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Physical interventions to interrupt or reduce the spread of respiratory viruses
AbstractObjective To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.Data selection Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow up. Non randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias.Data synthesis 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta analysis of six case control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure that is, the higher the risk the longer the distancing period.Conclusion Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. Overall, epidemics account for most of the 7% of total deaths from respiratory tract infections in the world.3 Our 2007 Cochrane review showed that physical interventions (personal hygiene, barriers, and distancing) are highly effective.4 However, the current mainstay of pandemic interventions still seems to be vaccines and antiviral drugs, with no evidence supporting their widespread use,5 6 7 8 9 10 especially against a seemingly mild threat such as the novel H1N1 virus. For example, in the most recent guidance document on planning for pandemic influenza from the World Health Organization, handwashing and masks were mentioned only twice and gloves and gowns once each, but vaccines and antivirals were cited 24 and 18 times, respectively.11We carried out a systematic review to update our 2007 Cochrane review on the evidence of the effectiveness of public health measures such as isolation, distancing, and barriers to interrupt or reduce the spread of respiratory viruses.MethodsWe considered trials (individual level or cluster randomised, or quasi randomised), observational studies (cohort and case control designs), and any other comparative design, carried out in people of all ages and provided that some attempt had been made to control for confounding. We included any intervention to prevent the transmission of respiratory viruses from animal to human or from human to human (isolation, quarantine, social distancing, barriers, personal protection, or hygiene) compared with no intervention ("do nothing") or another intervention. We excluded vaccines and antivirals.Outcome measures were mortality, numbers of cases of viral illness, the severity of viral illness, or proxies for any of these, and other measures of disease burden (such as admissions to hospital). No language restrictions were applied. Filters for study design included trials, cohort, case control and crossover studies, before and after, and time series. We scanned the references of included studies for other potentially relevant studies.We scanned the titles and abstracts of the studies identified by our search. When a study seemed to meet our eligibility criteria or information was insufficient to exclude it, we obtained the full text articles. We used a standardised form to assess the eligibility of each study, on the basis of the full article.Quality assessmentWe analysed randomised and non randomised studies separately. Risk of bias in the randomised studies was assessed for the method of randomisation, generation of the allocation sequence, allocation concealment, blinding, and follow up. Non randomised studies were assessed for the presence of potential confounders using the appropriate Newcastle Ottawa scales12 for case control and cohort studies, and a three point checklist for controlled before and after and ecological studies.13We assigned categories for risk of bias on the basis of the number of items judged inadequate in each study: up to one inadequate item represented a low risk of bias, up to three items a medium risk, and more than three items a high risk.Aggregation of data depended on the study design, types of comparisons, sensitivity, and homogeneity of definitions of exposure, populations, Hermes birkin bags fake and outcomes used. We calculated the I2 statistic for each pooled estimate to assess the impact of statistical heterogeneity.14 15When possible we carried out a quantitative analysis and summarised replica hermes handbags effectiveness as an odds ratio, with 95% confidence intervals. When a result was significant we calculated absolute intervention effectiveness as a percentage using the formula: intervention effectiveness=1odds ratio.ResultsOf a total 2958 potentially relevant studies scanned for the 2007 review and its 2009 update, 2790 were excluded on the basis of their titles or abstracts, and the full papers of the remaining 168 trials were retrieved. Fifty eight papers of 59 studies were finally included (table 1); eight of these studies were incorporated in the 2009 update. A list of excluded studies will be available in the published Cochrane update.Table 1 Overview of results of physical interventions and types of evidence to interrupt or reduce the spread of respiratory virusesView this table:View popupView inlineThe quality of the included randomised controlled trials varied (see web extra table). Three of the four trials were poorly reported, with two papers (three studies) giving no description of the randomisation sequence, allocation, or allocation concealment.16 17 One trial reported the generation of randomisation, but blinding was impossible owing to the nature of the intervention (gargling with water with or without povidone iodine compared with standard gargling with no attempt to mask the taste of iodine).18 Information provided in a subsequent brief report contradicted the original report.19 The design of the two trials was artificial and therefore the results were not generalisable to daily practice.17The quality of the cluster randomised trials varied (see web extra table). Only the highest quality trials20 21 22 29 reported cluster coefficients and carried out analysis of data by unit of (cluster) randomisation. Other common problems were a lack of description of randomisation procedures, partial reporting of outcomes, unclear numerators or denominators, unexplained attrition,23 24 25 26 and complete failure of double blinding27 or inappropriate choice of placebo.28 Two cluster randomised trials involving the use of face masks29 30 by contacts of patients with influenza and influenza like illness had poor compliance. This illustrates the difficulty of using bulky equipment in clinical trials in the absence of a real threat. In one trial the intervention targeted (randomised) clusters comprising households of index patients with influenza, up to three days after the onset of symptoms in the index case.29 This almost certainly underestimates the effect of the interventions, given that influenza how much is a hermes bag infectivity is highest soon after infection. Another study was underpowered to detect differences in effect between different types of masks.30 A further cluster randomised trial was rated as being at low risk of bias owing to careful evaluation of compliance in the intervention arm (hand sanitiser wipes and disinfection of surfaces).31Five of the seven case control studies had a medium risk of bias32 33 34 35 36 and two a low risk,37 38 mostly because of inconsistencies in the text and lack of adequate description of controls (see web extra table). Six of the 16 prospective cohort studies had a low risk of bias,39 40 41 42 43 44 six a medium risk,45 46 47 48 49 50 and three a high risk (see web extra table).51 52 53 One was a brief report of a small study with insufficient details to allow assessment.54 All five retrospective cohort studies had a high risk of bias (see web extra table).55 56 57 58 59 Six of the 13 controlled before and after studies had a low risk of bias,60 61 62 63 64 65 two a medium risk,66 67 and five a high risk (see web extra table).68 69 70 71 72 Many of the observational studies were poorly reported and the retrospective designs were prone to recall Hermes bag season with the main color coordination bias. The most common problem in all of these studies, however, was that circulation of the virus within the reference population was not reported, questioning the interpretation and generalisability of the conclusions.Reported results from randomised studiesHandwashing with or without antisepticsThree randomised controlled trials tested the effects of cleaning hands on inactivating the virus and preventing experimental colds due to rhinovirus. This resulted either in a reduction in the incidence of rhinovirus infection among volunteers using different combinations of acids for cleaning (P=0.025)17 or did not reach statistical significance (13% v 30% with combined denominator of only 60).17 When iodine treatment of the fingers was used, one of 10 volunteers in the intervention arm became infected compared with six of 10 in the placebo arm (P=0.06, Fisher's exact test).16Eight cluster randomised studies tested educational programmes to promote handwashing with or without antiseptic agents on the incidence of acute respiratory tract infections either in schools or in households. As a result of different definitions, comparisons, lack of reporting of cluster coefficients, and, in two cases, missing data for participants,23 24 meta analysis was not feasible. Three of the trials reported a lack of effect for the prevention of acute respiratory illness: risk ratios 0.94 (95% confidence interval 0.66 to 2.43),24 0.97 (0.72 to 1.30),22 and 1.10 (0.97 to 1.24).31 A possible explanation for the lack of effect is that because exposure to respiratory viruses is ubiquitous, repeated hand hygiene would be needed, which is not practical in busy settings such as schools. Nevertheless, the highest quality trials reported a significant decrease in respiratory illness in children aged up to 24 months (risk ratio 0.90, 0.83 to 0.97), although the decrease was not significant in older children (0.95, 0.89 to 1.01),21 and a 50% (65% to 34%) lower incidence of pneumonia in children aged less than 5 years in a low income country.20 Another study reported a decrease in respiratory tract infections of up to 38% with additional hand rubbing with benzalkonium chloride (risk ratios 0.69 for incidence of absence due to illness and 0.71 for duration of absence).26 One study reported a 43% reduction in absenteeism from school with the use of alcohol gel in addition to handwashing.25 Repeated handwashing significantly reduced the incidence of colds by as much as 20% in two trials.23 73Impregnated disposable handkerchiefsThree cluster randomised studies tested the effects of disposable handkerchiefs impregnated with virucide on the incidence and spread of acute respiratory tract infections. One study reported a reduced incidence from 14% to 5% in households over 26 weeks.27 A similar study reported a small non significant (5%) decrease across families.27 However, as the reduction in incidence was confined to primary illness, which would be unaffected by use of the tissues, it might be assumed that the tissues were ineffective. A community trial also reported a non significant reduction in secondary attack rates of acute respiratory tract infection (18.7% v 11.8%) during high circulation of influenza H3N2 and rhinoviruses in the community.28 This result is likely to be an underestimate because of the barrier effect of the untreated tissue wipes used as control.GarglingOne trial from Japan tested the effects of gargling with water compared with gargling with povidone iodine or gargling as usual.18 This trial is linked by its registration number to a subsequent short report19 and the reporting of the two is confusing. The incidence rate ratio for gargling with water was 0.64 (95% confidence interval 0.41 to 0.99) and for gargling with povidone iodine was 0.89 (0.60 to 1.33). Gargling with povidone iodine seemed to affect compliance because two participants switched to using water. Perhaps this potentially important study, totalling 387 participants in three arms, should be repeated in a larger population and with clearer reporting.Face masksTwo cluster randomised trials assessed the effects on transmission of wearing face masks. In one study carried out in Hong Kong29 face masks were worn after a rapid diagnosis for influenza. Households of the index case were randomised to wearing face masks plus education, handwashing with alcohol sanitiser soap plus education, or education on illness prevention (control group). Surgical face masks were worn by all household members when the index patient was at home. This is likely to be an underestimate of the effect because of the study design.
AbstractObjective To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.Data selection Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow up. Non randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias.Data synthesis 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta analysis of six case control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure that is, the higher the risk the longer the distancing period.Conclusion Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. Overall, epidemics account for most of the 7% of total deaths from respiratory tract infections in the world.3 Our 2007 Cochrane review showed that physical interventions (personal hygiene, barriers, and distancing) are highly effective.4 However, the current mainstay of pandemic interventions still seems to be vaccines and antiviral drugs, with no evidence supporting their widespread use,5 6 7 8 9 10 especially against a seemingly mild threat such as the novel H1N1 virus. For example, in the most recent guidance document on planning for pandemic influenza from the World Health Organization, handwashing and masks were mentioned only twice and gloves and gowns once each, but vaccines and antivirals were cited 24 and 18 times, respectively.11We carried out a systematic review to update our 2007 Cochrane review on the evidence of the effectiveness of public health measures such as isolation, distancing, and barriers to interrupt or reduce the spread of respiratory viruses.MethodsWe considered trials (individual level or cluster randomised, or quasi randomised), observational studies (cohort and case control designs), and any other comparative design, carried out in people of all ages and provided that some attempt had been made to control for confounding. We included any intervention to prevent the transmission of respiratory viruses from animal to human or from human to human (isolation, quarantine, social distancing, barriers, personal protection, or hygiene) compared with no intervention ("do nothing") or another intervention. We excluded vaccines and antivirals.Outcome measures were mortality, numbers of cases of viral illness, the severity of viral illness, or proxies for any of these, and other measures of disease burden (such as admissions to hospital). No language restrictions were applied. Filters for study design included trials, cohort, case control and crossover studies, before and after, and time series. We scanned the references of included studies for other potentially relevant studies.We scanned the titles and abstracts of the studies identified by our search. When a study seemed to meet our eligibility criteria or information was insufficient to exclude it, we obtained the full text articles. We used a standardised form to assess the eligibility of each study, on the basis of the full article.Quality assessmentWe analysed randomised and non randomised studies separately. Risk of bias in the randomised studies was assessed for the method of randomisation, generation of the allocation sequence, allocation concealment, blinding, and follow up. Non randomised studies were assessed for the presence of potential confounders using the appropriate Newcastle Ottawa scales12 for case control and cohort studies, and a three point checklist for controlled before and after and ecological studies.13We assigned categories for risk of bias on the basis of the number of items judged inadequate in each study: up to one inadequate item represented a low risk of bias, up to three items a medium risk, and more than three items a high risk.Aggregation of data depended on the study design, types of comparisons, sensitivity, and homogeneity of definitions of exposure, populations, Hermes birkin bags fake and outcomes used. We calculated the I2 statistic for each pooled estimate to assess the impact of statistical heterogeneity.14 15When possible we carried out a quantitative analysis and summarised replica hermes handbags effectiveness as an odds ratio, with 95% confidence intervals. When a result was significant we calculated absolute intervention effectiveness as a percentage using the formula: intervention effectiveness=1odds ratio.ResultsOf a total 2958 potentially relevant studies scanned for the 2007 review and its 2009 update, 2790 were excluded on the basis of their titles or abstracts, and the full papers of the remaining 168 trials were retrieved. Fifty eight papers of 59 studies were finally included (table 1); eight of these studies were incorporated in the 2009 update. A list of excluded studies will be available in the published Cochrane update.Table 1 Overview of results of physical interventions and types of evidence to interrupt or reduce the spread of respiratory virusesView this table:View popupView inlineThe quality of the included randomised controlled trials varied (see web extra table). Three of the four trials were poorly reported, with two papers (three studies) giving no description of the randomisation sequence, allocation, or allocation concealment.16 17 One trial reported the generation of randomisation, but blinding was impossible owing to the nature of the intervention (gargling with water with or without povidone iodine compared with standard gargling with no attempt to mask the taste of iodine).18 Information provided in a subsequent brief report contradicted the original report.19 The design of the two trials was artificial and therefore the results were not generalisable to daily practice.17The quality of the cluster randomised trials varied (see web extra table). Only the highest quality trials20 21 22 29 reported cluster coefficients and carried out analysis of data by unit of (cluster) randomisation. Other common problems were a lack of description of randomisation procedures, partial reporting of outcomes, unclear numerators or denominators, unexplained attrition,23 24 25 26 and complete failure of double blinding27 or inappropriate choice of placebo.28 Two cluster randomised trials involving the use of face masks29 30 by contacts of patients with influenza and influenza like illness had poor compliance. This illustrates the difficulty of using bulky equipment in clinical trials in the absence of a real threat. In one trial the intervention targeted (randomised) clusters comprising households of index patients with influenza, up to three days after the onset of symptoms in the index case.29 This almost certainly underestimates the effect of the interventions, given that influenza how much is a hermes bag infectivity is highest soon after infection. Another study was underpowered to detect differences in effect between different types of masks.30 A further cluster randomised trial was rated as being at low risk of bias owing to careful evaluation of compliance in the intervention arm (hand sanitiser wipes and disinfection of surfaces).31Five of the seven case control studies had a medium risk of bias32 33 34 35 36 and two a low risk,37 38 mostly because of inconsistencies in the text and lack of adequate description of controls (see web extra table). Six of the 16 prospective cohort studies had a low risk of bias,39 40 41 42 43 44 six a medium risk,45 46 47 48 49 50 and three a high risk (see web extra table).51 52 53 One was a brief report of a small study with insufficient details to allow assessment.54 All five retrospective cohort studies had a high risk of bias (see web extra table).55 56 57 58 59 Six of the 13 controlled before and after studies had a low risk of bias,60 61 62 63 64 65 two a medium risk,66 67 and five a high risk (see web extra table).68 69 70 71 72 Many of the observational studies were poorly reported and the retrospective designs were prone to recall Hermes bag season with the main color coordination bias. The most common problem in all of these studies, however, was that circulation of the virus within the reference population was not reported, questioning the interpretation and generalisability of the conclusions.Reported results from randomised studiesHandwashing with or without antisepticsThree randomised controlled trials tested the effects of cleaning hands on inactivating the virus and preventing experimental colds due to rhinovirus. This resulted either in a reduction in the incidence of rhinovirus infection among volunteers using different combinations of acids for cleaning (P=0.025)17 or did not reach statistical significance (13% v 30% with combined denominator of only 60).17 When iodine treatment of the fingers was used, one of 10 volunteers in the intervention arm became infected compared with six of 10 in the placebo arm (P=0.06, Fisher's exact test).16Eight cluster randomised studies tested educational programmes to promote handwashing with or without antiseptic agents on the incidence of acute respiratory tract infections either in schools or in households. As a result of different definitions, comparisons, lack of reporting of cluster coefficients, and, in two cases, missing data for participants,23 24 meta analysis was not feasible. Three of the trials reported a lack of effect for the prevention of acute respiratory illness: risk ratios 0.94 (95% confidence interval 0.66 to 2.43),24 0.97 (0.72 to 1.30),22 and 1.10 (0.97 to 1.24).31 A possible explanation for the lack of effect is that because exposure to respiratory viruses is ubiquitous, repeated hand hygiene would be needed, which is not practical in busy settings such as schools. Nevertheless, the highest quality trials reported a significant decrease in respiratory illness in children aged up to 24 months (risk ratio 0.90, 0.83 to 0.97), although the decrease was not significant in older children (0.95, 0.89 to 1.01),21 and a 50% (65% to 34%) lower incidence of pneumonia in children aged less than 5 years in a low income country.20 Another study reported a decrease in respiratory tract infections of up to 38% with additional hand rubbing with benzalkonium chloride (risk ratios 0.69 for incidence of absence due to illness and 0.71 for duration of absence).26 One study reported a 43% reduction in absenteeism from school with the use of alcohol gel in addition to handwashing.25 Repeated handwashing significantly reduced the incidence of colds by as much as 20% in two trials.23 73Impregnated disposable handkerchiefsThree cluster randomised studies tested the effects of disposable handkerchiefs impregnated with virucide on the incidence and spread of acute respiratory tract infections. One study reported a reduced incidence from 14% to 5% in households over 26 weeks.27 A similar study reported a small non significant (5%) decrease across families.27 However, as the reduction in incidence was confined to primary illness, which would be unaffected by use of the tissues, it might be assumed that the tissues were ineffective. A community trial also reported a non significant reduction in secondary attack rates of acute respiratory tract infection (18.7% v 11.8%) during high circulation of influenza H3N2 and rhinoviruses in the community.28 This result is likely to be an underestimate because of the barrier effect of the untreated tissue wipes used as control.GarglingOne trial from Japan tested the effects of gargling with water compared with gargling with povidone iodine or gargling as usual.18 This trial is linked by its registration number to a subsequent short report19 and the reporting of the two is confusing. The incidence rate ratio for gargling with water was 0.64 (95% confidence interval 0.41 to 0.99) and for gargling with povidone iodine was 0.89 (0.60 to 1.33). Gargling with povidone iodine seemed to affect compliance because two participants switched to using water. Perhaps this potentially important study, totalling 387 participants in three arms, should be repeated in a larger population and with clearer reporting.Face masksTwo cluster randomised trials assessed the effects on transmission of wearing face masks. In one study carried out in Hong Kong29 face masks were worn after a rapid diagnosis for influenza. Households of the index case were randomised to wearing face masks plus education, handwashing with alcohol sanitiser soap plus education, or education on illness prevention (control group). Surgical face masks were worn by all household members when the index patient was at home. This is likely to be an underestimate of the effect because of the study design.
Pop star Bieber released after drag
[UPDATED] MIAMI BEACH, Fla. A sober looking Justin Bieber was released from jail Thursday following his arrest on charges of driving under the influence, driving with an expired licence and resisting arrest. Police say they stopped the 19 year old pop star while he was drag racing down a Miami Beach street before dawn.
The Stratford, Ont., native was arrested after police said they saw him heading down a residential street in Miami Beach in a yellow Lamborghini at twice the speed limit. Officers say he had an expired licence, was initially not co operative when he was pulled over and smelled of alcohol.
Police say Bieber later admitted that he had been drinking, smoking marijuana and taking prescription medication. R singer Khalil Amir Sharieff was arrested in the same incident. He is charged with driving under the influence. Police said Khalil was driving a Ferrari.
Bieber and Khalil, wearing bright red jail fatigues, made their initial court appearance via a video link from jail. They remained silent while defence attorney Roy Black negotiated bond. Bieber's bond was set at $2,500. Khalil's bond was set at $1,000.
Black, a high profile lawyer whose clients have included Rush Limbaugh and William Kennedy Smith, said he thought the case would proceed "hopefully as any other case would" in light of Bieber's celebrity status. zone.
Earlier Thursday, police chief Ray Martinez said at a news conference that the singer was initially not co operative when the officer pulled him over. Martinez said the singer also had an invalid Georgia driver's licence and admitted to smoking marijuana, taking prescription medication and drinking.
According to the arrest report, Bieber "had slow deliberate movements" and a look of stupor on his face when the officer ordered him to exit his vehicle. Bieber was placed under arrest after repeatedly refusing to put his hands on his vehicle so the officer could pat him down to look for weapons, the report said. It says he cursed several times at the officer and demanded to know why he was being arrested.
Bieber failed a field sobriety test and was taken to the Miami Beach police station for a Breathalyzer, police said. Results haven't been released.
His publicist, Melissa Victor, did not offer an immediate comment.
The street where police say Bieber was racing in mid Miami Beach is a four lane residential street divided by a grass median dotted Hermes Kelly bag replica with palm trees. Along one side of the street are small apartment buildings, and on the other side are a high school, a youth centre, a golf course and a city firehouse.
It's a short drive from the area to trendy South Beach, where celebrities are known to let loose. George Avilas, who lives nearby said he didn't hear anything, but was not surprised to hear that people might be drag racing.
"There's so much partying in Miami Beach, it's been known to happen," he said. "It's 4 o'clock in the morning, everybody is just getting out of the bars."
Bieber was only 15 when his platinum selling debut "My World" was released. He'd placed second in a local singing contest two years earlier and began posting performances on YouTube, according to his official website. The videos caught the attention of a talent agent and eventually led to a recording contract.
He was positioned as clean cut and charming even singing for President Barack Obama and his family at Christmas but problems began to multiply as he got older; Thursday's arrest is just the latest in a series of troubling incidents.
Bieber has been accused of wrongdoing in California, but has never been arrested or charged. He is currently under investigation in a felony vandalism case after a neighbour reported the pop star threw eggs at his house and caused thousands of dollars of damage.
A neighbour had previously accused Bieber of spitting in his face, and a paparazzo called deputies after he said Bieber kicked him, but prosecutors declined to file charges in either instance. He was also accused of reckless driving in his neighbourhood, but in October prosecutors refused to seek charges because it was unclear whether Bieber was driving.
His arrest in Miami is unlikely to affect the current replica hermes birkin handbags investigation, which included nearly a dozen detectives searching Bieber's home last week searching for video surveillance and other evidence that could be used to pursue a vandalism charge.
Bieber is also being sued by a former bodyguard who says the singer repeatedly berated him, hit him in the chest and owes him more than $420,000 in overtime and other wages. The case is scheduled to go to trial in Los Angeles next month.
Under Florida law, people under the age of 21 are considered driving under the influence if they have a blood alcohol content of .02 per cent or more a level Bieber could reach with one drink.
For a first DUI offence, there is no minimum sentence hermes replica and a maximum of six months, a fine of $250 to $500, and 50 hours of community service. For anyone under 21, there is an automatic six month license suspension.
A first conviction for drag racing carries a sentence of up to six months, a fine of $500 to $1,000 and a one year license suspension.
Bieber's arrival in Florida earlier this week also is under investigation.
Police escorts from replica hermes handbags outlet the airport are not uncommon, but they must follow procedure because they involve city vehicles, Chiverton said.
[UPDATED] MIAMI BEACH, Fla. A sober looking Justin Bieber was released from jail Thursday following his arrest on charges of driving under the influence, driving with an expired licence and resisting arrest. Police say they stopped the 19 year old pop star while he was drag racing down a Miami Beach street before dawn.
The Stratford, Ont., native was arrested after police said they saw him heading down a residential street in Miami Beach in a yellow Lamborghini at twice the speed limit. Officers say he had an expired licence, was initially not co operative when he was pulled over and smelled of alcohol.
Police say Bieber later admitted that he had been drinking, smoking marijuana and taking prescription medication. R singer Khalil Amir Sharieff was arrested in the same incident. He is charged with driving under the influence. Police said Khalil was driving a Ferrari.
Bieber and Khalil, wearing bright red jail fatigues, made their initial court appearance via a video link from jail. They remained silent while defence attorney Roy Black negotiated bond. Bieber's bond was set at $2,500. Khalil's bond was set at $1,000.
Black, a high profile lawyer whose clients have included Rush Limbaugh and William Kennedy Smith, said he thought the case would proceed "hopefully as any other case would" in light of Bieber's celebrity status. zone.
Earlier Thursday, police chief Ray Martinez said at a news conference that the singer was initially not co operative when the officer pulled him over. Martinez said the singer also had an invalid Georgia driver's licence and admitted to smoking marijuana, taking prescription medication and drinking.
According to the arrest report, Bieber "had slow deliberate movements" and a look of stupor on his face when the officer ordered him to exit his vehicle. Bieber was placed under arrest after repeatedly refusing to put his hands on his vehicle so the officer could pat him down to look for weapons, the report said. It says he cursed several times at the officer and demanded to know why he was being arrested.
Bieber failed a field sobriety test and was taken to the Miami Beach police station for a Breathalyzer, police said. Results haven't been released.
His publicist, Melissa Victor, did not offer an immediate comment.
The street where police say Bieber was racing in mid Miami Beach is a four lane residential street divided by a grass median dotted Hermes Kelly bag replica with palm trees. Along one side of the street are small apartment buildings, and on the other side are a high school, a youth centre, a golf course and a city firehouse.
It's a short drive from the area to trendy South Beach, where celebrities are known to let loose. George Avilas, who lives nearby said he didn't hear anything, but was not surprised to hear that people might be drag racing.
"There's so much partying in Miami Beach, it's been known to happen," he said. "It's 4 o'clock in the morning, everybody is just getting out of the bars."
Bieber was only 15 when his platinum selling debut "My World" was released. He'd placed second in a local singing contest two years earlier and began posting performances on YouTube, according to his official website. The videos caught the attention of a talent agent and eventually led to a recording contract.
He was positioned as clean cut and charming even singing for President Barack Obama and his family at Christmas but problems began to multiply as he got older; Thursday's arrest is just the latest in a series of troubling incidents.
Bieber has been accused of wrongdoing in California, but has never been arrested or charged. He is currently under investigation in a felony vandalism case after a neighbour reported the pop star threw eggs at his house and caused thousands of dollars of damage.
A neighbour had previously accused Bieber of spitting in his face, and a paparazzo called deputies after he said Bieber kicked him, but prosecutors declined to file charges in either instance. He was also accused of reckless driving in his neighbourhood, but in October prosecutors refused to seek charges because it was unclear whether Bieber was driving.
His arrest in Miami is unlikely to affect the current replica hermes birkin handbags investigation, which included nearly a dozen detectives searching Bieber's home last week searching for video surveillance and other evidence that could be used to pursue a vandalism charge.
Bieber is also being sued by a former bodyguard who says the singer repeatedly berated him, hit him in the chest and owes him more than $420,000 in overtime and other wages. The case is scheduled to go to trial in Los Angeles next month.
Under Florida law, people under the age of 21 are considered driving under the influence if they have a blood alcohol content of .02 per cent or more a level Bieber could reach with one drink.
For a first DUI offence, there is no minimum sentence hermes replica and a maximum of six months, a fine of $250 to $500, and 50 hours of community service. For anyone under 21, there is an automatic six month license suspension.
A first conviction for drag racing carries a sentence of up to six months, a fine of $500 to $1,000 and a one year license suspension.
Bieber's arrival in Florida earlier this week also is under investigation.
Police escorts from replica hermes handbags outlet the airport are not uncommon, but they must follow procedure because they involve city vehicles, Chiverton said.
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Podcasts are the new Xanax
I'm not an early adopter. I'll only start wearing new styles of clothing once they're practically out of date, and I won't move into a neighborhood until it's fully saturated with upscale coffee shops. I was the last person I know to download music and to stop paying for long distance phone calls.
Podcasts were different. I took to them instantly, or at least as soon as I noticed them on my computer. Before long, listening to podcasts was almost medicinal.
This was partly because I'm an expatriate an American living in Paris. I didn't just miss specific people back home, I missed knowing what Americans were doing, thinking, and talking about. After more than a dozen years away, my cultural references were dated, and I often spoke in turn of the century slang.
Movies and TV shows were little help. Most were heavily produced, and usually arrived in France after a lag. But podcasts downloaded everywhere simultaneously. And many were essentially just long, unedited conversations. I could take a bath in Paris while listening to someone in Los Angeles complain about her dating life. Podcasts immersed me in colloquial English and put me back in the American zeitgeist.
At first, this seemed like a virtuous habit. Unlike the time sink of binge watching a TV series, podcasts actually made me more efficient. Practically every dull activity folding laundry, applying makeup became tolerable when I did it while listening to a country singer describing his hardscrabble childhood, or a novelist defending her open marriage.
Sure, most of my conversations soon consisted of small facts that I'd heard on a previous day's podcast. But my fake hermes kelly bagd obsession was educational. I was learning American history by listening toPresidential, which devoted an episode to each president.
And as a mother of three with a full time job, podcasts gave me the illusion of having a vibrant social life. I was constantly "meeting" new people. My favorite hosts started to seem like friends: I could detect small shifts in their moods, and tell when they were flirting with guests.
I could take a bath in Paris how much is a hermes handbag while listening to someone in Los Angeles complain about her dating life.
Unlike actual friendships, which were tingedwith jealousy and resentment, these were stress free. A good podcast conversation was like a dinner party full of fascinating people, but without the risk of saying something stupid and embarrassing myself.
I soon realized that my real life friends were listening to podcasts too. "Terry sounds a little bored. I think she's not an animal person," one emailed me recently, while listening toFresh Airhost Terry Gross interview a wildlife photographer. (Gross perked up once the photographer described how being away at photo shoots affected his marriage.)
Last summer, I discovered the most important advantage of podcasts over people: You can doze off in the middle of a podcast conversation without offending anyone.
The first time this happened, I was listening to aTED Radio Hourpodcast about the nature of time, and woke up eight hours later. I'd taken sleeping pills on and off since entering my 40s. But once I started listening to podcasts before bed, I didn't need the pills anymore.
A good podcast conversation was like a dinner party full of fascinating people, but without the risk of saying something stupid and embarrassing myself.
My challenge was finding the Hermes Kelly bag replica right before bed podcast. It couldn't have jarring theme music. And it had to be intelligent enough to lift me out of my own thoughts and worries, but not so gripping that it would keep me awake.
I couldn't fall asleep to podcasts that made me anxious about my social status or had a party you're not invited to vibe.
The ideal podcast was the adult equivalent of a bedtime story: older people with calm voices, discussing a topic that mildly interested me. Think David Axelrod interviewing Madeleine Albright about her career, or a B list comedian explaining how she overcame her cocaine addiction. When I found a podcast that worked, I'd listen to it night after night, until I practically knew it by heart. election, when I switched to a roster of political podcasts. I was so anxious about the election, hearing people analyze the news was the only thing that calmed me down.
Like all addictions, podcasts helped until they didn't. I was barely interacting with my husband. And I realized that I'd panic a little when I couldn't find my favorite headphones, or when it was just me alone, without any voices in my head. Podcasts still lulled me to sleep, but I'd be awake again five hours later, needing to hear another one.
And there was something vampiric about devouring a person's whole life in an 80 minute podcast interview, then moving on to someone else. Increasingly, I retained little of what I heard. I'd spend a gripping half hour learning about the presidency of Martin Van Buren, but the next day I couldn't tell you anything about him.
Soon after the election, I decided to go cold turkey, at least at night. I switched from podcasts to melatonin. My life felt eerily silent at first, and I had some sleepless nights. Eventually I found that it was enough to insert the earphones, plugged into nothing, before going to sleep. It was the equivalent of carrying around a pack of cigarettes without smoking them.
Still, my birthday is coming up, replica hermes handbags outlet and I'm planning to give myself a special bedtime treat: a sleeping pillanda 40 minute podcast. Just this once, it can't hurt.
I'm not an early adopter. I'll only start wearing new styles of clothing once they're practically out of date, and I won't move into a neighborhood until it's fully saturated with upscale coffee shops. I was the last person I know to download music and to stop paying for long distance phone calls.
Podcasts were different. I took to them instantly, or at least as soon as I noticed them on my computer. Before long, listening to podcasts was almost medicinal.
This was partly because I'm an expatriate an American living in Paris. I didn't just miss specific people back home, I missed knowing what Americans were doing, thinking, and talking about. After more than a dozen years away, my cultural references were dated, and I often spoke in turn of the century slang.
Movies and TV shows were little help. Most were heavily produced, and usually arrived in France after a lag. But podcasts downloaded everywhere simultaneously. And many were essentially just long, unedited conversations. I could take a bath in Paris while listening to someone in Los Angeles complain about her dating life. Podcasts immersed me in colloquial English and put me back in the American zeitgeist.
At first, this seemed like a virtuous habit. Unlike the time sink of binge watching a TV series, podcasts actually made me more efficient. Practically every dull activity folding laundry, applying makeup became tolerable when I did it while listening to a country singer describing his hardscrabble childhood, or a novelist defending her open marriage.
Sure, most of my conversations soon consisted of small facts that I'd heard on a previous day's podcast. But my fake hermes kelly bagd obsession was educational. I was learning American history by listening toPresidential, which devoted an episode to each president.
And as a mother of three with a full time job, podcasts gave me the illusion of having a vibrant social life. I was constantly "meeting" new people. My favorite hosts started to seem like friends: I could detect small shifts in their moods, and tell when they were flirting with guests.
I could take a bath in Paris how much is a hermes handbag while listening to someone in Los Angeles complain about her dating life.
Unlike actual friendships, which were tingedwith jealousy and resentment, these were stress free. A good podcast conversation was like a dinner party full of fascinating people, but without the risk of saying something stupid and embarrassing myself.
I soon realized that my real life friends were listening to podcasts too. "Terry sounds a little bored. I think she's not an animal person," one emailed me recently, while listening toFresh Airhost Terry Gross interview a wildlife photographer. (Gross perked up once the photographer described how being away at photo shoots affected his marriage.)
Last summer, I discovered the most important advantage of podcasts over people: You can doze off in the middle of a podcast conversation without offending anyone.
The first time this happened, I was listening to aTED Radio Hourpodcast about the nature of time, and woke up eight hours later. I'd taken sleeping pills on and off since entering my 40s. But once I started listening to podcasts before bed, I didn't need the pills anymore.
A good podcast conversation was like a dinner party full of fascinating people, but without the risk of saying something stupid and embarrassing myself.
My challenge was finding the Hermes Kelly bag replica right before bed podcast. It couldn't have jarring theme music. And it had to be intelligent enough to lift me out of my own thoughts and worries, but not so gripping that it would keep me awake.
I couldn't fall asleep to podcasts that made me anxious about my social status or had a party you're not invited to vibe.
The ideal podcast was the adult equivalent of a bedtime story: older people with calm voices, discussing a topic that mildly interested me. Think David Axelrod interviewing Madeleine Albright about her career, or a B list comedian explaining how she overcame her cocaine addiction. When I found a podcast that worked, I'd listen to it night after night, until I practically knew it by heart. election, when I switched to a roster of political podcasts. I was so anxious about the election, hearing people analyze the news was the only thing that calmed me down.
Like all addictions, podcasts helped until they didn't. I was barely interacting with my husband. And I realized that I'd panic a little when I couldn't find my favorite headphones, or when it was just me alone, without any voices in my head. Podcasts still lulled me to sleep, but I'd be awake again five hours later, needing to hear another one.
And there was something vampiric about devouring a person's whole life in an 80 minute podcast interview, then moving on to someone else. Increasingly, I retained little of what I heard. I'd spend a gripping half hour learning about the presidency of Martin Van Buren, but the next day I couldn't tell you anything about him.
Soon after the election, I decided to go cold turkey, at least at night. I switched from podcasts to melatonin. My life felt eerily silent at first, and I had some sleepless nights. Eventually I found that it was enough to insert the earphones, plugged into nothing, before going to sleep. It was the equivalent of carrying around a pack of cigarettes without smoking them.
Still, my birthday is coming up, replica hermes handbags outlet and I'm planning to give myself a special bedtime treat: a sleeping pillanda 40 minute podcast. Just this once, it can't hurt.
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patient communication about imminent death
Results: "False optimism about recovery" usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. "False optimism about recovery" was the result an association between doctors' activism and patients' adherence to the treatment calendar and to the "recovery plot," which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did not want to pronounce a "death sentence" and the patient did and did not want to hear it.
Conclusion: Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solutions have to be found outside the doctor patient relationship itself for example, by involving "treatment brokers."
See also Education and debate p 1400Almost all patients with cancer want to know their diagnosis and most patients also want to be informed about the chance that they will be cured.1 This does not imply that these patients want to hear the really bad news about their condition. Many patients, when they fear that their prognosis is rather poor, do not ask for precise information and do not hear it if it is provided by the doctor. 2 3 Our study started from the observation that, after their first course of chemotherapy virtually all patients with small cell lung cancer in a university hospital programme showed a "false optimism" about their recovery, in the sense that the patients' interpretations of their prognosis were considerably more optimistic than those of their doctors. It was not unusual for a patient to tell relatives and friends that the doctor had informed them that they were cured, when actually the cancer was not cured and the life expectancy of these patients was a maximum of two years.
We explored the reasons why virtually all these patients showed this false optimism. This topic is important because patients' ideas about their prognosis affect the choices they make regarding their treatment and end of life care. 4 5 Initially we assumed that features of the communication between doctors (and nurses) and patients had caused this conflict between actual prognosis and what these patients seemed to believe. We examined which aspects of communication between doctors (and nurses) and patients contribute to the fact that patients do not know their poor prognosis. We studied in actual practice what information was given and what information was received and the effects on decision making about treatment and end of life care.6The researcher (AT) initially carried out a study on the role of nurses in decisions concerning euthanasia on a ward for lung disease.7 Only the final phase of euthanasia could be observed, however, because the preparatory process had usually taken place in the outpatient clinic. To determine the handbag Hermes copy moment when patients begin to talk about euthanasia and to investigate comprehensively the subsequent process we also had to make observations in the outpatient clinic. During observations in the clinic it became apparent that patients there rarely dealt with their approaching death. In the waiting room, terminal patients with a maximum life expectancy of a few months said that the doctor had told them that they were cured. They were making plans for the future. In this way, by spending much time observing at the clinic and by focusing on the context of euthanasia, AT discovered the widespread occurrence, familiar to doctors and nurses, of false optimism about recovery. She also discovered that those concerned in the treatment of these patients in daily medical practice considered this false optimism to be a more important problem than euthanasia.
We designed a qualitative observational (ethnographic) study to discover and explore factors in the communication between patients and staff (doctors and nurses) that contribute to false optimism. 8 9 Data were collected through (full time) observation of patients in the lung diseases ward and clinic of a university hospital. After obtaining consent from patients, AT attended their outpatient clinic consultations, had informal conversations with patients and relatives in the clinic waiting room, accompanied them to x ray and other hospital services, and also conducted more formal interviews with patients and staff. On many occasions patients were visited at home, particularly in the terminal phase of their illness when they had stopped attending the outpatient clinic. Funerals were attended and a small number of bereaved spouses interviewed.
In a first stage (1992 4) the researcher (AT) observed a group of 17 patients from initial diagnosis to their death. The size of the sample was based on AT's experience that it was not possible to keep intensive contact with more than about 15 patients and their families. After an initial analysis of the data collected in this first copy handbag Hermes stage, in a second stage (1995 7) a group of 18 patients was observed from initial diagnosis to their death. Data from this second group of copy Hermes Kelly handbag patients confirmed and specified findings from the first group.
From the start of both stages of data collection all new patients with a diagnosis of small cell lung cancer were asked to participate and to give their informed consent. The procedure was approved by the ethics committee. Only two eligible patients were not approached because they avoided any contact with the researcher (AT) from the outset. All approached patients gave their consent to be observed and interviewed and agreed to publication of anonymised extracts of observations and conversations in which they participated. Selection bias cannot be excluded but is unlikely. Participants' ages ranged from 45 to 70 years, and most Hermes handbag fake (28) were men. Most of them were or had been heavy smokers, had attained a relatively low level of education, and had been employed in heavy physical work. All patients had received a first course of chemotherapy. Most of them received further courses after recurrence of the tumour. Radiotherapy was given only as a second or third line treatment in 13 cases, sometimes in combination with chemotherapy.
Box 1 : Bad news consultation
Mr G and his wife come to see the consultant for the results.
"We talked on Monday after the bronchoscopy," says the consultant, "and I told you then that I was almost certain that there is a tumour in your lungs. That's how it looked. And, unfortunately, I must tell you that the lab tests have shown that it is cancer."
The consultant pauses, with a serious expression on his face.
Mr G closes his eyes. "How long have I got, doctor?"
"The type of lung cancer you have is very aggressive. It grows very fast. On the other hand and that's an advantage if I may say so this type of cancer is very sensitive to chemotherapy. It can certainly be treated. We can offer you treatment with chemotherapy, and I would definitely advise you to accept it. If we don't do anything, without treatment it could soon be over. In two or three months it could be the end. With therapy you must think in terms of years. It's difficult to say at this moment how long. It depends on so many things, for instance, how you respond to the therapy. We must wait and see how it develops before I can say anything definite."
After a short pause, the consultant continues, "At this moment we don't know whether it has spread. That must be investigated. But I can tell you that malignant cells have been found in the lymph glands. However, whether it has spread or not makes no difference to treatment. The advantage of chemotherapy is that it goes through the whole body."
"I want to try everything," interrupts Mr G, "Everything. I cannot leave her behind." He looks at his wife.
"We'll fight it together," says the consultant encouragingly, "However, I must tell you a few things about the treatment. Chemotherapy has side effects. Your hair will fall out. You might feel sick. But we can give you something for that. The therapy also affects your blood, and before we can give you any new treatment your blood must be healthy again. Treatment will be given in five sessions. Each time you will have chemotherapy."
Results: "False optimism about recovery" usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. "False optimism about recovery" was the result an association between doctors' activism and patients' adherence to the treatment calendar and to the "recovery plot," which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did not want to pronounce a "death sentence" and the patient did and did not want to hear it.
Conclusion: Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solutions have to be found outside the doctor patient relationship itself for example, by involving "treatment brokers."
See also Education and debate p 1400Almost all patients with cancer want to know their diagnosis and most patients also want to be informed about the chance that they will be cured.1 This does not imply that these patients want to hear the really bad news about their condition. Many patients, when they fear that their prognosis is rather poor, do not ask for precise information and do not hear it if it is provided by the doctor. 2 3 Our study started from the observation that, after their first course of chemotherapy virtually all patients with small cell lung cancer in a university hospital programme showed a "false optimism" about their recovery, in the sense that the patients' interpretations of their prognosis were considerably more optimistic than those of their doctors. It was not unusual for a patient to tell relatives and friends that the doctor had informed them that they were cured, when actually the cancer was not cured and the life expectancy of these patients was a maximum of two years.
We explored the reasons why virtually all these patients showed this false optimism. This topic is important because patients' ideas about their prognosis affect the choices they make regarding their treatment and end of life care. 4 5 Initially we assumed that features of the communication between doctors (and nurses) and patients had caused this conflict between actual prognosis and what these patients seemed to believe. We examined which aspects of communication between doctors (and nurses) and patients contribute to the fact that patients do not know their poor prognosis. We studied in actual practice what information was given and what information was received and the effects on decision making about treatment and end of life care.6The researcher (AT) initially carried out a study on the role of nurses in decisions concerning euthanasia on a ward for lung disease.7 Only the final phase of euthanasia could be observed, however, because the preparatory process had usually taken place in the outpatient clinic. To determine the handbag Hermes copy moment when patients begin to talk about euthanasia and to investigate comprehensively the subsequent process we also had to make observations in the outpatient clinic. During observations in the clinic it became apparent that patients there rarely dealt with their approaching death. In the waiting room, terminal patients with a maximum life expectancy of a few months said that the doctor had told them that they were cured. They were making plans for the future. In this way, by spending much time observing at the clinic and by focusing on the context of euthanasia, AT discovered the widespread occurrence, familiar to doctors and nurses, of false optimism about recovery. She also discovered that those concerned in the treatment of these patients in daily medical practice considered this false optimism to be a more important problem than euthanasia.
We designed a qualitative observational (ethnographic) study to discover and explore factors in the communication between patients and staff (doctors and nurses) that contribute to false optimism. 8 9 Data were collected through (full time) observation of patients in the lung diseases ward and clinic of a university hospital. After obtaining consent from patients, AT attended their outpatient clinic consultations, had informal conversations with patients and relatives in the clinic waiting room, accompanied them to x ray and other hospital services, and also conducted more formal interviews with patients and staff. On many occasions patients were visited at home, particularly in the terminal phase of their illness when they had stopped attending the outpatient clinic. Funerals were attended and a small number of bereaved spouses interviewed.
In a first stage (1992 4) the researcher (AT) observed a group of 17 patients from initial diagnosis to their death. The size of the sample was based on AT's experience that it was not possible to keep intensive contact with more than about 15 patients and their families. After an initial analysis of the data collected in this first copy handbag Hermes stage, in a second stage (1995 7) a group of 18 patients was observed from initial diagnosis to their death. Data from this second group of copy Hermes Kelly handbag patients confirmed and specified findings from the first group.
From the start of both stages of data collection all new patients with a diagnosis of small cell lung cancer were asked to participate and to give their informed consent. The procedure was approved by the ethics committee. Only two eligible patients were not approached because they avoided any contact with the researcher (AT) from the outset. All approached patients gave their consent to be observed and interviewed and agreed to publication of anonymised extracts of observations and conversations in which they participated. Selection bias cannot be excluded but is unlikely. Participants' ages ranged from 45 to 70 years, and most Hermes handbag fake (28) were men. Most of them were or had been heavy smokers, had attained a relatively low level of education, and had been employed in heavy physical work. All patients had received a first course of chemotherapy. Most of them received further courses after recurrence of the tumour. Radiotherapy was given only as a second or third line treatment in 13 cases, sometimes in combination with chemotherapy.
Box 1 : Bad news consultation
Mr G and his wife come to see the consultant for the results.
"We talked on Monday after the bronchoscopy," says the consultant, "and I told you then that I was almost certain that there is a tumour in your lungs. That's how it looked. And, unfortunately, I must tell you that the lab tests have shown that it is cancer."
The consultant pauses, with a serious expression on his face.
Mr G closes his eyes. "How long have I got, doctor?"
"The type of lung cancer you have is very aggressive. It grows very fast. On the other hand and that's an advantage if I may say so this type of cancer is very sensitive to chemotherapy. It can certainly be treated. We can offer you treatment with chemotherapy, and I would definitely advise you to accept it. If we don't do anything, without treatment it could soon be over. In two or three months it could be the end. With therapy you must think in terms of years. It's difficult to say at this moment how long. It depends on so many things, for instance, how you respond to the therapy. We must wait and see how it develops before I can say anything definite."
After a short pause, the consultant continues, "At this moment we don't know whether it has spread. That must be investigated. But I can tell you that malignant cells have been found in the lymph glands. However, whether it has spread or not makes no difference to treatment. The advantage of chemotherapy is that it goes through the whole body."
"I want to try everything," interrupts Mr G, "Everything. I cannot leave her behind." He looks at his wife.
"We'll fight it together," says the consultant encouragingly, "However, I must tell you a few things about the treatment. Chemotherapy has side effects. Your hair will fall out. You might feel sick. But we can give you something for that. The therapy also affects your blood, and before we can give you any new treatment your blood must be healthy again. Treatment will be given in five sessions. Each time you will have chemotherapy."
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Rampant City Crush United
The champions were comprehensively outplayed and beaten by their rivals at the Etihad Stadium, with Sergio Aguero netting twice either side of a Yaya Toure goal before Samir Nasri also got in on the act.
Wayne Rooney's fantastic free kick in the 87th minute made him the top scorer in Manchester derbies with 11 goals, but it was scant consolation for David Moyes' men.
The visitors were missing Robin van Persie due to a groin strain, although David Moyes is hopeful the injury will only keep the Dutchman out for one match. Danny Welbeck and Ashley Young started against City, with Shinji Kagawa benched. Manuel Pellegrini preferred Alvaro Negredo to Edin Dzeko in attack.
The physical style of Negredo and City captain Vincent Kompany upset United almost from the get go and after 16 minutes, the hosts forged ahead.
Poor defending from United down the right led to the opener. Chris Smalling was left one on one with Nasri, and Antonio Valencia failed to track back quickly enough as Aleksandar Kolarov passed his City team mate on the overlap. The Serbian crossed from the left, and Aguero netted with a stylish volley.
Rooney was booked in the Hermes Kelly handbag copy first half for persistent fouling as Kompany won their personal duel.
One minute of added on time at the end of the first half proved crucial for City as they doubled their lead. Pablo Zabaleta won a corner off Young and from Nasri's set piece, Negredo headed down for Toure to force replica Hermes bag the ball home.
Two minutes after the interval, a third City goal arrived. Negredo spun Nemanja Vidic on the left side of the area and knocked a simple cross over for Aguero who had not been tracked to net his second goal of the game.
Kompany made a key contribution as Samir Nasri scored a fourth bag Hermes imitation goal in the 50th minute. Jesus Navas crossed from the right and Kompany drew away the centre backs, allowing Nasri to volley home at the far post.
Tom Cleverley was introduced by Moyes for Young, and United improved. Valencia had a penalty appeal turned down after tussling with Kolarov on the right side of the area.
Patrice Evra headed against the post in the 81st minute, and finally United got on the scoresheet when Rooney flighted home a wonderful free kick three minutes from time.
City and United move on to Capital One Cup assignments in midweek at home to Wigan and Liverpool respectively. City's next league game is away to Aston hermes replica bag Villa next Saturday, when United host West Brom.
The champions were comprehensively outplayed and beaten by their rivals at the Etihad Stadium, with Sergio Aguero netting twice either side of a Yaya Toure goal before Samir Nasri also got in on the act.
Wayne Rooney's fantastic free kick in the 87th minute made him the top scorer in Manchester derbies with 11 goals, but it was scant consolation for David Moyes' men.
The visitors were missing Robin van Persie due to a groin strain, although David Moyes is hopeful the injury will only keep the Dutchman out for one match. Danny Welbeck and Ashley Young started against City, with Shinji Kagawa benched. Manuel Pellegrini preferred Alvaro Negredo to Edin Dzeko in attack.
The physical style of Negredo and City captain Vincent Kompany upset United almost from the get go and after 16 minutes, the hosts forged ahead.
Poor defending from United down the right led to the opener. Chris Smalling was left one on one with Nasri, and Antonio Valencia failed to track back quickly enough as Aleksandar Kolarov passed his City team mate on the overlap. The Serbian crossed from the left, and Aguero netted with a stylish volley.
Rooney was booked in the Hermes Kelly handbag copy first half for persistent fouling as Kompany won their personal duel.
One minute of added on time at the end of the first half proved crucial for City as they doubled their lead. Pablo Zabaleta won a corner off Young and from Nasri's set piece, Negredo headed down for Toure to force replica Hermes bag the ball home.
Two minutes after the interval, a third City goal arrived. Negredo spun Nemanja Vidic on the left side of the area and knocked a simple cross over for Aguero who had not been tracked to net his second goal of the game.
Kompany made a key contribution as Samir Nasri scored a fourth bag Hermes imitation goal in the 50th minute. Jesus Navas crossed from the right and Kompany drew away the centre backs, allowing Nasri to volley home at the far post.
Tom Cleverley was introduced by Moyes for Young, and United improved. Valencia had a penalty appeal turned down after tussling with Kolarov on the right side of the area.
Patrice Evra headed against the post in the 81st minute, and finally United got on the scoresheet when Rooney flighted home a wonderful free kick three minutes from time.
City and United move on to Capital One Cup assignments in midweek at home to Wigan and Liverpool respectively. City's next league game is away to Aston hermes replica bag Villa next Saturday, when United host West Brom.
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Qaida's Core Weakened
intelligence officials are trying to assess just how dangerous al Qaida still is.
They seem to agree that core al Qaida the group that launched the Sept. 11 attacks and looked to bin Laden for guidance Hermes necklace replica is in trouble. The sessions went on for hours. Officials discussed the growing threat from Iran and their concern about cyberattacks and weapons proliferation.
What was dramatically different was how long the discussion on al Qaida lasted: It clocked in at just minutes.
The head of the National Counterterrorism Center, Matthew Olsen, summed up the al Qaida threat this way: "The bottom line, I think, is that al Qaida is weaker now than it has been in the last 10 years," he told the Senate Intelligence Committee on Wednesday.
At a House Intelligence Hermes white gold necklace knock off Committee hearing Thursday, Director of National Intelligence James Clapper said: "As long as we sustain the pressure on it, we judge that core al Qaida will be of largely symbolic importance to the global jihadist movement. But regional affiliates, and to a lesser extent Hermes necklace copy small cells and individuals, will drive the global jihad agenda."
Threat Shifting, But Not Disappearing
Experts say officials are talking about more than just a terrorist group that is decentralized. What they are saying is that something more significant than that has happened: Al Qaida, as a movement, has fragmented. And according to Bruce Hoffman, a professor at Georgetown University and a terrorism expert, that means that the threat al Qaida presents has fundamentally changed.
"The threats may not be as serious as 9/11 and 2001 type threats, because the groups are smaller and, fortunately, less capable," Hoffman says. "Nonetheless, they are much more difficult to identify, much more difficult to track, and much more difficult to anticipate, prevent. intelligence community is turning its focus to groups like al Qaida's arm in Yemen or Islamic militias in Somalia such as al Shabab. It released a video message this week that called on jihadis to focus on the United States; their leader said President Obama was waging a war against Muslims.
This is the kind of clarion call that al Qaida used to sound.
Audrey Kurth Cronin, a professor at the School of Public Policy at George Mason University, says the hearings revealed another important development closer to home the intelligence community has become far less breathless about al Qaida.
"I think that we're returning to a slightly more normal perspective on terrorism," Cronin says. "We're not seeing al Qaida as the only organization that uses terrorism, and we're going back to a broader view where we have threats of terrorism from many different sources, and I think that is the transition that is under way."
Groups May Exploit Arab Spring Instability
This broader view means that officials aren't focusing exclusively on al Qaida affiliates. Instead, they are trolling for any terrorist groups that might be seeking to take advantage of the instability that has followed the Arab Spring. In some cases it might be groups aligned with al Qaida; in other cases they might not.
Consider the availability of guns and other weapons. According to intelligence officials, before the fall of dictator Moammar Gadhafi in Libya, an AK 47 in North Africa cost about $1,000. With the flood of weapons coming out of Libya, an AK 47 now costs about half that.
Georgetown's Hoffman says that's only the beginning.
"If the Syrian government falls and there is the same instability that attended the fall fake Hermes necklace of the Gadhafi regime with the fall of Bashar Assad's regime, the region could be flooded with weapons," he says.
Whether that will help fledgling al Qaida affiliates or new groups is still to be determined. And that's why intelligence officials are watching the developments so closely.
The more immediate question, however, is where this leaves al Qaida.
"The bottom line is, when is it 'rest in peace al Qaida?' " says Cronin.
"And my answer would be 'not yet,' some things require the passage of time. All the indicators are positive, particularly with respect to al Qaida's core," Cronin says. "Al Qaida has declined. But only a historian can declare it is dead."
intelligence officials are trying to assess just how dangerous al Qaida still is.
They seem to agree that core al Qaida the group that launched the Sept. 11 attacks and looked to bin Laden for guidance Hermes necklace replica is in trouble. The sessions went on for hours. Officials discussed the growing threat from Iran and their concern about cyberattacks and weapons proliferation.
What was dramatically different was how long the discussion on al Qaida lasted: It clocked in at just minutes.
The head of the National Counterterrorism Center, Matthew Olsen, summed up the al Qaida threat this way: "The bottom line, I think, is that al Qaida is weaker now than it has been in the last 10 years," he told the Senate Intelligence Committee on Wednesday.
At a House Intelligence Hermes white gold necklace knock off Committee hearing Thursday, Director of National Intelligence James Clapper said: "As long as we sustain the pressure on it, we judge that core al Qaida will be of largely symbolic importance to the global jihadist movement. But regional affiliates, and to a lesser extent Hermes necklace copy small cells and individuals, will drive the global jihad agenda."
Threat Shifting, But Not Disappearing
Experts say officials are talking about more than just a terrorist group that is decentralized. What they are saying is that something more significant than that has happened: Al Qaida, as a movement, has fragmented. And according to Bruce Hoffman, a professor at Georgetown University and a terrorism expert, that means that the threat al Qaida presents has fundamentally changed.
"The threats may not be as serious as 9/11 and 2001 type threats, because the groups are smaller and, fortunately, less capable," Hoffman says. "Nonetheless, they are much more difficult to identify, much more difficult to track, and much more difficult to anticipate, prevent. intelligence community is turning its focus to groups like al Qaida's arm in Yemen or Islamic militias in Somalia such as al Shabab. It released a video message this week that called on jihadis to focus on the United States; their leader said President Obama was waging a war against Muslims.
This is the kind of clarion call that al Qaida used to sound.
Audrey Kurth Cronin, a professor at the School of Public Policy at George Mason University, says the hearings revealed another important development closer to home the intelligence community has become far less breathless about al Qaida.
"I think that we're returning to a slightly more normal perspective on terrorism," Cronin says. "We're not seeing al Qaida as the only organization that uses terrorism, and we're going back to a broader view where we have threats of terrorism from many different sources, and I think that is the transition that is under way."
Groups May Exploit Arab Spring Instability
This broader view means that officials aren't focusing exclusively on al Qaida affiliates. Instead, they are trolling for any terrorist groups that might be seeking to take advantage of the instability that has followed the Arab Spring. In some cases it might be groups aligned with al Qaida; in other cases they might not.
Consider the availability of guns and other weapons. According to intelligence officials, before the fall of dictator Moammar Gadhafi in Libya, an AK 47 in North Africa cost about $1,000. With the flood of weapons coming out of Libya, an AK 47 now costs about half that.
Georgetown's Hoffman says that's only the beginning.
"If the Syrian government falls and there is the same instability that attended the fall fake Hermes necklace of the Gadhafi regime with the fall of Bashar Assad's regime, the region could be flooded with weapons," he says.
Whether that will help fledgling al Qaida affiliates or new groups is still to be determined. And that's why intelligence officials are watching the developments so closely.
The more immediate question, however, is where this leaves al Qaida.
"The bottom line is, when is it 'rest in peace al Qaida?' " says Cronin.
"And my answer would be 'not yet,' some things require the passage of time. All the indicators are positive, particularly with respect to al Qaida's core," Cronin says. "Al Qaida has declined. But only a historian can declare it is dead."
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Proposed 'veterans court' may not reach those who need it most
"I saw a kid (a soldier) get shot in the face. He died right in front of me," Smith said. "It wasn't even in battle. We were just standing around and somebody's gun went off. explosion.
"It was in a convoy. We passed over the spot and the kid was behind us."
Then there was a kid who was really a kid. An Iraqi child "with half his face blown off. That really hit me hard necklace Hermes copy because I had two little girls at home,'' Smith said.
Gregory Bowles was a kid himself when he joined the Marines right after high school during the Vietnam War , following in the footsteps of an uncle who fought in World War II and Korea.
"I'd see him in those dress blues and thought, man, that's it," Bowles said. "Nobody tells you about the other stuff."
The other stuff for Bowles was dragging body parts and body bags out of the bush outside of Saigon and Da Nang during the American evacuation.
"I'd never seen a dead body before that," Bowles said.
A member of his detail went missing and was found dead, barb wired to a tree with a punji stake in his chest.
"There was a note. It said 'Americans Go Home,'" Bowles said.
Two servicemen. Two wars. Gregory Bowles is 67 now and has been wrestling with his post war "demons" for 42 years. Jamie Smith is 47 and has been at it for 10.
But their symptoms of post traumatic stress disorder are hauntingly similar. Unexplained anger. Sleeplessness. A gnawing unease that could only be quieted with drugs first prescribed, then otherwise. Next came the arrests. And job loss. And the alienation of loved ones, the homelessness. The spiral down that led to desperation. Crime.
Both have multiple drug offenses. Bowles also has a conviction of robbery by force and Smith was Hermes replica necklace charged with domestic violence. Both have been in jail and housing for homeless veterans.
A bill being voted on next week by the state Senate will create a "Veteran's Treatment Court Pilot Program." The bill, sponsored by Sen. Jeff Van Drew (D 1st District) and Sen. Diane Allen (R 7th District) will help troubled veterans who are arrested for minor offenses skirt the regular judicial system and instead get the counseling, healthcare and other assistance they need.
An Assembly bill, which cartier earrings replica was passed a month ago and had six bi partisan sponsors, shares the exact language as the Senate bill.
"We can't have these people who served and sacrificed for us sitting in jail cells," Van Drew said. "Their problems are a cry for help. We want to get them the proper care and counseling and get them on the right track."
The bill establishes a three year program to divert "nonviolent offenders" who served in wars "away from the criminal justice system and into appropriate treatment" for drugs and alcohol abuse and mental health issues.
Under that language, however, veterans such as Smith and Bowles would not be eligible.
"While I applaud the effort, which is long overdue, the bill leaves too many veterans out," said Thomas Roughneen, the leading attorney at Citizen Soldier Law, a Chatham practice that specializes in helping veterans and military personnel.
"The awful truth is that many of these people have offenses that are violent or serious, and they are the ones who need help the most," said Roughneen, who is a lieutenant colonel in the New Jersey Army National Guard and an Iraq War veteran.
"Domestic violence is more prevalent than we think among these veterans and it is the start of their downward spiral," he said.
To prove his point, he introduced the cases of Smith and Bowles, neither of whom would have been eligible for the replica Hermes yellow gold necklace new program, as examples of why the program should be expanded to include veterans who might fall outside the criteria, on a case by case basis.
"Their problems all stem from the service," Roughneen said. "The men who went off to serve their country were not the men who came home. Their families want them to get treatment, not thrown in jail."
Roughneen has a letter from Smith's estranged wife, Lisa, to the court after he was charged with drug possession in 2016 which said in part, "It's sad to watch a man you love so much change into someone you can't be around. It's heartbreaking . all we ever wanted was treatment for Jamie."
He admits making threats but said he never struck or manhandled his wife, a statement supported by his wife's letter.
Bowles, who grew up in Elizabeth, said he came from a "law and order family. My father was a city cop. We were on the straight and narrow. I never even smoked a joint before the Marines."
"I saw a kid (a soldier) get shot in the face. He died right in front of me," Smith said. "It wasn't even in battle. We were just standing around and somebody's gun went off. explosion.
"It was in a convoy. We passed over the spot and the kid was behind us."
Then there was a kid who was really a kid. An Iraqi child "with half his face blown off. That really hit me hard necklace Hermes copy because I had two little girls at home,'' Smith said.
Gregory Bowles was a kid himself when he joined the Marines right after high school during the Vietnam War , following in the footsteps of an uncle who fought in World War II and Korea.
"I'd see him in those dress blues and thought, man, that's it," Bowles said. "Nobody tells you about the other stuff."
The other stuff for Bowles was dragging body parts and body bags out of the bush outside of Saigon and Da Nang during the American evacuation.
"I'd never seen a dead body before that," Bowles said.
A member of his detail went missing and was found dead, barb wired to a tree with a punji stake in his chest.
"There was a note. It said 'Americans Go Home,'" Bowles said.
Two servicemen. Two wars. Gregory Bowles is 67 now and has been wrestling with his post war "demons" for 42 years. Jamie Smith is 47 and has been at it for 10.
But their symptoms of post traumatic stress disorder are hauntingly similar. Unexplained anger. Sleeplessness. A gnawing unease that could only be quieted with drugs first prescribed, then otherwise. Next came the arrests. And job loss. And the alienation of loved ones, the homelessness. The spiral down that led to desperation. Crime.
Both have multiple drug offenses. Bowles also has a conviction of robbery by force and Smith was Hermes replica necklace charged with domestic violence. Both have been in jail and housing for homeless veterans.
A bill being voted on next week by the state Senate will create a "Veteran's Treatment Court Pilot Program." The bill, sponsored by Sen. Jeff Van Drew (D 1st District) and Sen. Diane Allen (R 7th District) will help troubled veterans who are arrested for minor offenses skirt the regular judicial system and instead get the counseling, healthcare and other assistance they need.
An Assembly bill, which cartier earrings replica was passed a month ago and had six bi partisan sponsors, shares the exact language as the Senate bill.
"We can't have these people who served and sacrificed for us sitting in jail cells," Van Drew said. "Their problems are a cry for help. We want to get them the proper care and counseling and get them on the right track."
The bill establishes a three year program to divert "nonviolent offenders" who served in wars "away from the criminal justice system and into appropriate treatment" for drugs and alcohol abuse and mental health issues.
Under that language, however, veterans such as Smith and Bowles would not be eligible.
"While I applaud the effort, which is long overdue, the bill leaves too many veterans out," said Thomas Roughneen, the leading attorney at Citizen Soldier Law, a Chatham practice that specializes in helping veterans and military personnel.
"The awful truth is that many of these people have offenses that are violent or serious, and they are the ones who need help the most," said Roughneen, who is a lieutenant colonel in the New Jersey Army National Guard and an Iraq War veteran.
"Domestic violence is more prevalent than we think among these veterans and it is the start of their downward spiral," he said.
To prove his point, he introduced the cases of Smith and Bowles, neither of whom would have been eligible for the replica Hermes yellow gold necklace new program, as examples of why the program should be expanded to include veterans who might fall outside the criteria, on a case by case basis.
"Their problems all stem from the service," Roughneen said. "The men who went off to serve their country were not the men who came home. Their families want them to get treatment, not thrown in jail."
Roughneen has a letter from Smith's estranged wife, Lisa, to the court after he was charged with drug possession in 2016 which said in part, "It's sad to watch a man you love so much change into someone you can't be around. It's heartbreaking . all we ever wanted was treatment for Jamie."
He admits making threats but said he never struck or manhandled his wife, a statement supported by his wife's letter.
Bowles, who grew up in Elizabeth, said he came from a "law and order family. My father was a city cop. We were on the straight and narrow. I never even smoked a joint before the Marines."
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Quantifying Wikipedia Usage Patterns Before Stock Market Moves
AbstractFinancial crises result from a catastrophic combination of actions. Vast stock market datasets offer us a window into some of the actions that have led to these crises. Here, we investigate whether data generated through Internet usage contain traces of attempts to gather information before trading decisions were taken. We present evidence in line with the intriguing suggestion that data on changes in how often financially related Wikipedia pages were viewed may have contained early signs of stock market moves. Our results suggest that online data may allow us to gain new insight into early information gathering stages of decision making.IntroductionThe complex behaviour of our society emerges from decisions made by many individuals. In certain combinations, these numerous decisions can lead to sudden catastrophe, as demonstrated during crowd disasters and financial crises. Stock market data provide extremely detailed records of decisions that traders have made, in an area in which disasters have a widespread impact. As a result, these stock market records have generated considerable scientific attention1,2,3,4,5,6,7,8,9,10,11,12,13,14.Human decision making does not, however, consist solely of the final execution of a chosen action, such as a trade recorded at a stock exchange. Instead, within the constraints of available resources, we often begin by gathering information to help us identify what the consequences of possible actions might be15.With Internet provision becoming so widespread, online resources have become the first port of call in many quests for new information. As a rule, providers of such online resources collect extensive data on their usage, adding to a range of new large scale measurements of collective human behaviour16,17,18,19,20,21. In this way, the ubiquity of the Internet in everyday life has not only changed the way in which people collect information to make decisions, but has opened up new avenues for scientists to investigate the early information gathering stages of decision making processes.Previous studies have demonstrated that analysis of search data can provide insight into current or even subsequent behaviour in the real world. For example, changes in the frequency with which users look for certain terms on search engines such as Google and Yahoo! have been correlated with changes in the numbers of reports of flu infections across the USA22, the popularity of films, games and music on their release23, unemployment rates24,25, tourist numbers25, and trading volumes in the US stock markets26,27. A recent study showed that Internet users from countries with a higher per capita gross domestic product (GDP) search for proportionally more information about the future than information about the past, in comparison with Internet users from countries with a lower per capita GDP28.In work most closely related to the study presented here, Preis, Moat and Stanley outline an analysis of historic data which suggests that changes in search volume for financially relevant search terms can be linked to stock market moves29. A further study analysed data from Twitter and considered the emotions of traders, rather than their information gathering processes, suggesting that changes in the calmness of Twitter messages could be linked to changes in stock market prices30.In this study, we investigate whether data on the usage of the popular online encyclopaedia Wikipedia31,32,33,34 can be linked to subsequent decisions made in the stock markets. Specifically, can we find any evidence that changes in the numbers of views or edits to articles relating to companies and other financial topics on Wikipedia may provide insight into the information gathering process of investors?ResultsTo investigate the relationship between changes in large scale information gathering behaviour on Wikipedia and market participants' trading decisions, we consider data on how often pages on the English language Wikipedia have been viewed, and how often pages on the English language Wikipedia have been edited. Wikipedia entries can be both viewed and edited by any Internet user.We calculate two measures of Wikipedia user activity: the average number of page views and the average number of page edits that have taken place for a given Wikipedia page in week t, where we define weeks as ending on a Sunday. All names of Wikipedia pages used and further details on data pre processing are provided in the Supplementary Information. To quantify changes in information gathering behaviour, we choose one measure of Wikipedia user activity n(t), either page view or page edit volume, and calculate the difference between the page view or page edit volume for week t, to the average copy cartier earrings page view or page edit volume for the previous t weeks: n(t, t) = n(t) N(t 1, t) with N(t 1, t) = (n(t 1) + n(t 2) + + n(t t))/t, where t is measured in units of weeks.We begin our comparison of changes in Wikipedia usage to subsequent stock market movements in this historic data by implementing a hypothetical investment strategy that uses data on either Wikipedia page views or Wikipedia page edits to trade on the Dow Jones Industrial Average (DJIA), following the approach introduced by Preis, Moat, and Stanley29. In this hypothetical strategy, we sell the DJIA at the closing price p(t + 1) on the first trading day of week t + 1 if the volume of views or edits has increased in week t such that n(t, t) > 0. We then close the position by buying the DJIA at price p(t + 2) at the end of the first trading day of the following week t + 2. Note that mechanisms exist which make it possible to sell stocks on a financial market without first owning them. If instead the volume of views or edits has decreased or remained the same in week t such that n(t, t) 0, then we buy the DJIA at the closing price p(t + 1) on the first trading day of week t + 1, and sell the DJIA at price p(t + 2) at the end of the first trading day of the coming week t + 2 to close the position.We calculate the cumulative return R of a strategy by taking the natural log of the ratio of the final portfolio value to the initial portfolio Hermes necklace imitation value. If we take a short position selling at the closing price p(t + 1) and buying back at price p(t + 2) then the change in the cumulative return R for a strategy is log(p(t + 1)) log(p(t + 2)). If we take a long position buying at the closing price p(t + 1) and selling at price p(t + 2) then the change in the cumulative return R is log(p(t + 2)) log(p(t + 1)). In this way, buy and sell actions have symmetric impacts on the cumulative return R of a strategy. In addition, we neglect transaction fees, since the maximum number of transactions per year when using this strategy is only 104, allowing one closing and one opening transaction per week. We note that inclusion of transaction fees would of course diminish any profit if this hypothetical strategy were to be used in the real world. However, this assumption does not have consequences for conclusions about the relationship between user activity on Wikipedia and movements in the DJIA.We compare the returns from the Wikipedia data based strategies to the returns from a random strategy. In the random strategy, a decision is made each week to buy or sell the DJIA. The probability that the DJIA will be bought rather than sold is always 50%, and the decision is unaffected by decisions in previous weeks. This random strategy leads to no significant profit or loss. For the statistical comparisons reported in the following sections, we use 10,000 independent realisations of this random strategy for the period between 10th December 2007 and 30th April 2012. We find no evidence that the overall return from these 10,000 realisations is significantly positive or significantly negative (mean return = 0.0002, V = 25012353, p = 0.97, = 0.05, two tailed one sample Wilcoxon signed rank test of symmetry of distribution of returns around 0). We use a non parametric test to check this point, as the distribution of returns deviates significantly from the normal distribution (D = 0.1716, p = 0.05, Kolmogorov Smirnov test). Similarly, the remainder of the analyses of return distributions reported here also use non parametric tests. Throughout the rest of the results, the cumulative returns R of all non random strategies are stated in terms of standard deviations above or below the mean cumulative return of the random strategy.Views and edits of Wikipedia articles about companies listed in the DJIAFigure 1 shows the distributions of returns from two portfolios of 30 hypothetical strategies, trading weekly on the DJIA. These trading strategies are based on changes in how often the 30 Wikipedia pages describing the companies in the DJIA were viewed (blue) and edited (red) during the period December 2007 April 2012, with t = 3 weeks. The distribution of returns from 10,000 independent realisations of a random strategy is also shown (gray). The distribution of returns from 10,000 independent realizations of a random strategy is also shown (gray). Data is displayed using a kernel density estimate and the ggplot2 library36, with a Gaussian kernel and bandwidth calculated using Silverman's rule of thumb37. Whereas we show in the text that random strategies lead to no significant profit or loss, we find that the returns of Wikipedia article view based strategies for this period are significantly higher than the returns of the random strategies (mean R = 0.50; W = 199690, p = 0.005, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). There is however no statistically significant difference between the returns from the Wikipedia edit based strategies and the random strategies (mean R = 0.09; W = 140781, p > 0.9, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).We find that there are significant differences between these three distributions (2 = 10.21, df = 2, p = 0.006, = 0.05; Kruskal Wallis rank sum test). Our analysis shows that the returns of Wikipedia page view based strategies for this period are significantly higher than the returns of the random strategies (mean R = 0.50; W = 199690, p = 0.005, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). There is however no statistically significant difference between the returns from the Wikipedia edit based strategies and the random strategies (mean R = 0.09; W = 140781, p > 0.9, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).Views and edits of Wikipedia articles about financial topicsWe investigate whether these results extend to Wikipedia articles on more general financial topics. To address this question, we make use of the fact that Wikipedia contains lists of pages relating to specific topics. Here, we examine view and edit data for 285 pages relating to general economic concepts, as listed in the subsection "General economic concepts" on the English language Wikipedia page "Outline of economics".Figure 2 shows the results of an analysis of the distribution of returns from two portfolios of 285 hypothetical strategies, trading weekly on the DJIA. These strategies are based on changes in how often these 285 financially related Wikipedia pages were viewed (blue) and edited knock off Hermes necklace (red) during the same period, again with t = 3 weeks. As before, we find that there is a significant difference between the returns generated by the random strategies, the Wikipedia view based strategies and the Wikipedia edit based strategies (2 = 307.88, df = 2, p = 0.05; Kruskal Wallis rank sum test). As before, the returns of Wikipedia page view based strategies are significantly higher than the returns of random strategies for this period (mean R = 1.10; W = 2286608, p = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Once again however, we find no evidence of a statistically significant difference between the returns from the Wikipedia edit based strategies, and the random strategies (mean R = 0.12; W = 1516626, p = 0.19, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Our analysis shows that the returns of Wikipedia page view based strategies are significantly higher than the returns of random strategies for this period (mean R = 1.10; W = 2286608, p = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Once again however, we find no evidence of a statistically significant difference between the returns from the Wikipedia edit based strategies, and the random strategies (mean R = 0.12; W = 1516626, p = 0.19, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).The lack of relationship found for the data on Wikipedia edits may simply reflect the substantial difference in the volume of data available for views and for edits, despite the much larger number of pages considered in this second analysis. For example, across the whole period, the Wikipedia articles on financial topics had an average of 1,351,796 views each, but replica Hermes yellow gold necklace only 431 edits. Of these pages, the most viewed page had 14,449,973 views, in comparison to 4832 edits. The least viewed page had 2,033 views, whereas 43 of the 285 pages in question had no edits at all. For the purposes of this study, we therefore do not consider edit data further.Strategy returns in different yearsThe period of time we investigate here includes a particularly large drop in the DJIA in 2008. We therefore investigate what the returns from these trading strategies would have been for each individual year in our study period. Again, we consider the returns of strategies based on changes in views of the 285 financially related Wikipedia pages, again with t = 3 weeks. In Figure 3, the distribution of returns from the trading strategies are shown for each of the four years for which we have full Wikipedia page view data (blue) alongside returns from random strategies for that year (grey). The distribution of returns from the trading strategies, again with t = 3 weeks, are shown for each of the four years for which we have full Wikipedia page view data (blue) alongside returns from random strategies for that year (grey). Whilst returns differ from year to year (mean return for each year in standard deviations of random strategy returns for the given year: 2008, 0.89; 2009, 0.19; 2010, 0.19; 2011, 0.55; 2 = 129.49, df = 3, p W = 2156094, p W = 1584915, p = 0.001; 2010: W = 1585336, p = 0.001; 2011: W = 1915511, p = 0.05; all two tailed two sample Wilcoxon rank sum tests, using comparisons to the random strategy distributions for the given year).We find that returns do differ from year to year (mean return for each year in standard deviations of random strategy returns for the given year: 2008, 0.89; 2009, 0.19; 2010, 0.19; 2011, 0.55; 2 = 129.49, df = 3, p W = 2156094, p W = 1584915, p = 0.001; 2010: W = 1585336, p = 0.001; 2011: W = 1915511, p = 0.05; all two tailed two sample Wilcoxon rank sum tests, using comparisons to the distribution of random strategy returns for the given year).The effect of tWe investigate the effect of changes in t on the returns from the trading strategies. Again, we consider portfolios of trading strategies based on changes in views of the 285 financially related Wikipedia pages. The mean return from trading strategies, expressed in standard deviations of random strategy returns, is shown in Figure S1 (see Supplementary Information) for t = 1 to 10 weeks. We find that the mean return of the strategies does differ significantly for the different values of t we tested (2 = 93.26, df = 9, p t between 1 and 10 weeks (all Ws > 1950000, all psMean return of the DJIA following increases and decreases in Wikipedia viewsTo complement the trading strategy analysis, we carry out a further analysis of weekly DJIA returns following increases and decreases in views of Wikipedia articles on financial topics.For each of the 285 Wikipedia articles on financial topics, we identify all weeks t within our study period in which the volume of page views increased in week t such that n(t, t) > 0, using t = 3. Across this set of weeks, we calculate the mean return of the DJIA during week t + 1, log(p(t + 2)) log(p(t + 1)). Similarly, we calculate the mean return of the DJIA during week t + 1 for the set of weeks in which the volume of page views decreased in week t such that n(t, t)Between these two sets of weeks, we find a significant difference in the mean return of the DJIA during week t + 1 (W = 78012, p = 0.05, two tailed two sample Wilcoxon rank sum test). Following a decrease in views of Wikipedia pages relating to financial topics, we find a mean DJIA weekly return of 0.0027 a return significantly greater than 0 (V = 39592, p = 0.05, two tailed one sample Wilcoxon signed rank test). In contrast, following an increase in views of Wikipedia pages relating to financial topics in week t, we find a mean DJIA weekly return of 0.0021, significantly less than 0 (V = 2222, p = 0.05, two tailed one sample Wilcoxon signed rank test). The results of this analysis are therefore in line with the relationship between changes in views of Wikipedia articles on financial topics and subsequent movements in the DJIA suggested by the trading strategy analysis.
AbstractFinancial crises result from a catastrophic combination of actions. Vast stock market datasets offer us a window into some of the actions that have led to these crises. Here, we investigate whether data generated through Internet usage contain traces of attempts to gather information before trading decisions were taken. We present evidence in line with the intriguing suggestion that data on changes in how often financially related Wikipedia pages were viewed may have contained early signs of stock market moves. Our results suggest that online data may allow us to gain new insight into early information gathering stages of decision making.IntroductionThe complex behaviour of our society emerges from decisions made by many individuals. In certain combinations, these numerous decisions can lead to sudden catastrophe, as demonstrated during crowd disasters and financial crises. Stock market data provide extremely detailed records of decisions that traders have made, in an area in which disasters have a widespread impact. As a result, these stock market records have generated considerable scientific attention1,2,3,4,5,6,7,8,9,10,11,12,13,14.Human decision making does not, however, consist solely of the final execution of a chosen action, such as a trade recorded at a stock exchange. Instead, within the constraints of available resources, we often begin by gathering information to help us identify what the consequences of possible actions might be15.With Internet provision becoming so widespread, online resources have become the first port of call in many quests for new information. As a rule, providers of such online resources collect extensive data on their usage, adding to a range of new large scale measurements of collective human behaviour16,17,18,19,20,21. In this way, the ubiquity of the Internet in everyday life has not only changed the way in which people collect information to make decisions, but has opened up new avenues for scientists to investigate the early information gathering stages of decision making processes.Previous studies have demonstrated that analysis of search data can provide insight into current or even subsequent behaviour in the real world. For example, changes in the frequency with which users look for certain terms on search engines such as Google and Yahoo! have been correlated with changes in the numbers of reports of flu infections across the USA22, the popularity of films, games and music on their release23, unemployment rates24,25, tourist numbers25, and trading volumes in the US stock markets26,27. A recent study showed that Internet users from countries with a higher per capita gross domestic product (GDP) search for proportionally more information about the future than information about the past, in comparison with Internet users from countries with a lower per capita GDP28.In work most closely related to the study presented here, Preis, Moat and Stanley outline an analysis of historic data which suggests that changes in search volume for financially relevant search terms can be linked to stock market moves29. A further study analysed data from Twitter and considered the emotions of traders, rather than their information gathering processes, suggesting that changes in the calmness of Twitter messages could be linked to changes in stock market prices30.In this study, we investigate whether data on the usage of the popular online encyclopaedia Wikipedia31,32,33,34 can be linked to subsequent decisions made in the stock markets. Specifically, can we find any evidence that changes in the numbers of views or edits to articles relating to companies and other financial topics on Wikipedia may provide insight into the information gathering process of investors?ResultsTo investigate the relationship between changes in large scale information gathering behaviour on Wikipedia and market participants' trading decisions, we consider data on how often pages on the English language Wikipedia have been viewed, and how often pages on the English language Wikipedia have been edited. Wikipedia entries can be both viewed and edited by any Internet user.We calculate two measures of Wikipedia user activity: the average number of page views and the average number of page edits that have taken place for a given Wikipedia page in week t, where we define weeks as ending on a Sunday. All names of Wikipedia pages used and further details on data pre processing are provided in the Supplementary Information. To quantify changes in information gathering behaviour, we choose one measure of Wikipedia user activity n(t), either page view or page edit volume, and calculate the difference between the page view or page edit volume for week t, to the average copy cartier earrings page view or page edit volume for the previous t weeks: n(t, t) = n(t) N(t 1, t) with N(t 1, t) = (n(t 1) + n(t 2) + + n(t t))/t, where t is measured in units of weeks.We begin our comparison of changes in Wikipedia usage to subsequent stock market movements in this historic data by implementing a hypothetical investment strategy that uses data on either Wikipedia page views or Wikipedia page edits to trade on the Dow Jones Industrial Average (DJIA), following the approach introduced by Preis, Moat, and Stanley29. In this hypothetical strategy, we sell the DJIA at the closing price p(t + 1) on the first trading day of week t + 1 if the volume of views or edits has increased in week t such that n(t, t) > 0. We then close the position by buying the DJIA at price p(t + 2) at the end of the first trading day of the following week t + 2. Note that mechanisms exist which make it possible to sell stocks on a financial market without first owning them. If instead the volume of views or edits has decreased or remained the same in week t such that n(t, t) 0, then we buy the DJIA at the closing price p(t + 1) on the first trading day of week t + 1, and sell the DJIA at price p(t + 2) at the end of the first trading day of the coming week t + 2 to close the position.We calculate the cumulative return R of a strategy by taking the natural log of the ratio of the final portfolio value to the initial portfolio Hermes necklace imitation value. If we take a short position selling at the closing price p(t + 1) and buying back at price p(t + 2) then the change in the cumulative return R for a strategy is log(p(t + 1)) log(p(t + 2)). If we take a long position buying at the closing price p(t + 1) and selling at price p(t + 2) then the change in the cumulative return R is log(p(t + 2)) log(p(t + 1)). In this way, buy and sell actions have symmetric impacts on the cumulative return R of a strategy. In addition, we neglect transaction fees, since the maximum number of transactions per year when using this strategy is only 104, allowing one closing and one opening transaction per week. We note that inclusion of transaction fees would of course diminish any profit if this hypothetical strategy were to be used in the real world. However, this assumption does not have consequences for conclusions about the relationship between user activity on Wikipedia and movements in the DJIA.We compare the returns from the Wikipedia data based strategies to the returns from a random strategy. In the random strategy, a decision is made each week to buy or sell the DJIA. The probability that the DJIA will be bought rather than sold is always 50%, and the decision is unaffected by decisions in previous weeks. This random strategy leads to no significant profit or loss. For the statistical comparisons reported in the following sections, we use 10,000 independent realisations of this random strategy for the period between 10th December 2007 and 30th April 2012. We find no evidence that the overall return from these 10,000 realisations is significantly positive or significantly negative (mean return = 0.0002, V = 25012353, p = 0.97, = 0.05, two tailed one sample Wilcoxon signed rank test of symmetry of distribution of returns around 0). We use a non parametric test to check this point, as the distribution of returns deviates significantly from the normal distribution (D = 0.1716, p = 0.05, Kolmogorov Smirnov test). Similarly, the remainder of the analyses of return distributions reported here also use non parametric tests. Throughout the rest of the results, the cumulative returns R of all non random strategies are stated in terms of standard deviations above or below the mean cumulative return of the random strategy.Views and edits of Wikipedia articles about companies listed in the DJIAFigure 1 shows the distributions of returns from two portfolios of 30 hypothetical strategies, trading weekly on the DJIA. These trading strategies are based on changes in how often the 30 Wikipedia pages describing the companies in the DJIA were viewed (blue) and edited (red) during the period December 2007 April 2012, with t = 3 weeks. The distribution of returns from 10,000 independent realisations of a random strategy is also shown (gray). The distribution of returns from 10,000 independent realizations of a random strategy is also shown (gray). Data is displayed using a kernel density estimate and the ggplot2 library36, with a Gaussian kernel and bandwidth calculated using Silverman's rule of thumb37. Whereas we show in the text that random strategies lead to no significant profit or loss, we find that the returns of Wikipedia article view based strategies for this period are significantly higher than the returns of the random strategies (mean R = 0.50; W = 199690, p = 0.005, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). There is however no statistically significant difference between the returns from the Wikipedia edit based strategies and the random strategies (mean R = 0.09; W = 140781, p > 0.9, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).We find that there are significant differences between these three distributions (2 = 10.21, df = 2, p = 0.006, = 0.05; Kruskal Wallis rank sum test). Our analysis shows that the returns of Wikipedia page view based strategies for this period are significantly higher than the returns of the random strategies (mean R = 0.50; W = 199690, p = 0.005, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). There is however no statistically significant difference between the returns from the Wikipedia edit based strategies and the random strategies (mean R = 0.09; W = 140781, p > 0.9, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).Views and edits of Wikipedia articles about financial topicsWe investigate whether these results extend to Wikipedia articles on more general financial topics. To address this question, we make use of the fact that Wikipedia contains lists of pages relating to specific topics. Here, we examine view and edit data for 285 pages relating to general economic concepts, as listed in the subsection "General economic concepts" on the English language Wikipedia page "Outline of economics".Figure 2 shows the results of an analysis of the distribution of returns from two portfolios of 285 hypothetical strategies, trading weekly on the DJIA. These strategies are based on changes in how often these 285 financially related Wikipedia pages were viewed (blue) and edited knock off Hermes necklace (red) during the same period, again with t = 3 weeks. As before, we find that there is a significant difference between the returns generated by the random strategies, the Wikipedia view based strategies and the Wikipedia edit based strategies (2 = 307.88, df = 2, p = 0.05; Kruskal Wallis rank sum test). As before, the returns of Wikipedia page view based strategies are significantly higher than the returns of random strategies for this period (mean R = 1.10; W = 2286608, p = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Once again however, we find no evidence of a statistically significant difference between the returns from the Wikipedia edit based strategies, and the random strategies (mean R = 0.12; W = 1516626, p = 0.19, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Our analysis shows that the returns of Wikipedia page view based strategies are significantly higher than the returns of random strategies for this period (mean R = 1.10; W = 2286608, p = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied). Once again however, we find no evidence of a statistically significant difference between the returns from the Wikipedia edit based strategies, and the random strategies (mean R = 0.12; W = 1516626, p = 0.19, = 0.05, two tailed two sample Wilcoxon rank sum test, Bonferroni correction applied).The lack of relationship found for the data on Wikipedia edits may simply reflect the substantial difference in the volume of data available for views and for edits, despite the much larger number of pages considered in this second analysis. For example, across the whole period, the Wikipedia articles on financial topics had an average of 1,351,796 views each, but replica Hermes yellow gold necklace only 431 edits. Of these pages, the most viewed page had 14,449,973 views, in comparison to 4832 edits. The least viewed page had 2,033 views, whereas 43 of the 285 pages in question had no edits at all. For the purposes of this study, we therefore do not consider edit data further.Strategy returns in different yearsThe period of time we investigate here includes a particularly large drop in the DJIA in 2008. We therefore investigate what the returns from these trading strategies would have been for each individual year in our study period. Again, we consider the returns of strategies based on changes in views of the 285 financially related Wikipedia pages, again with t = 3 weeks. In Figure 3, the distribution of returns from the trading strategies are shown for each of the four years for which we have full Wikipedia page view data (blue) alongside returns from random strategies for that year (grey). The distribution of returns from the trading strategies, again with t = 3 weeks, are shown for each of the four years for which we have full Wikipedia page view data (blue) alongside returns from random strategies for that year (grey). Whilst returns differ from year to year (mean return for each year in standard deviations of random strategy returns for the given year: 2008, 0.89; 2009, 0.19; 2010, 0.19; 2011, 0.55; 2 = 129.49, df = 3, p W = 2156094, p W = 1584915, p = 0.001; 2010: W = 1585336, p = 0.001; 2011: W = 1915511, p = 0.05; all two tailed two sample Wilcoxon rank sum tests, using comparisons to the random strategy distributions for the given year).We find that returns do differ from year to year (mean return for each year in standard deviations of random strategy returns for the given year: 2008, 0.89; 2009, 0.19; 2010, 0.19; 2011, 0.55; 2 = 129.49, df = 3, p W = 2156094, p W = 1584915, p = 0.001; 2010: W = 1585336, p = 0.001; 2011: W = 1915511, p = 0.05; all two tailed two sample Wilcoxon rank sum tests, using comparisons to the distribution of random strategy returns for the given year).The effect of tWe investigate the effect of changes in t on the returns from the trading strategies. Again, we consider portfolios of trading strategies based on changes in views of the 285 financially related Wikipedia pages. The mean return from trading strategies, expressed in standard deviations of random strategy returns, is shown in Figure S1 (see Supplementary Information) for t = 1 to 10 weeks. We find that the mean return of the strategies does differ significantly for the different values of t we tested (2 = 93.26, df = 9, p t between 1 and 10 weeks (all Ws > 1950000, all psMean return of the DJIA following increases and decreases in Wikipedia viewsTo complement the trading strategy analysis, we carry out a further analysis of weekly DJIA returns following increases and decreases in views of Wikipedia articles on financial topics.For each of the 285 Wikipedia articles on financial topics, we identify all weeks t within our study period in which the volume of page views increased in week t such that n(t, t) > 0, using t = 3. Across this set of weeks, we calculate the mean return of the DJIA during week t + 1, log(p(t + 2)) log(p(t + 1)). Similarly, we calculate the mean return of the DJIA during week t + 1 for the set of weeks in which the volume of page views decreased in week t such that n(t, t)Between these two sets of weeks, we find a significant difference in the mean return of the DJIA during week t + 1 (W = 78012, p = 0.05, two tailed two sample Wilcoxon rank sum test). Following a decrease in views of Wikipedia pages relating to financial topics, we find a mean DJIA weekly return of 0.0027 a return significantly greater than 0 (V = 39592, p = 0.05, two tailed one sample Wilcoxon signed rank test). In contrast, following an increase in views of Wikipedia pages relating to financial topics in week t, we find a mean DJIA weekly return of 0.0021, significantly less than 0 (V = 2222, p = 0.05, two tailed one sample Wilcoxon signed rank test). The results of this analysis are therefore in line with the relationship between changes in views of Wikipedia articles on financial topics and subsequent movements in the DJIA suggested by the trading strategy analysis.
Proehl Carlson Obituary
Carlson (Holt, Proehl), Deborah Ann Age 62 of New Brighton, MN passed away on April 2, 2017 due to complications from kidney cancer. Deb was born on October 22, 1954 in Omaha, NE, to parents Lloyd JoAnn Holt. She graduated from Richfield High School and earned degrees in secondary education and nursing from Mankato State University. Deb held a variety of nursing positions ultimately becoming the Director of Nursing at the U of M's Boynton Health. Deb married Harry Carlson on November 2, 2003. Deb was a vivacious lady who lit up the room with Hermes Birkin bag imitation her smile and was young at heart. She had a passion for dancing to the hard rock music of those half her age. Her focus was singly on her family. Hermes bag imitation She poured her kindhearted personality into being an amazing mother, often saying that raising her Hermes Kelly handbag copy children was her proudest accomplishment. She leaves behind her husband, her brother Mark (Sheryl) Holt, her son David (Heather) Proehl, daughter Michelle (Allan) Vitus and grandson Ethan, step children Tom Carlson (Kari Slettemoen) Hermes Kelly handbag imitation and Mick (Bev) Carlson and grandchildren Van and Sydney. Memorial gathering to be held at Silverwood Park Island in St. Anthony at 11AM, Saturday April 8th.
Carlson (Holt, Proehl), Deborah Ann Age 62 of New Brighton, MN passed away on April 2, 2017 due to complications from kidney cancer. Deb was born on October 22, 1954 in Omaha, NE, to parents Lloyd JoAnn Holt. She graduated from Richfield High School and earned degrees in secondary education and nursing from Mankato State University. Deb held a variety of nursing positions ultimately becoming the Director of Nursing at the U of M's Boynton Health. Deb married Harry Carlson on November 2, 2003. Deb was a vivacious lady who lit up the room with Hermes Birkin bag imitation her smile and was young at heart. She had a passion for dancing to the hard rock music of those half her age. Her focus was singly on her family. Hermes bag imitation She poured her kindhearted personality into being an amazing mother, often saying that raising her Hermes Kelly handbag copy children was her proudest accomplishment. She leaves behind her husband, her brother Mark (Sheryl) Holt, her son David (Heather) Proehl, daughter Michelle (Allan) Vitus and grandson Ethan, step children Tom Carlson (Kari Slettemoen) Hermes Kelly handbag imitation and Mick (Bev) Carlson and grandchildren Van and Sydney. Memorial gathering to be held at Silverwood Park Island in St. Anthony at 11AM, Saturday April 8th.
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questions in Natalee Holloway case
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