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Effects of Fluoride and Calcium Phosphate-Based Varnishes in Children at High Risk of Tooth Decay: A Randomized Clinical Trial
Stroke and Athletes: A Scoping Review
10.3390/ijerph181910045
Paul B. Tchounwou
McCaughan, E. M.
Flannagan, C.
Parahoo, K.
Bingham, S. L.
Brady, N.
Connaghan, J.
Maguire, R.
Thompson, S.
Jain, S.
Kirby, M.
O'Connor, S. R.
Effects of a Brief E-Learning Resource on Sexual Attitudes and Beliefs of Healthcare Professionals Working in Prostate Cancer Care: A Pilot Study
Eilís M. McCaughan
Carrie Flannagan
Kader Parahoo
Sharon L. Bingham
Nuala Brady
John Connaghan
Roma Maguire
Samantha Thompson
Suneil Jain
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Seán R. O'Connor
Institute of Nursing and Health Research, Ulster University, Jordanstown BT37 0QB, UK
Northern Health and Social Care Trust, Antrim BT41 2RL, UK
Department of Computer and Information Sciences, University of Strathclyde, Glasgow G11 XH, UK
Urology Department, Belfast City Hospital, Belfast BT9 7AB, UK
Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast BT9 7AE, UK
Clinical Oncology, Northern Ireland Cancer Centre, Belfast City Hospital, Belfast BT9 7AB, UK
Faculty of Health and Human Sciences, University of Hertfordshire, London AL10 9AB, UK
The Prostate Centre, London W1G 7AF, UK
Centre for Public Health, Queen's University Belfast, Belfast BT12 6BA, UK
Int. J. Environ. Res. Public Health 2021, 18(19), 10045; https://doi.org/10.3390/ijerph181910045
Received: 9 August 2021 / Revised: 10 September 2021 / Accepted: 16 September 2021 / Published: 24 September 2021
(This article belongs to the Section Digital Health)
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Sexual issues and treatment side effects are not routinely discussed with men receiving treatment for prostate cancer, and support to address these concerns is not consistent across settings. This study evaluates a brief e-learning resource designed to improve sexual wellbeing support and examine its effects on healthcare professionals' sexual attitudes and beliefs. Healthcare professionals (n = 44) completed an online questionnaire at baseline which included a modified 12-item sexual attitudes and beliefs survey (SABS). Follow-up questionnaires were completed immediately after the e-learning and at 4 weeks. Data were analysed using one-way, repeat measures ANOVAs to assess change in attitudes and beliefs over time. Significant improvements were observed at follow-up for a number of survey statements including 'knowledge and understanding', 'confidence in discussing sexual wellbeing' and the extent to which participants felt 'equipped with the language to initiate conversations'. The resource was seen as concise, relevant to practice and as providing useful information on potential side effects of treatment. In brief, e-learning has potential to address barriers to sexual wellbeing communication and promote delivery of support for prostate cancer survivors. Practical methods and resources should be included with these interventions to support implementation of learning and long-term changes in clinical behaviour.
sexual wellbeing; prostate cancer; e-learning
Prostate cancer is the most common male cancer and long-term side effects associated with different treatment approaches are common [1,2]. In a recent large-scale survey, approximately 80% of men reported poor sexual function post-treatment [3]. Treatment guidelines [4,5] endorse delivery of psychosexual care for prostate cancer patients with recommendations made for the minimal level of support that should be provided. Despite evidence indicating that men with prostate cancer want healthcare professionals to discuss sexual issues and side effects of treatment [6,7,8], sexual aspects of recovery are often not discussed during post-treatment follow-up appointments and support is not provided consistently across settings [9]. Consequently, men with prostate cancer frequently report that they do not receive adequate information to manage sexual concerns [10,11]. This can be associated with increased psychological morbidity, including depression and relational dissatisfaction, as well as reductions in self-efficacy and overall quality of life [11].
Initiating discussions around sexual concerns in clinical practice can be challenging. A number of interpersonal factors have been identified as potential communication barriers. Healthcare professionals often regard patients' sexual lives as being too personal to ask about [12]. Wider social influences and attitudes to sex and sexuality, including embarrassment, not being comfortable with the topic or not wishing to cause offence may also lead to active avoidance of the issue [12]. Healthcare professionals also report a perception that management of sexual issues is not within their professional role and that they feel unequipped to deal with sexual issues [13,14]. Other factors, including limited availability of onward referral services can also limit discussions further. Given their frequency and substantial impact [3], sexual concerns and potential side effects of treatment should be discussed routinely with all patients. Healthcare professionals have an essential role in ensuring patients' sexual concerns are addressed and that appropriate support is provided, including onward referral to relevant services. There is therefore a clear need for approaches that provide healthcare professionals with the skills and capacity to routinely deliver sexual care and support. However, there is currently limited evidence exploring how communication can be enhanced and how conversations around sexual wellbeing can be supported in routine practice.
A study exploring evidence regarding knowledge and attitudes of oncology nurses and factors linked to provision of sexual support [15] concluded that continuing communication skills training education is needed to address assumptions around sexual issues that restrict sexual care communication in cancer care. Similar findings were found in a mixed-methods review exploring barriers to communication around sexual wellbeing in clinical practice that identified themes covering attitudes to sex and sexual wellbeing, patient factors, organisational factors, strategies to overcome barriers and training needs [16]. This review found healthcare professionals acknowledged the importance of discussing and providing support for sexual wellbeing needs, but recognised it is not routinely provided and highlighted a need for brief educational and support tools to promote effective conversations with patients.
For healthcare professionals to adequately address sexual wellbeing issues, they require an awareness of the impact of sexual issues on patients as well as knowledge and skills to effectively engage with patients and assess needs to provide appropriate evidence-based management [17]. In addition, they may require interventions designed to address attitudinal barriers to sexual wellbeing discussions in practice. Easily accessible, evidence-based e-learning modules can provide an approach by which all healthcare professionals in primary, and secondary care settings, who provide support for patients diagnosed with, or receiving active treatment for prostate cancer can undertake foundation level training to ensure they are prepared to deliver essential information and support to patients. Such interventions have the potential to improve healthcare professional communication and patient-important outcomes [18]. As attitudinal factors can act as barriers to healthcare professionals' communication regarding sexual wellbeing concerns in patients with prostate cancer, the aim of the study was to evaluate a brief e-learning resource entitled 'talking about sex after prostate cancer' and explore its effects on healthcare professionals' attitudes and beliefs around sexual wellbeing and prostate cancer, and their perspectives on its use.
2.1. Study Design
A pilot study design was used with evaluations at baseline and at two follow-up time-points (immediately after and 4 weeks after completion of the e-learning). A minimum sample of 43 participants was calculated in G*power [19] based on a one-way repeat measures ANOVA using a power of 0.95 and a small estimated effect size of 0.01. Ethical approval for the study was provided by the Office for Research Ethics Committees Northern Ireland (reference number: 17/NI/014).
2.2. Study Population
Participants were healthcare professionals working in the area of prostate cancer care. No exclusions were applied to professional group or years of clinical experience. Recruitment was via e-mail invitation, posters located in clinical areas and through social media messages. A link to the e-learning resource was also included on the healthcare professional online learning platform of Prostate Cancer UK. Written, informed consent was obtained from all participants who took part in the study.
2.3. Intervention Content
A systematic, iterative and theory-based approach was used to develop the content and structure of the e-learning resource. The development phase included establishment of an expert group consisting of men with prostate cancer, and healthcare professionals working in uro-oncology and primary care settings; conduct of evidence reviews [16] and qualitative data synthesis from semi-structured interviews and focus group discussions with end users and field content experts. These were used to identify core or essential elements of the resource. In addition, content and healthcare professional perspectives on feasibility and acceptability were also evaluated at a 2-h facilitated workshop attended by 21 clinical nurse specialists that included small group discussions and demonstrations. After building initial versions of the resource, modifications were made based on usability testing and further rounds of qualitative interviews. Following this, a final version of the resource was built as a SCORM package integrated into a moodle open-source e-learning platform (https://talkingaboutsex-cancercare.org/course/view.php?id=2, accessed on 6 August 2021). A number of interactive elements and reflective activities are included in the resource such as a 'virtual tutor', quiz questions, videos showing patient and partner interviews, conversation demonstrations and goal-setting activities.
The resource consists of three sections: (1) an introduction and background to the area, (2) a framework for structuring sexual wellbeing discussions in practice and (3) methods with which to integrate learning into routine practice. Section one is aimed at raising awareness around the impact of prostate cancer on sexual wellbeing, including the effects of different treatment options. It also discusses key barriers preventing sexual wellbeing concerns being addressed in men with prostate cancer (from a societal and health system perspective, as well as patient and partner, and healthcare professional perspectives). Section two introduces an Engagement, Assessment, Support and Signposting (EASSi) framework as a means of addressing key barriers to routine engagement around sexual wellbeing with patients in the clinical setting. This framework is aimed at providing a mechanism to ensure healthcare professionals have the knowledge and skills to effectively engage with and support men and their partners. Of the four components included in the tool, 'Engagement' is focused on ensuring routine sexual wellbeing discussions take place with all men, acknowledging that such sexual issues are not easy to discuss and recognising that associated side effects of treatment can have a substantial impact. The 'Assessment' component includes questions on treatment type and relationship status to provide tailored support. The 'Support' component provides appropriate information on common sexual challenges (relevant to treatment and relationship status) and information on coping strategies. The 'Sign-posting' component provides other support options including online self-management and other resources specific to individual needs. Section three of the e-learning resource includes activities to support integration of learning into routine practice, including suggested goal setting activities and downloadable resources, including patient handouts and a simplified A4 poster version of the engagement framework to remind healthcare professionals to use the EASSi framework in routine practice.
2.4. Data Collection
The primary outcome measure was change in sexual attitudes and beliefs survey (SABS) scores. Good internal consistency (Cronbach's alphas of 0.75 to 0.82) and test–retest reliability (r = 0.85; p < 0.001) of the survey has been demonstrated [20]. In the current study, we used a modified version of the SABS to ensure it related specifically to prostate cancer care. Modifications were based on pilot testing of the survey involving a sample of healthcare professionals who were not involved in the main study (n = 66). Changes made to the survey and internal consistency measures are described in Supplementary Table S1. The modified survey consisted of twelve statements including perceptions around sexual wellbeing knowledge and understanding and confidence in discussing sexual concerns with patients. Each question was rated on a four-point Likert scale based on the extent to which the participant agreed or disagreed with each statement (1 = Strongly Disagree; 4 = Strongly Agree). Five items are reversed during scoring. A total score ranging from 12 to 48 is assigned with lower scores indicating greater barriers to sexual wellbeing communication. Acceptable internal consistency of the modified survey was observed (Cronbach's alpha: 0.69). Pre-test measurements were recorded prior to completion of the e-learning at Timepoint 0 (T0), immediately after completion at Timepoint 1 (T1) and at 4 weeks (Timepoint 2; T2). Additional questions were also included at Timepoint 1 and 2 exploring perspectives on usefulness and usability. E-mail reminders were sent to participants requesting they complete the follow-up survey at Timepoint 2.
2.5. Data Analysis
Data were exported into SPSS version 25.0 (SPSS, Chicago, IL, USA) which was used to provide a descriptive analysis of demographic details and to analyse the sexual attitudes and beliefs survey data. One-way repeat measures ANOVAs with within-subject effects were used to test for overall significant changes over time in total scores and scores for each statement. Pairwise comparisons were used to test for significant differences between each timepoint. A Bonferroni adjusted p value of 0.004 (0.05/12) was used to allow for multiple comparisons. Descriptive statistics were also used to summarise participant ratings of usefulness and utility.
3.1. Participant Characteristics
Between January and June 2019, 44 participants completed the baseline survey (T0) and the follow-up questionnaires immediately after the e-learning (T1) and at 4 weeks (T2). The majority of participants were nurses working in urology and oncology settings with between five and twelve years of clinical experience. The most common reasons stated for undertaking the e-learning resource were to improve knowledge and communication skills when discussing sexual issues with patients. Participant demographics are summarised in Table 1.
3.2. Sexual Attitudes and Beliefs
The greatest potential barriers to sexual wellbeing discussions at baseline (T0) were with 'I feel confident in my ability to address the sexual concerns of men living with prostate cancer' (mean score/4 = 2.59: 95% CI = 2.40–2.73) and 'I know the right language to use when discussing sexual concerns' (mean score/4 = 2.52: 95% CI = 2.38–2.66) (See Table 2). The overall SABS scores on completion of the e-learning module did not change significantly from baseline. However, examination of individual statement scores revealed that there were significant within subject changes after completing the e-learning for key attitudes and beliefs. These included 'awareness and understanding of how prostate cancer and its treatment might affect men's sexual wellbeing' (F = 23.657; P = 0.001) and 'agreeing that sexual issues should be discussed with partners' (F = 12.192; P = 0.001). In addition, participants were significantly more to agree that they had 'I am confident in my ability to address sexual concerns' (F = 27.351; P = 0.001) and 'I know the right language to use when discussing sexual concerns' (F = 27.013; P = 0.001) (See Table 2).
Pairwise comparisons were used to identify where these significant differences were in terms of the different timepoints. This revealed significant differences in 'understanding' between T0 and T1 (mean score/4 = 3.18 vs. 3.79, respectively: P = 0.001) and between T0 and T2 (mean score/4 = 3.8 vs. 3.61, respectively: P = 0.001). For 'confidence in ability to address sexual concerns', significant differences were found between T0 and T1 (mean score/4 = 2.59 vs. 3.13, respectively: P = 0.001) but not between T0 and T2 (mean score/4 = 2.59 vs. 2.66, respectively: P = 0.063). Analysis of agreement with the statement that 'sexual issues should be discussed with partners' revealed significant differences between T0 and T1 (mean score/4 = 2.93 vs. 3.45, respectively: P = 0.001) and between T0 and T2 (mean score/4 = 2.93 vs. 3.39, respectively: P = 0.001). For the question on having the right language to use when discussing sexual concerns, significant differences were found between both T0 and T1 and T0 and T2 (mean score/4 = 2.52 vs. 2.98, respectively: P = 0.001 and mean score/4 = 2.52 vs. 2.85, respectively: P = 0.001).
3.3. Usefulness and Usability
Participant ratings on usefulness and usability immediately after completion revealed the e-learning resource was seen as containing relevant information (3.81/4; SD: 0.37) (see Table 3).
Free text comments on experience of using the resource were summarised into categories and identified that users found the interactive design to be the most frequent positive feature of the e-learning (n = 14/44: 31.8%). Other useful features identified were the addition of a practical framework to structure sexual wellbeing discussions (n = 13/44: 29.5%), the use of demonstration videos to help facilitate practice and rehearsal of conversations (n = 12/44: 27.3%) and inclusion of downloadable resources (n = 10/44: 22.7%). All participants (n = 44/44: 100%) accessed a link provided to an online version of the engagement framework included in the resource. The majority (n = 29/44: 65.9%) accessed at least one of the downloadable resources (for example, the patient handout). Suggested improvements to the resource included providing greater depth of information on sexual aids, stating recommended dosages where information on medications was included and developing the resource as a mobile app-based version. When asked as part of the survey completed at Timepoint 2 (4 weeks after completing the e-learning resource), over one-third (n = 14/44: 31.8%) provided examples where they had applied learning from the resource into their clinical practice. This included initiating discussions with patients they would not have previously spoken to about sexual wellbeing.
This pilot study aimed to evaluate a brief e-learning resource that was designed to provide foundation level training to improve routine sexual wellbeing communication in prostate cancer care. Although overall SABS scores on completion of the e-learning did not change, significant improvements were observed for a number of individual survey item scores, indicating changes in important attitudes and beliefs. Baseline data indicated that participants regarded sexual wellbeing care and support as an important part of their professional role. However, confidence in their ability to address sexual concerns of men living with prostate cancer, and not knowing the right language to use when discussing sexual concerns, were both identified as potential barriers to discussing sexual wellbeing with patients (i.e., participants did not agree that they had confidence, or the right language to discuss sexual concerns), meaning that they had the greatest potential to improve following the e-learning resource. Completion of the e-learning resulted in significant improvements in both of these attitudinal factors, as well as in self-perceived knowledge and awareness of prostate cancers' impact on sexual wellbeing. In addition, participants had a greater recognition that partners should be involved in sexual wellbeing discussions. An important finding was that improvement in perception of participants' capacity to know the right language when discussing sexual wellbeing was maintained at least 1 month after completing the e-learning resource. These findings support the contention that brief e-learning can be an effective method of changing healthcare professionals' attitudes and beliefs towards sexual wellbeing discussions in prostate cancer care. These effects were also similar to those observed in other studies examining more intensive, workshop-based interventions [21,22]. It is uncertain, however, whether changes in attitudes observed in this and in other studies would translate to longer-term changes in practice. For this to occur, such changes need to be maintained beyond the short-term period. Learning may need to be repeated and applied in everyday practice in order to facilitate measurable behavioural changes [23,24,25,26]. This contention is reinforced by findings from studies that suggest to address gaps between attitudes and actual clinical behaviour, additional training, including simulated practice and rehearsal, may be required [27,28]. Use of goal setting techniques included in this intervention were included to provide strategies to ensure discussions around sexual wellbeing become routine. However, goal setting techniques by themselves may not be sufficient to change practice [29,30]. One study, exploring the effects of a workshop-based intervention found participants infrequently discussed sexual wellbeing with patients as part of their practice after training, with most participants not reaching previously set targets [22].
There is evidence from existing studies to suggest that despite acknowledging that sexual care is part of their role there is often uncertainty over who is responsible for discussing sexual wellbeing issues, with healthcare professionals often being unaware of whether other colleagues discuss these issues with patients [31,32]. Healthcare professionals may also be uncertain as to when, and how to refer patients to other services, including sexual counselling. Level of discomfort has also been shown to be a significant predictor of addressing patients' sexual concerns [33,34]. Such discomfort has been attributed to a fear of embarrassing patients or wanting to avoid "opening a can of worms" [35]. However, patients often expect healthcare professionals to raise the issue, and are comfortable with such conversations taking place [36,37]. To address these issues, interventions aimed at normalising sexual wellbeing conversations in clinical practice should be more widely implemented and should be a component of undergraduate healthcare professional training.
Previous sexual wellbeing communication training has frequently been based on existing sexual care models such as PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) [38,39,40,41,42]. This model places an emphasis on explicit 'permission' or approval to talk about sexual concerns at any point where it might be discussed and consider timing by ensuring patients are 'ready' to discuss sexual concerns. Furthermore, while educational interventions based on existing sexual care models such as PLISSIT and BETTER [43] provide well-developed and structured approaches, they often have limited active behaviour change components to support effective implementation into practice. These models may also include aspects that may present limitations to ensuring brief sexual care discussions are part of standard practice. These barriers can provide an 'opt-out' option leading to healthcare professionals not initiating discussions, potentially based on a perception that the patient is not ready or does not wish to discuss sexual issues [44]. While the EASSi engagement framework included in the e-learning draws on some aspects of these existing models, it attempts to build upon them by ensuring wider access to routine sexual care and support in prostate cancer care [45]. Its theoretical underpinning is more closely related to brief behaviour change models such as the 5 A's model [46], which has been used as a framework to guide discussions in behavioural counselling interventions for smoking cessation and weight loss [47,48]. We postulate that addition of this simple, practical EASSi framework to guide and structure sexual wellbeing discussions may have resulted in the sustained improvement in participants' perception that they had the right 'language' to use when discussing sexual concerns that was observed 1 month after completing the e-learning.
The intervention examined in this study can be used across settings and without specific training or expertise in sexual care counselling. In addition, it includes evidence-based behavioural change elements. The brevity of the framework and the combination of a routine assessment alongside provision of appropriate support also means it can be used at any stage in care, from pre-treatment to longer-term follow-up. Findings also indicate that the resource was seen as being easy to use and relevant to practice. The resource was used and viewed differently by various healthcare professionals in terms of its design, and function. This is in agreement with data from a recent systematic review exploring e-learning that concluded that effectiveness of training interventions can be influenced by learning style and mode of delivery [49]. e-learning is an increasingly substantial component of continuing professional development programmes for healthcare professionals. It offers numerous distinct advantages in comparison to face-to-face learning including wider reach, easier user access and improved usability [30,50]. e-learning resources have also been shown to have comparable efficacy and improved cost-effectiveness to traditional learning [51].
A number of limitations need to be taken into account when interpreting the findings of this study. The study did not include a control group or a randomised design. The sample size was also relatively small and comprised mainly of healthcare professionals from a nursing background. Furthermore, findings are based on a unidimensional outcome measure and analysis of individual survey items. This may reduce the ability to make strong conclusions on effectiveness of the e-learning resource and the generalisability of these findings. These factors should be considered in the design of further studies in this area.
Healthcare professionals should routinely engage with all patients to provide information and support to address and mange sexual wellbeing issues. However, existing communication and attitudinal barriers can limit this engagement and these barriers can be difficult to overcome. Providing healthcare professionals with only knowledge and awareness of the impact of prostate cancer and treatment on patient's sexual wellbeing may not be sufficient to change practice. Including a practical framework to facilitate and structure sexual wellbeing conversations, and including behaviour change techniques such as reminders and prompts, may have contributed to the changes in important attitudes and beliefs around sexual wellbeing in this study that could support changes in clinical practice and behaviour. To support this, these tools should provide a practical resource to guide and support healthcare professionals to initiate sexual wellbeing discussions in routine clinical practice and should include tangible support in the form of downloadable materials to use in practice. Application of learning in practice may promote increased engagement around sexual wellbeing, ensuring fundamental but individualised support is provided for men and their partners. This has potential to address current gaps in care by addressing barriers to sexual wellbeing communication and providing a framework to promote routine delivery of essential sexual wellbeing support for men living with prostate cancer. Further studies are needed to explore the longer-term effectiveness of this e-learning resource and its impact on healthcare professional behaviour and patient important outcomes.
The following are available online at https://www.mdpi.com/article/10.3390/ijerph181910045/s1, Figure S1: Boxplots showing distribution of Sexual Attitude and Beliefs Survey scores for each statement (Q1–Q12) and total survey scores from participants in the pilot study (n = 44), Table S1: Changes made to the Sexual Attitudes and Beliefs Survey based on testing carried prior to the pilot study (n = 66 participants) and internal consistency measures of each item.
Conceptualization, E.M.M., K.P., C.F., S.R.O., R.M., J.C., S.T., S.J. and M.K.; Data curation, C.F. and S.R.O.; Formal analysis, C.F. and S.R.O.; Funding acquisition, E.M.M., K.P., R.M., S.T., S.J. and M.K.; Investigation, E.M.M., S.R.O., S.L.B., C.F. and J.C.; Methodology, E.M.M., K.P., S.R.O., R.M., J.C., S.T., N.B., S.J., S.L.B. and M.K.; Writing-original draft, S.R.O.; Writing—review and editing, E.M.M., K.P., C.F., S.R.O., R.M., N.B., S.T., S.J., S.L.B. and M.K. All authors have read and agreed to the published version of the manuscript.
This research is supported by funding from the Movember Foundation and Prostate Cancer UK as part of the TrueNORTH maximizing sexual well-being project (TrueNTH/19).
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Office for Research Ethics Committees Northern Ireland (reference number: 17/NI/014).
Informed consent was obtained from all participants involved in the study.
The data presented in this study are available on request from the corresponding author. The data are not publically available due to their containing information that could compromise the privacy of research participants.
The authors would like to thank all those who took part in the study. We also wish to acknowledge our colleague and the principal investigator of this project, the late Eilís McCaughan. Her expertise and dedication to supporting those who felt the impact of cancer treatment had a profound impact on this work.
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Table 1. Participant demographics (n = 44).
Participant Characteristic
Number (%)
Profession Nurse: 31 (70.5%)
Radiographer: 6 (13.6%)
Doctor: 5 (11.4%)
Cancer Support Worker: 2 (4.5%)
Years in practice 0–4 years: 7 (15.9%)
5–12 years: 32 (72.7%)
More than 12 years: 5 (11.4%)
Days per week providing care for patients with prostate cancer 1–2 days per month: 8 (1.2%)
1–2 days per week: 24 (54.5%)
Previous training in sexual health or wellbeing communication Yes: 8 (18.2%)
Primary reason for undertaking the e-learning To improve communication skills: n = 13 (29.5%)
To improve knowledge: n = 20 (45.5%)
To support evidence-informed practice: n = 3 (6.8%)
To increase confidence is discussion sexual wellbeing: n = 8 (18.2%)
Table 2. Mean pre and post scores for sexual attitude and beliefs survey questions (n = 44).
Within Subject
Pairwise Comparisons
Statement ***
P a
T0 vs. T1
1. I understand how prostate cancer and its treatment might affect men's sexual wellbeing 3.18
(2.98–3.41) 3.79
(3.31–3.62) 23.653 0.001 ** 0.001 ** 0.001 **
2. I am uncomfortable talking about sexual issues with men living with prostate cancer * 2.76
(2.73–3.06) 5.373 0.009 0.028 0.865
3. I feel confident in my ability to address the sexual concerns of men living with prostate cancer 2.59
(2.58–3.03) 27.355 0.001 ** 0.001 ** 0.063
4. Talking about sexual concerns with men living with prostate cancer can 'open a can of worms' * 2.82
5. Sexual concerns are an important topic to discuss with men living with prostate cancer 3.61
6. Discussing sexual concerns with men living with prostate cancer is part of my job 3.37
7. I make time to discuss sexual concerns with men living with prostate cancer 2.98
(2.81–3.16) 12.292 0.001 ** 0.034 0.0013 **
8. Sexual issues should be discussed only if initiated by men living with prostate cancer * 3.26
9. I find it difficult to talk to older men living with prostate cancer about sexual concerns * 2.88
10. I know the right language to use when discussing sexual concerns with men living with prostate cancer 2.52
11. Sexual issues should be discussed with partners of men living with prostate cancer 2.93
12. Men living with prostate cancer do not expect healthcare professionals to ask about sexual concerns * 2.24
Total score/48(95% CI) 35.14
(34.82–36.87) 37.08
(35.72–37.75) 3.145 0.060 0.134 0.587
T0 = Timepoint 0 (baseline). T1 = Timepoint 1 (immediately post completion). T2 = Timepoint 2 (1-month post completion). *** Modified sexual attitudes and beliefs questionnaire consists of 12 statements scored/4 based on the following criteria: 1 = Strongly Disagree; 2 = Disagree; 3 = Agree; 4 = Strongly Agree. A total score is assigned/48. ** Indicates a significant effect. * indicates a score which is reversed for data analysis. a Bonferroni-adjusted P value for multiple comparisons: P < 0.004. CI = confidence interval. Boxplots showing the distribution of scores for each statement are shown in Supplementary Figure S1.
Table 3. Participant views on usefulness and usability recorded following completion of the e-learning resource (n = 44).
Mean/4 (SD)
1. The e-learning resource included information that will be useful for my practice 3.81 (0.37)
2. I would recommend others use the e-learning module 3.01 (0.40)
3. I will use the e-learning resource as a resource 3.53 (0.42)
4. I thought the e-learning resource was easy to use 3.42 (0.54)
Each statement is scored/4 based on the following criteria: 1 = Strongly Disagree; 2 = Disagree; 3 = Agree; 4 = Strongly Agree. SD = Standard Deviation.
McCaughan, E.M.; Flannagan, C.; Parahoo, K.; Bingham, S.L.; Brady, N.; Connaghan, J.; Maguire, R.; Thompson, S.; Jain, S.; Kirby, M.; O'Connor, S.R. Effects of a Brief E-Learning Resource on Sexual Attitudes and Beliefs of Healthcare Professionals Working in Prostate Cancer Care: A Pilot Study. Int. J. Environ. Res. Public Health 2021, 18, 10045. https://doi.org/10.3390/ijerph181910045
McCaughan EM, Flannagan C, Parahoo K, Bingham SL, Brady N, Connaghan J, Maguire R, Thompson S, Jain S, Kirby M, O'Connor SR. Effects of a Brief E-Learning Resource on Sexual Attitudes and Beliefs of Healthcare Professionals Working in Prostate Cancer Care: A Pilot Study. International Journal of Environmental Research and Public Health. 2021; 18(19):10045. https://doi.org/10.3390/ijerph181910045
McCaughan, Eilís M., Carrie Flannagan, Kader Parahoo, Sharon L. Bingham, Nuala Brady, John Connaghan, Roma Maguire, Samantha Thompson, Suneil Jain, Michael Kirby, and Seán R. O'Connor. 2021. "Effects of a Brief E-Learning Resource on Sexual Attitudes and Beliefs of Healthcare Professionals Working in Prostate Cancer Care: A Pilot Study" International Journal of Environmental Research and Public Health 18, no. 19: 10045. https://doi.org/10.3390/ijerph181910045
Supplementary File 1:
ZIP-Document (ZIP, 145 KiB)


text:
package net.sourceforge.myvd.types;

import java.util.ArrayList;
import java.util.Iterator;

import com.novell.ldap.LDAPException;
import com.novell.ldap.LDAPSearchRequest;
import com.novell.ldap.rfc2251.RfcFilter;

public class Filter {

	private FilterNode root;

	public Filter(String val) throws LDAPException {
		RfcFilter rfcFilter = new RfcFilter(val.trim());
		this.root = createFilter(rfcFilter.getFilterIterator(),null);
	}

	public Filter(FilterNode root) {

		this.root = root;
	}

	public void setValue(String val) throws LDAPException {
		RfcFilter rfcFilter = new RfcFilter(val.trim());
		this.root = createFilter(rfcFilter.getFilterIterator(),null);
	}

	public String getValue() {
		return this.root.toString();
	}

	private  FilterNode createFilter(Iterator itr,FilterNode parent) {
        int op=-1;
        //filter.append('(');
        String comp = null;

        boolean isFirst = true;

        FilterNode ret = null;

        while (itr.hasNext()){
            Object filterpart = itr.next();
            if (filterpart instanceof Integer){
                op = ((Integer)filterpart).intValue();
                switch (op){
                    case LDAPSearchRequest.AND:

                        ret = new FilterNode(FilterType.AND,new ArrayList<FilterNode>());
                        if (parent != null) {
                    		parent.addNode(ret);
                    	}
                        break;
                    case LDAPSearchRequest.OR:
                    	ret = new FilterNode(FilterType.OR,new ArrayList<FilterNode>());
                        if (parent != null) {
                    		parent.addNode(ret);
                    	}
                        break;
                    case LDAPSearchRequest.NOT:
                    	ret = new FilterNode(null);
                        if (parent != null) {
                    		parent.addNode(ret);
                    	}
                        break;
                    case LDAPSearchRequest.EQUALITY_MATCH:{
                    	ret = new FilterNode(FilterType.EQUALS,(String)itr.next(),new String((byte[])itr.next()));
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    }
                    case LDAPSearchRequest.GREATER_OR_EQUAL:{
                    	ret = new FilterNode(FilterType.GREATER_THEN,(String)itr.next(),new String((byte[])itr.next()));
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    }
                    case LDAPSearchRequest.LESS_OR_EQUAL:{
                    	ret = new FilterNode(FilterType.LESS_THEN,(String)itr.next(),new String((byte[])itr.next()));
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    }
                    case LDAPSearchRequest.PRESENT:
                    	ret = new FilterNode(FilterType.PRESENCE,(String)itr.next(),"");
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    case LDAPSearchRequest.APPROX_MATCH:
                    	ret = new FilterNode(FilterType.EQUALS,(String)itr.next(),new String((byte[])itr.next()));
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    case LDAPSearchRequest.EXTENSIBLE_MATCH:
					    Object extOid = itr.next();
						Object attributeName = itr.next();
						Object filterValue = itr.next();

						StringBuilder sb = new StringBuilder();

						if (attributeName instanceof String) {
							sb.append(attributeName);
						} else {
							sb.append(new String((byte[]) attributeName));
						}

						sb.append(":");

						if (extOid instanceof String) {
							sb.append(extOid);
						} else {
							sb.append(new String((byte[]) extOid));
						}

						String filterValueText = "";

						if (filterValue instanceof String) {
							filterValueText = (String)filterValue;
						} else {
							filterValueText = new String((byte[]) filterValue);
						}

                    	ret = new FilterNode(FilterType.EXT,sb.toString(),filterValueText);
                    	if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                    	break;
                    case LDAPSearchRequest.SUBSTRINGS:{
                    	StringBuffer val = new StringBuffer();
                        String name = (String)itr.next();

                        boolean noStarLast = true;
                        while (itr.hasNext()){
                            op = ((Integer)itr.next()).intValue();
                            switch(op){
                                case LDAPSearchRequest.INITIAL:
                                    val.append((String)itr.next());
                                    val.append('*');
                                    noStarLast = false;
                                    break;
                                case LDAPSearchRequest.ANY:
                                    if( noStarLast)
                                        val.append('*');
                                    val.append((String)itr.next());
                                    val.append('*');
                                    noStarLast = false;
                                    break;
                                case LDAPSearchRequest.FINAL:
                                    if( noStarLast)
                                        val.append('*');

                                    val.append((String)itr.next());
                                    break;
                            }

                        }

                        ret = new FilterNode(FilterType.SUBSTR,name,val.toString());
                        if (parent != null) {
                    		if (parent.getType() == FilterType.NOT) {
                    			parent.setNot(ret);
                    		} else {
                    			parent.getChildren().add(ret);
                    		}
                    	}
                        break;
                    }
                }
            } else if (filterpart instanceof Iterator){
            	createFilter((Iterator)filterpart, ret);
            }

        }

        return ret;
    }

	public FilterNode getRoot() {
		return this.root;
	}

	public ArrayList<FilterNode> listNodes(String attributeName) {
		ArrayList<FilterNode> results = new ArrayList<FilterNode>();
		this.findNodes(this.root,attributeName,results);
		return results;
	}

	private void findNodes(FilterNode root,String attributeName,ArrayList<FilterNode> res) {
		Iterator<FilterNode> it;

		switch (root.getType()) {
			case PRESENCE :
			case SUBSTR:
			case EQUALS :
			case GREATER_THEN :
			case LESS_THEN : if (root.getName().equalsIgnoreCase(attributeName)) {
							 	res.add(root);
							 	return;
							 }
							 break;
			case AND : it = root.getChildren().iterator();
					   while (it.hasNext()) {
						   findNodes(it.next(),attributeName,res);
					   }
					   break;

			case OR :  it = root.getChildren().iterator();
					   while (it.hasNext()) {
						   findNodes(it.next(),attributeName,res);
					   }
					   break;

			case NOT : findNodes(root.getNot(),attributeName,res);
					   break;

		}
	}

	private int computeLength() {
		return this.root.computeLength();
	}
}

redpajama_set_name: RedPajamaGithub


I was very fortunate enough to have been a part of the creation of this short film as third assistant camera (camera production assistant) while I was studying abroad in South Korea. The film's english title is called "Retriever" and will be showcased at the Court Mértage (Short Film Corner) at Festival de Cannes.
The film's run time is around 25 minutes and will be showcased from May 16 to May 22nd in Cannes, France.


First you need to craete a twitter application (https://apps.twitter.com) and generate a consumer (api) key and consumer (api) secret.
With this key and secret, you must call https://api.twitter.com//oauth2/ once to generate the bearer key.
curl -XPOST https://api.twitter.com//oauth/token -u apikey:api-secret --data "grant_type=client_credentials"


"Paranoid" is a song by the British rock band Black Sabbath, featured on their second album Paranoid (1970). It is the first single from the album, while the B-side is the song "The Wizard". It reached number 4 on the UK Singles Chart and number 61 on the Billboard Hot 100.


text:
Precipitation total (Sat) Czechia
Central Europe Multi Model HD
Model charts MULTI-CEUR
Area Europe Central Europe Eastern Europe Southern Europe Southeastern Europe
Country Please select Germany Switzerland Liechtenstein Austria Albania Andorra Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark England Estonia Finland France Greece Hungary Ireland Italy Kosovo Latvia Lithuania Luxembourg Moldova Monaco Montenegro Netherlands North Macedonia Northern Ireland Norway Poland Portugal Romania Russia West San Marino Scotland Serbia Slovakia Slovenia Spain Sweden Turkey Ukraine United Kingdom Vatican City Wales
Regions Please select Jihoceský Jihomoravský Karlovarský Kraj Vysocina Královéhradecký Liberecký Moravskoslezský Olomoucký Pardubický Plzenský Prague Stredoceský Ústecký Zlínský
Temperature (°C) Flash-Flood-Index Thunderstorm risk (%) Significant Weather Precipitation, 1h (mm) Precipitation, 6h (mm) Precipitation, 24h (mm) Accumulated total precipitation (mm) Gusts, 1h (kph) Cloud coverage (%) Mixed-Layer CAPE (J/kg)
Significant Weather
Temperature (°C) Temperature (Grid) (°C) Temperature 2m, Ens. minimum (°C) Temperature 2m, Ens. maximum (°C)
Gusts, 1h (kph) Gusts, 1h Ens. maximum (kph) Gusts, 1h Ens. minimum (kph)
Cloud coverage (%) Cloud coverage, Ens. maximum (%) Cloud coverage, Ens. minimum (%)
Precipitation, 1h (mm) Precipitation, 3h (mm) Precipitation, 6h (mm) Precipitation, 24h (mm) Precipitation, 24h, Ens. minimum (mm) Precipitation, 24h, Ens. maximum (mm) Accumulated total precipitation (mm) Total precipitation, Ens. maximum (mm) Total precipitation, Ens. minimum (mm)
Thunderstorm risk (%) Thunderstorm risk, 6h average (%) Thunderstorm risk, 6h maximum (%) Reflectivity motion (km/h) Mixed-Layer CAPE (J/kg) CAPE (Mixed layer), Ens. maximum (J/kg) CAPE (Mixed layer), Ens. minimum (J/kg) Entire Atmosphere Precipitable Water (mm) Maximum Potential Precipitable Water (mm) Flash-Flood-Index Flash-Flood-Index, 6h average Flash-Flood-Index, 6h maximum Pot. flash flood intensity (mm) Pot. flash flood intensity, 6h average (mm) Pot. flash flood intensity, 6h maximum (mm)
Temperature 2m <0°C (%) Temperature 2m >20°C (%) Temperature 2m >30°C (%) Precipitation, 1h >0.1mm (%) Precipitation, 1h >1mm (%) Precipitation, 1h >10mm (%) Gusts, 1h >65kph (%) Gusts, 1h >90kph (%) Gusts, 1h >119kph (%) Cloud coverage >2/8 (%) Cloud coverage >4/8 (%) Cloud coverage >6/8 (%) ML CAPE >100 J/kg (%) ML CAPE >500 J/kg (%) ML CAPE >1000 J/kg (%)
Here are all the probabilities parameters. These are calculated from all members of an ensemble run.
Swiss HD 1x1 ICON-D2 Swiss-MRF AROME Swiss HD 4x4 Swiss HD 4x4 (ECMWF) Swiss HD Nowcast ICON-EU ICON-EU (Flash) HARMONIE RUSSIA MULTI-CEUR ECMWF 6z/18z ECMWF IFS HRES ICON GFS UKMO ARPEGE GEM ACCESS-G CMA GDAPS/UM MULTI-GLOBAL
COSMO-D2 EURO-4 HIRLAM-FMI HIRLAM GFS/FV3
Swiss HD 1x1 ICON-D2 Swiss-MRF AROME Swiss HD 4x4 Swiss HD 4x4 (ECMWF) Swiss HD Nowcast ICON-EU ICON-EU (Flash) HARMONIE MULTI-CEUR ECMWF IFS HRES ICON GFS UKMO ACCESS-G
09:00am 10:00am 11:00am 12:00pm 01:00pm 02:00pm 03:00pm 04:00pm 05:00pm 06:00pm 07:00pm 08:00pm 09:00pm 10:00pm 11:00pm
12:00am 01:00am 02:00am 03:00am 04:00am 05:00am 06:00am 07:00am 08:00am 09:00am 10:00am 11:00am 12:00pm 01:00pm 02:00pm 03:00pm 04:00pm 05:00pm 06:00pm 07:00pm 08:00pm 09:00pm 10:00pm 11:00pm
12:00am 01:00am 02:00am 03:00am 04:00am 05:00am 06:00am 07:00am
+014 +015 +016 +017 +018 +019 +020 +021 +022 +023 +024 +025 +026 +027 +028 +029 +030 +031 +032 +033 +034 +035 +036 +037 +038 +039 +040 +041 +042 +043 +044 +045 +046 +047 +048 +049 +050 +051 +052 +053 +054 +055 +056 +057 +058 +059 +060
2023012918#142023012918#152023012918#162023012918#172023012918#182023012918#192023012918#202023012918#212023012918#222023012918#232023012918#242023012918#252023012918#262023012918#272023012918#282023012918#292023012918#302023012918#312023012918#322023012918#332023012918#342023012918#352023012918#362023012918#372023012918#382023012918#392023012918#402023012918#412023012918#422023012918#432023012918#442023012918#452023012918#462023012918#472023012918#482023012918#492023012918#502023012918#512023012918#522023012918#532023012918#542023012918#552023012918#562023012918#572023012918#582023012918#592023012918#60
Mon, 01/30/2023 at 09:00amMon, 01/30/2023 at 10:00amMon, 01/30/2023 at 11:00amMon, 01/30/2023 at 12:00pmMon, 01/30/2023 at 01:00pmMon, 01/30/2023 at 02:00pmMon, 01/30/2023 at 03:00pmMon, 01/30/2023 at 04:00pmMon, 01/30/2023 at 05:00pmMon, 01/30/2023 at 06:00pmMon, 01/30/2023 at 07:00pmMon, 01/30/2023 at 08:00pmMon, 01/30/2023 at 09:00pmMon, 01/30/2023 at 10:00pmMon, 01/30/2023 at 11:00pmTue, 01/31/2023 at 12:00amTue, 01/31/2023 at 01:00amTue, 01/31/2023 at 02:00amTue, 01/31/2023 at 03:00amTue, 01/31/2023 at 04:00amTue, 01/31/2023 at 05:00amTue, 01/31/2023 at 06:00amTue, 01/31/2023 at 07:00amTue, 01/31/2023 at 08:00amTue, 01/31/2023 at 09:00amTue, 01/31/2023 at 10:00amTue, 01/31/2023 at 11:00amTue, 01/31/2023 at 12:00pmTue, 01/31/2023 at 01:00pmTue, 01/31/2023 at 02:00pmTue, 01/31/2023 at 03:00pmTue, 01/31/2023 at 04:00pmTue, 01/31/2023 at 05:00pmTue, 01/31/2023 at 06:00pmTue, 01/31/2023 at 07:00pmTue, 01/31/2023 at 08:00pmTue, 01/31/2023 at 09:00pmTue, 01/31/2023 at 10:00pmTue, 01/31/2023 at 11:00pmWed, 02/01/2023 at 12:00amWed, 02/01/2023 at 01:00amWed, 02/01/2023 at 02:00amWed, 02/01/2023 at 03:00amWed, 02/01/2023 at 04:00amWed, 02/01/2023 at 05:00amWed, 02/01/2023 at 06:00amWed, 02/01/2023 at 07:00am
SHD ICD2 SNOW S4x4 SEZ4 ARM HRM MUHD ICHD SMRF ECMWF
IFS GFS
Mon 01/30/2023, 09:00am CET
Central Europe Multi Model HD (3 days) from 01/29/2023/18z
SEZ4
MUHD
ICHD
SMRF
The multi-model is a product that combines different high-resolution regional models for Central Europe into one forecast by dynamic weighting. A major advantage of the multi-model is that extreme solutions from one model do not bias the forecast in that direction. The multi-model will therefore never represent an outlier variant and thus can be taken as a good starting point for more detailed considerations.
If, for example, the multi-model predicts extremely high amounts of precipitation for a region, then this is a serious indication that it will come true, since this forecast is supported by several independent weather models and the impact of extreme solutions have been damped.
For some parameters we also offer the maximums and minimums of the model ensemble, from which you can see the upper or lower end of the predicted values and their variation.
Furthermore, we can use the multi-model forecasts to calculate important indices for specific severe weather hazards, such as the flash flood index.
Also, with the multi-model, as in an EPS (Ensemble Prediction System), we can derive a probability of the occurrence of certain threshold values (e.g. how high is the probability that the temperature will fall below 0°C?). We offer such parameters in the "Probabilities" subgroup.

redpajama_set_name: RedPajamaCommonCrawl


Starting new D&D group for beginners!
I'm looking to start a new D&D group designed for beginners, but anyone is welcome!
I'd like to run 1e but 3.5e is also an option if the group wants. I can be the DM or if someone else has a desire, we can alternate. Game times will be once a week on a weekend depending on schedules.
About me: My name is Mike and I'm a 30 year old married man with a 2 year old. I have an office location we can use on the corner of Commercial Boulevard and Dixie Highway (zip code 33334). Email me at JenkinsM82@Gmail.com.
D&D for Noobs Members-Only You do not have access to read this forum.


For most tobacco users, tobacco cravings or urges to smoke can be powerful. But you're not at the mercy of these cravings.
When an urge to use tobacco strikes, remember that although it may be intense, it will probably pass within five to 10 minutes whether or not you smoke a cigarette or take a dip of chewing tobacco. Each time you resist a tobacco craving, you're one step closer to stopping tobacco use for good.
Here are few tips to help you resist the urge to smoke or use tobacco when a tobacco craving strikes.
Short-acting nicotine replacement therapies such as nicotine gum, lozenges, nasal sprays or inhalers can help you overcome intense cravings.
Urges for tobacco are likely to be strongest in the situations where you smoked or chewed tobacco most often, such as at parties or bars, or while feeling stressed or sipping coffee. Identify your trigger situations and have a plan in place to avoid them entirely or get through them without using tobacco.
If you feel like you're going to give in to your tobacco craving, tell yourself that you must first wait 10 more minutes and then do something to distract yourself for that period of time. Try going to a public, smoke-free zone. These simple tricks may be enough to derail your tobacco craving.
Give your mouth something to do to fight a tobacco craving. Chew on sugarless gum or hard candy, or munch on raw carrots, celery, nuts or sunflower seeds — something crunchy and satisfying.
You might be tempted to have just one cigarette to satisfy a tobacco craving. But don't fool yourself into believing that you can stop there. More often than not, having just one leads to another and you may end up using tobacco again.
Physical activity can help distract you from tobacco cravings and reduce their intensity. Even short burst of physical activity such as running up and down the stairs a few times can make a tobacco craving go away. Get out for a walk or jog.
If you're stuck at home or the office, try squats, deep knee bends, push ups, running in place, or walking up and down a set of stairs.
Smoking may have been your way to deal with stress. Resisting a tobacco craving can itself be stressful. Take the edge off stress by practicing relaxation techniques, such as deep-breathing exercises, yoga, massage or listening to calming music.
Call up on with a family member, friend or support group member for help in your effort to resist a tobacco craving. Chat on the phone, go for a walk together, share a few laughs, or get together to commiserate about your cravings.
Remember, trying something to beat the urge is always better than doing nothing. And each time you resist a tobacco craving, you're one step closer to being totally tobacco-free.
Previous PostDoes Alcohol consumption affect your Blood Pressure levels?


Click the button below to add the Blue Ribbon Police Station to your wish list.
Calling all future Police! This sturdy Two level wooden toy Police station has a ramp at the lower level for the Police Car to enter. Check in with the Officer at the Front desk, but be careful, you could be moved to jail on the upper level! Comes with furniture and dolls.
Blue Ribbon toys are crafted from sustainable rubberwood and painted using only non-toxic finishes. Blue Ribbon Toys are designed to enhance developmental skills and are intended to last generations.


The three locations are in the famous Franschhoek region, the upmarket suburb of Constantia or at the charming seaside village of Kommetjie. From the exterior of all three properties any passerby would not give them another moment's notice. Behind the seeming less plain façade belies an experience waiting to be relished.
The group is part of the international chain of the iPrefer Group, and certainly lives up to their standards.
Each property has its own unique features and qualities that distinguish it from the other. The Constantia property is set in the heart of the beautiful and charming Constantia allowing guests for easy access to the heart of the mother city. The grace and charm of the area are echoed in the overall ambience of the property with attention to detail in all aspects of the service.
The accommodation on offer is wide and varied from elegant suites, to family suites, pool suites to superior double rooms.
The rates include breakfast for all three hotels, allowing the guests the freedom to choose lunch and dinner venues whilst you are out and about discovering the mother city and surrounds. The friendly and welcoming staff will also recommend, and make dinner reservations for you in need. Private chauffeurs will whisk you away and bring you back to the hotel upon conclusion of your evening to allow you to relax and enjoy the full fruits that Cape Town offers. Wine farms in the world famous Constantia valley are on your doorstep as well as numerous eateries offering a variety of delightful tastes to amaze and tantalize your taste buds.
The Last Word at Kommetjie offers a traveler a unique seaside experience with endless views over the Long Beach and the Atlantic Ocean. Stepping off the property one can feel the sea sand press through your barefoot toes. Upstairs the accommodation offers elegant suites while downstairs you have the option of junior suites or superior double rooms which open up onto their own secluded garden.
Eight Kilometers of pristine white sand stretches away as far as the eye can see. Sitting in the dining room enjoying a leisurely breakfast allows the body and soul to unwind while you contemplate your day ahead. Take a drive down to the Cape Point at the tip of South Africa, or amble through to close by village of Kommetjie. If you feel more adventurous drive through to Cape Town either via the picturesque Chapman's Peak Drive or via ou Kapse Weg.
The Last Word Franschhoek offers eight superior double rooms and two pool suites. Situated in wine area of Franschhoek with the French flair allows the visitor the opportunity to explore the delights of the town and the nearby wineries and farms. Elegance and flair abounds with some of the top restaurants and eateries situated in the town giving the foodie in you endless choices. If you are looking to escape the stress of modern life and to be indulged look no further than the Last Word.


text:
Q: What's the right place to dispose a libgdx Screen Hello I am working out a game and I wonder how to dispose resources as I am experiencing memory problems.
I have something like this:
public SplashScreen implements Screen {
    @Override
    public void render(float delta) {
    }
    @Override
    public void dispose() {
        if (batch != null)
            batch.dispose();
        batch = null;
    }
}

public MapScreen implements Screen {
    @Override
    public void render(float delta) {
    }
    @Override
    public void show() {
        splashScreenInstance.dispose();
    }
    @Override
    public void dispose() {
        if (mesh != null)
        mesh.dispose();
        mesh = null;
    }
}

And I am disposing the splash screen as soon as the show method of MapScreen is called. Previously I'd settled the screen to the MapScree. Still the render method of the splashScreenInstance is called and I'd received null pointer exceptions. Why this is so?
I'd expect that once I set another screen, the previous one is no longer rendered. This is not seemingly so. I'd tried disposing right after setting the screen using the game instance, right after the hide method is called on the screen I want to dispose and finally on the show method of the next screen. All of these cases still renders the previous screen a few times before rendering the current one.
I really need to recover memory and also I don't want to test each time (On the render method) for null pointers as this has performance penalties.
Any suggestions?
Thanks

A: This is how I usually handle this problem:
public SplashScreen implements Screen {
    @Override
    public void render(float delta) {
        // I assume that you have a reference to the game somewhere to switch the screen
        game.setScreen(new MapScreen());
        dispose();
        return;
    }
}

I first set the new Screen, then dispose() the current one and then immediately stop any further execution of the current screen via return. This way the current render cycle should be stopped and in the next cycle the render() of your next screen will be called.
Another approach might be to call dispose() in your hide() method of the Screens, because that is going to be the last method being called before the Game will use the next screen. This is especially useful when there could be several different next screens. In that case there will still be only a single place of dispose() and that will be in the hide() method.

A: Where are you calling setScreen? Since everything should be happening in the rendering thread (even InputListeners) you should be able to call setScreen in your first Screen and then return from the render method. The Game instance will automatically call hide on your first Screen which is where you can call dispose.

redpajama_set_name: RedPajamaStackExchange


All of the patients involved in this story were hospitalized at Mount Carmel West, a major hospital in Columbus, Ohio, between 2015 and 2018. All of them were in intensive care. Some of them were terminal. Some of them, like a 44-year-old man who wasn't in extremely ill health before he developed trouble breathing, seem like they should have survived their trip to the hospital. All of them received doses of fentanyl, a powerful painkiller, well in excess of normal amounts -- which led to their deaths.
Currently, at least six wrongful death lawsuits have been filed regarding the patients -- and more are likely to follow. The real mystery, however, is not what happened in this hospital, but how it happened. Everyone seems to agree that there are checks and balances in place that should have prevented even one overly-large dose going out -- let alone a few dozen of them.
Normally, when a doctor orders a drug, the prescription is reviewed by a pharmacist -- who has the power to stop the prescription from going out. It's then dispensed by an automated machine that should send warning signals that a dose is too high. The nurse who administers the drug also has the ability to prevent the drug from getting to the patient.
Internal records should have also raised a red flag once patient charts were reviewed. While errors can happen somewhere along the way, the sheer number of errors that took place indicates that the entire system was broken -- or that one charismatic doctor was somehow able to overcome it.
If you suspect medical malpractice in the death of your loved one, it's important to ask questions. The truth of what happened to your loved one is out there but it may take some effort to uncover.


text:
Sergeant Steel – Lovers & Maniacs
Posted on May 1, 2010 by Skid in Uncategorized // 0 Comments
SERGEANT STEEL
LOVERS & MANIACS
Released 2010 (Sergeant Steel)
01. Hammer Of Love
02. Chasing Love
03. Looking For An Angel
04. Still In Love
05. Taking The World By Storm
06. Seizin' The Crown
07. Love Hurtz
08. High On Life
09. Miss U Tonite
10. Nuts Of Steel
Phil Vanderkill – lead vocals
Jack Power – guitar and vocals
Chuck Boom – guitar and vocals
Cosy Coxx – bass
Kevin King – drums and percussion
Ben Bateman – keyboards and piano
Produced and mixed by Jack Power. Mastered by Beau Hill.
Sergeant Steel seem to be a band with an identity problem. In one breath they will show glimpses of brilliance and in the next you'll be left wondering what the hell is going on in their heads! Not only are the songs themselves all over the place, but these Austrians jump all over genres like popcorn in a hot-air popper.
After multiple listens I still have no idea if Sergeant Steel want to be a sleazy glam band, a majestic Queen inspired outfit or something completely different! With the energetic and sleazy "Hammer Of Love" the band concoct a memorable and completely unconventional sleaze sound — the song is far from perfect yet it unexplainably works on many levels As quickly as that song grows on you the band loses focus with the horrendous "Looking For An Angel", a track best forgotten even if it does have some cool guitar work, while the following "Still In Love" is a Queen-esque ballad that is decent for what it is. "Taking The World By Storm" starts off with a keyboard driven intro before rapid firing drum beats kick in and are followed by Rob Halford screams — the song has its moments but seems to be stuffed full of too many different ideas.
The second half of Lovers & Maniacs starts off alright with the heavy, almost traditional metal sounding, "Seizin' The Crown" and "Love Hurtz", which slowly builds into something half decent. Then comes "High On Life", a song that heavily relies on the keyboards and almost succeeds with the melodic chorus, before the ballad "Miss U Tonite" (complete with harmonica work) goes nowhere. Then from left field comes "Nuts Of Steel", a Judas Priest type anthem that includes more killer guitar work. It is a great way to conclude an otherwise strange album.
I'm honestly not sure what to say about Lovers & Maniacs, it is all over the map. It isn't just the CD that is inconsistent though, some of the songs themselves take so many turns that can't help but wonder what the hell just happened — it sounds more like a compilation album than a collective effort by one single band. One moment you will be subjected to growling vocals and the next high pitched wails — while the music itself is anything from heavy metal, to keyboard pomp, to glam, to oddball stuff complete with a brass section. I liked the songs "Hammer Of Love" and "Nuts Of Steel" but in between those two tracks Sergeant Steel, for the most part, lost me. The musicianship is clearly there, especially evident with the guitar duo, but what needs a lot of work is the songwriting itself. I think naming this CD 'Identity Crisis' would have been more fitting.
www.sergeant-steel.com – www.myspace.com/sergeantsteelonline
Reviewed by Skid for Sleaze Roxx, May 2010
Buy The CD:
Purchase at SergeantSteel.bigcartel.com
Purchase at eBay.com


text:
September 26, 2018 by Kristine Jacobson 1 Comment
It all started with a tutu and a mom's desire for her unique daughter to have something unique to wear.
Missi Jean's daughter, Ava, was born with Down Syndrome on Down Syndrome Day (March 21, 2014) and has a heart defect. She wanted to dress her sweet daughter in something besides the typical "Wal-Mart clothing" that all of the other children were wearing.
So, she crafted a tutu for Ava and posted a photo on social media of her daughter wearing the tutu.
Instantly, her friends wanted Missi to make tutus for their children, and a business was born.
Tutu Little, named after Ava because her nickname is "Little," has now expanded to include onesies, tutu dresses, baby shoes, pants and her extremely popular unicorn outfits, which have recently boosted her sales by 157 percent!
Missi Jean and her children, Eli and Ava
Starting a Businesses
Prior to starting Tutu Little, Missi worked in retail and had recently managed a retail store.
When Ava was born, her life turned upside down. Not only was she adjusting to a newborn, but she was adjusting to parenting a child with special needs.
"We didn't find out for sure that she had Down Syndrome until the day she was born," Missi said of Ava. "With her being my first child, it was already a whirlwind, and we knew from what the doctor said that her immune system would be weaker."
Because of Ava'a health concerns, Missi had hoped to stay home with Ava for as long as possible. So, when the tutu orders started coming in, it was a blessing.
"At first, I didn't know this was going to turn into a business," she said. "When it did, it was a happy surprise."
The business, which she operates from her home in Grand Island, allowed her the flexibility to take Ava to six physical therapy sessions per week and other doctors appointments yet still bring in an income.
Missi is also a single mom and is grateful for the help her parents provide in watching her children (she now has a two-year-old son, Eli) and with the sewing and operating a home-based business.
Missi said she learned to sew from her mom and grandma. She and her mom sew all of the clothing for Tutu Little and ship them around the world to places like New Zealand, England, Canada, Puerto Rico, Germany and Australia.
She has spent countless hours learning Photoshop and refining her sewing skills by researching and reading. She also joined GROW Nebraska, a non-profit organization that exists to support and empower local entrepreneurs. Missi sells Tutu Little clothing at the GROW Nebraska store in Kearney.
She learned great business tips from GROW Nebraska's monthly training opportunities, including a session about becoming licensed to sell Husker-themed clothing.
"I was blown away by how complicated everything is with trademarks," she said. "The trainings helped so much in that aspect of the business."
Unicorns & Superheroes
While the business first started with tutu's, Missi has a keen eye for keeping up on the latest trends. She is often asked to make birthday party outfits and noticed a trend with unicorns. She created her popular unicorn outfit to fill multiple requests for unicorn-themed birthday clothing. The outfit includes rainbow sparkly leggings, a tutu, a shirt that can be personalized with the child's name and an elaborate matching headband complete with a unicorn horn.
"They can have the full matching outfit for their birthday or they can just wear it for fun or play or whatever they want to do," Missi said.
She also makes a lot of superhero outfits, newborn hospital homecoming outfits, Halloween costumes (including the popular Wonder Woman outfit) and other special occasion clothing.
With the holidays coming up, Missi is ready to bring on the glitter.
"For Christmas, we do a lot more glitter and sparkle and a lot more red and green," she said. "We will be doing red and green tutus. And, we will probably do some really sparkly outfits for New Year's."
She sells her clothing on her Etsy shop (www.etsy.com/shop/tutulittles) mainly in sizes 2T to Age 6.
For more information or to order, visit Tutu Little on Etsy or on the TuTu Little Facebook page.
Enter Your Email Here to Read More Stories about Nebraska Moms
Filed Under: Making A Difference Tagged With: Children's Clothing, Coming Home Outfits, Halloween Costumes, Tutu Little, TuTus
Sandy Kraus says
Love this story!. I'll keep her in mind for my granddaughter!


The WooCommerce – Search By SKU plugin is a plugin found on WordPress.org that allows search by SKU on both backend and frontend.
However, we have reported conflicts with this plugin due to the way it extends the search functionality by creating a custom loop which doesn't apply our loop filtering.
Products that are restricted to wholesale roles in the backend show up in search results for non-wholesale users on the front end.
However, when you click through to the single product page you will get redirected back to the shop page as part of the visibility restrictions we enforce.


text:
Q: How to execute remote SSH command in background using PHP exec()? Is there a simple way to execute SSH commands in the background on remote machines from PHP without using ssh2_*? The PHP script is executed by the user from bash (no Apache involved), so it's not an issue of rights. I've tried doing this:
exec("ssh -f -o UnknownHostsFile=/dev/null -o StrictHostKeyChecking=no -i {$keyFile} {$user}@{$ip} {$remoteCommand} 2>&1 >/dev/null </dev/null");

For example:
exec("ssh -f -o UnknownHostsFile=/dev/null -o StrictHostKeyChecking=no -i /home/data/id_rsa user@192.168.0.19 '/home/user/script.sh ; exit' 2>&1 >/dev/null </dev/null");

All PHP variables have been escaped with escapeshellarg() and $remoteCommand is a bash script on the remote machine that sleeps for a few minutes and then starts executing some commands.
My problem is that if I execute that SSH command from bash, it gives control back to bash immediately. If I execute it from php using exec() it waits until the remote command executes. I've tried adding 2>&1 >/dev/null </dev/null after /home/user/script.sh, but the execution still doesn't return control to the PHP script.

A: I think you are missing an & at the end of your command for sending the execution to the background.


text:
Q: MaxOccurs, invalid content and more- schemas Ok initial queries are fixed, but I've still some bits that I'm confused on.
Here's the xml:
<?xml version="1.0" encoding="UTF-8"?>
<bookstore xmlns:xsd='http://www.w3.org/2001/XMLSchema-instance' xsd:noNamespaceSchemaLocation='schema.xsd'>
    <book category="COOKING">
      <title lang="en">Everyday Italian</title>
      <author>Giada De Laurentiis</author>
      <year>2005</year>
      <price>30.00</price>
      <photo>http://puu.sh/gNzTB/258d022e33.jpg</photo>
    </book>

    <book category="CHILDREN">
      <title lang="en">Harry Potter</title>
      <author>J K. Rowling</author>
      <year>2005</year>
      <price>29.99</price>
      <photo>http://puu.sh/gNzV9/e27dfc1b55.jpg</photo>
    </book>

    <book category="WEB">
      <title lang="en">XQuery Kick Start</title>
      <author>James McGovern</author>
      <author>Per Bothner</author>
      <author>Kurt Cagle</author>
      <author>James Linn</author>
      <author>Vaidyanathan Nagarajan</author>
      <year>2003</year>
      <price>49.99</price>
    </book>

    <book category="WEB">
      <title lang="en">Learning XML</title>
      <author>Erik T. Ray</author>
      <year>2003</year>
      <price>39.95</price>
    </book>
</bookstore>

Heres the schema:
<xsd:schema xmlns:xsd='http://www.w3.org/2001/XMLSchema'>
<!-- define elements (elements with attributes or other elemens inside are complex) -->
    <xsd:element name='author' type='xsd:string' />
    <xsd:element name='year' type='xsd:gYear' />
    <xsd:element name='price' type='xsd:decimal' />
    <xsd:element name='photo' type='xsd:anyURI' />

<!-- define attributes -->
    <xsd:attribute name='category' type='xsd:string'/>
    <xsd:attribute name='lang' type='xsd:string'/>

<!-- structure -->
    <xsd:element name='title'>
        <xsd:complexType>
            <xsd:simpleContent>
                <xsd:extension base='xsd:string'>
                    <xsd:attribute ref='lang'/>
                </xsd:extension>
            </xsd:simpleContent>
        </xsd:complexType>
    </xsd:element>

    <xsd:element name='book'>
        <xsd:complexType>
            <xsd:sequence>
                <xsd:element ref='title'/>
                <xsd:element ref='author' maxOccurs='10'/>
                <xsd:element ref='year'/>
                <xsd:element ref='price'/>
                <xsd:element ref='photo' minOccurs='0'/>
            </xsd:sequence>
            <xsd:attribute ref='category'/>
        </xsd:complexType>
    </xsd:element>

    <xsd:element name='bookstore'>
        <xsd:complexType>
            <xsd:sequence>
                <xsd:element ref='book' maxOccurs='unbounded'/>
            </xsd:sequence>
        </xsd:complexType>
    </xsd:element>

</xsd:schema>

*

*When I initially tried to add such parameters(?) as min/max occurs on the initial definitions, I was rebuffed with errors. But when I added them to the ref instances of the same elements, the changes were accepted. Why is this? It seems to me that such parameters should hold position in the initial definition?

For clarification I mean I got errors with:
<xsd:element name='author' type='xsd:string' maxOccurs='10'/>

But not with:
<xsd:element ref='author' maxOccurs='10'/>

*With the structure, mainly the title element with the attribute 'lang' I got errors with type string not being allowed as it was supposedly stated twice, once in the initial xsd:string spot, and again in complexType. Now I found a fix involving simpleContent and extensions but I'm not really sure HOW that fixed it. Any ideas?

Thank-you!


text:
Top articles of the week: August 30
This week on Blue & Green Tomorrow, campaigners have called on the Vatican Bank to divest its investments in the fossil fuel industry.
We also reported on the UK energy supplier Ovo Energy receiving an £8 million investment from former US vice president Al Gore's firm. In other news, Australian MP George Christensen admitted he got it wrong on dumping coal waste into the Great Barrier Reef.
1. Unexpected methane leakage discovered on the US Atlantic sea floor
Ilaria Bertini: Scientists have found at least 570 vents off the US East Coast that are leaking methane – one of the most powerful greenhouse gases on Earth – and fear they could eventually contribute to global warming. Read more.
2. Australian MP says he 'got it wrong' on dumping coal waste on Great Barrier Reef
Jemma Collins: Coalition MP George Christensen has admitted he was wrong to support the dumping of millions of tonnes of dredge spoil from Abbot Point, into the Great Barrier Reef. He says he will now look at other options. Read more.
3. Scottish salmon farmers under scrutiny over seals shooting
Ilaria Bertini: The Scottish salmon industry is battling conservationists and animal rights campaigners over the killing of seals, seen as a threat to the industry. Hundreds of mammals were killed last year but the Scottish government has refused to publish new data revealing how many animals were shot in 2014. Read more.
4. Cuadrilla taking legal action against anti-fracking protest group
Jemma Collins: Energy firm Cuadrilla is taking legal action against protestors in Lancashire, with Manchester High Court to hear the case on Thursday August 28. Read more.
5. Pope Francis urged to divest Vatican from fossil fuels
Tom Revell: Campaigners have called on the Vatican Bank to ditch all its investments in the fossil fuel industry, and throw its considerable weight behind the growing divestment movement. Read more.
6. EvoEnergy: renewable energy investments offer better returns than pension funds
Tom Revell: An investment in a renewable energy project can offer significant and reliable long-term income to private investors in retirement, perfectly complimenting a pension, according to new research. Read more.
7. Tackling climate change could address economic and social challenges, says report
Charlotte Malone: Addressing climate change could deliver better living standards and shared prosperity, according to a report from thinktank IPPR. Whilst tackling climate change is an important goal in its own right, the report argues it could solve some of the economic and social challenges the UK faces. Read more.
8. Scottish referendum: business coalition speaks in favour of independence
Ilaria Bertini: After 130 business leaders defended the union on Wednesday, another group of 200 figures has responded to back the referendum, arguing that independence would help businesses of all sizes to thrive, while a possible exit of the UK from the EU would instead threaten the country's prosperity. Read more.
9. Al Gore's firm invests £8m in Ovo Energy
Charlotte Malone: UK energy supplier Ovo Energy has received an £8 million investment from former US vice president Al Gore's firm. The deal comes as the regulator is seeking to make the energy market more competitive and reduce the dominance of the big six suppliers. Read more.
10. Wildlife trade: new report reveals the extent of bear trafficking in Asia
Ilaria Bertini: New analysis by wildlife charity TRAFFIC has revealed at least 2,801 bears have been traded dead or alive for their parts and derivatives between 2000 and 2011 in Asia, especially in Cambodia and China. Read more.
Related Topics:Climate ChangefarmersFossil Fuelsgreat barrier reefmethaneRenewable EnergysalmonscotlandtraffickingVaticanwildlife trade


The European Parliament's agricultural committee began adopting dozens of amendments to the EU's future farm policy on Wednesday (23 January), but approval remains far from certain when the full Parliament considers compromise proposals in March.
With committee voting due to continue today, lawmakers are under pressure to approve a Common Agricultural Policy (CAP) without knowing how much they have to spend and with just 11 months to go before implementation.
The stakes are high for the European Parliament, which for the first time has legislative powers over policies that will govern agriculture.
"It is going to be a difficult debate and a lot of [my] colleagues are not satisfied with the compromises made in the agricultural committee," British MEP Linda McAvan (Alliance of Liberals and Democrats) said during a hearing in the European Parliament's environment and food committee.
The environment panel met to discuss the CAP with Ireland's farm minister as the agricultural committee began a two-day session of voting on CAP amendments.
The two panels have differed sharply over policies, including the environment committee's support for tougher 'greening' requirements for farmers and for requiring the EU to monitor the impact of its farming subsidies have on food production in developing countries.
European Commission and Council officials have conceded that whatever new policies are approved, implementation will almost certainly be delayed by a year, until 2015, because there will not be enough time for national governments and farmers to absorb the new regulations.
Simon Coveney, Ireland's minister of agriculture and food, said a quick deal on the 2014-2020 CAP is a priority and he expects agreement soon. Ireland currently holds the six-month presidency of the EU Council.
There are no easy answers to several thorny environmental issues, the minister said, including linking farmers' direct payments to requirements to diversify their crops and dedicate 7% of their land to buffers and other so-called ecological focus areas.
The agricultural committee began two days of votes on the two main financial pillars of the CAP, direct payments to farmers and rural development, as well as proposals to phase out price supports for sugar and planting right for wine producers.
The EU Council, representing the 27 member states, is due to finalise an overall budget for 2014-2020 at a 7-8 February summit in Brussels. The next budget is likely to deliver cuts to most EU programmes, including what has traditionally been its largest, the CAP.
The European Environmental Bureau, and NGO, said in a statement: "After months of deliberation the Agriculture committee of the European Parliament has finally voted on CAP reform proposals. Rather than fixing a broken subsidy system they have instead proposed to add extra layers of bureaucracy and increase complexity, which would do nothing to improve the environmental performance of European farms. The Committee even voted to reduce the environmental potential of the CAP pillar 2. Their vote did support 25% minimum spending on the environment, but that is simply a preservation of the status quo.
Preserve at least 7% of land for focus areas such as buffer areas or permanent grassland to help reduce emissions.
Agriculture Commissioner Dacian Ciolo? has called the proposals for the next CAP – covering 2014-2020 - "both simple and efficient".
Yet farm groups and some national representatives fear the EU executive's greening proposals could cause administrative headaches and even drive smaller farmers out of business – defeating goals to encourage small-scale production and to bring young people into a rapidly ageing industry.
The organisation representing Europe farmers and farm cooperatives – Copa-Cogeca - says the Commission's greening proposals would introduce new layers of reporting while threatening farm income by requiring, for example, that 30% of direct payments to linked to greening performance.