text:
High Peak
'Established in 1975 with the aim of preserving our local footpaths by walking them, we are forty years old and have a membership of around 150 people ...'
'The walking available from the town centre is excellent and varies from short easy walks to challenging day-long hikes. The renowned and stunning Millennium Walkway within the Torrs Gorge can be accessed by footpaths from several places in the town, and the walkway links directly to 2 local nature reserves, and the Sett Valley Trail, as well as providing a vital link to the Goyt Way ... The 14-mile Trespass Trail (a circular walk starting in New Mills) was devised as part of the 75th anniversary celebrations of the Kinder Scout Mass Trespass.'
'The Touchstones illustrate Air, Water, Earth and Fire. The stones are situated on a five-mile walk around the edges of the village. A central Touchstone combines all four elements. A celtic symbol is present on all the touchstones to signify the millennium.'
'Extends from the River Wye and Pavilion Gardens in Buxton to the confluence of the River Dane with the River Wheelock at Middlewich - a measured distance 40.6 miles. After the first 3 miles of climbing the rest of the route is generally downhill.' Note that Discover Cheshire no longer seem to provide access to a description of the full route via their Website.
A walker's guide to the Dane Valley Way : a walk from Buxton to Middlewich following the River Dane as closely as present paths allow (South and East Cheshire Area of the Ramblers' Association, 1999) [The Chronicle Series] | Dane Valley Way [GPS Cycle & Walking Routes]
'What makes Derwent Edge particularly special for me are the rocky tors that are sprinkled along the route. These weathered gritstone outcrops form all manner of wonderful shapes, with equally colourful names - Salt Cellar, Cakes of Bread and Wheelstones. It is difficult and even unfair to select favourites, but the walk along Derwent Edge is truly wonderful. It's a good long walk and high enough that you can feel the air and space around you ...'
'Stretching from Ladybower Reservoir in the north to Shardlow in the south, the walk through the valley offers varied scenery and a way-marked route. Passing through the Peak District National Park via Chatsworth Park and the breath taking scenery around the Derbyshire dales and Derwent Valley Mills World Heritage Site, the riverside path continues to Journey's End where the Derwent flows into the River Trent.'
National Heritage Corridor [Derwent Valley Trust]
A new challenge event: 'There will be two routes of 24.5 and 13 miles, to be completed in 10 hours from the Burbage Institute, Buxton (SK044729).' Held Early October.
'Officially opened in 2012 following a project by a group of residents to celebrate the area's rich heritage. The trail, funded by the Heritage Lottery Fund and other local contributions, provides an opportunity for everyone who lives in or visits the area to enjoy its historical and environmental diversity ... You can follow one of four colour-coded trails, and along each you'll find a number of information boards that describe the characteristics of the area you're in.'
Hadfield & Padfield Heritage Trail Group
'Walks from the Buxton Line ... Walks from the Glossop Line ... Walks from the Hope Valley Line ... The Six Stations Walk'
'The PLACES OF INTEREST section is an extensive guide to any visitor wishing to explore what our wonderful area has to offer. You'll find superb walks, printable maps, guides and information about our gorgeous area.' Details of about two dozen Walks.
'Encircles Kinder Scout and will provide an iconic new long-distance and challenging riding route in the centre of the country. It draws on existing bridleways, the Pennine Bridleway and the Trans-Pennine Trail to establish a 55 mile circular route through dramatic scenery.'
'The MoorLIFE Project produced a series of downloadable audio guides for use as self-guided walking tours across some of the stunning areas which have benefited from conservation works under the project. Each trail consists of a series of MP3 tracks, a route map showing the stopping points for each trail. Photos accompany each trail, and the tracks can be played on a pc or laptop, offering a virtual tour to these moorlands, their history and the work we have carried out under the MoorLIFE project.'
'New Mills has an extensive conservation area which has contributed to preserving and enhancing the architectural heritage and character of the town's public buildings, shops, and houses.'
'Stretching from the moorland tops of the South Pennines to the gentle limestone scenery of the Derbyshire Dales, the route embraces the urban edges of Sheffield and Oldham, as well as Staffordshire's rugged moorland and the undulating slopes of Cheshire. Follow the route along existing footpaths, tracks, quiet lanes, former railway lines and a canal towpath. Enjoy some quiet and little known corners of the national park. Walk it in day stages or tackle it all in one go ...' Launched in June 2017.
'268 miles of chasing the Pennine Mountain tops along the rugged backbone of England, from the Peak District through the Yorkshire Dales and over Hadrian's Wall to the Cheviots. Amongst the finest upland walking in England.'
'Walk round Buxton passing through many of the woodlands which surround the town. This guide also describes links to the walk from the town centre and from Poole's Cavern Visitor Centre; using these links, the route can be completed as three shorter circular walks, each of about 3-4 miles/5-6km.'
'The 1932 Mass Trespass on Kinder Scout has been described as the most significant event in the century-old battle for the Right to Roam on Britain's mountains and moorlands, now enshrined in law under the 2000 Countryside and Rights of Way Act ... Now you can follow in the footsteps of the trespassers by walking the Trespass Trail, a 14-mile walk starting and finishing at New Mills, where there are rail connections from Manchester and Sheffield.' ALERT Unfortunately, the Trespass Trail Website (and the Friends of Kinder Trespass?) seem no longer; so I have changed the Link to a description by LDWA.
Friends of Kinder Trespass
Directory Statistics
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text:
Pizza Hut Reviews & Details
Pizza Hut
8210 Windfall Ln
(317) 856-9989
Pizza Hut is located at 8210 Windfall Ln in Camby near the intersection of Windfall Ln and Enterprise Dr. Their menu consists of American dishes . Call (317) 856-9989 for delivery or takeout.
- Cuisine:American
- Service:Delivery and Takeout
- On The Menu:Pizza
- Major Intersection:Windfall Ln And Enterprise Dr
Tell us more about Pizza Hut Camby!
Pizza Hut Reviews, Camby
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subset: commoncrawl


text:
Talking about risk in the context of genomic tests (TARGET): development and evaluation of an educational program for clinicians
Gene expression profiling (GEP) test scores calculate risks of recurrence and likely benefit of adjuvant chemotherapy in ER-positive, HER2-negative, early-stage breast cancer. As health literacy and numeracy skills in the general population are poor, healthcare professionals (HCPs) require a wide repertoire of communication skills to explain clearly risk of recurrence scores (RSs) and uncertainty. We developed and evaluated an educational program for HCPs discussing GEP test results and adjuvant treatment.
Eight-hour workshops contained elements aimed at improving knowledge, communication skills and self-awareness; these included the science underpinning GEP tests, an interactive risk psychology lecture, exercises and facilitated group discussions regarding seven filmed scenarios involving discussions about high, intermediate and low RSs. Attendees were recorded explaining RSs with patient simulators pre and post workshop. Researchers, blinded to time point, analysed recordings using a study-specific scoring system. Primary objective outcomes were improvements post workshop in HCPs' competence and confidence when communicating 17 pre-specified key information areas. We estimated odds ratios (OR) using conditional logistic regression to compare pre- and post-workshop scores.
65 HCPs attended. Objective analyses revealed significant positive shifts post workshop which included explaining GEP tests (OR 2.98; 95% CI 1.38–6.42; P = .001), recurrence RSs (OR 3.99; 95% CI 1.72–9.25; P < .001), benefits of chemotherapy (OR 3.99; 95% CI 1.82–8.75; P < .001; and harms OR 2.31; 95% CI 1.37–3.92; P < .001) using jargon free language (OR 5.29; 95% CI 2.27–12.35; P < .001). Patient simulator assessments also showed significant improvements as did HCPs' self-assessments and ratings of their self-confidence when discussing different GEP tests with diverse patient types (P < .001).
These short, intensive, interactive TARGET workshops significantly improved HCPs' communication about GEP results in ways likely to promote more informed decision-making by patients about chemotherapy.
KeywordsRisk of recurrence Genomic test results Breast cancer Chemotherapy Communication
There have been exciting advances in diagnostics, surgical and radiotherapy techniques and systemic therapies for women with early-stage breast cancer (EBC). Better understanding about the molecular biology of cancer has permitted more targeted treatment, and thus many patients have genuine prospects of cure or living longer. Most patients with cancer want collaborative roles in treatment decision-making [1], but discussions about the logic and rationale behind treatment recommendations have become increasingly complex and demand excellent communication skills. Decision-making about adjuvant chemotherapy in particular requires careful balancing between likely absolute benefits in terms of preventing recurrence versus the unpleasant side effects and inconvenience of treatment. Explaining risks and benefits to patients is never easy and health literacy and numeracy skills are frequently poor in the general populations of the US, Canada, Australia and EU [2, 3]. Perceptions about health risk information are strongly related to numeracy so women with inadequate numeracy skills are more likely to overestimate their chances of dying from breast cancer and the absolute risk reduction of breast cancer screening [4, 5]. Many patients also believe that in the context of life-threatening disease, more treatment is better than less.
Various decision aids such as Adjuvant! On-line were designed to help clinicians determine and discuss treatment recommendations. Studies show, however, that patients' numeracy profoundly affects their ability to interpret numerical estimates of treatment efficacy [6]. In the UK, NHS Predict V2.1 is a prognostication and treatment benefit tool providing survival estimates 5 and 10 years following surgery with and without adjuvant therapy (hormone therapy, chemotherapy and trastuzumab) [7]. Clinicians can show patients relevant information with text, graphs, charts or in icon arrays. Clinico-pathologic features of the tumour are good prognostic indicators for most patients, but for some, the additional assessment of the risk of recurrence, not just survival estimates, is also pertinent for decision-making. Linking such decision-aid information to other factors that might determine treatment recommendations can be confusing for patients.
Several gene expression profiling (GEP) tests including EndoPredict® (EPclin score), Oncotype DX® Breast Recurrence Score and Prosigna® are approved to guide adjuvant chemotherapy decisions for patients with oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative and lymph node (LN)-negative breast cancer. Discussing the classifications of high, intermediate or low risk are somewhat illusory as all GEP recurrence RSs are on a continuum with their cut-offs based on clinical trial data. In one survey, a third of women receiving risk of recurrence test results did not fully understand these discussions [8]. Health literacy may affect patients' retention of RS test results, their capacity for processing information, understanding and decision-making [5]. Results from a study examining patients' understanding and preferences for six different Oncotype DX risk score formats of increasing complexity showed high error rates irrespective of health literacy or numeracy [9].
Even when RSs suggest high or low risk of recurrence, interpretation of these is subject to various unconscious biases. The personality characteristics of patients and doctors, especially their tolerance of uncertainty, may contribute to indecision or seemingly irrational choices [10]. Clinicians less tolerant of uncertainty may, when encountering ambiguous clinical situations, order more diagnostic tests or extra treatments than colleagues who are more accepting [11]. Furthermore, they may be less likely to discuss uncertainty openly with patients or engage in shared decision-making [12, 13]. Anxious patients with lower tolerances of ambiguity are often uncomfortable forgoing all possible treatments including chemotherapy even if benefits are modest or negligible.
Consequently health care professionals (HCPs) require personal numeracy expertise and wide repertoires of communication skills when explaining concepts to patients craving certainty about their prognoses and treatment outcomes.
As clinicians admit to communication difficulties when discussing GEP test scores, we developed an 8-h educational program—Talking About Risk in the context of GEnomic Tests (TARGET). The intervention's central aim was to assist HCPs when communicating OncotypeDX® and EndoPredict® results thus helping their patients to receive clearer information about putative adjuvant chemotherapy benefits permitting more educated shared decision-making.
Workshop development and contents
Research shows that improving both the competence and the self-confidence of HCPs are necessary prerequisites for the effectiveness of educational initiatives and transfer of skills into a clinic setting. Programs must include areas that enhance skills development (SD), knowledge acquisition (KA) and personal awareness (PA) [14, 15, 16].
We developed training materials following review of the risk literature and discussions with key clinicians and scientists. We mapped out the difficulties encountered explaining high, intermediate and low RSs together with the added challenges faced when communicating with patients with diverse personality and socio-educational characteristics. Other difficulties included developing understandable explanations that survival following adjuvant treatments is dependent on the risk of distant recurrence of breast cancer, how to transform percentages into different graphical representations, translating risks of recurrence into simple but non-patronising language, and the pros and cons of using analogies to describe risk.
TARGET contents and educational aims
Knowledge acquisition
Skills development
Personal awareness
An interactive session with a lecture about the psychology of risk and uncertainty and group exercises on basic numeracy, tolerance of uncertainty and frequency descriptors of numerical concepts
Module 1
An interview with a basic scientist about the principles underpinning GEP tests
Module 2
2 scenarios in which 2 oncologists discuss a high and a low risk, EndoPredict® test results with patients
Module 3
3 scenarios in which different oncologists and a specialist nurse discuss low, intermediate and high OncotypeDX® RSs
Module 4
2 further OncotypeDX® scenarios filmed following the publication of the TAILORx trial which changed some of the cut-offs and classifications of risk
Workshops lasted approximately 8 h and were facilitator-led encouraging group discussion between participants about the specific communication skills displayed by oncologists in different scenarios, and practical exercises on different means of conveying risk information needed for decision-making and handling varied patient reactions. Workshops concluded with attendees generating lists of optimal and necessary points that must be covered when discussing GEP test results.
After designing, piloting and refining the program, we conducted an evaluation of its efficacy and acceptability with HCPs actively engaged in discussing RSs.
Participants based in the UK were recruited through SHORE-C website adverts and flyers distributed at breast cancer meetings following presentations showcasing filmed materials. Workshops were accredited 9 Continuing Professional Development (CPD) points from the Royal College of Physicians. Brighton & Sussex Medical School Regional Ethics Committee approved and sponsored the study (ref: ER/RMLS21/1) funded by the Breast Cancer Research Foundation.
On the morning prior to and the afternoon following the workshop, participants were recorded explaining RSs with simulated patients. Their case studies were based on real clinical situations, and included consultations with low-risk patients, who nevertheless wished to have chemotherapy, and higher risk patients averse to chemotherapy. Before recording, participants read their assessment case study, the GEP test result, and any associated reports, printed handouts or additional information which they normally used in their own clinical practice, such as Predict outputs. They could access computer notes and displays if required. All simulated patients were experienced in improvisation and well briefed about breast cancer, its symptoms and reasons for the consultation. To enhance authenticity, different actors and scenarios were used pre and post workshop.
Participants gave written consent to all assessments prior to the first recording.
Assessments of recorded interviews
There were three separate assessments of all digitally recorded interviews: (1) objective assessment by trained researchers, (2) self-assessment by attendees and (3) patient simulator assessment.
An independent data manager assigned random numbers to each digital interview which researchers assessed using a study-specific checklist, blinded to assessment time point. Researchers' coding involved checking the presence of 17 key communication and information areas, together with the HCP's competence ('did not do this', 'not very well', 'reasonably well', 'very well'). Areas covered issues such as explaining the patient's risk of recurrence with and without treatment, implications for survival, making appropriate use of print outs/graphs to aid understanding about RSs and other general communication behaviours including structuring and summarising information.
Following each recorded interview, HCPs self-rated their performances on all 17 areas, and how satisfied and confident they felt with their interviews and chemotherapy decisions.
Post interview, simulated patients also scored their HCP's communication skills on the same 17 items, indicated the decision made and provided general comments for feedback.
Self-confidence questionnaires
Instruments similar to those used in previous assessments of our educational interventions [17, 18] were adapted for attendees to self-rate their confidence pre and post workshop when discussing 9 general aspects of RSs on a scale from 0 (none) to 10 (very confident).
Self-awareness, numeracy and communication exercises
- (1)
The Intolerance of Uncertainty Scale (IUS) measures responses to uncertainty, ambiguous situations and the future [19]. Intolerance of uncertainty is the tendency to consider possibilities of a negative event as unacceptable and threatening irrespective of the probability of its occurrence. Individuals with high intolerances attempt to make seemingly less risky choices, so the scale has utility when examining HCPs' decision-making behaviours.
- (2)
Basic numeracy-related skills, in particular the facility to transform probabilities into proportions, proportions into percentages and vice versa, are vital when helping patients to understand risk. Participants completed a basic numeracy assessment (based on Schwartz) probing their numeracy abilities [20].
- (3)
Attendees also completed a short exercise examining frequencies and verbal descriptors. They imagined a fictitious drug for indigestion and indicated how many people out of 100 might get various side effects described as 'fairly common', 'often', 'unlikely' and 'very rare'.
At the workshop conclusion, attendees rated the quality of the educational materials, specific aspects of the content, and whether or not they would recommend the program to colleagues.
Our a priori hypotheses were that post workshop (a) attendees' communication when discussing GEP test results would improve, namely that their competence would be measurably better, and (b) that they would feel more confident conducting these interviews, that is, their self-efficacy/self-confidence would be enhanced.
Statistical analyses
As the primary objective outcome was the analysis of participants' digitally recorded interviews with simulated patients, pre and post workshop, each of the two researchers coding interviews performed rate–rerate reliability checks on their own assessments and inter-coder reliability checks for 10% of each other's interviews. Both rate–rerate and inter-coder reliability were examined using Kappa coefficients. A conditional logistic regression model was used to compare pre- and post-workshop scores for confidence levels and for the presence and competent handling of each key communication item, using a numeric score for responses 0 (did not do this), 1 (not very well), 2 (reasonably well), 3 (very well). This model estimates, for each individual, the probability that a score is observed post workshop rather than before it. This probability is expressed in terms of the difference between pre- and post-scores. The parameter of interest in the model is the odds ratio (OR). The larger the OR, the more likely it is that higher scores are observed post workshop. No distributional assumptions are required for the scores. Thus, this approach provides a robust method for before-and-after comparisons. The key data used by the estimation procedure are numbers of attendees with different scores at the two time points. Large positive ORs occur when changes fall towards larger score values rather than smaller values. Each item reflects a distinctive communication area, the interpretation of which is of interest on its own. We do not make an overall communication recommendation based on amalgamation of all items; neither do we control the overall error rate. Consequently, corrections for multiple testing are not necessary. The results are exploratory and all inferential statements are valid marginally; that is, they are to be interpreted individually for each item [21, 22].
We also analysed the levels of agreement between (a) coder and HCP, (b) coder and actor and (c) actor and HCP on their assessment of competence for every information area post workshop. For each of the communication areas, firstly the rating was dichotomised as (0 = 'did not do this' or 'not very well' and 1='reasonably well' or 'very well'), and secondly a binary variable was formulated to indicate agreement (1 = Yes, 0 = No) between each pair of raters for each recording. We used a logistic regression model for this variable to estimate an overall odds of agreement in each information area considered. To yield chance-corrected measures of agreement, models incorporated corrections for chance agreement in the linear predictor following Lipsitz et al. [23]. The total score for Intolerance of Uncertainty Scale was analysed using a linear regression model with attendees' levels of confidence on each area of information as explanatory variables.
Between March and July 2018, seven workshops were attended by 65 breast cancer specialists (38 women; 27 men), of whom 32 were oncologists, 24 surgeons and 9 nurses.
Analyses of digital recordings
The inter-rater (two coders) and rate–rerate reliability showed good agreement (k = .9123; SE = .0712; k = .8101, SE = .1517 , respectively). A descriptive analysis of pre- and post-workshop scores (supplementary Tables D–G) show the trends of improvement in most communication areas and HCP self-reported confidence overall by speciality.
High levels of agreement (concordance) were observed between coders, HCPs and simulated patients for ratings of "reasonably well" and "very well" responses across the 17 items. There were too few disagreements in these data for some items to make any further analyses of agreement worthwhile.
Attendees expressed significantly higher levels of confidence with their discussions following post-workshop interviews (OR 3.27; 95% CI 1.53–6.99; P = .0022).
Intolerance of Uncertainty Scale (IUS)
Participants' mean IUS score was in the normal range but 12/65 (18%) had high scores, 7 of whom were extremely intolerant of uncertainty (Supplementary table H). Higher intolerance of uncertainty was associated with lower self-rated confidence when discussing prognosis with patients with EBC and when discussing intermediate RSs (beta = − 1.67; 95% CI − 2.89 to − .45; P = .009; beta = − 1.76; 95% CI − 3.15 to − 0.37, P = .016). Higher intolerance of uncertainty scores was also associated with higher levels of self-rated confidence when discussing high RSs generally and when communicating with patients of lower socio-educational background (beta = 1.81; 95% CI 0.16–3.45; P = .035; beta = 1.95; 95% CI 0.18–3.72, P = .035.)
Basic numeracy
Results from the basic numeracy exercise
A person taking Drug A has a 1% chance of an allergic reaction. If 1000 people take the drug, how many will have a reaction? (10)
63 (97%)
A person taking Drug B has a 1 in a 1000 chance of an allergic reaction. What % of people taking the drug will have a reaction? (0.1%)
54 (83%)
The chance of getting a serious viral infection is 0.0005. How many of 10,000 exposed people might get the infection? (5)
38 (58%)
Imagine I flip a fair coin 1000 times. How many times will the coin land heads up? (500)
55 (85%)
Frequency and verbal descriptors
Participants attributed wide numerical ranges to the different verbal descriptors: The term 'fairly common' elicited a range from 10/100 to 90/100; likewise 'often' produced estimates ranged from 1 to 90, 'unlikely' 0.1 to 30 and 'very rare' 0.01 to 10.
General self-confidence
Feedback at workshop completion revealed that most attendees found TARGET useful (9.6/10), informative 9.6/10) and enjoyable (9.7/10) and 100% would 'definitely' recommend the program to their colleagues.
This intervention was designed specifically to assist HCPs when discussing GEP test scores with patients and implications these have for adjuvant chemotherapy recommendations. There are many generic aspects of the program which are suitable for any HCP tasked with explaining risk to patients.
TARGET was based on successful evidence-based educational packages that contain elements enhancing knowledge acquisition, skills development and self-awareness [17, 18]. Prior research shows that interventions which change both competence and self-confidence/efficacy often transfer successfully into a clinical setting and are enduring [14, 15]. Objective analyses of attendees' pre- and post-workshop interviews revealed positive behavioural changes in the style and content of discussions and an increase in HCPs' reported self-confidence.
An important feature of TARGET was enhancement of attendees' personal awareness about their own numeracy skills and attitudes to uncertainty. Conversations with patients about the rationale and logic for different management policies requires discussion about the potential risks and benefits of adjuvant treatments aimed at reducing recurrence, and the impact that recurrence has on survival. During such discussions many different numbers are provide in dissimilar formats. Numeracy skills of general populations in the US and UK are often poor, and many get confused by numbers with different denominators and experience difficulties with percentages [24]. Studies show that even with decision aids that include graphs, bar charts and icon arrays, some patients have difficulty identifying their own personal risks [25]. It is really important therefore that HCPs communicating risk information can transform numbers into formats appropriate for individual patients in order to truly permit shared/collaborative decision-making. Some TARGET attendees, in common with many highly educated people, had personal numeracy difficulties [26], in particular problems converting percentages into proportions, proportions into percentages and calculating expected frequencies from probabilities.
Using verbal descriptors seems a reasonable way to circumvent numeracy difficulties. Attendees' responses to the verbal descriptors for common side effect exercise demonstrated widely differing ranges. This revealed the pitfalls if, when discussing risk, numbers are avoided altogether and communicators rely instead on verbal descriptors or frequencies. There is no way of knowing if either their colleagues' or patients' interpretations of phrases such as 'fairly common' would match their own. The European drug regulatory agency (EMA) has definitions for numbers that should be associated with words relating to side effect frequencies and the Royal College of Anaesthetists has produced pictorial charts assisting understanding about risk, e.g. 'rare' is described as 1:10,000, with a sketch and description of 'someone in a small town' [27].
Ambiguity about management options can 'leak' through in obvious and nuanced ways during interviews with patients. Interestingly, those attendees with a high intolerance of uncertainty had lower levels of confidence when discussing intermediate risk of recurrence scores with patients. In clinic settings, these HCPs would be more likely to prescribe chemotherapy especially when faced with an anxious patient, also intolerant of uncertainty, and who had an intermediate or borderline risk score.
One limitation of this work is that unless communication skills programs are made a mandatory part of training, then HCPs who attend workshops maybe a self-selected group, although we saw that the baseline skills of participants ranged widely. TARGET workshops lasted 8 h, split over 2 days but could be adapted for shorter modular-based delivery, lasting 2 h per module. It is unknown whether or not this would produce the same improvements. To assist with wider dissemination, we have produced a facilitator handbook with time-coded transcripts of scenarios enabling facilitators to stop at key points and engage groups in exercises or discussions. There are suggested prompts and comments about the issues illustrated and for less experienced facilitators, examples of structuring teaching sessions. Facilitator training programs are currently being held.
Although TARGET focussed on OncotypeDX® and EndoPredict® RSs, other available GEP tests share similar communication challenges. Discussing risk and managing the understandable anxiety and uncertainty of women about their need for adjuvant chemotherapy and ultimate decision-making demands a wide repertoire of communication skills that TARGET workshops appeared to enrich.
We wish to thank all the HCPs who permitted us to film their unscripted scenarios for the TARGET course materials, the attendees on workshops and the patient simulators.
This study was funded by the Breast Cancer Research Foundation (BCRF17-050).
Compliance with ethical standards
Conflict of interest
LJF has received research grants from Bristol Myers Squibb, and from Novartis. LJF has received speaker honorarium from Amgen, TEVA, Voluntis, Oncolia, Pfizer, Eisai and Genomic Health and had a consultancy role with Puma Biotechnology, Roche, Eisai, Voluntis, AstraZeneca and Takeda. VAJ has received research grants from Aventis Pharma trading as Sanofi. All other authors have no conflicts of interest to declare.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards (ref: ER/RMLS21/1). The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request
Supplementary material
- 1.Chewning B, Bylund CL, Shah B, Arora NK, Gueguen JA, Makoul G (2012) Patient preferences for shared decisions: a systematic review. Patient Educ Couns 86(1):9–18CrossRefGoogle Scholar
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Copyright information
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.


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Amid a sea of clapping hands, swaying hips and scouse vocal chords working in unison, Dolly Parton's 9 to 5 the Musical brought the house down at the Liverpool Empire theatre last night.
Re-worked as a stage show, the 1980 comedy film starred the lady herself Dolly Parton, Jane Fonda and Lily Tomlin, and it's a pleasure to watch in 2013 and see none of the humour has been lost in its transition from screen to stage.
Greeted by a video projection of Dolly who warmly welcomes us and explains that times have changed since the 70s - setting the scene for the lowly female secretaries we are about to meet - and acts as 'narrator' throughout the show including a farewell 'Thank you, Liverpool!'. A nice touch to see Dolly's taken the time to record a special clip for each venue across the UK.
Our trio of under-appreciated women are lead by widowed single mum Violet Newstead (Jackie Clune) who is constantly overlooked for promotion despite years' of dedicated service, downtrodden divorcee Judy Bernley (Natalie Casey) who's discovering there's more to life than being slave to a man and the bubbly blonde Doralee Rhodes (Amy Lennox) who gets judged for her 'Backwards Barbie' looks and desperately wants to be counted for her skills rather than her curves.
Patricia Resnick has expertly adapted her original screenplay to stage and woven in the superbly upbeat, and at at times surprisingly moving, musical numbers (all penned by Parton) opening and closing of course with the inimitable anthem 9 to 5.
Natalie Casey's caterpillar to butterfly performance as Judy, executed with a mixture of perfect comic timing and raw emotion in show stopper "Get Out and Stay Out" is a joy to watch. There's some definite scene stealing as we see unrequited burning love played out in raunchy fantasy 'Heart to Hart' by personal assistant Roz Keith (Anita Louise Combe) while Ben Richards shines as sleazy boss Franklin J Hart.
From meek grumbling over the water cooler through to accidentally poisoning and kidnapping their bigoted boss, the plot unravels in ridiculously absurd fashion and we're rooting for the gals every step of the way as they grasp a chance to change their lives for the better.
One of the most fun, feel good shows you are likely to see this year so get the girls together (or brings the boys to remind 'em of what they've got) and make a night of it.
Click rating: ***** What a way to make a living!
9 to 5 is at the Liverpool Empire until Sat 3rd August.
Book tickets: http://www.atgtickets.com/shows/dolly-parton-9-to-5-the-musical/liverpool-empire/
Review: Dolly Parton's 9 to 5 The Musical at Liverpool Empire theatreby Angela Johnson. Published Wed 31 Jul 2013 16:10, last updated: 30/01/15
Amid a sea of clapping hands, swaying hips and scouse vocal chords working in unison, Dolly Parton's 9 to 5 the Musical brought the house down at the Liverpool Empire theatre last night.
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'Lenore' is a well-known poem by American poet Edgar Allan Poe, a writer remembered for his dark tales and mournful poetry. 'Lenore' depicts the death of a. The poem "Alone" by Edgar Allan Poe was not published during his lifetime. It was not until that the poem was verified as being an authentic Poe poem. Among the American Romantics, Edgar Allan Poe is one of them. He has written not is about the analysis of symbols used in Poe"s selected poems. . literary works to give meaning that goes beyond what is evident to the reader. Without.
Poe's stature as a major figure in world literature is primarily based on his ingenious and profound short stories, poems, and critical theories, which established a. "Annabel Lee" is the last complete poem composed by American author Edgar Allan Poe. Like many of Poe's poems, it explores the theme of the death of a. Edgar Allan Poe was an American writer, editor, and literary critic. Poe is best known for his In January , Poe published his poem "The Raven" to instant success. His wife died .. Works with obvious meanings, he wrote, cease to be art.
This article lists all known poems by American author and critic Edgar Allan Poe ( January 19, . "The Divine Right of Kings" is attributed to Edgar Allan Poe, though not fully proven. It appeared in Graham's Magazine in October The "King". It doesn't have any meaning in an absolute sense. One could say what it is about, but that isn't what was asked. Poems aren't riddles that need to be solved. Annabel Lee is a rhyming poem with a lilting rhythm Poe penned in May , the year he died. It tells of the love between two people, one. "Romance" is one of the rarest creations of Edgar Allan Poe, where the American stanza, he mentions "eternal Condor years", meaning many passing years.


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AAMU Menĺs Basketball to Hold Summer Camp
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The Alabama A&M men's basketball team will officially kick off the summer by hosting Donnie Marsh's Basketball camp, which will be held from June 12-15 at the T. M. Elmore Gym.
The camp is open to boys and girls in the 2nd through 12th grade and will run from 8 a.m. to 4 p.m. throughout the week.
The cost of the camp is $130 per participant, which includes a daily lunch and a camp t-shirt. An award ceremony will take place on the last day of camp.
The men's basketball camp is geared toward building a foundation for development. Fundamental and advanced techniques in ball handling and dribble moves; shooting and passing; rebound; offensive skill work and defensive concepts; and an emphasis on a team first approach, will be a part of the daily program.
"We are excited about our first opportunity to get young bulldogs into the fold and have them learn from our staff," Head Coach Donnie Marsh said. "We are excited about getting kids on campus and in Elmore Gym so they can learn some things about the game.
Campers are asked to bring a t-shirt, gym shorts and gym shoes.
Registration can be completed online by clicking here or in-person on the first day of camp from 7-8:00 a.m.
For more information or if you have any questions, contact Coach Donnie Marsh at 256-372-4024 or Coach Kevin Brumfield at 256-372-4010.
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Matt Delooze - Oneball back up + christmas article
Hi everyone, just wanting to let anyone interested know that Matt has posted a new Christmas article/follow up, also the One Ball Media website is back up.
Love, Adrian Steer
pretty good article .. something is very wrong with this celebration imo
|All times are GMT. The time now is 10:57 PM.


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Drivers can expect to pay high prices at the pump this holiday weekend, but the good news is some relief is on the way.
We saw some of the highest gas prices this summer since 2014, that's according to Triple A.
Right now Americans are paying a national average of 2.84 a gallon, but that could drop about 14 cents because once fall hits stations switch to a cheaper winter blend of gasoline.
We asked consumers what they thought about gas prices finally dropping.
"I think it's great cause my business I'm on the road a lot and drive a lot of miles," said Minot resident Jerry Clark.
"I don't think they're that bad right now I mean they've been a lot worse," said Minot resident Kelly Smith.
KX news: What do you think would be a reasonable gas price?
"2.50 or so," said Minot resident Jacob Niess.
North Dakotans are currently paying a statewide average of 2.80 per gallon.


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20 Pigeons Sat On One Tree How Many Will Uh Flew It In One Day So Taht All The Riddles To Solve
Solving 20 Pigeons Sat On One Tree How Many Will Uh Flew It In One Day So Taht All The RiddlesHere we've provide a compiled a list of the best 20 pigeons sat on one tree how many will uh flew it in one day so taht all the puzzles and riddles to solve we could find.
Our team works hard to help you piece fun ideas together to develop riddles based on different topics. Whether it's a class activity for school, event, scavenger hunt, puzzle assignment, your personal project or just fun in general our database serve as a tool to help you get started.
Here's a list of related tags to browse: Nature Riddles Tree Riddles 3rd Grade Riddles Riddle Of The Day Gun Riddles Mind Tricks Tree Riddles Bird Riddles
The results compiled are acquired by taking your search "20 pigeons sat on one tree how many will uh flew it in one day so taht all the" and breaking it down to search through our database for relevant content.
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Carrying Trees
Riddle Of The Day 3rd Grade Riddles
Solved: 67%
20 Pigeons Riddle
20 pigeons sat on the branches of a tree. A man shot 1 pigeon with his gun. How many were left on the tree?
Bird Riddles Tree Riddles
Solved: 68%
What Does An Oak Tree Do At A Theatre When The Movie Ends
Hint: The same thing we all do.
Tree Riddles Daily Riddles
Solved: 57%
Saturn Has Them Riddle
Saturn has them. Married people wear them. A tree's age can be determined by counting them. What is it?
Planet Riddles Tree Riddles
Solved: 88%
Mother's Day Cards
Mothers Day Riddles Holiday Riddles
Solved: 49%
Tree Dog Riddle
Dog Riddles Tree Riddles
Solved: 58%
The Tree And The Teacher Riddle
First Grade Riddles Riddles For Teachers
Solved: 33%
Mom Is Ready To Take On The Day
This is an original riddle for mom to share with family on Mother's Day. Can you figure out what the 4 pictures represent and solve the riddle?
Once this comes into play
Mom is ready to take on the day
But if you ever take it away
There's going to be hell to pay
Mom is ready to take on the day
But if you ever take it away
There's going to be hell to pay
Hint: It's highly addictive.
Mothers Day Riddles Mom Riddles
Solved: 63%
St. Patricks Day Shamrocks
St Patricks Day Riddles Holiday Riddles
Solved: 50%
St Patricks Day Frogs
St Patricks Day Riddles Animal Riddles
Solved: 25%
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Have some tricky riddles of your own? Leave them below for our users to try and solve.


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Pain is an unpleasant sensation caused by damage to nerve endings, the purpose of which is to alert the body of an injury or dangerous effect that must be stopped or be avoided.
Type 1 Diabetes could be a Factor in Broken Bones?
Poor blood sugar control puts people with type 1 diabetes at increased risk for fragility fractures, a new study shows.
Role of the immune system in hypertension
Millions of people in the United States and across the world have hypertension, a condition that, without proper management, can contribute to the risk of heart disease and stroke.
Small molecule could delay onset in multiple sclerosis
Treatment with a small molecule could delay the damage that multiple sclerosis inflicts in the brain and other parts of the central nervous system, say scientists.
Read moreSmall molecule could delay onset in multiple sclerosis


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Orange Creamsicle
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2 years ago
All different kinds of good. This bud will take you places, anywhere from a trip down memory lane to a trip around your house to a trip across the universe. Such an incredible taste, literally like the very popsicle itself. Where I am right now (off a king sized spliff) is better than I have ever felt right now, this bud brings me truly closer to myself, the world, the universe, and beyond.
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- Euphoric
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The concerted effort to end abortion is much more diverse and holistic than it gets credit for.
In any debate about abortion, someone will eventually say that pro-lifers only care about babies until birth or only care about children in the womb, not outside of it. The pro-choice advocacy group NARAL even uses this ubiquitous cliché in an ongoing public campaign that encourages supporters to share memes spotlighting "pro-life hypocrisy."
However, to make the claim of "pro-life hypocrisy," one must intentionally ignore vast swaths of the pro-life movement. There are millions of people globally who advocate for the unborn and also support women, children, and those in poverty. They include the religious and non-religious, gay and straight people, people of all races and ethnicities, and, yes, both men and women (in basically equal numbers). The accusation of "pro-life hypocrisy" centers one group of conservative, pro-life voices and dismisses a multiplicity of others.
This cliché distorts our picture of the pro-life movement and is often used to dismiss the larger moral argument that a person in utero is a human being who deserves legal protection. Its invocation allows pro-choice advocates to hold their opponents to abstracted standards of radicalism in order to sidestep substantive debate.
As I survey the pro-life landscape, I see many American pro-life organizations and institutions that seek to bless women and children outside the womb. To name but a few, Feminists for Life is dedicated to "systematically eliminating the root causes that drive women to abortion—primarily lack of practical resources and support—through holistic, woman-centered solutions." The New Wave Feminists, who made headlines last year after being removed as formal sponsors …
Trumpet Media
Latest posts by Trumpet Media (see all)
- Pro-Lifers Aren't Hypocrites - June 16, 2019
- Oops! 10 Funny Distractions Pastors Faced While Preaching on Sunday - June 16, 2019
- Are Guns Inherently Evil? - June 16, 2019


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Princeton Tec League flashlight
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difficult for me to understand, he says. All of which is followed by intense regret, and, subsequently, more impulsive actions; literally anything will do if it stifles the shame spiral. Catching a symptom before it kicks off into something more serious is good, but not when youre prone to analyzing, going through every emotion with a fine-toothed comb to try to make sure its the correct way to be feeling or thinking. In reality, they may have just not been aware whatsoever, she says. How can I fix.
This is what it's like to date someone with, borderline, personality, disorder
For relationships to have a chance of succeeding, this is watchmojo dating a critical piece: people with BPD arent acting with malice or being difficult, but acting on their own internal logic with limited emotional resources. This is not helpful and certainly not an easy quality to deal with in someone you share your life with, but the key to it working is understanding why the person does the things they do so you can work together to help them. Sometimes among the arguments, the fits of anger and rage, the distrust, the paranoia, the mood swings, it seems like my girlfriend is a completely different person. But successfully dating someone with BPD requires more than knowing it is possible or receiving validation that it can be hardit requires understanding exactly how the illness affects someones perception of themselves and their interactions with partners., email Us, passion and Fear in BPD Relationships. If you fall for someone with BPD then I wont lie, you will be in for an experience you may not have had before.
Bone-aching fury when your clothes horse doesnt open, so you throw it at the wall, which makes a hole you never get around to filling. Navigating through this emotional minefield can be difficult and painful for both of you, but knowing that their thoughts and behaviors are the product of intensely powerful perceptional distortions deeply rooted in their mental health disorder, rather than a reflection of your own shortcomings, can. We spoke of the perfect wedding, of names for our children we dared to dream. Even if you ensure your physical safety, having to deal with the intense mood swings and emotional storms of your partner over a long period of time can be highly stressful for you too.
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I think included already in ROM zip file. Have you flashed this ROM?
Press and hold menu button from your home screen, and Google Now will appear with white screen background.
================================================== ===========
If you really want to know and install Google Now for any ICS custom ROM, please refer to:
Sent from my GT-I8150 using xda premium


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Black Faux Fur Monochrome Coat
Choose a Way to Rent
|True to Size
This coat is soft and fuzzy and you just want to pet it. But it is A LOT of coat. The coat is big and loose and longer than I expected. It is also very thick and furry. I kind of looked like I was being hugged by a big black bear. Obviously, I couldn't wear it out, but I did want to spend some time snuggling with it.
Not the softest faux fur.
Rented this for a wedding weekend in Maine. Loved having it. It was very cozy, but looked great. Felt perfect for formal East Coast winter.
Fit well and warm. I have long arms and the sleeves were just barely long enough.
It fits true to size and is warm and comfortable but I didn't wear it out because it was unseasonably warm out.
Great...super comfy.
Fun jacket! Oversized pea coat style. The faux fur is good quality. Got a bunch of compliments on it. Totally not my usual style, but that's why it was fun to try through RTR.
I rented this for a trip to Wisconsin, and it kept me warm! Very versatile.
I think your dry cleaning has spoiled the fabric of this jacket And it smells of the product!
I LOVED THIS JACKET! So warm and cute and it is a great length not too long or short. Would definitely recommend!
Fit perfectly and I'm a S-M when it comes to coats, small in the body but usually get mediums bc I have long arms. This coat fit perfectly. I wore it for a GNO, it was snowing and cold but I was kept perfectly warm with this in tow. I was afraid it would be overbearing for my small frame but it was the perfect amount of fluff. Other than my boyfriend calling me a pimp I would say it was a win.
Great fun coat buttons are loose
Very comfy. Cozy. Lot's of compliments
Bulky and not very flattering but still love it. Rented to take with me on a ski trip as my "going out" coat.
Super unflattering, definitely runs large and makes me look like a giant walking puppet.
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I wore this several times over the week I had it. I loved the look and felt great in it.
I love this jacket. It's very warm and the fake fur is really well done. It is a beautiful deep black color. This is a very warm, fluffy, thick jacket. It might overwhelm a smaller framed person. The only problem I had was not with the jacket, but with the cleaning. It smells like someone dunked it in febreeze. It made all of the garments shipped with it smell heavily enough to where my friends were sneezing when they got near me.
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I had to read the first verse of Luke 4 thrice. It says, "Jesus, full of the Holy Spirit, left the Jordan and was led by the Spirit into the wilderness, where for forty days He was tempted by the devil." Jesus, who was full of the Holy Spirit, was led by the Spirit into… Continue reading Don't Just Shoo Your Wilderness Season Away
Why I Gave All My Starbucks Stickers Away + My 2019 Faith Goals
I first used a planner in 2010 during my second half of sophomore year in college. I have found planners handy ever since. I recently shared here how my love for journaling came about because of my use of planners. I personally prefer planners that are basic -- lined, A5, open flat and stitch-bound. I… Continue reading Why I Gave All My Starbucks Stickers Away + My 2019 Faith Goals
Five Takeaways from "Down To Earth Discipling"
I recently finished Scott Morton's "Down To Earth Discipling", a book published by the NavPress. What made me pick this from the bookstore is its (very!) relatable preface. Related link: "Seasoned staff member Scott Morton shares the beginnings of The Navigators movement" The book is basically a relevant reference on biblical discipling. It has 13… Continue reading Five Takeaways from "Down To Earth Discipling"
When A Student Gets Emotional Because of the Question, "How Are You?"
I facilitated a class of graduating students few Saturdays ago in De La Salle University (DLSU). I was given two weeks to prepare for this class. But I roughly had a day of preparation because I was swamped by other things. This facilitation is part of an on-going assessment of me for a part-time role… Continue reading When A Student Gets Emotional Because of the Question, "How Are You?"
Why A Common Goal Matters: What I Learnt In Front of 95+ Souls
God recently gave us an amazing privilege to facilitate a workshop to more than 95 senior high school students in a campus in Manila. And by "us", I mean our church family. Even though the 18 of us came from two ministry areas, there was an unspoken teamwork to a common goal: preach the gospel.… Continue reading Why A Common Goal Matters: What I Learnt In Front of 95+ Souls


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Want to ward off the apocalypse? Invest in women's health and rights›Guest Contributor // June 27, 2019 // By Kathleen Mogelgaard & Robert Engelman
World population continues to grow. The latest UN projections, released this week, indicate that we will add another 2 billion people to the planet by 2050 and 3 billion by the end of the century. While population growth is ebbing in many countries—and even starting to contract in a few—population growth in some countries remains brisk, if not breakneck.
Race, Bias, and Equity in Prenatal Care: No Pregnant Woman is the Same›Dot-Mom // On the Beat // June 26, 2019 // By Amanda King
It's disturbing to see the data going in the wrong direction and it means we have to go beyond what we've been doing, said Terri D. Wright, Vice President of Programs and Community at the Eugene and Agnes E. Meyer Foundation at a recent event on equitable prenatal care in the United States hosted by The Jennifer Bush-Lawson Foundation and the American Medical Association at Duke University in DC. "We can't do the same things the same way and expect a different outcome," she said. "We've got to do something different."
Reservoirs in Parched Chennai, City of Millions, Are Dry. Can Better Forecasting Avert Future Crises?›Choke Point // June 25, 2019 // By Brett Walton
Residents of Chennai, by all accounts, are miserable and anxious. The city's main reservoirs are dry, depleted by the failure of successive monsoons to provide replenishing rains. The shortfall has crippled the piped distribution network, which is now meeting just half of typical demand through a mix of secondary sources: desalinated water, groundwater, and the impoundments from nearby stone quarries. Even that supply is far from adequate. Piped water reaches households once a week or less. Tanker trucks, an expensive alternative, dole out water by the bucketful to desperate crowds.
Partnerships, Politics, & Plastic Pollution: A Conversation with Rob Kaplan on Reducing Ocean Plastics›Friday Podcasts // June 21, 2019 // By Benjamin Bosland
"I've never seen this kind of political and public sector engagement in an environmental topic happen so fast," said Rob Kaplan, the Founder and CEO of Circulate Capital in an interview with Ambassador David Balton following a recent Wilson Center event on reducing marine plastic pollution. Interest in reducing ocean plastics has gone from a blip on the radar at ocean conferences to "now becoming a top priority," said Kaplan.
Transforming Africa: Women and Young People Will Drive Progress›From the Wilson Center // On the Beat // June 18, 2019 // By Nazra Amin
"Too often in the United States, the narrative that we hear about Africa is one of poverty, war, and ineffective or failed states. It is a crisis, a place best engaged through aid packages and humanitarian assistance," said Keith Lee, President and Chief Operating Officer of Brown Capital Management at a recent Wilson Center event hosted by the Africa Program. "This has never been the entire story, and today more than ever, Africa is undergoing enormous transformations that challenge this narrative," Lee said.
Inclusive Protection of Civilians During Conflicts: Making a Case for the Environment›Guest Contributor // June 12, 2019 // By Wim Zwijnenburg
It is important to take an inclusive and tangible approach to protecting civilians by protecting the environment during armed conflicts. In recent decades, the link between conflict, the environment and the protection of civilians has become painstakingly clear. From Iraq to Ukraine, Libya to Yemen, dozens of incidents have surfaced where environmental damage resulting from conflict has led to acute or chronic health risks to civilians and their communities, undermining their socioeconomic development.
Top 5 Posts of May 2019›What You Are Reading // June 11, 2019 // By Benjamin Dills
Sustainable solutions for Chinese communities featured in two of our top posts for May. In the top post, Karen Mancl digs into the soil quality of Chinese farmland. Conservation agriculture mixes ancient farming practices with new technology to reclaim and restore land disturbed by construction and intense industrial farming. Mancl features in our list again with her piece focusing on the potential of sand bioreactors to be an affordable, right-sized alternative to mechanical wastewater treatment plants for rural China villages.
Urban Elites' Livestock Exacerbate Herder-Farmer Tensions in Africa's Sudano-Sahel›Guest Contributor // June 10, 2019 // By Matt Luizza
In recent years, conflict between herders and farmers for access to increasingly scarce natural resources in Africa's Sudano-Sahel has escalated. While the problems fueling these tensions are both hyper-local and transnational in nature, one important piece of the puzzle has been overlooked. The real "elephant in the room" is who owns the livestock.
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