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However medications versed order ribavirin 200 mg mastercard, nine states made quality or consumer satisfaction information for marketplace health plans publicly available this year (Exhibit 4) nioxin scalp treatment purchase ribavirin 200 mg overnight delivery. Of these treatment associates discount ribavirin 200mg on-line, eight states made quality or consumer satisfaction data available directly on their marketplace web site medicine kit for babies purchase ribavirin 200 mg otc, while one state, Utah, linked to external quality data. The data do not identify the options that a state-based marketplace may be considering for future years. Beginning in 2016, all marketplaces will be required to display quality metrics using a federal quality rating system, developed by the U. Department of Health and Human Services, that aggregates multiple metrics into scores depicted as a star rating. Five states converted a single source of data-such as accreditation status or consumer satisfaction data-into a star rating, while three states-Maryland, New York, and Oregon-implemented comprehensive quality rating systems that incorporated multiple data sources (Exhibit 5). State Action on Quality Improvement in State-Based Marketplaces 7 States had strong interest in moving forward with quality reporting, but some chose instead to focus on immediate operational needs or proceeded in a more limited way than originally planned because of technical challenges. Instead, for plan year 2014, California opted to display a simplified rating system encompassing 10 survey questions on consumer satisfaction based on services delivered in 2011. California, for the initial plan selection and certification process, required insurers to submit detailed information on plan performance and quality improvement through the eValue8 survey, a value-based purchasing tool that collects standardized data on hundreds of quality and performance metrics. Other marketplaces, such as those in Maryland, New York, and Vermont, drew on long-standing quality reporting requirements in their states. To maximize the effectiveness of quality and delivery system reform efforts and ease the burden of reporting requirements, marketplaces can align their quality improvement strategies, measurements, and programs with other payers. Health insurance marketplaces allow consumers to compare plans side by side based on variables like cost, benefits, and quality ratings. While there is some evidence that consumers use quality information to guide coverage decisions, there are also limitations to its usefulness, particularly in the initial years. Many consumers are navigating the complexities of selecting a private insurance plan for the first time this year, and are likely to be more focused on factors like premiums and cost-sharing. As a result, consumers lacked the tools to make plan choices informed by quality data. Because marketplace health plans are new entities that must build experience to accurately report on quality, and all states must State Action on Quality Improvement in State-Based Marketplaces 9 implement the federal quality rating system in 2016, consumers also should be educated on year-toyear differences in health plan quality scores. In addition, states can enhance the value of their public quality reporting by evaluating how consumers used available information to make purchasing decisions, and by considering additional features such as the ability to drill down to individual quality metrics. A health insurance marketplace is just one of many purchasers and payers operating in an environment crowded with diverse quality measure sets and initiatives. While this diversity allows for innovation, the lack of alignment among goals and metrics can burden providers and insurers, dilute efforts to bring evidence-based reforms to their maximum potential, and make comparisons more challenging. Final regulations require states to display a federally developed quality rating system in 2016, while allowing them to also display their own metrics pursuant to forthcoming guidance. Insurers may be encouraged to improve their performance simply because quality data is made public. But even the most robust public quality reporting system is limited in its ability to drive competition based on quality, partly because consumers will be comparing plans based on other factors, such as cost, covered benefits, and provider networks. Policymakers also will need to consider the infrastructure, such as information technology systems, needed by marketplaces and insurers to conduct quality improvement activities. A foundation of reliable, timely, and comparable performance data for all marketplace health plans will be essential for analyzing the effect of quality improvement efforts on outcomes and costs. It also will be critical in deciding on next steps-for instance, approving plans based on quality and performance or tying financial incentives to plan performance-which may further drive plans to compete on quality. The Affordable Care Act offers state health insurance marketplaces a foundation for promoting quality improvement and delivery system reform and most state marketplaces are working toward these goals. Recent federal regulations requiring uniformity in quality reporting in all marketplaces also may help consumers compare plans based on quality, although it will be important to educate consumers on the differences between quality rating systems that states may be using this year and the federal system yet to be put in place. Although not reviewed for purposes of this paper, states in which the federal government is managing the marketplace, including state-partnership marketplaces, have discretion over certain policy decisions affecting the operation of the marketplace in their state, including setting standards to promote quality and delivery system reforms. Our findings are based on public information-such as state laws, regulations, subregulatory guidance, marketplace solicitations, and other materials related to marketplace development-and interviews with state regulators. Data on public quality metrics were confirmed, where possible, by browsing the available plan offerings on state marketplace websites. These features may change or be periodically unavailable as states continue to develop their marketplaces.
The content that can be provided for the local curriculum is as follows: (1)knowledge about malaria transmission; (2)knowledge about malaria vectors; (3)vector life environment; (4) community behavior; (5)prevention of malaria transmission; (6)handling malaria sufferers; (7)prevention of mosquito bites; (8)control of malaria vectors; (9)utilization of technology for malaria vector control; and (10)prevention of malaria as a cultural issue treatment 5 of chemo was tuff but made it buy generic ribavirin 200 mg line. Curative handling is awaiting the arrival of the patient medicine research buy generic ribavirin 200mg line, so that treatment is never complete treatment 911 buy ribavirin 200mg with amex. Malaria elimination can only be achieved through simultaneous preventive and curative handling treatments for depression generic 200 mg ribavirin. Preventive and curative handling are carried out on each component to includea human component, larval control, adult mosquito control, control of mosquito habitat ecology, and treatment of malaria sufferers. The human component focuses on efforts to prevent contact with malaria vectors, control vector populations, and conduct environmental management. Basic education will provide knowledge that creates a culture of preventing malaria in the community. The need for early education is in accordance with the results of th is research, suggesting that knowledge is important for behavior change. Soard of Directors of the National Society of the Colonial Dames of America in the State of Alabama Mrs. The Dames purchased the house from the Mobile Historic preservation Society In 1957 and set about renovating it. Although the actual dates that the original structure of the Conde-Charlotte Museum House was built are not definitely known, Nicholas Holmes, respected Mobile architect with a special interest in historic architecture, believes that the main portion of the building dates back to 1720, possibly earlier. Holmes concluded that, because of the similarity of brick and mortar contained in the house to that used in the construction of Fort Conde, along with the use of "whip sawn" lumber, some parts of the house were built around the 1720s. The building is thought to have later served as a jail, then a courthouse, before being bought, renovated, and turned into a residence by the Kirkbride family in 1849; they owned the house until 1926. In addition to housing all the ancestry records of the Alabama Dames, the Conde-Charlotte Museum House is used to educate the public about the importance of our ancestors, those who have gone before us. The house showcases the history of Mobile under the five flags that have flown over her; Spanish, French, English, Confederate, and United States of America. The dining room is called the American room (1813), and contains a period North Carolina corner cupboard as well as a silver tea service made by Simon Cauldron, who was a silversmitb in New York before moving to Demopolis, Alabama as a member of the French vine and olive colony. The heritage of the National Society of Colonial Dames of America in Alabama is displayed in our museum house, a proud symbol of our linkage to our distinguished and cherished ancestors. Copies of In Grate/u/ Remembrance may be purchased by contacting the CondeCharlotte Museum House, 104 Theatre Street, Mobile, Alabama 36602. Tl1eygave up their homelands and the comforts of their known civilization to face the uncertainties of a long sea voyage and the hardships of new settlers in a strange land. The National Society of the Colonial Dames of America in the State of Alabama is comprised of women in the common bond of colonial ancestry. Each member has documented her descent from one or more of tl10se courageous settlers who made his marlz of significance in the early life of his colony. They settled from Maine to Georgia in those thirteen original colonies, from which tl1ey would forge the United States of America. Our ancestors were polished aristocrats and rough adventurers, merchants and planlcrs, mariners and traders, religious zealots and political exiles, each one either following a dream or escaping a nigl1b:nare. Tl1eycame to a beautiful wilderness and cleared tl1c land, built their homes, tilled the soil, and raised their families. They faced freezing winters and attacks by Indians, constant shortages of basic supplies, and loss of contact with loved ones at home. The short biographies in this volume have been submitted by individual Alabama Dames who, through documented fact (and in some cases, a bit of family legend) have recreated a time in history spanning the firsl one lmndred fifty years in the life of colonial America. Each writer has included sources for her essay,primarily to serve as aids for otl1cr researchers in their own quests: a prof cssional genealogist has not been engaged to certify the contents of this book. We do nol assume responsibility for the material in tl1is collection of vignettes, and we encourage anyone with questions to consult the primary sources listed with each entry. A special note about one of the major sources for these biographies tl1at was cited again and again: Adventurers of Purse and Person. The first one, issued in 1956, was compiled and edited by Annie Lash Jester in collaboration with Martha Woodruff Hiden, and was publisl1cdby Princeton University Press.
Ralph Donnelly medications by class discount ribavirin 200mg visa, Victor Tennery medications in spanish ribavirin 200mg otc, and colleagues undertook a study that medications ending in lol quality 200mg ribavirin, in 1976 medicine bobblehead fallout 4 cheap 200 mg ribavirin overnight delivery, reported that improved insulation was crucial to improving the efficiency of industrial processes. ConventionaiJy activated sludge sewage Oak Ridge municipal sewage treatment plant. This process ebrninated the need for or ceramics, facilitated the waste flows and energy-consuming pump aerators. Three men wanted on criminal charges, holding hand grenades with the pins pulled, took over the plane carrying 27 passengers and 4 crew members. After circling Oak Ridge for two tense hours, the plane flew to Lexington for refueling. In less than an hour, it was back over Oak Ridge, with the skyjackers again threatening to crash the plane into the facilities if their payoff demands were not met by 1:00 p. Ground investigators, in the meantime, learned that the criminals were from Oak Ridge, Knoxville, and Detroit and were prison escapees and bail jumpers. After lengthy negotiations by radio, the criminals landed the plane at Chattanooga, where they received part of the cash ransom and left the area headed south. The criminals, however, shot the copilot and forced the pilot to get the plane airborne. The skyjackers ordered the plane to Cuba, where the pilot made a safe landing, even without tires. After their return to the United States, the exhausted passengers commented that the highlight of their trip was watching Cuban soldiers take the ransom money from the criminals and march them away under guard. As the drama unfolded aboard the airplane, the Laboratory and Oak Ridge facilities reopened at 3:00 p. The incident, in fact, caused little stir in the Oak Ridge community because both a National Guard airlift to Fort Campbell and a mock Civil Defense disaster drill had been planned and were under way in the town on that holiday. Two days following the incident, the Laboratory restored its nuclear reactors to full operation. This incident at Oak Ridge was one of the most frightening of more than 150 skyjacking attempts made during the early 1970s, prompting the intense airport security screening instituted in the following years. Research on use of organisms to treat waste efficiently, however, has proceeded slowly. Moreover, municipalities seldom build new sewage treatment plants; they are capital -intensive, timeconsuming projects that may require a decade or more to negotiate and construct. Therefore, energy savings derived from more efficient sewage treatment would be a long time coming. In contrast to long-lived sewage systems, homeowners replace several electric appliances each decade. Believing that aggregate energy sav ings could be substantial, Laboratory researchers launched detailed studies of ways to improve the efficiency of heat pumps, refrigerators, furnaces, water heaters, and ovens. Their computer analysis of refrigerator designs, for example, indicated that energy use for these appliances could be halved through installing better insulation, adding an antisweat heater switch, improving compressor efficiency, and increasing condenser and evaporator surface areas. Laboratory energy-saving recommendations for home appliances were incorporated into the design standards of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers and also into experimental appliances designed by subcontractors under the management of Virgil Haynes at the Laboratory. Scientists had long known that applying heat and pressure to coal could produce liquids, gases, and solids for fue l. Efforts to tum scientific theories and blueprints into commercial ventures, however, had been minimal. In re ponse to this major federal initiative, Murray Rosenthal announced an interagency agreement with the Office of Coal Research that brought the Laboratory into fossil energy research. This agreement culminated in the Coal Technology Program headed by Jere Nichol s, later renamed the Fossil Energy Program under Eugene McNee e, and budgeted at $20 million annually. It included fundamental studies of the structure of coal, the carcinogenic properties of coal conversion products, a hydrocarbon reactor, and a potassium boiler to improve the efficiency of producing electricity by burning fossil fuel s. For one project, Henry Cochran and colleagues in the Chemistry and Chemical Technology divisions built a model hydrocarbon reactor that mixed finely ground coal with hydrogen under high pressure and heat to form synthetic oil, plus a substitute for natural gas and a coke-like solid fuel. Modeling experiments identified the optimal combination of pressure and heat for fuel production.
An analysis of the service loading indicated that there were three components of the loading medications rapid atrial fibrillation discount ribavirin 200 mg without prescription. There was a constant preload medicine 1700s purchase ribavirin 200 mg with visa, at a There was level determined by the farmer who installed the dual wheel treatment stye discount ribavirin 200 mg with mastercard. There was also a load caused by the widely varying It was concluded torque applied by the power train to the drive wheel medications vitamins ribavirin 200 mg without prescription. Metallurgical examination of several failed U-bolts indicated that only a shallow case of each bolt contained the desired tempered martensite microstructure. The material change prevented service failures, although the cost of the alloy steel was greater than that of the plain carbon steel it replaced. The U-bolt failures also initiated a general review of the manufacture of this item. The bar stock was cut to length, threads were rolled and the blanks were then stored. No U-bolt made in this manner has failed in the two years since the production methods were changed. Besides totally eliminating service failures, the new production methods have substantially reduced manufacturing costs. Roll threading is faster than cutting threads (and produces a thread more resistant By cutting all blanks to the same length, that of the to fatigue). Only because the part designed by evolution failed was the general review started. In the review the engineers examined the interrelations between the function and design of the U-bolt, its material and the methods by which it was made. From this systems approach to design, a the success of far superior product at a far lower cost was achieved. Particular attention is given to failures caused by fatigue fractures of wing components. Some case histories involving those fatigue failures of the wing which relate to design are presented. Since this paper deals with the period of 1^6k through 1973; information on accidents was, in part, taken from records and files accumulated by the Civil Aeronautics Board but now maintained by the National Transportation Safety Board. To assist in the determination of probable cause in accidents or incidents involving a material failure, the Safety Board maintains a metallurgical laboratory in Washington, D. Listed as fabric, fiberglass or wood were failures known to have been caused by separation or breakage of these nonmetallic components. Also shown are the probable cause(s) and/or contributing factor(s) for each of the failures. It should be pointed out that all the aircraft shown in Table 2 were not required by the existing regulations to be designed and substantiated in fatigue at the time of their certification. Ten of the fifteen accidents involving fatigue fractures occurred on aircraft types having more than one failure; Eeechcraft l8 series (5 failures). Some examples of fatigue failures which show design as a cause or contributing factor are illustrated in the following examples. In the accident of June 22, 1972, the failure of the wing was precipitated by a fatigue fracture through the lower spar cap that initiated at the toe of a weld used to secure a gusset plate to the top side of the lower spar cap (see arrows "0" in Figures 1 and 2). This low strength at the surface and the geometric stress riser at the toe of the weld contributed to fracture initiation in fatigue. The spars, as they were designed and manufactured, were inherently susceptible to fatigue cracking Changing the original design in these cases was not a practical solution, and inspections were performed periodically to detect cracking before ultimate failure occurred. Post accident examination of the X-ray films disclosed that substantial cracks were in the spars during some of these Inspections and should have been detected during the inspection. The probable cause of these accidents were, therefore, attributed to Inadequate inspection. The modification consisted of attaching steel straps to increase the structural integrity of the area. That was the steel main spar carry-through fitting shown by arrows "F" in Figures 3 and ^4-. Multiple fatigue cracks had originated in the inside surface of the fitting along the line where the inner wall changes from a cylindrical to a conical surface near the closed end of the tubular section. The metallurgical examination on the failed fitting, however, indicated that no attempt had been made to form a true radius or improve the surface finish after the drilling operation. Also recommended was the replacement of fittings with an improved design if possible, at the time of this inspection.
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But it is not the feeling of self-importance or pride that distinguishes Ezeulu from other male members of his clan symptoms rheumatoid arthritis cheap 200 mg ribavirin otc. His identity is totally dependent on the native culture as he lives a prestigious and prosperous life as a Chief Priest of the native religion chi infra treatment 200 mg ribavirin. This is a conscious technique used by the author to enhance the ambivalence and to elevate the final alienation of Ezeulu administering medications 6th edition discount ribavirin 200mg visa. So all the respect and prestige that Ezeulu enjoys is a direct contribution of his native religion and culture 4 medications list discount ribavirin 200 mg fast delivery. Ezeulu himself should be aware of this role of native religion in preserving his status at Umuaro. He always tries to appropriate Ulu as the supreme deity of Umuaro and in the process he has earned a few enemies also like the Priest of Idemili. He is very dedicated to his profession and values the native religion as the back bone of Umuaro. Though he recognises white man not as a threat, he is conscious of their hidden aim and believes that they are here on a purpose. It is the prestige that the native religion conferred upon him that prevents him from this direct involvement. The position of Chief Priest at the same time prevents Ezeulu from becoming a mimic man like Unachukwu or Isaac and adds to the complexity of his ambivalence. As Ezeulu cannot enter himself into the religion and customs of the white man and not being able to restraint his curiosity he asks his son Oduche to join the missionaries. This decision of Ezeulu to send his son to the white man has created a lot of criticisms in the village. In fact, Ezeulu became only a medium, a tool at the will of Winterbottom to lure a native boy. But Achebe depicts him as a wise and compassionate colonial officer who never contempt the native people. However, the inherent threat of colonial authority is present inside him and he is also a manipulator and exploiter of the natives. Captain Winterbottom is much like the coloniser Charles Grant who introduced "partial reforms" as he was very careful in his dealing with the natives. He comes as a special officer appointed by the British Government to pacify the war between Okperi and Umuaro. Ezeulu is asked to be a witness by the white man and Ezeulu who is against war confesses the crime of Umuaro. The people of Umuaro lead by Nwaka are very much distressed by this unbiased act of Ezeulu and they see him as a traitor. He further longs to cement his relationship with the white man and has no second thoughts when Winterbottom requested him to send one of his sons to the missionary. But by the time many of the villagers began to develop bitterness against Ezeulu "because he had spoken the truth before the white man" (6) and they began to see him as "a friend of the white man. But in theory, by calling Ezeulu as "the on ly witness of truth" Winterbottom was attributing an inferior status to one of his subject. This novel status elevates the pride of Ezeulu and encourages him to execute further actions that distinguish him from his counterparts. Though Ezeulu sent Oduche to the missionary school he is unwilling to free Oduche from his control. He wants Oduche to remain both as a faithful son and a learner of the new religion. At first he had thought that since the white man had come with great power and conquest it was necessary that some people should learn the ways of his deity. Oduche informs his father that he will not be there to help building a homestead for his brother as he is assigned to go to Okperi by the Church. He asked me to send one of my children to learn the ways of his people and I agreed to send you. Even though the pride of being a friend of the white man lessens or overpowers his fear. So he allows his son to continue his dealings with the church by suppressing his fear. This creates ambivalent and conflicting thoughts in his mind: But now Ezeulu was becoming afraid that the new religion was like a leper. Ezeulu had already spoken strongly to his son who was becoming more strange every day.
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