum Depression Scale (EPDS) to new mothers.
Providers were unable to close the children's medical records until they had entered the EPDS score or 1 of the precoded reasons for not administering the EPDS.
An EPDS of 10 or greater was considered a positive result, and providers could not close the medical record until a management plan or referral was recorded.
The providers administered the EPDS 98% of the time and always referred mothers with positive scores. Overall, 20.1% of the women who completed the EPDS at 2 weeks, 2 months, 4 months, or 6 months had positive scores.
EPDS scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.
Screening Before 2 Months Not Useful The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months. However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
If women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.
Clinical ContextAll new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
This is a study of a screening program using electronic cues to providers of well-child visits in a pediatric clinic to examine the efficacy of the cue on screening for postpartum depression and the prevalence of postpartum depression in adolescent new mothers in the first 6 months after delivery.
Study Highlights
• The Colorado Adolescent Maternity Program is a comprehensive prenatal delivery and postnatal care program for 12- to 21-year-old mothers in 1 US state located in an urban hospital, serving a low-income population.
• Providers of well-child care were a pediatrician and 2 mid-level providers with training in adolescent medicine.
• An electronic medical record system is used for practice improvement, and all child health records were flagged electronically with prompts to providers to administer the EPDS to mothers of children at well-child visits.
• The EPDS is a 10-item validated and reliable scale with a score of 10 or higher reliably identifying 90% of cases in other studies.
• Responses were on a 4-point scale with a score range from 0 to 30, with higher scores indicating higher depressive symptoms.
• Mothers were given a pencil-and-paper version of the EPDS to complete while waiting for their child to be seen.
• Providers collected and scored the EPDS forms, discussed results with mothers, and recorded the scores in the children's electronic medical records.
• After 5 months, providers were unable to close the children's electronic records unless they had administered the EPDS at least once or given a reason why it was not administered.
• During the study period, providers saw 418 electronic screening cues for the EPDS associated with 204 mothers.
• In 5 cases, mothers were not with the child; of the remaining cues, providers responded to 99%.
• None of the mothers refused to complete the EPDS.
• Mean age of mothers was 18 years, 36% were black and 44% were Hispanic, 87% were Medicaid recipients, mean parity was 1.4, and 51% were living with a biological parent.
• Overall, 20.1% of mothers who completed the EPDS at 2 weeks and at 2, 4, and 6-month well-child visits met the referral criteria of a score of 10 or higher on the EPDS.
• The prevalence of depressive symptoms ranged from 17.0% at 2 weeks to 16.5% at 2 months to 10.3% at 4 months and 18.5% at 6 months.
• Although the prevalence was highest at the 2-week visit, this was the least reliable measurement because only 12% of mothers met depression referral criteria at 2 visits, and 8% resolved the symptoms at the following visit.
• The incidence of depressive symptoms decreased from 16.5% at 2 months to 5.7% at 4 months and 1.9% at 6 months, with only 2 cases that would have been missed if the mothers had been screened only once.
• 94.5% of the mothers who met the referral criteria did so at the first screening.
• The authors recommended that screening at 2 months identifies most mothers who develop postpartum depression and that screening at 6 months was preferable to screening at 4 months.
• Of 40 mothers who met referral criterion, 8.6% were 22 years or older.
• They were referred for further evaluation and treatment.
• The authors concluded that screening of mothers at the well-child visit in the first 6 months was feasible and was associated with an accurate diagnosis of postpartum depressive symptoms.
Clinical Implications
• Use of an electronic cue to providers for screening for postpartum depression using the EPDS in mothers at well-child visits is associated with high compliance by providers and mothers.
• The EPDS used at the well-child visit at 2 and 6 months is helpful for diagnosing depressive symptoms in new mothers.
Saturday, June 27, 2009
Auto Insurance
Depending on the type of coverage you buy, auto insurance pays to fix your car if you’re in an accident, pays the medical costs of anyone you injure in an accident, and pays to repair other vehicles or property. The liability portion of your auto insurance policy covers you if you are found liable for causing injury or damage with your vehicle.
The six basic types of auto insurance coverage, according to the Insurance Information Institute are:
• Bodily injury liability -- covers injuries to other people.
• Medical payments, or personal injury protection (PIP) coverage -- covers injuries to yourself and your passengers. Sometimes lost wages and funeral costs also are paid by this type of auto insurance coverage.
• Property damage liability -- covers damage to other people’s property.
• Collision -- covers damage to your car from hitting another car or an inanimate object, or as a result rolling over. It even covers damage to your car from potholes.
• Comprehensive -- the catch-all auto insurance coverage for damage from hailstones, earthquakes, vandalism, theft or anything other than what’s covered under collision coverage.
• Uninsured and underinsured motorist coverage -- reimburses you if the other driver doesn’t have auto insurance, or doesn’t have enough to cover your expenses.
Your auto insurance generally covers you as well as someone driving your car with your permission.
Most states require drivers to carry liability insurance. Liability coverage represents about half of most auto insurance premiums, according to ComparisonMarket.com, an online insurance comparison site.
Some auto lenders also require that owners carry auto insurance, and auto lease companies almost always require anyone who wants to lease a car to carry auto insurance with set levels of minimum coverage.
Several states have no-fault insurance laws, meaning that your auto insurance provider pays for your damages even if another driver is at fault. You can still sue for non-economic damages such as pain and suffering in all of these states.
Regardless of what coverage you get, experts recommend comparison shopping to find the best auto insurance deal for you. Several online sites give you access to multiple insurance quotes. You may be able to get a good deal by buying auto insurance from your homeowners or renters insurance provider
Structured Settlement Payment
Structured settlement payments are used more frequently these days because they offer substantial benefits to all parties involved in the structured settlement agreement. Victims receive tax-free payments and defendants get an end to litigation as the result of reaching a structured settlement agreement
How to Sell Structured Settlement Payments
Many people who receive monthly annuity payments under a settlement agreement do not realize they can sell all or a portion of their stream of annuity payments in exchange for a cash lump sum. Getting paid this money can be a way to help fund the current life needs of your family. Receiving the cash now rather than waiting a period of a year or more for a stream of inflexible payments structured in the future can be a big advantage to some people. Factoring is the name of the process of selling ones legal right to receiving future structured payments in exchange for a the present value of that money. This sale becomes a legal contract with the settlement company.
Companies now offer to pay for your rights to receive future annuity payments under structured agreements. The settlement companies offer annuitants the benefit of direct access to cash.
student loan consolidation interest rate
Federal student loans will have different rates depending on type and disbursement dates. For example, rates for Stafford loan disbursed before July 1, 2006 will remain variable until consolidated. Visit StaffordLoan.com or ParentPLUSLoan.com for more details on federal student loan interest rates.
Private Student Loan Consolidation Rates
Private student loan consolidation interest rates are variable, based on either the LIBOR (London Interbank Offered Rate) or the Prime rate, plus a margin for borrower and/or co-signer credit.
Origination fees can range between 1% and 5% depending upon your individual credit or the credit of a co-signer. Any fees that associated with the loan are capitalized (added to the loan) typically at the time repayment begins, which increases the amount borrowed but avoids any out-of-pocket expenses at loan closing.
View interest rate example for graduate private loan consolidation.
Free Non-Student Loan Debt Consultation
Do you have more debt outside of student loans? Please request a free debt consultation today. Consolidate your debt into one lower payment, avoid bankruptcy, and be debt free in as little as 12-48 months.
Friday, June 26, 2009
Houston Criminal Defense Lawyer
Copper Repiping
Copper repiping is a process of refitting existing pipes in a dwelling or business. Most structures built 25 or more years ago were fitted with iron pipes coated with zinc, normally called galvanized pipes. As the galvanized pipes age, the zinc lining tends to erode allowing rust to form. Once galvanized pipes begin to deteriorate, they need to be replaced. Most people prefer to replace galvanized pipes with copper pipes, in a process referred to as copper repiping.
A water system is composed of two measurable parts: pressure and volume. The pressure is measured as pounds per square inch (p.s.i.). Water pressure represents the force with which the water passes through the pipes and out of your faucets. Water volume represents the amount of water that can flow through your pipes and out through the faucets in a given period of time.
Homeowners usually decide to initiate copper repiping when they begin to see a dramatic drop in water pressure. Decreased water pressure is often very annoying; washing machines fill up more slowly, and garden hoses have a much weaker spray. Perhaps the most evident result of low water pressure is in the shower - instead of a forceful stream, the bather only experiences a dissatisfying trickle of water.
Other ways you know it is time for copper repiping is when the tap water appears discolored due to rust, when a foul odor comes from the tap, or when pipes begin to leak. Plumbers can come into the home and test to see if the problems are being caused by eroding pipes, and make recommendations whether it is time for copper repiping.
Copper is the preferred material for interior pipes because it is lightweight, safe and durable, and does not rust. Because it is also flexible, meaning that plumbers can easily bend and form it within existing walls, it is ideal for repiping.
Wednesday, June 24, 2009
Give Blood Pressure Drugs to All
Blood-pressure-lowering drugs should be offered to everyone, regardless of their blood pressure level, as a safeguard against coronary heart disease and stroke, researchers who conducted a meta-analysis of 147 randomized trials (comprising 958,000 people) conclude in the May 19 issue of BMJ. “Guidelines on the use of blood-pressure-lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure,” write Drs Malcolm R Law and Nicholas Wald (Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine, Queen Mary University of London, UK). “Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.” “Whatever your blood pressure, you benefit from lowering it further,” Law told heartwire . “Everyone benefits from taking blood-pressure-lowering drugs. There is no one who does not benefit because their blood pressure is so-called normal.”
Six years ago, Law and Wald advocated the use of a polypill--containing a statin, three blood-pressure-lowering drugs (each at half the standard dose), folic acid, and aspirin--which they maintained could prevent heart attacks and stroke if taken by everyone 55 years and older and by everyone with existing cardiovascular disease.
In the current meta-analysis, which included people aged 60 to 69, they singled out blood-pressure-lowering drugs to determine the quantitative efficacy of different classes of antihypertensive agents in preventing coronary heart disease (CHD) and stroke. They also sought to determine who should receive treatment.
All Antihypertensives Prevent CHD and Stroke
Overall, the results of the meta-analysis showed that in people aged 60 to 69 with a diastolic blood pressure before treatment of 90 mm Hg or a systolic blood pressure of 150 mm Hg, three drugs at half standard dose in combination (as in the polypill) reduced the risk of CHD by approximately 46% and of stroke by 62%. However, when used individually, a single antihypertensive agent at standard dose had about half this effect.
The five main classes of blood-pressure-lowering drugs--thiazides, beta blockers, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, and calcium-channel blockers--were similarly effective in preventing CHD events and strokes, with the exception of calcium-channel blockers, which had a greater preventive effect on stroke than the other four agents (relative risk, 0.92; 95% confidence interval, 0.85 to 0.98).
People with and without cardiovascular disease derived equal benefit, with similar percentage reductions in CHD events and stroke, and regardless of what their blood pressure was before treatment. Even patients with blood pressures considered to be low--110 mm Hg systolic and 70 mm Hg diastolic--showed fewer CHD events and a reduced incidence of stroke when taking an antihypertensive.
Law and Wald also report that calcium-channel blockers reduced the incidence of heart failure by 19%, and that the other antihypertensive agents reduced heart failure by 24%.
In an accompanying editorial, Dr Richard McManus (University of Birmingham, UK) and Dr Jonathan Mant (University of Cambridge, UK) write that the findings of Law and Wald will contribute to debate on the management of hypertension in several areas. “Taken at face value, these findings provide tacit support for the use of a ‘polypill’ to lower the risk of cardiovascular disease in people likely to be at high risk (such as all people over the age of 55) without first checking their blood pressure.”
In a comment to heartwire , McManus added that he believes that the findings reinforce the view that treatment to lower blood pressure should be offered on the basis of risk, regardless of blood pressure.
Throwing the Baby Out With the Bath Water
On the other side of the Atlantic, hypertension experts were not so sanguine in their opinion of Law and Wald’s conclusions.
Commenting on this study for heartwire , Dr James Elliott (Rush Medical College, Chicago, IL) said he took issue with the authors’ suggestion that the measuring of blood pressure was unnecessary.
“Professors Wald and Law made the revolutionary comment some years ago that we should abandon blood pressure and simply treat everyone at high CVD risk with their magic polypill, which they claimed reduced heart disease and stroke by 90%.This meta-analysis is an unusual compilation of data that supports that hypothesis.”
Abandoning blood pressure measuring is like throwing the baby out with the bath water, Elliott said.
Elliott also took issue with the meta-analysis, which he called “old-fashioned.”
“I think Wald and Law have become the ultimate lumpers. They have included the 37 studies where beta blockers were used against placebo in people with heart attacks, and they have lumped those in with all the other kinds of therapies that we use to lower blood pressure and prevent other events. Nobody, as far as I can remember, has ever included that set of 37 trials in with the other antihypertensive trials because it represents such a different population. They have done the old-fashioned, simple meta-analysis. But there are better ways to understand the data.”
A Meta-Analysis Is Like a Sausage
Adding his opinion, Dr Franz Messerli (St Luke’s-Roosevelt Hospital Center, New York City) said that by including 147 trials in their meta-analysis, the authors had to make numerous assumptions, “some possibly valid, others clearly not.”
Because the “blood pressure fall was not reported in patients with a history of coronary heart disease, they estimated this fall from a meta-analysis of blood pressure trials. This is clearly inappropriate since the fall in blood pressure depends on the pretreatment level, and patients with coronary heart disease who often are hypotensive (particularly post MI) will not respond the same way as do patients with hypertension,” he told heartwire.
It is little surprise that beta blockers now, all of a sudden, look better than in any other review ever done, Messerli added. “Numerous meta-analyses have clearly demonstrated that beta blockers do not reduce the risk of coronary heart disease in hypertension, despite the fact that they lower blood pressure. Thus, despite its appearance of being bigger and better, this study is yet another example of my dictum: A meta-analysis is like a sausage, only God and the butcher know what goes in it and neither would ever eat any.”
Top Tips for Cheaper Home Insurance
Reduce your premium by implementing effective security measures and reduce your risk of making a claim.
•Change the locks – If you’ve moved to a new home you never know who might still have a key. It is important to maintain locks. Five-lever mortise locks are recommended for external doors while windows should ideally have two bolt locks.
•Install a good home security system - Sometimes there are alarm systems that might be preferred by an insurer. The NACOSS standard alarm can cut premiums with some companies by 7.5%.
•Time-switch lights – Your home is more vulnerable to theft when you are not around. Time-switch lights will give the impression that you are at home.
•If you are away – Remember to cancel newspaper and milk deliveries and ask someone you can trust to open and close the curtains and collect mail.
•Keys – Don’t leave them in obvious places such as under a doormat. Also beware of ‘hook n crook’ thefts – where keys are left so close to a door that a burglar can simply hook them through a letterbox and open the door.
•Install security lighting – illuminate your visitors for their safety as well as your own. Unwelcome visitors are less likely to loiter if they’re ‘in the spotlight’.
•Join a neighbourhood watch campaign – this can help to reduce your premium if you inform the home insurance company of your participation in a scheme. It can reduce your premiums by up to 5%.
•Avoid frozen and burst pipes – If you think pipes are frozen, turn off water at the valve and header tank to cut down the water that can escape.
•Look out for subsidence – One of the most common problems to affect the home but usually covered in your building insurance policy. Look to see the excess level on subsidence and if your garden walls are covered.
•Fire – Fit a smoke alarm and take simple steps to avoid accidents. Most fires in the home are caused by smoking or cooking; never smoke in bed, don’t leave cigarettes lying around and don’t leave cooking unattended. Other fire tips include closing doors at night to contain fires, check the home is safe before going to bed and keep matches away from children.
•Don’t smoke – As covered above, the fire risk greatly increases if you smoke cigarettes. Most insurers will now ask if you are a smoker.
•Increase your voluntary excess – The amount of excess is the money you are willing to pay on claims. So, for example, if you had a £50 excess and a £100 claim you would pay half and the insurer the other half. The higher the excess you are willing to pay, the lower your premium. This can be as much as 20% with some companies for as little as £250 excess.
•Think about your cover – Do you really need accidental damage cover? This can increase premiums by 25%. Think carefully about the add-ons you need.
•Don’t claim unless you need to – The fewer the claims, the higher your no claims discount. So for minor issues that would be inexpensive for you to cover with your own cash, think twice before making a claim.
Web- and Computer-Based Smoking Cessation Programs May Be Effective for Adult Smokers
Web-based and computer-based smoking cessation programs may be effective for adult smokers, according to the results of a meta-analysis of randomized controlled trials (RCTs) reported in the May 25 issue of the Archives of Internal Medicine.
"The effects of Web- and computer-based smoking cessation programs are inconsistent in...RCTs," write Seung-Kwon Myung, MD, MS, from National Cancer Center in Goyang, South Korea, and colleagues. "To date, recommended smoking cessation strategies include brief tobacco dependence treatment; individual, group, and telephone counseling; numerous effective medications; and telephone quitline counseling."
The review authors identified 287 articles by searching MEDLINE (PubMed), EMBASE, and the Cochrane Review in August 2008, with 2 evaluators independently selecting and abstracting eligible studies. The final analyses included 22 RCTs, which enrolled a total of 29,549 participants (16,050 were randomly assigned to Web or computer-based smoking cessation program groups and 13,499 to control groups).
The intervention had a significant effect on smoking cessation, based on a random-effects meta-analysis of all 22 trials (relative risk [RR], 1.44; 95% confidence interval [CI], 1.27 - 1.64). Results were similar in the 9 trials of a Web-based intervention (RR, 1.40; 95% CI, 1.13 - 1.72) and in the 13 trials of a computer-based intervention (RR, 1.48; 95% CI, 1.25 - 1.76).
Results were also similar in subgroups based on different levels of methodologic study quality, stand-alone vs supplemental interventions, type of abstinence rates used as outcomes, and duration of follow-up period. However, Web-based or computer-based smoking cessation programs did not appear to be effective in adolescent populations (RR, 1.08; 95% CI, 0.59 - 1.98).
Limitations of this meta-analysis include identification of only 3 RCTs in adolescents, inability to evaluate overall socioeconomic status of the participants, lack of evaluation of smokeless tobacco use, and failure to use biochemical validation techniques for abstinence rates.
Some of the study authors noted various disadvantages of online health behavior change programs, including potential breaches of privacy and security and lack of accessibility for smokers who are elderly, less educated, or living in developing countries.
"The meta-analysis of RCTs indicates that there is sufficient clinical evidence to support the use of Web- and computer-based smoking cessation programs for adult smokers," the study authors write. "The programs increase the smoking cessation rate about 1.5 times more than in the control group and obtain an abstinence rate at 12-month follow-up of 9.9%."
Four of the review authors have received funding from the Centers for Disease Control and Prevention (CDC). The remaining review author has disclosed no relevant financial relationships. The contents of the meta-analysis are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
Clinical Context
In 2000, smoking was reported to be responsible for an estimated 4.9 million premature deaths worldwide. It is the single greatest cause of preventable disease and premature death. According to the Clinical Practice Guideline, published by the US Public Health Service in 2008, recommended smoking cessation strategies include brief tobacco dependence treatment; individual, group, and telephone counseling; numerous effective medications (eg, nicotine replacement and bupropion); and telephone quitline counseling for treating tobacco use and dependence. In addition, some studies have found that computer-based or Web (Internet)-based smoking cessation programs are effective as well. However, the effects of Web-based and computer-based smoking cessation programs are inconsistent in RCTs.
The aim of this study was to examine the effects of Web-based and computer-based smoking cessation programs in RCTs via a meta-analytic approach.
Study Highlights
• Investigators conducted a search of MEDLINE (PubMed), EMBASE, and the Cochrane Review in August 2008.
• The keywords used for the literature search were as follows: smoking cessation, quit smoking, or tobacco cessation; Internet program, computer program, online program, or Web program; and trial or intervention.
• 2 evaluators independently selected and reviewed eligible studies.
• The outcome measures included point-prevalence abstinence, sustained abstinence, prolonged abstinence, and continuous abstinence.
• Of 287 articles searched, 22 RCTs, which included 29,549 participants with 16,050 enrolled in Web-based or computer-based smoking cessation program groups and 13,499 enrolled in control groups, were included in the final analyses.
• Of note, of the 22 trials, 10 used supplemental interventions for smoking cessation, such as counseling, classroom lessons, nicotine replacement, bupropion medication, or quitlines.
• In a random-effects meta-analysis of all 22 trials, the intervention group had a significant effect on smoking cessation, approximately 1.5 times higher than the control group (RR, 1.44; 95% CI, 1.27 - 1.64).
• When data were pooled, the abstinence rate at the 12-month follow-up was significantly higher in the intervention group (9.9%; 95% CI, 8.9% - 10.9%) vs the control group (5.7%; 95% CI, 5.1% - 6.3%), as well as at 6-month follow-up.
• Similar findings were observed in 9 trials using a Web-based intervention (RR, 1.40; 95% CI, 1.13 - 1.72) and in 13 trials using a computer-based intervention (RR, 1.48; 95% CI, 1.25 - 1.76).
• Subgroup analyses revealed similar findings for different levels of methodologic rigor, stand-alone vs supplemental interventions, type of abstinence rates used, and duration of follow-up period.
• Regarding age group, the Web-based or computer-based smoking cessation programs obtained a significant greater abstinence rate for adults (RR, 1.49; 95% CI, 1.31 - 1.70) but not for adolescent populations (RR, 1.08; 95% CI, 0.59 - 1.98).
• Limitations of the study were that the findings could not be applied to smokeless tobacco users, and there were the possible disadvantages of online health behavior change programs (such as the potential for privacy and security breaches, low quality of information, and problems with computer system performance).
• Other limitations were that access to these programs in developing countries would be problematic, there was a lack of biochemical validation techniques within the trials, and some articles may have been missed because a search was not conducted in a psychiatry-specific database.
Clinical Implications
• Smoking cessation strategies include brief tobacco dependence treatment; individual, group, and telephone counseling; numerous effective medications (eg, nicotine replacement and bupropion); and telephone quitline counseling.
• The meta-analysis of RCTs indicates sufficient clinical evidence to support the use of Web-based and computer-based smoking cessation programs for adult smokers.
Guidelines on Managing Obesity in Pregnancy
"Obesity is associated with reduced fertility primarily as a result of oligo-ovulation and anovulation," write Michelle A. Kominiarek, MD, and colleagues from the ACOG. "The increased risks for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity associated with obesity are well established....Obese patients are more likely to be admitted earlier in labor, need labor induction, require more oxytocin, and have longer labor."
To identify pertinent articles published in the English language between January 1975 and November 2008, the guidelines authors searched the MEDLINE database, the Cochrane Library, and ACOG's own internal resources and documents. The reviewers gave priority to articles reporting findings from original research and also consulted review articles and commentaries, but they did not consider abstracts of research presented at symposia and scientific conferences. Using the method outlined by the US Preventive Services Task Force, the reviewers evaluated the identified studies for methodologic quality.
Recommendations from professional societies including ACOG and the National Institutes of Health were also reviewed. Reference lists from identified articles were used to help identify additional studies. When reliable research findings were not available, the reviewers used expert opinions from obstetrician-gynecologists as a basis for their recommendations.
Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:
• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.
• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.
• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.
Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:
• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.
• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.
• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.
• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.
• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.
• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.
• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.
• As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.
Additional points made by the authors of the practice bulletin include the following:
• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.
• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.
• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.
• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.
• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.
"As the rate of obesity increases, it is becoming more common for providers of women's health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery," the guidelines authors write. "The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes."
Clinical Context
Obesity is associated with adverse outcomes of pregnancy, and the incidence in reproductive-age women has increased in the United States by 70% from 1994 to 2003. Bariatric surgery is the most effective treatment of morbid obesity for improvement of comorbidities and quality of life but has consequences for subsequent pregnancy.
This is a review of the risks associated with obesity and recommendations on care of pregnant women who have previously undergone bariatric surgery.
Study Highlights
• Increased maternal body mass index increases the risk for stillbirth by 2.1 to 4.3 times and increases the risk for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity but not the risk for preterm delivery.
• Bariatric surgery is available to women with a body mass index of 40 kg/m2 or higher or 35 kg/m2 or higher and other comorbidities.
• The procedure may have restrictive and malabsorptive effects.
• The number of bariatric procedures per year has increased from 12,480 in 1998 to 113,500 in 2005, and 80% are performed in women, with one half of them performed in women with a mean age of 40 years.
• Operative complications of bariatric surgery include anastomotic leaks, bowel obstructions, internal or ventral hernias, band erosion, and band migration; all gastrointestinal tract problems occurring after surgery should be evaluated for these complications.
• Dumping syndrome with associated nausea, weight loss, cramps, bloating, and distension may occur.
• Rapid weight loss follows bariatric surgery with improvement in fertility, but bariatric surgery is not considered a treatment of infertility.
• Women undergoing bariatric surgery are more likely to have had previous cesarean delivery (15.4% vs 10.5%; P = .006), gestational diabetes (9.4% vs 5.0%; P < .001), preeclampsia, and given birth via cesarean delivery (25.2% vs 12.2%; P < .001).
• After bariatric surgery, the risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia is reduced.
• Although the risk for premature rupture of membranes is increased after bariatric surgery, the risk for preterm delivery is not increased.
• Some authorities recommend waiting 12 to 24 months after bariatric surgery before conceiving to minimize exposure of the fetus to rapid maternal weight loss.
• Should pregnancy occur before this timeframe, closer surveillance of nutritional status is recommended.
• The rate of congenital anomalies and perinatal death after bariatric surgery is not increased.
• After bariatric surgery, there is a lower rate of large-for-gestational-age infants and macrosomia.
• The ACOG recommends the following for women after bariatric surgery:
o Contraceptive counseling is important especially for adolescents because pregnancy rates double after bariatric surgery.
o Nonoral administration of hormonal contraception should be considered because of a higher failure rate with oral contraception because of malabsorption.
o Medications may not be well absorbed, and testing for therapeutic levels may be indicated.
o During pregnancy, there should be a high index of suspicion for gastrointestinal tract symptoms being complications of the bariatric surgery.
o Counseling for weight gain and nutrition should be offered during pregnancy.
o Because of dumping syndrome, an alternate method to the 50-g glucose load to screen for gestational diabetes should be considered.
o Bariatric surgery is not an indication for cesarean delivery, although the rate of cesarean delivery may be as high as 62%.
o There is no consensus on management of pregnant patients who have had an adjustable gastric banding procedure, but early consultation with a bariatric surgeon is recommended.
o Nutrition consultation is recommended because of macronutrient and micronutrient effects of surgery because of malabsorption.
o An evaluation for micronutrient deficiencies at the beginning of pregnancy should be considered.
Clinical Implications
• Bariatric surgery is associated with a reduced risk for preeclampsia, hypertension, pregestational and gestational diabetes, and an increased incidence of cesarean delivery in pregnant women.
• In pregnant women with a history of bariatric surgery, some of the ACOG recommendations include: contraceptive counseling for adolescents, prenatal care assessment for nutritional deficiencies, and non-oral administration of hormonal contraception.
Mortgage calculator
Mortgage calculator capability can be found on most financial calculators such as the HP-12C, in most desktop spreadsheet programs such as Microsoft Excel and on the Web.
UsesWhen purchasing a new home most buyers choose to finance a portion of the purchase price via the use of mortgage. Prior to the wide availability of mortgage calculators, those wishing to understand the financial implications of changes to the five main variables in a mortgage transaction were forced to use compound interest rate tables. These tables generally required a working understanding of compound interest mathematics for proper use. In contrast, mortgage calculators make answers to questions regarding the impact of changes in mortgage variables available to everyone.
Mortgage calculators can be used to answer such questions as:
If I borrow $250,000 at a 7% annual interest rate and pay the loan back over thirty years, with $3,000 annual property tax payment, $1,500 annual property insurance cost and .5% annual private mortgage insurance payment, what will my monthly payment be? The answer is $2,142.42.
You can use an online mortgage calculator to see how much property you can afford. A lender will compare your total monthly income and your total monthly debt load. A mortgage calculator can help you add up all your income sources and compare this to all your monthly debt payments. It can also factor in a potential mortgage payment and other associated housing costs (property taxes, homeownership dues, etc.). You can test different loan sizes and interest rates. Generally speaking, lenders do not like to see all of your debt payments (including your property expense) exceed around 40% of your total monthly pretax income. Some mortgage lenders are known to allow as high as 55%.
mortgage
mortgageis the transfer of an interest in property (or the equivalent in law - a charge) to a lender as a security for a debt - usually a loan of money. While a mortgage in itself is not a debt, it is the lender's security for a debt. It is a transfer of an interest in land (or the equivalent) from the owner to the mortgage lender, on the condition that this interest will be returned to the owner when the terms of the mortgage have been satisfied or performed. In other words, the mortgage is a security for the loan that the lender makes to the borrower.
This comes from the Old French "dead pledge," apparently meaning that the pledge ends (dies) either when the obligation is fulfilled or the property is taken through foreclosure.
In most jurisdictions mortgages are strongly associated with loans secured on real estate rather than on other property (such as ships) and in some jurisdictions only land may be mortgaged. A mortgage is the standard method by which individuals and businesses can purchase real estate without the need to pay the full value immediately from their own resources. See mortgage loan for residential mortgage lending, and commercial mortgage for lending against commercial property.
The cost to the borrower is measured by the annual percentage rate (APR), which is an effective annual rate of interest and fees paid by the borrower.
In many countries, though not all (Iran) or (Bali, Indonesia is one exception, it is normal for home purchases to be funded by a mortgage. Few individuals have enough savings or liquid funds to enable them to purchase property outright. In countries where the demand for home ownership is highest, strong domestic markets have developed, notably in Ireland, Spain, the United Kingdom, Australia and the United States.
Tuesday, June 23, 2009
Insurance
Monday, June 22, 2009
mesothelioma
Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing mesothelioma. Unlike lung cancer, there is no association between mesothelioma and smoking, but smoking greatly increases risk of other asbestos-induced cancer. Compensation via asbestos funds or lawsuits is an important issue in mesothelioma (see asbestos and the law).
The symptoms of mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall) or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan, and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy (inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis), which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
Merchant account
A merchant account is a contract under which an acquiring bank extends a line of credit to a merchant, who wishes to accept payment card transactions of a particular card association brand. Without such a contract, one cannot directly accept payments by any of the major credit card brands. When using an intermediary payment service provider (such as PayPal), the merchant account is in fact held by the service proMerchant accounts are marketed to merchants by two basic methods: either directly by the processor or sponsoring bank, or by an authorized agent for the bank and additionally directly registered with both Visa and MasterCard as an ISO/MSP (Independent Selling Organization / Member Service Provider). Marketing details are by card issuers like Visa and MasterCard, and are enforced by various rules and fines.vider itself.
austin dwi attorney
Criminal Defense Attorney - Austin Texas(DWI) Drunk Driving Trial Defense Attorney
Don’t Let A Texas Driving While Intoxicated (DWI) Arrest Ruin Your Life! Know Your Texas DWI Rights!I will fight for your license, your freedom and your dignity. JAIL RELEASE - CALL NOW 512-469-6056
When you have been investigated or arrested for any criminal offense such as Driving While Intoxicated (DWI), or any Felony Charge, you have an absolute right to be concerned. Facing criminal charges may be one of the most frightening things you have encountered. Some of the possible consequences that can result from a Driving While Intoxicated (DWI) conviction include the restriction or loss of a driver’s license, an increase in insurance costs, fines, court costs, a Driver’s License Surcharge of between $3,000.00 and $6,000.00, and even the possibility of jail. As you can see, Driving While Intoxicated (DWI) can be a very serious charge. The law says that the County Attorney needs only to prove that after drinking you were not able to drive your car in a “normal” capacity. That sounds pretty cut and dried, but it is not quite as simple as that. You see, if challenged, the County Attorney must also show all of the following:
That the arresting officer made the arrest properly, That you were properly advised of your rights, That the equipment the officer used to test you was working accurately, and Even that the person operating the equipment was certified to operate the equipment.
Further, the officer that administers the “standard field sobriety tests” should have successfully completed the National Highway Traffic Safety Administration Standardized Field Sobriety Testing student class before administering these tests. I have successfully completed training for the National Highway Traffic Safety Administration Standardized Field Sobriety Testing. What does that mean to you? It means that in addition to grading you on your performance of the tests, I will also grade the officer to ensure that he or she conducted the tests properly. If the tests were not conducted properly, this can be disclosed to the County Attorney or the jury to show that the tests results were unreliable and should not be believed. When you retain me I’ll insist that the County Attorney provide us with the names and address of anyone he plans to call as a witness as well as copies of every written or recorded statements of their testimony. This will allow us to prepare our questions of them. I’ll insist that the County Attorney provide us with any information or material he has which could show that you are not guilty of the charges against you, or which may help you get a lighter sentence. I’ll insist on receiving copies of any videos that show your sobriety tests, whether in the field or at the station. I’ll insist on receiving copies of records showing that the equipment used for tests was functioning properly and that the person giving the tests was properly certified. As you can see, what looks simple gets pretty complex. As your criminal defense attorney I will insist that all this information be provided and that you and I walk through all this information as we discuss and proceed on your case.
Drunk Driving (DWI) Trial Defense AttorneyCriminal Defense Attorney - Austin Texas DRIVER LICENSE SUSPENSION - Your arrest may have included a cancellation of your Texas driving privileges for a specific period of time. YOU HAVE ONLY 15 DAYS FROM THE DATE OF YOUR ARREST TO REQUEST A HEARING ON THIS MATTER. I believe that this hearing is extremely important, not only to challenge your suspension but also as an opportunity for your attorney to question the arresting officer to find out exactly what he is going to say in court. If you retain our office to represent you, part of that representation includes representing you at the driver license suspension. However, remember you must request this hearing no later than 15 days from your arrest so it is important that you contact me as soon as possible to schedule an appointment. If your Texas driving privileges are ultimately suspended, in most cases we can get you a Texas license that will allow you to drive to and from work. WARNING BEWARE: TEXAS DRIVER LICENSE SURCHARGE!! Beginning with any Texas DWI Conviction for an offense committed on or after 09/01/03, the Texas Department Of Public Safety is authorized to charge a surcharge on your Driver’s License. This charge will range from $1,000.00 to $2,000.00 a year for three years. Depending on whether you provided a breath sample, and the results, you could be facing a $6,000.00 fee to keep your license. BREATH TEST CASES: I own an Intoxilyzer 5000. If you took a breath test at the jail, this is the same model of machine that you used. I have also completed training under the Department of Transportation regulations as an Intoxilyzer Operator and Maintenance Technician. I also have access to various Breath Test Experts that may be helpful in your case. Just because your results were over a certain limit, does not automatically prove you guilty. The government with all of its resources can frequently make your life miserable; regardless of whether you have actually committed the crime. Real life criminal law is NOT like television. Cases are not resolved in one hour, and the solutions are normally not simple. Hiring a criminal defense trial lawyer can be the most important decision you make. When you find yourself, a family member, or friend in this situation, you need an experienced and well-skilled attorney who practices only in the area of criminal defense law. For better or worse, criminal law has its own unique practice and methodology. Frequently you will find attorneys who practice criminal law, but also handle personal injury, divorce, and other matters. They may be good attorneys, but I believe that criminal law is too specialized to risk my clients to any distractions facing an attorney who handles multiple types of law and who is not in the trenches everyday. Please call and schedule an appointment at your earliest convenience, because I can help you through the unfamiliar territory of the criminal justice system. Because each case is different and special, I offer a free initial consultation where you and I can sit down and discuss the charges against you and what options are available to you. To assist you financially in paying any attorney fees, I offer flat rate fees and flexible payment plans that will allow you to hire me as your criminal defense attorney so that I can start immediately to protect your rights.
DWI Information and Facts: You can never have too much information at your finger tips.
A breath test or field sobriety test does not automatically prove you guilty. According to the federal government, accuracy of field sobriety tests are as follows: HGN test......................77% Walk and turn.............68% One leg stand.............65%
Evaluating A Texas Drunk Driving DWI Case and the Deciding Factors. In most Texas DWI cases, there are 3 pieces of evidence that are open to interpretation of the law.
Police Reports: The police report is only the officer's interpretation. Were you properly read your Miranda warnings? Did the police officer stop you for a valid reason? Were any statements made by you coerced, taken out of context, or misinterpreted? Important: The Intoxilyzer 5000 assumes that everyone has the same blood breath partition ratio, hematocrit ratio and assumes that all samples are at an air temperature of 93.2 F. Texas DWI Law does not utilize any methods which would allow for a retest of samples given. The computer software is proprietary and is not available to scientific peer review. There are many things which have been shown to affect a breath test score. These machines are generally not available for inspections by anyone outside of law enforcement. Texas does not allow for non-law enforcement or government personnel to become certified as breath test technical operators. Much of the Texas breath program remains limited to outsiders despite a generally assumed belief that these machines have undergone and passed wide general scientific review. Field Sobriety Tests: Police make arrests on the basis of probable cause. This is not the same thing as "beyond reasonable doubt." It is not a police officer's job to determine if someone is guilty. Many police offers choose to arrest on the basis of caution. There is much technical training for a police officer in the field of Texas DWI Law. There is no law in Texas which states they must keep up their training on a yearly or any other type of basis with respect to standardized field sobriety training. Many police officers do not make any form of notes on the side of the road with respect to numerous details. Most police officers do not include mitigating or exculpatory information in their reports, mainly negative observations. Where there distractions during the testing? Were you nervous or tired during the testing? If there was a video taping of the event, does it accurately depict your true state of sobriety at the time, or was it unfairly effected by perhaps traffic, poor lighting, noise, or lack of sound. What is your true balance and coordination? Do you have any physical disabilities that can cause false results?
austin dwi
If the Death Penalty Capital of the World Can Do It...
Harris County DA Pat Lykos has announced that she will allow first time DWI offenders to apply for Pretrial Diversion and/or be eligible for a Deferred Prosecution:
Harris County District Attorney Pat Lykos announced plans Friday for a program that allows first-time DWI and drug offenders to avoid conviction, an idea she acknowledged could be a hard sell to the public.
The plan, referred to as pretrial diversion and scheduled to begin in August, was heartily endorsed by the county’s defense attorneys, supported by the sheriff deputies’ and the Houston police officers’ unions, but strongly opposed by the local chapter of Mothers Against Drunk Drivers.
“What we’re trying to do is prevent recidivism. So, it’s a carrot-stick approach,” Lykos said. “With respect to DWI, that’s an absolute plague in Harris County. If we can get first offenders, get them into treatment … and divert them so they don’t become repeat offenders, that’s going to have enormous dividends. And the same thing for first-time drug possession.”
This move was, and I know I’m repeating myself here, “supported by the sheriff deputies’ and the Houston police officers’ unions”. For all you law and order folks out there, doesn’t that endorsement convince you that it can’t be an all-bad idea, can it?
Heck, even Williamson County, not known for its soft-on-crime reputation allows DWI defendants with no prior criminal history to apply for what they call Pretrial Intervention – the same thing as Travis County’s Pretrial Diversion.
Isn’t it about time the progressive folks in charge of our Travis County Attorney’s Office here in Austin do the same thing?
Game cheats
Fight Night Round 4 – PS3, 360
Release date: June 23
Sports games aren’t generally GR’s specialty, cup of tea, or favorite piece of ass, but when Fight Night Round 3 debuted as a launch title on the Xbox 360 almost four years ago, the title immediately became a hit. Think about it: how many times have you heard people go on about Round 3’s lifelike (at the time) next-gen graphics, the ease of the thumbstick-based controls or the smooth as butter sim/arcade-y gameplay? All the time, huh?
It shouldn’t come as a surprise that Round 4 is one of our most eagerly anticipated games of the year. EA promises faster gameplay, an incredibly robust create-a-fighter mode, elimination of those stupid face-rubbing minigames, and star of The Hangover, Mike Tyson. Considering UFC 2009 Undisputed sold over a million copies in its first month, we bet casual AND sports fans are eagerly awaiting this future hit.
WHAT ELSE?
The Conduit – WiiRelease date: June 23
Haven’t been a hell of a lot of FPSes on Nintendo’s sleek machine since its launch, even though that’s one genre we thought we’d see a lot of. Developer High Voltage seeks to reinvigorate interest with this shooter set in Washington DC with an alien conspiracy to wrap your All Seeing Eye around. We dug the multiplayer and Battlestar Galactica’s Mark Sheppard (Romo Lampkin) voices the main dude.Overlord II – PC, PS3, 360Release date: June 23
The first was something of a cult hit and in the next week you’ll have more minions at your disposal. You play again as a badass with little monsters to do your bidding. Apparently, the increase in minion AI enables them to ride mounts and sail ships. Lazy bastards.
Call of Juarez: Bound in Blood – PC, PS3, 360Release date: June 29
Yeah, we’ve seen what Modern Warfare 2 and ODST have in store for us later this year, but in the meantime why not journey back to the old west with the follow-up to the original criminally overlooked title? As GR head honcho Eric Bratcher wrote during the fallout of E3, “In one half-hour session, we shot up a bar, stormed out of town on a stolen stagecoach, traded hot lead with the sheriff’s posse as they galloped alongside us, and used a cannon to blow up a riverboat. Plus, it’s the only shooter this year that let us fan the hammers of two pistols at once.”DON'T FORGET
Marvel vs Capcom 2 – Xbox Live, PSNRelease date: June 29
Resident Evil Archives: Resident Evil – WiiRelease date: June 23
The Wii remake of the GameCube remake of the PS1 game that was ported to the DS and Sega Saturn makes its graceful re-re-re-debut. If you didn’t check it out 13 years ago, give it a shot now.2 3 4 Next » 
Friday, June 19, 2009
games
Fun Free Online Games from AddictingGamesWelcome to Addicting Games, the largest source of the best free online games including funny games, flash games, arcade games, dress-up games, internet games, shooting games, word games, RPG games, racing games, and much more. Thousands of choices from some of the best developers around, like Armor Games, Games2Win, and even yours truly, Addicting Games! With tons of reviews & ratings, gamers of all skill levels are sure to find hot new games every day. This is the best place on the web to play games for free! Play Games on the One-and-Only Addicting Games! Whatever game you feel like turning on, we’ve got it here. Including free online games! If you’re ready to start playing right now, simply choose from the following categories: Action, Sports, Puzzle & Board, Shooting, Arcade & Classic, Strategy, Adventure, Life & Style, & NewsGames. Need some Holiday-themed game action? Check out our Holiday Games spotlight!Embed Your Favorite Games: Add your favorite games from AddictingGames.com to your Blog, MySpace or Facebook page, and beyond so you can play on your own website or webpage! Just copy and paste the codes we make available here. And check back often! We keep the list updated with the latest and greatest free online games! Submit a Game: Don’t just play games on AddictingGames.com, submit them! Give the gift of fun to fellow gamers. Submit your game now and we might put it in front of an audience of millions. We may even sponsor it for cash! Simply upload your game directly to the Addicting Games website using the game submission form. We'll take a peek, and if it checks out, we'll promote it on our website, give you all the credit and link back to your site. Submit your game here and who knows you could be famous! Want more cool games, videos, & TV shows? Check out:Shockwave Online Games, Free Online Games, Internet Games, Free Game Downloads, Kids Online Games Nick Jr NickJr, Kids, Coloring Pages, Kids Crafts, Games for Kids, Olivia Nickelodeon Nick, Games, Kids Games, Miranda Cosgrove, Keke Palmer, iCarly Nick at Nite Family Fun, George Lopez, Home Improvement, Family Matters, Family TV Nicktoons Wolverine, Iron Man, Speed Racer, Avatar, Cartoons Parents Connect Parents, Babies, Pregnancy, Baby, Pregnant Nick Arcade Kids Games Spongebob Spongebob Episodes, Spongebob Games, SpongeBob Patrick, SpongeBob Squarepants Episodes, SpongeBob Video Quizilla Quiz, Quizzes, Stories, Poems, Lyrics TV Land TV Shows The N Girls Game, Quiz, Degrassi, Saved By The Bell, That 70’s Show, Girl Games, Free Games for Girls Neopets Virtual Pets Gametrailers Game Reviews, Video Games, Cheat Codes Comedy Central Comedy, Online Games, Funny Jokes, Jeff Dunham Spike Movie Trailers, Amazing Videos, Girl Videos, UFC The Ultimate Fighter Atom Funny Videos ALL ACTION SPORTS PUZZLE & BOARD SHOOTING ARCADE & CLASSIC STRATEGY/RPG ADVENTURE LIFE & STYLE DOWNLOADS Play Games Free Games Free Online Games Flash Games Free Internet Games
