text:
Charlie looks forward to life on the road
Charlie Landsborough
Published: 14:21 Thursday 17 September 2015
Veteran singer songwriter Charlie Landsborough is back on the road this autumn performing a series of UK dates.
The musical maestro will be dipping into his extensive back catalogue when he takes to the stage at the Embassy Theatre, Skegness next month.
Charlie's songs are drawn from personal experience, growing up in Birkenhead in a large but poor family, joining the army, teaching at schools and playing music in the evenings.
It wasn't until he hit 50 that he had his first big hit 'What Colour Is The Wind' a song inspired by a question from a small blind child.
Now Charlie is looking forward to returning to Lincolnshire, which holds some affectionate musical memories.
"I remember playing in Wrangle and various other little clubs around Lincolnshire," he explained. "I used to dive there and back on my own. All that east side of the country been very good for my type of music.
"I look forward appearing in Skegness, I have been going there for years it is a lovely theatre with nice staff and facilities."
"We will do the songs that people know us for, intersperse those with covers and resurrect some old numbers not done for a long time."
Life on the road is not lonely for Charlie, who tours the country in a motorhome with wife Thelma and son Jamie.
He said: "We travel together and have some wonderful experiences along the way. Touring is fabulous because you meet great people from all walks of life and see so much of the country. If we have a day off we park the motor home up and visit places we would never see otherwise."
"Jamie is a fine singer and songwriter in his own right. I have three sons, two of them gifted musically - both are good guitar players but are more into rock and blues."
With a varied life spent in a series of odd jobs, serving in the army and a 15 year teaching career, Charlie is never short of a tale or two to entertain the audience. And the next chapter in his musical career is being written with a new album due for release in March.
Charlie said: "I have done variety of jobs and am old enough to have had a lot of experiences, been a teacher, in the army and worked on the railway, but the common thread was the music.
He added: "There is a rough version of the new album that has been put together. My producer has been ploughing through potential songs and we pick out what we think will be a nice mixture."
An Evening with Charlie Landsborough is at The Embassy Theatre, Skegness on Thursday, October 15. Tickets £20, children £10, are available on 01507 613100 or online at www.embassytheatre.co.uk


text:
package org.springframework.plugin.core;

/**
 * Central interface for plugins for the system. This interface is meant to be extended by concrete plugin interfaces.
 * Its core responsibility is to define a delimiter type and a selection callback with the delimiter as parameter. The
 * delimiter is some kind of decision object concrete plugin implementations can use to decide if they are capable to be
 * executed.
 *
 * @author Oliver Gierke
 */
public interface Plugin<S> {

	/**
	 * Returns if a plugin should be invoked according to the given delimiter.
	 *
	 * @param delimiter
	 * @return if the plugin should be invoked
	 */
	boolean supports(S delimiter);
}

redpajama_set_name: RedPajamaGithub


Rural areas are in prime focuses for Corporate India under their Corporate Social Responsibility programmes. Corporate are selecting deep rural villages in various states to bring social change in villages. This week, Sahara India Pariwar has also announced for adoption of 1000 villages in 7 states for holistic development for the people.
Billionaire Mukesh Ambani- run Reliance Foundation has undertaken a CSR initiative on rural transformation, which covers 24 of the poorest pockets across 10 states, engaging 20,000 farming households from 250 villages. For the initial phase, 24 pockets across Gujarat, Rajasthan, Madhya Pradesh, Chhattisgarh, Odisha, Jharkhand, Maharashtra, Andhra Pradesh, Karnataka and Tamil Nadu were selected.
Sahara India Pariwar Chairman Subrata Roy Sahara has said, We are fully and emotionally adopting 1000 villages covering 4.5 lakh rural household touching the lives of over 25 lakh people in 7 states. We are making 20 clusters of 50 villages each. There shall be a Central Point Village in each cluster with central Medical Center and an Employment Center along with other services for overall operation, caring and helping the villagers of these 50 villages.
Last month, Reliance Foundation chairperson Nita Ambani made an important announcement in Selarpur, Gujrat during his visit to Selarpur. She said that, Reliance Foundation programme covers 24 of the poorest pockets across 10 states, engaging 20,000 farming households from 250 villages. After reaching this tribal village with population of 1,357, Ambani interacted with women. She was offered a ride on a bullock-cart, driven by 70-year old Kumiben Chaudhary. He interacted with local farmers there. In her interactions with the community, she shared the long term objectives of the progamme and how the self -sustaining model of the programme will be beneficial and helpful for them on a long term basis.
She educated the local people about the Reliance Foundation Initiatives. She said, the 'Bharat India Jodo' initiative's endeavour is to bridge the divide between rural and urban India, through holistic transformation of the communities. So far the programme has benefits over 100,000 people from 20,000 marginal households from about 250 villages.
It is worth mentioning that , in October 2010, Reliance Foundation launched Mission BIJ, its flagship program focusing on supporting smallholder farmers. BIJ, which stands for 'Bharat India Jodo' (BIJ) aims to bridge the gap between rural and urban areas. Its overall goal is to make farming a profession of first choice by empowering smallholder farmers. Spread across 10 states, Mission BIJ provides support to smallholder farmers along the supply chain through input support, technical assistance, post harvest and marketing support. Initially envisaged as an agricultural focused program, Mission BIJ focuses on eventually work with farmers and communities on a comprehensive rural development strategy, including education, health, and infrastructure and community development.
"Rural transformation can be achieved through self sustained agriculture, and that will help bridge the divide between rural and urban India," Neeta Ambani said, talking to media during her visit to Selarpur village in Mangrol tehsil of Surat district (Gujrat) on March 13, 2013.
Selapur is a part of the Netrang Cluster, one of the 24 clusters across 24 agro-ecological zones in ten states where Foundation is implementing its 'Bharat India Jodo' (BIJ) initiative.
"Urban India is growing with such a fast pace and 70 per cent of India is living in rural India. Our concern is how that India can be brought into the pace of development," she added.
Ambani said, "A modest beginning was made by engaging almost 20,000 farming households across 200-odd villages. Over 15,000 hectares of land owned by the marginal farmers there has already been brought back into productivity".
"One year ago there was widespread malnutrition here. In their staple diet there was no nutritional food. They were only growing jowar and lentils…today they are growing 62 vegetables in Reliance Nutritional Gardens (RNG) and even supplying it to the local schools for children," Ambani said.
The programme also focuses on building institutions owned, controlled and run by the community, and specific interventions like water harvesting, mixed farming, marketing, etc.
Under BIJ, local youths were given 55-day training on how to revive the local water resources. "Though last year we received only 600 mm of rain against the average 1000 mm, we succeeded in taking two crops," said 27-year old Jasubhai Chaudhary.
"The whole thing is about making them agro-sustainable," Ambani said, when asked about future plans of the BIJ.
Reliance Foundation, envisaged to become one of the foremost professional philanthropic organizations in the world, was incorporated in 2010. The Foundation focuses on five core pillars: education, health, rural development, urban renewal, and promotion and protection of India's art and culture. The Foundation embodies corporate systems and processes driven organization operating on a not for profit basis, with the overall aim to create and support meaningful and innovative activities that will address some of India's most pressing development challenges.
Reliance Foundation has also started an initiative to set up a world-class multidisciplinary university in Maharashtra as well as revamping and creating a world class tertiary care hospital in Mumbai. According to the information available in the Reliance Industries website, Reliance Foundation is also planning interventions in the space of education and health services that aim to address the service delivery challenges on the ground in rural India.


text:
Ebelsbach er en kommune i Landkreis Haßberge i Regierungsbezirk Unterfranken i den tyske delstat Bayern. Den er administrationsby for Verwaltungsgemeinschaftet af samme navn.

Geografi
Bækken Ebelsbach løber gennem kommunen; Den har sit udspring i Hofstetten , og munder efter 15 kilometer ud i Altmain ved Eltmann. Ebelsberg (335 moh.) i Naturpark Haßberge, danner kommunegrænsen mod øst, Schönberg (340 moh.) mod nordvest. Ebelsbach udgør sammen med Breitbrunn, Kirchlauter og Stettfeld Verwaltungsgemeinschaft Ebelsbach.

Der et to slotte i Ebelsbach, det ene i byen Ebelsbach (privateje), det andet i Gleisenau (ejes af kommunen).

Inddeling
Kommunen består ud over Ebelsbach af landsbyerne Gleisenau, Rudendorf, Schönbach, Schönbrunn og Steinbach.

redpajama_set_name: RedPajamaWikipedia


I came across this reipe today. These look SOOOOO good! They can be made at hone with just a hanful of ingredients. Crazy Domestic has a great step by step tutorial on how to make these delicious looking treats.


With a record number of homeless, Mayor Bloomberg attempts to form programs that will soon end homelessness.
By Denise Joseph • Apr 28th, 2008 • Category: 'Sup Wit Dat Tat?
Wilbert Phillippe explains the story behind his tattoo.


Focus on managing your finances this month.
Read what your sign's 2018 horoscope predictions have in store for you, or check out the Leo personality profile.
With your birthday now in the rearview mirror, Virgo season welcomes a different energy. Now, after several weeks of indulging your inner-lion, it's time to get serious a bit more serious about your finances. Leos love to entertain, and thus have the tendency to go a bit overboard when it comes to fun. Fueled by the new moon on Sunday, September 9, you'll begin a new cycle that embraces encourages strategic budgeting as opposed to big spending. Remember, Leo darling, money is fluid. Just as currency is always in motion, your bank account will also ebb and flow. If your current monetary situation is causing you strife, try setting small, realistic goals to help you get back on track. Nothing is set in stone.
On Wednesday, September 12, Jupiter and Pluto form one final connection in the sky. This alignment previously occurred on January 15 and April 14, and in many ways, captures the spirit of 2018. Over the past several months, you've had many important realizations about your domestic sphere.
You've discovered that home is a concept, family is a choice, and you are strong enough to modify these things in accordance with your values. It takes a long time to not just learn what you want, but also find the confidence to communicate your needs. Mid-month there will be an important opportunity for you to celebrate your independence. Make it happen, Leo darling.
When you know what's going on with your community, you gain a deeper understanding of the collective consciousness.
After several weeks of prudential money-management, you'll be ready to step back on the scene by the end of the month. The sun moves into Libra on Saturday, September 22, activating the area of your chart linked to a local network. Under the sky, focus on strengthening your bonds with peers, including your colleagues or classmates.
Gossip is never cute, but staying in the loop does have its advantages: When you know what's going on with your community, you gain a deeper understanding of the collective consciousness. What trends, thoughts, and ideas are making a difference? Ultimately, this insight can help strengthen your professional or creative choices — and what lion wouldn't want that.
Finally, September concludes with a full moon in like-minded fiery Aries on Monday, September 24. Full moons always reveal the truth, and this month, the revelation will be coming from afar. Keep an eye on your voicemails, emails, and DMs: When the universe needs to deliver it a message, it will use whatever pathways are open and available. The news may be unexpected, so be sure to arm yourself with Drybar's Triple Sec 3-in-1: a smart spray that instantly infuses your mane with volume, texture, and body. That way, no matter what the cosmos serve up, you'll be camera-ready.


Need more information about booking Home 8446372 ?
detached cottage, semi-troglodyte, ground floor, facing south, healthy and clear, cool in summer and mild winter. Large fireplace with bois.Jardin and private courtyard fully enclosed and private. situated in wine village dependent on a small town character, equidistant from the Futuroscope and Puy du Fou.
The cottage is independent, but if you need advice or information corresponding living nearby is at your disposal. Many flyers and posters, located inside the house, offer tours and activities in the region.
You can get in touch with Andree (the owner) through the contact form on this page.
Send Andree (the owner) an email through the contact form on this page. Alternatively, if there's a phone number on this page, you can call them.
How do I contact Andree (the owner)?
If you've already booked, go to Manage your holiday booking to view Andree the owner's contact details or send them a message.
Or send Andree (the owner) an enquiry through the Contact the owner/manager form if you'd like a quote or more info first.
When you pay online through the Book your stay form, a booking request is sent to Andree (the owner). You'll find out within 24 hours whether they've accepted - no money will leave your account before then.
You can also request a quote from Andree (the owner) through the contact form. The owner will email you the total cost for your dates and a link to book and pay online.
Use the Book your stay form to pay provisionally online. You can pay by credit/debit card or PayPal. Andree (the owner) will have 24 hours to accept the booking and no money will leave your account before then.
Why can't I call Andree (the owner) before booking?
You'll need to contact Andree (the owner) to do this. Send them a message in Manage your holiday booking or through the contact form on this page.
You can request to change the dates or number of people on your booking via the Manage your holiday booking page. To change your holiday dates use the Edit booking button. If you need to change the number of guests staying then send Andree (the owner) a message.
If Andree (the owner) agrees, they'll send you a revised quote outlining the changes. You can review and accept/decline this from the Manage your holiday booking page. You'll have 48 hours to take action before the revised quote expires.
Estimated price per night based on a weekly stay. Owner fees of $58.00 per stay may apply. Enter your dates to see the total cost.
semi-troglodyte gite located in a wine boutique village near Saumur.


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6 The experimental method of enquiry aims at establishing regular events which can be repeated. Consequently, unique or rare events are ruled out of account. Moreover, the experiment imposes limiting conditions on nature, for its aim is to force her to give answers to questions devised by man. Every answer of nature is therefore more or less influenced by the kind of question asked, and the result is always a hybrid product. The so-called "scientific view of the world" based on this can hardly be anything more than a psychologically biased partial view which misses out all those by no means unimportant aspects that cannot be grasped statistically.
12 Schopenhauer: "All events in a man's life would accordingly stand in two fundamentally different kinds of connection: firstly, in the objective, causal connection of the natural process; secondly, in a subjective connection which exists only in relation to the individual who experiences it, and which is thus as subjective as his own dreams….That both kinds of connection exists simultaneously, and the selfsame event, although linking two totally different chains, nevertheless falls into place in both, so that the fate of one individual invariably fits the fate of the other, and each is the hero of his own drama while simultaneously figuring in a drama foreign to him - this is something that surpasses our powers of comprehension, and can only be conceived as possible by virtue of the most wonderful preestablished harmony".
In his view "the subject of the great dream of life…is but one", the transcendental Will, the prima causa, from which all causal chains radiate and, because of the circular parallels, stand to one another in a meaningful relationship of simultaneity.Schopenhauer believed in the absolute determinism of the natural process and furthermore in a first cause. There is nothing to warrant either assumption. The first cause is a philosophical mythologem which is only credible when it appears in the form of the old paradox ("to be/not to be"), as unity and multiplicity at once.
20 In man's original view of the world (20) as we find it among primitives, space and time have a very precarious existence. They become "fixed" concepts only in the course of his mental development, thanks largely to the introduction of measurement. In themselves, space and time consist of nothing. They are hypostatised concepts born of the discrimination activity of the conscious mind, and they form the indispensable co-ordinates for describing the behaviour of bodies in motion. They are, therefore, essentially psychic in origin, which is probably the reason that impelled Kant to regard them as apriori categories.
But if space and time are only apparently properties of bodies in motion and are created by the intellectual needs of the observer, then their relativization by psychic conditions is no longer a matter for astonishment but is brought within the bounds of possibility.This possibility presents itself when the psyche observes not external bodies, but itself.
Space and time, the conceptual coordinates of bodies in motion, are probably at bottom one and the same (which is why we speak of a long or short "space of time". Synchronicity in space can equally well be conceived as perception in time, but remarkably enough it is not so easy to understand synchronicity in time as spatial, for we cannot imagine any space in which future events are objectively present and could be experienced as such through a reduction of this spatial distance since experience has shown that under certain conditions space and time can be reduced almost to zero, causality disappears along with them, because causality is bound up with the existence of space and time and physical changes, and consists essentially in the succession of cause-and-effect.
For this reason synchronistic phenomena cannot in principle be associated with any conceptions of causality. Hence the interconnection of meaningfully coincident factors must necessarily be thought of as acausal" (Jung-Synchronicity28-29).
Boe: Cambray20:Jung is speaking here about acausal coincident phenomena that are meaningfully linked, but the collapse of space time together with the disappearance of the principle of causality is remarkably congruent with the best theories in physics for the origins of the universe. The point in this is to try and articulate what Jung may be reaching for with his theory of synchronicity.
It is as if at the deepest level he is finding a place for the psyche at the origins of the universe through the psychoid archetype. This is not an intelligent design argument but an indication that the universe is as permeated with psyche as it is with space, time, and matter; that synchronicities provide traces of an original undifferentiated state. In such a cosmogony I suggest Jung is leading us to see psyche as another of the potentials inherent in the singularity.
"In this case of chance, synchronistic phenomena were probably at work, operating both with and against the known laws of nature to produce, in archetypal moments, synthesis which appeared to us miraculous... This presupposes not only an all-pervading, latent meaning which can be recognised by consciousness, but during that preconscious time, a psychoid process with which a physical event meaningfully coincides. Here the meaning cannot be recognised because there is as yet no consciousness".
35 Judgement must therefore rely much more on the irrational functions of consciousness, that is on sensation (the "sense du reel") and intuition (perception by means of subliminal contents).
The I Ching, which we can well call the experimental foundation of classical Chinese philosophy, is one of the oldest known methods for grasping a situation as a whole and thus placing the detail against the cosmic background - the interplay of Yin and Yang.
40 Mantic procedures: The method best adapted to the nature of chance is the numerical method. Since the remotest times men have used numbers to establish meaningful coincidences, that is, coincidences that can be interpreted.
There is something peculiar, one might even say mysterious, about numbers. They have never been entirely robbed of their numinous aura. If, so a textbook of mathematics tells us, a group of objects is deprived of every single one of its properties or characteristics there still remains, at the end, it's number, which seems to indicate that number is something irreducible.
(I am not concerned here with the logic of this mathematical argument, but only with it is psychology!) The sequence of natural numbers turns out to be unexpectedly more than the mere stringing together of identical units: it contains the whole of mathematics and everything yet to be discovered in this field.
The most elementary quality about an object is whether it is one or many. Number helps more than anything else to bring order into the chaos of appearances. It is the predestined instrument for creating order, or for apprehending an already existing, but still unknown, regular rearrangement or "orderedness".
It may well be the most primitive element of order in the human mind, seeing that the numbers 1 to 4 occurred with the greatest frequency and have the widest incidence. In other words, primitive patterns of order are mostly triads or tetrads. That numbers have an archetypal foundation is not, by the way, the conjecture of mine but of certain mathematicians. Hence it is not such an audacious conclusion after all if we define number psychologically as an archetype of order which has become conscious.
Boe: an archetype of order which has become conscious.
41 Remarkably enough, the psychic images of wholeness which spontaneously produced by the unconscious, the symbols of the self in mandala form, also have a mathematical structure.
70 In Chinese philosophy one of the oldest and most central ideas is that of Tao, which the Jesuits translated as "God". But that is correct only for the Western way of thinking. Richard Wilhelm brilliantly interprets it as "meaning" (Sinn). The concept of Tao pervades the whole philosophical full of China. Causality occupies this paramount position with us, but it acquired its importance only in the course of the last two centuries, thanks to the levelling influence on the statistical method on the one hand and the unparalleled success of the natural sciences on the other, which brought the metaphysical view of the world into disrepute.
There was something undefined and complete, coming into existence before Heaven and Earth. How still it was and formless, standing alone, and undergoing no change, reaching everywhere and in no danger (of being exhausted)!
It may be regarded as the Mother of all things.
and I give it the designation of the Dao (the Way or Course).
Making an effort (further) to give it a name I call it The Great.
Great, it passes on (in constant flow). Passing on, it becomes remote.
Having become remote, it returns.
Therefore the Dao is great; Heaven is great; Earth is great; and the (sage) king is also great. In the universe there are four that are great, and the (sage) king is one of them. Man takes his law from the Earth; the Earth takes its law from Heaven; Heaven takes its law from the Dao. The law of the Dao is its being what it is.
71 Wilhelm describes it as "a borderline conception lying at the extreme edges of the world of appearances". In it, the opposites " cancel out in nondiscrimination", but still potentially present.
90 The synchronicity principle possesses properties that may help to clear up the body-soul problem. Above all it is the fact of causeless order, or rather, of meaningful orderedness, that may throw light on psychophysical parallelism.
The "absolute knowledge" which is characteristic of synchronistic phenomena, a knowledge not mediated by the sense organs, supports the hypotheses of a self-subsistant meaning, or even expresses its existence.
Such a form of existence can only be transcendental, since, as the knowledge of future or spatially distant events shows, it is contained in a psychically relative space and time, that is to say in an irrepresentable space-time continuum.
96 Synchronicity is not a philosophical view but an empirical concept which postulates an intellectually necessary principle. This cannot be called either matterialism or metaphysics.
No serious investigator would assert that the nature of what is observed to exist, and of that which observes, namely the psyche, are known and recognised quantities. If the latest conclusions of science are coming nearer and nearer to a unitary idea of being, characterised by space and time on the one hand and by causality and synchronicity on the other, that has nothing to do with materialism. Rather it seems to show that there is some possibility of getting rid of the incommensurability between the observed and the Observer. The result, in that case, would be a unity of being which would have to be expressed in terms of a new conceptual language….
99 It is difficult to divest conceptual language of its causalistic colouring. Thus the word "underlying" despite its causalistic connotation, does not refer to anything causal, but simply to an (100) existing quality, an irreducible contingency which is "Just-so". The meaningful coincidence or equivalents of the psychic and physical state that have no causal relationship to one another means, in general terms, that it is a modality without a cause, an "acausal orderedness".
The question now arises whether our definition of synchronicity with reference to the equivalence of psychic and physical processes is capable of expansion, or rather, requires expansion. This requirement seems to force itself on us when we consider the above, wider conception of synchronicity as an "acausal orderedness". Into this category come all "acts of creation", a priori factors such as the properties of natural numbers, the discontinuities of modern physics, etc.
Boe: synchronicity = "acausal orderedness" = all "acts of creation"


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Already some time ago, the APIC has published a guideline for the qualification of contract laboratories. Although this interesting Guide was already published in 2012 it is not well known in industry. The guideline is supposed to define uniform requirements for the "life cycle management" of contract laboratories. In addition the APIC had already prepared a guideline for the management of suppliers with a focus on the suppliers of materials a manufacturer of active ingredients needs. But it became clear that another guideline specifically for contract laboratories was needed.
This guideline covers the entire process from the identification of contract laboratories to the "ongoing monitoring".
Interesting aspects are e.g. a flow chart depicting the entire process, a detailed checklist for the selection of the contract laboratory, a detailed questionnaire to assess the contract laboratory, and, in Annex 3 (Risk Assessment), specific proposals for how the service and the performance of a laboratory can be evaluated.
This guideline is not well known in the pharmaceutical industry, but it is of interest for all those who are involved in selecting and dealing with contract laboratories.
Please see the full APIC Guideline for Qualification & Management of Contract Quality Control Laboratories for more detailed information.


text:
A Better-Funded Movement Is Growing To Counter The NRA
By Tim Mak
The year since the shooting at Marjory Stoneman Douglas High School in Parkland, Fla., has led to a less favorable political landscape for the National Rifle Association. Democrats won control of the House of Representatives in the midterm elections, and many ran on platforms contrary to the NRA. For the first time now, a growing and better-funded movement now exists to counter the gun rights group. NPR's Tim Mak has more on the NRA's changing influence.
TIM MAK, BYLINE: After his daughter's death in Parkland, Fla. - one year ago tomorrow - Fred Guttenberg sat in his house grieving.
FRED GUTTENBERG: To me, I thought the first thing I need to do is to remove the grip of the gun lobby. And I walked around my house kind of, like, in a daze, saying to anybody who will listen, we're going to go after their money.
MAK: Parkland motivated people like him to get active in politics, joining a growing movement led by Everytown For Gun Safety, an adversary to the NRA founded by former New York City Mayor Michael Bloomberg. This is the first sustained, well-funded opposition that the NRA has ever faced. And the gun rights group acknowledges this. Here's a spokesperson for the NRA's lobbying arm, Jennifer Baker.
JENNIFER BAKER: What has changed is that for the first time the gun control groups are well-funded and have efforts nationwide. They have an infinite amount of resources as they are funded by billionaire Michael Bloomberg, who is decidedly anti-gun. And so he has allowed these organizations to have a presence in the state capitals on lobbying and to really put forth an effort we've never seen.
MAK: For decades, the National Rifle Association has been a driving political force. Its large grassroots membership alone gives its positions heavy weight. In an interview with NPR, their spokesperson put its membership between 5 and 6 million.
BAKER: We have more dues-paying members than any other grassroots organization in the world.
MAK: But last week, the House Judiciary Committee held the first hearing on gun violence in eight years, a reflection of the new Democratic House majority. And today, that same committee is marking up legislation expanding background checks for firearm sales, something polls suggest most Americans support. The bill's supporters argue that the legislation's consideration alone indicates a changing national conversation about gun issues.
JOHN FEINBLATT: It was considered the third rail of American politics.
MAK: That's John Feinblatt, the president of Everytown For Gun Safety.
FEINBLATT: That was true for Democrats, it was true for Republicans - no more.
MAK: And the NRA is mired in a Senate investigation into whether it worked with Russia to influence American politics in 2016. Feinblatt also points out that the NRA spent less money in the 2018 midterms than in previous midterms.
FEINBLATT: The NRA staged a disappearing act. They were really nowhere to be seen compared to previous years.
MAK: The NRA counters that all of these supposed changes are just hype, that polling on background checks overstates its support, that their lower fundraising is a reflection of how their supporters feel less threatened with Trump as president. And the NRA does not believe that new gun restrictions will go anywhere because of allies in the Republican-controlled Senate. And they also point to a Supreme Court where they believe they have a majority on gun rights issues.
BAKER: Practically speaking, the landscape has not changed for the prospect of enacting federal gun control. In the Senate, they don't have the 60 votes that they need, and there is a pro-Second Amendment president in the White House. But what has changed is that we now have a majority of Supreme Court justices who are originalists.
MAK: And Richard Feldman, a former NRA lobbyist, agrees and says that not only will gun legislation not pass into law but that the push from Democrats will also energize NRA supporters.
RICHARD FELDMAN: That's what gets them activated. That's what gets them motivated. That's what gets them to send much higher contributions to the very groups that are dedicated to protect that issue.
MAK: One year after the Parkland shooting, the political realities are changing, but the National Rifle Association remains a force to be reckoned with. Tim Mak, NPR News, Washington.
(SOUNDBITE OF TESK'S "LEGO") Transcript provided by NPR, Copyright NPR.
Corrected: February 12, 2019 at 11:00 PM CST
In an earlier version of this report, we mistakenly referred to John Feinblatt as John Greenblatt.
Tim Mak
Tim Mak is NPR's Washington Investigative Correspondent, focused on political enterprise journalism.
See stories by Tim Mak

redpajama_set_name: RedPajamaCommonCrawl


text:
Politicians, merchants, and colonial maritime war: The political and economic background of the American Act of 1708
Shinsuke Satsuma*
During the War of the Spanish Succession (1702-13), there were attempts to support colonial maritime war by legislation, and the American Act of 1708 can be seen as their culmination. Historians who study privateering or colonial history have referred to this act in several contexts, such as reform in prize administration, naval impressment in American colonies, and Spanish-American trade. However, the political and economic interests behind this act have not been fully investigated. By examining the process of the enactment of the American Act together with antecedent attempts to promote colonial maritime war in parliament, this article reveals the political and vested interests involved in the act, the relations between them, and the influence they had on the content of the act. This analysis will show the complex interaction between politics, trade, and colonial maritime war in the early-18th-century American colonies.
Parliamentary History
Published - 2013 6月
社会学および政治科学
この成果は、次の持続可能な開発目標に貢献しています
「Politicians, merchants, and colonial maritime war: The political and economic background of the American Act of 1708」の研究トピックを掘り下げます。これらがまとまってユニークなフィンガープリントを構成します。
Maritime War Social Sciences 100%
Merchants Arts & Humanities 49%
American Colonies Arts & Humanities 39%
politician Social Sciences 39%
political interest Social Sciences 34%
act Social Sciences 31%
Policymaker Arts & Humanities 29%
Impressment Arts & Humanities 26%
Satsuma, S. (2013). Politicians, merchants, and colonial maritime war: The political and economic background of the American Act of 1708. Parliamentary History, 32(2), 317-336. https://doi.org/10.1111/1750-0206.12018
Politicians, merchants, and colonial maritime war : The political and economic background of the American Act of 1708. / Satsuma, Shinsuke.
In: Parliamentary History, Vol. 32, No. 2, 06.2013, p. 317-336.
Satsuma, S 2013, 'Politicians, merchants, and colonial maritime war: The political and economic background of the American Act of 1708', Parliamentary History, vol. 32, no. 2, pp. 317-336. https://doi.org/10.1111/1750-0206.12018
Satsuma S. Politicians, merchants, and colonial maritime war: The political and economic background of the American Act of 1708. Parliamentary History. 2013 6月;32(2):317-336. doi: 10.1111/1750-0206.12018
Satsuma, Shinsuke. / Politicians, merchants, and colonial maritime war : The political and economic background of the American Act of 1708. In: Parliamentary History. 2013 ; Vol. 32, No. 2. pp. 317-336.
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Tony Battista Quits Twitter! Help Bring Back BAT!
- - - RT this to help bring Tony Battista back to Twitter.
Today, on a cold and slushy fourth day of February in the year 2015, tastynation's favorite "pretty boy trader" quit Twitter, and our own Tom Sosnoff is to blame.
Today's broadcast began and marched on in typical fashion - Vonetta schooled everyone on advances in robotic technology, Tony barked like a dog twice to emphasize a point, and Tom rolled his eyes every time $AAPL was mentioned in polite conversation. But then, several minutes into the broadcast, Tom dropped a snub that echoed around the world: he dissed Tony's social media presence right in the middle of Confirm and Send (fast-forward to about the 15-minute mark to catch the burn in all its glory).
Though Tom's entitled to his opinion, the question remains... do we want to live in a world devoid of Tweets from Tony Battista? I know I don't. So here's what YOU can do... show The BAT you want him back on Twitter by Retweeting the the Tweet below.
RT this and help us get Tony back on Twitter!


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It's that time of the decade again (years ending in "4" or "9" since 1984), and, unfortunately, there is still reason for money to be sent to help people in Africa. This time the ebola epidemic is the cause. Despite some lyrical changes and your usual onslaught of today's artists of note, Bono is still singing the money line, thirty years later. Sinead O'Connor does her part by providing the unintentional comedy and curious wonderment as to why she received the invite.


text:
Telemedicine for Diabetes (69)
Published on 1.9.2017 in Vol 2 , No 2 (2017) :Jul-Dec
The Effect of Telehealth on Quality of Life and Psychological Outcomes Over a 12-Month Period in a Diabetes Cohort Within the Whole Systems Demonstrator Cluster Randomized Trial
Shashivadan P Hirani 1 ; Lorna Rixon 1 ; Martin Cartwright 1 ; Michelle Beynon 1 ; Stanton P Newman 1 ; WSD Evaluation Team 2
Shashivadan P Hirani1, BSc (Hons), MSc, CPsychol, PhD ;
Lorna Rixon1, BSc (Hons), MSc, CPsychol, PhD ;
Martin Cartwright1, BSc (Hons), MSc, CPsychol, PhD ;
Michelle Beynon1, BSc (Hons), MSc ;
Stanton P Newman1, B Soc Sci (Hons), D Phil, CPsychol, MRCP ;
WSD Evaluation Team
1Centre for Health Services Research, School of Health Sciences, University of London, London, United Kingdom
Stanton P Newman, B Soc Sci (Hons), D Phil, CPsychol, MRCP
Centre for Health Services Research
Northampton Square
London, EC1V 0HB
Phone: 44 0207 040 0881
Fax:44 0207 040 0881
Email: Stanton.Newman.1@city.ac.uk
Background: Much is written about the promise of telehealth and there is great enthusiasm about its potential. However, many studies of telehealth do not meet orthodox quality standards and there are few studies examining quality of life in diabetes as an outcome.
Objective: To assess the impact of home-based telehealth (remote monitoring of physiological, symptom and self-care behavior data for long-term conditions) on generic and disease-specific health-related quality of life, anxiety, and depressive symptoms over 12 months in patients with diabetes. Remote monitoring provides the potential to improve quality of life, through the reassurance it provides patients.
Methods: The study focused on participant-reported outcomes of patients with diabetes within the Whole Systems Demonstrator (WSD) Telehealth Questionnaire Study, nested within a pragmatic cluster-randomized trial of telehealth (the WSD Telehealth Trial), held across 3 regions of England. Telehealth was compared with usual-care, with general practice as the unit of randomization. Participant-reported outcome measures (Short-Form 12, EuroQual-5D, Diabetes Health Profile scales, Brief State-Trait Anxiety Inventory, and Centre for Epidemiological Studies Depression Scale) were collected at baseline, short-term (4 months) and long-term (12months) follow-ups. Intention-to-treat analyses testing treatment effectiveness, were conducted using multilevel models controlling for practice clustering and a range of covariates. Analyses assumed participants received their allocated treatment and were conducted for participants who completed the baseline plus at least one follow-up assessment (n=317).
Results: Primary analyses showed differences between telehealth and usual care were small and only reached significance for 1 scale (diabetes health profile-disinhibited eating, P=.006). The magnitude of differences between trial arms did not reach the trial-defined minimal clinically important difference of 0.3 standard deviations for most outcomes. Effect sizes (Hedge's g) ranged from 0.015 to 0.143 for Generic quality of life (QoL) measures and 0.018 to 0.394 for disease specific measures.
Conclusions: Second generation home-based telehealth as implemented in the WSD evaluation was not effective in the subsample of people with diabetes. Overall, telehealth did not improve or have a deleterious effect quality of life or psychological outcomes for patients with diabetes over a 12-month period.
JMIR Diabetes 2017;2(2):e18
doi:10.2196/diabetes.7128
telehealth; self-monitoring; health-related quality of life: diabetes-specific quality of life
The increasing demands of diabetes care on health resources in many countries [1] has led to the development of innovative information-communication-technology–based interventions that facilitate patient self-care and the monitoring and communication of disease status to health care professionals [2]. The range of technologies includes disc- and computer-based systems [3], Web-based interventions [4,5], mobile apps [6], remote monitoring systems [7,8], and combinations of these. One system gaining traction in the last 10 years is telehealth, which involves the remote exchange of physiological or symptom data between a patient and health care professional [9,10]. Algorithms within systems logging the data sent can alert health care professionals when disease-specific clinical parameters are breached; allowing the potential for earlier intervention, which can reduce the frequency with which expensive hospital-based care is required, and thereby improving patient outcomes (eg, reducing avoidable hospitalizations, improving clinical parameters) and health-related quality of life (HRQoL), the latter of which is the focus of this paper.
Primary studies and systematic reviews that have examined the effect of telehealth on HRQoL in people with diabetes, typically conclude that telehealth leads to QoL improvements, potentially because of improved care processes and health status, and reductions in worry about timely interventions as physiological and physical status are being monitored by health care professionals. For example, one potential pathway by which telehealth impacts patient outcomes is the increased feelings of reassurance participants get by being more closely monitored by the health care team, the other potential mediating mechanism it that increasing knowledge of the condition and increasing confidence leads to improvements in self-care behaviors, such as checking feet regularly, and so on [11]. However, in 1 systematic review [12], it was not possible to quantitatively synthesize the evidence on patient outcomes due to the heterogeneity of the patient-reported outcomes (PROMS). The authors found 5 studies that measured HRQoL, and of these 4 reported no significant differences [13-16], which is consistent with a recent randomized controlled trial (RCT) that found no differences in PROMs in a UK-based telehealth service [7]. In contrast, Chumbler et al. [17] found statistically significant improvements in 3 of 8 short-form (SF-36) subscales (role functioning, bodily pain, and social functioning) after 1 year of home telehealth. A further source of heterogeneity in the studies is the mixture of generic versus disease specific measures of HRQoL.
Few studies, however, have examined psychological distress. This is despite some contention about whether telehealth, despite monitoring benefits, can have potentially detrimental effects increasing patient burden and distress [18], through greater isolation and reduced face-to-face contact with health care professionals [19], and at times low acceptability of telehealth [20].
The evidence base for telehealth in people with diabetes is characterized by methodologically weak studies that generate equivocal findings and the studies have been critiqued for their variability in quality (small samples, poor methodology, few RCTs) and heterogeneity (in systems examined and outcomes measured) that has made the information produced difficult to interpret or synthesize [12]. The effectiveness of telehealth, in terms of QoL benefits, has yet to be substantiated in high-quality trials. Furthermore, few studies have used diabetes-specific QoL instruments, which are more sensitive to changes in this population than generic QoL measures, and few studies have extended the psychosocial outcomes to examine anxiety and depression.
The current study was part of the Whole Systems Demonstrator (WSD) programme, commissioned by the UK Department of Health. A previous paper has already reported on the effect of telehealth on HbA1c control in the larger diabetes trial cohort [21]. This paper reports on a subsample of the cohort providing data on the PROMs. It aimed to address the inconsistencies in data observed in previous research in telehealth and patient-reported QoL outcomes, and evaluated the effectiveness of telehealth in a sample of people with diabetes, examining its effect on HRQoL and psychological distress in the short and long term. It was hypothesized that should telehealth demonstrate significant improvements in QoL measures, these would be detected in disease-specific measures to a greater degree than generic QoL measures; and that telehealth would significantly improve psychological distress due to the reassurance the monitoring systems would provide to patients.
Design and Randomization
The WSD evaluation was one of the largest trials evaluating telehealth and telecare in the United Kingdom. The detailed protocol and design for the WSD evaluation has been reported elsewhere [22]. Within the evaluation, the WSD Telehealth Trial (n=3230) was a multicenter, pragmatic, cluster-RCT of telehealth across 3 regions in England (Cornwall, Kent, and the London Borough of Newham) with a nested questionnaire study, the WSD Telehealth Questionnaire Study (1573/3230, 48.7%).
Participants in the trial were allocated to a trial arm (ie, telehealth or usual care) using cluster randomization, based on participants' registration with a general practice. Allocation was balanced for region (WSD site), practice size, deprivation index, non-white proportion and prevalence of diabetes, chronic obstructive pulmonary disease, and congestive heart failure, using an algorithm by the trial statistician. For individual participants, trial arm allocation was maintained from the main trial, through to the questionnaire study and diabetes participant analyses. The WSD Telehealth Questionnaire Study involved a total of 204 general practices recruited across the 3 WSD Sites, of which 111 contributed participants to the diabetes questionnaire analysis; 46.8% (52/111) in the control and 53.2% (59/111) in the intervention trial arm.
Participants diagnosed with diabetes were recruited between May 2008 and December 2009 from 4 primary care trusts across the 3 WSD regions. Final 12-month follow-ups were conducted in December 2010. Participants in the trial were invited to take part in a nested questionnaire study measuring PROM. Neither participants nor assessors could be blinded to trial arm allocation, due to the nature of the intervention. Participants not allocated to receive telehealth were informed that they would be offered the technology at the end of the trial period, following a reassessment of need.
The study protocol was approved by the Liverpool Research Ethics Committee (Reference number: 08/H1005/4). Full consent procedures are available in the protocol papers by Bower et al. [22] and Cartwright et al. [8]. In brief, practices at each of the sites signed memorandums of agreement to participate in the trial. Telehealth trial participants provided signed, informed consent to share data with the trial team; with those going onto the questionnaire study, providing further signed consent.
Adult patients at participating general practices were deemed eligible for the study if they were diagnosed with diabetes according to: (1) the Quality Outcomes Framework register in primary care, (2) a confirmed diagnosis in medical records as indicated by general practice Read Codes or the International Statistical Classification of Diseases and Related Health Problems-10 codes, or (3) confirmation of diabetes by a clinician involved in their care. Participants were not excluded because of additional co-morbidities. However, they were required to have sufficient cognitive capacity and English language skills to complete a self-reported questionnaire and use telehealth kit.
Participants were also required to have a landline telephone for broadband Internet connection, and in the London Borough of Newham an additional requirement was a television set. Local WSD project teams paid for financial costs associated with the telehealth (including phone calls to the monitoring centers, broadband service, and data transmission to the monitoring centers).
Telehealth Treatment: Intervention Arm
WSD sites delivered variations of a 'second generation' telehealth [23] that had a focus on monitoring vital signs, symptoms, and self-management behaviors, and providing health education in common. A full description of the intervention is published elsewhere [8].
In general, participants with diabetes in the trial arm received a glucometer and blood pressure monitor, plus additional peripherals depending on clinical need (eg, weighing scales, pulse oximeter, peak-flow meter, thermometer). The peripheral devices were attached to a home monitoring system comprising a base unit with a liquid-crystal display screen to allow questions about health and educational messages to be transmitted to participants or set-top box that connected to a television allowing symptom questions, educational videos, and a graphic history of clinical readings to be accessed via a dedicated channel. Participants were asked to take measurements via the peripherals on a schedule determined via individual circumstances (eg, daily readings, twice weekly readings).
Data transmitted by participants to a monitoring center were processed via an algorithm for unusual patterns, out of range values, and/or missing data. Contravening a rule triggered an alert to an operator at a monitoring center who would follow a decision tree to determine an appropriate response. The range of responses included: doing nothing—wait and see approach; requesting a repeat reading through the telehealth kit, contacting the participant or their named informal carer, arranging a visit to the participant's home by their community matron, or referring to another health care service, as appropriate. The intervention arm participants received the telehealth in addition to usual health and social care. At the end of the 12-month trial participants were given the option of keeping telehealth or having it removed from their home.
Usual-Care Treatment: Control Arm
Participants randomized to the control arm received usual health and social care in line with local protocols for the 12-month duration of the trial (eg, combination of community matrons, district nurses, specialist nurses, general practice, and hospital services based on clinical need). At the end of the trial control participants were offered the installation of telehealth services in their homes, if they were still eligible following a needs assessment.
Trial Assessment Procedures
Outcome measures were self-completed by participants. At baseline, a trained researcher was on hand to explain or clarify the meaning of particular questions or assist with the completion of the questionnaire. Two further assessments were conducted at short-term follow-up conducted at approximately 4 months (median duration = 128 days; interquartile range [IQR] = 47 days) and a long-term assessment, conducted at approximately 12-months (median duration = 366 days; IQR = 54 days).
The short-term follow-up questionnaire was primarily administered as a postal survey with 1 reminder letter for nonresponders; some participants also received telephone reminders. Long-term follow-up surveys were posted to participants, with nonresponders contacted to arrange home interviews with a trained researcher in line with the baseline protocol. Participants who withdrew from the trial, including intervention participants who asked for the telehealth equipment to be removed before the end of the trial period, were not sent further questionnaires.
Generic and disease-specific HRQoL was assessed by: (1) the SF-12 [24] subscales for physical component summary (PCS), and mental component summary (MCS), (2) EuroQual (EQ-5D) York-Tariff [25], 1990, which produces a summary index over 5 domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), (3) the diabetes health profile (DHP) [26] with subscales measuring psychological distress, barriers to activity and disinhibited eating, and (4) study-specific diabetes HRQoL measures of social marginalization and social conspicuousness. Measures were also taken of anxiety with the brief state trait anxiety inventory (STAI) [27] and depressive symptoms by the 10-item Center for Epidemiologic Studies Depression scale (CESD-10) [28]. Higher scores on the QoL instruments pertained to better QoL and higher scores on the anxiety and depression instruments indicated greater psychological distress.
Demographic information recorded included age, sex, ethnicity, number of co-morbid conditions, and level of education. Participants' levels of deprivation were allocated using an Index of Multiple Deprivation score [29] as assessed through postcodes.
Sample Size Calculation
For the disease-specific aspects of the questionnaire study, a power calculation was conducted on the basis of detecting a small effect size, equivalent to a Cohen d of 0.3 [30], allowing for an intracluster correlation coefficient of 0.05, power of 80% and P<.05. This indicated that between 420 and 520 participants would be required to allow sufficient power to detect this small difference taking account of the cluster design. These numbers were inflated by 10% to allow for the maximum possible increase in sample size due to variable cluster size. The required minimum sample size increased to 550.
Missing data rates (at the scale/item level used in analyses) among those returning questionnaires at short and long term were low (≤3%) and were imputed (m=10) using the SPSS MCMC function within each administration. Thereafter, standard multiple imputation procedures were employed [31]. Details of multiple-imputation processes are available from the authors.
Sample Characteristics
Frequencies and mean scores are reported for each trial arm at each follow-up. Analyses were conducted on a modified intention-to-treat basis (ie, available case analyses—where data was available for baseline plus at least 1 follow-up point).
Detecting Telehealth Effects
Repeated measures in each outcome over the 1-year follow-up period were analyzed with linear mixed-effects modeling procedures to detect: trial-arm effects, time effects, and their interaction. This method took account of the hierarchy within the data observations (ie, assessment points, were nested within participants, nested within general practices). Data are presented as estimated marginal means (EMMs) with standard errors (SE).
Covariates to adjust for case-mix differences between trial arms were: age, sex, deprivation, ethnicity, co-morbidities, highest education level, WSD site, number of devices, and baseline outcome score. For all parameter tests the alpha level was set to .05; Sidak's adjustment was used to compensate for post hoc multiple comparisons; 95% confidence intervals (CI) were used to account for the uncertainty in the estimates. Effect sizes for the trial arm effects of each outcome were reported as Hedge's g. Analyses were conducted in SPSS v19.
Sample Recruitment and Attrition
Of the 3230 participants in the WSD Telehealth Trial, 23.6% (763/3230) were indexed as participants with diabetes. Of the 1573 participants in the nested telehealth questionnaire study, 28.9% (455/1573) were people with diabetes; of these 54.1% (246/455) were in the intervention arm and 45.9% (209/455) were in the usual care arm. Figure 1 shows participants per trial arm within the questionnaire study.
Baseline sample characteristics by trial arm of the 455 questionnaire participants are reported in Table 1. The mean age of the sample was approximately 65 years with most participants being of white, British/Irish ethnicity. Most participants came from the London Borough of Newham WSD Site, and were mainly male. The sample had on average 2 co-morbid conditions and the majority (247/455, 54.3%) had received little formal education. On average, the intervention group received just short of 3 telehealth devices. In the telehealth arm 237 glucometers were distributed, with 232 blood pressure monitors, 185 weight scales, and 56 pulse oximeters.
Unadjusted means by trial arm for baseline PROM data are presented in Table 1. CIs calculated around each mean suggested differences between the telehealth and usual care groups were not statistically significant in any measure at baseline.
Physical and mental health component scores for the SF12 and EQ5D health status measures were lower/equal than population averages, but were considered appropriate for a population in this age range with long-term conditions [24,25]. Both anxiety and depression levels were slightly high with the depression level means close to the cut-off point for screening clinical levels of depression. The diabetes health profile (DHP) scales and additional social-based HRQoL scales (social conspicuousness and social marginalization) did not indicate problems with diabetes specific QoL, and showed a relatively well-functioning long-term condition sample.
Figure 1. All sites CONSORT diagram for the WSD Telehealth Diabetes Trial.
View this figure
Table 1. Site, sex, and ethnicity frequencies per trial arm of the questionnaire participants with diabetes.
Intervention (n=246)
n (%) Control (n=209)
n (%) Total (N=455)
Sitea
Cornwall 64 (26.0) 55 (26.3) 119 (26.2)
Kent 44 (17.9) 46 (22.0) 90 (19.8)
London Borough of Newham 138 (56.1) 108 (51.7) 246 (54.1)
Sexa
Female 115 (46.7) 84 (40.2) 199 (43.7)
Male 131 (53.3) 125 (59.8) 256 (56.3)
Non-white 79 (32.1) 72 (34.4) 151 (33.2)
White British / Irish 167 (67.9) 137 (65.6) 304 (66.8)
aNot multiply imputed.
Table 2. Baseline sample characteristics per trial arm of questionnaire participants with diabetes.
Mean (standard error) Control (n=209)
Mean (standard error) Total (N=455)
Mean (standard error)
Age, yearsa 64.72 (.874) 65.27 (.875) 64.97 (.620)
Deprivation score 35.12 (.957) 33.70 (.896) 34.47 (.661)
Number of Comorbiditiesa 2.11 (.118) 2.17 (.128) 2.14 (.087)
Amount of telehealth - number of devicesa 2.89 (.047) 0.16 (.051) 1.64 (.073)
Level of education 0.83 (.078) 0.97 (.088) 0.89 (.059)
SF-12b Physical Component Scale 30.31 (0.61) 30.75 (0.66) 30.51 (0.45)
SF-12 Mental Component Scale 35.27 (0.57) 35.38 (0.61) 35.32 (0.42)
EQ5Dc scale 0.50 (0.02) 0.52 (0.03) 0.51 (0.02)
State Anxiety scale (Brief STAId) 11.37 (0.29) 10.92 (0.31) 11.16 (0.21)
Depression scale (CESD10e) 11.10 (0.44) 10.32 (0.45) 10.74 (0.32)
Disinhibited Eating DHPf-subscale 42.44 (1.28) 41.39 (1.24) 41.96 (0.90)
Psychological Distress DHP-subscale 23.84 (1.54) 24.03 (1.66) 23.93 (1.12)
Barriers to Activity DHP-subscale 32.58 (1.44) 32.81 (1.65) 32.69 (1.08)
Social Impact DHP-subscale 12.20 (1.03) 11.79 (1.04) 12.01 (0.73)
Social Marginalization DHP-subscale 13.61 (1.09) 13.64 (1.13) 13.62 (0.79)
Social Conspicuousness DHP-subscale 10.30 (1.21) 9.22 (1.17) 9.81 (0.84)
bShort-Form 12 item survey.
cEuroQual EQ-5D.
dState Trait Anxiety Inventory.
eCenter for Epidemiologic Studies Depression scale.
fDiabetes Health Profile.
Table 3. Parameter estimates for trial arm and time in the linear mixed-effects modeling analysis for available cases (n=317).
Trial Arm Time Time × Trial Arm
Estimate Standard error Significance Estimate Standard error Significance Estimate Standard error Significance
SF 12 - PCSa 0.338 1.801 0.851 0.335 0.703 0.634 −0.298 0.976 0.760
SF 12 - MCSb 1.806 1.776 0.309 −0.024 0.639 0.970 0.024 0.881 0.978
EQ5Dc 0.087 0.068 0.201 0.021 0.026 0.417 −0.050 0.036 0.167
Anxiety −0.232 1.053 0.825 0.604 0.415 0.146 −0.250 0.568 0.660
Depression 0.488 1.364 0.720 0.100 0.528 0.849 −0.189 0.734 0.797
Psychological Distress −1.161 4.63 0.802 0.042 1.826 0.982 3.491 2.64 0.187
Barriers to Activity 3.561 4.524 0.431 1.779 1.694 0.294 −1.293 2.441 0.596
Disinhibited Eating 10.674d 3.847d 0.006d 1.754 1.649 0.287 −0.649 2.386 0.786
Social Marginalization −3.476 3.677 0.345 −0.703 1.493 0.638 2.288 2.087 0.273
Social Conspicuousness −2.275 3.374 0.500 0.764 1.427 0.592 1.610 1.973 0.415
aShort Form 12-item Physical Component Summary.
bShort Form 12-item Mental Component Summary.
dSignificant effects (P<.05).
Table 3 presents key parameter estimates for the effect of trial arm, time, and their interaction from linear mixed-effects modeling analyses (adjusting for case-mix) conducted for each outcome (parameters for covariates are not presented). Only 1 effect from the 10 PROMs was significant, on the DHP disinhibited eating subscale—where a significant trial arm effect was detected. Adjusted means (EMMs) for each outcome measure by trial arm and time point are presented in Figure 2, (for unadjusted means see Multimedia Appendix 1).
Parameter estimates indicate that being a member of the telehealth intervention trial arm provides an approximately 10-point advantage on the DHP disinhibited eating scale (after the intracluster correlation, all covariates and data hierarchy are taken into account), as indicated by EMM of the DHP disinhibited eating scale of the control (mean=35.512, SE=2.074) and intervention arms (mean=45.861, SE=2.086; F1,757.625=7.697, P=.006). Effect-size estimates reveal this to be a small to medium effect, however the effect size had large 95% CIs, which crossed the 0 border (Figure 3).
The only measure to have ES CI that did not cross the 0 mark was the EQ-5D. However, the estimated effect size was very small (Cohen criteria) and the upper CI did not exceed 0.2, suggesting that although this is a robust ES, its magnitude is unlikely to have a substantial clinical impact.
Sensitivity analyses (ie, analyses per protocol, with complete cases, and/or excluding covariates) indicated similar trends in effects.
Figure 2. Covariate adjusted mean scores (with 95% confidence interval) for each patient-reported outcomes by trial arm. ST: short-term, LT: long-term.
Figure 3. Effect size estimates for the (a) generic quality of life (QoL) and psychosocial well-being outcomes, and (b) the disease-specific QoL outcome measures.
This analysis examined the effect of telehealth on participant reported outcomes in a relatively large sample of patients with diabetes, who partook in the WSD telehealth trial. Overall scores for the sample indicate that physical and mental health component scores for the SF12 and EQ5D health status measures were similar to a population with diabetes. Both anxiety and depression levels were slightly high, with the depression level means close to the cut-off point for screening clinical levels of depression. The DHP scales and additional social-based HRQoL scales (social conspicuousness and social marginalization) did not indicate problems with diabetes-specific QoL, and indicated a relatively well-functioning long-term condition diabetes sample.
The telehealth group means generally indicated marginally better generic HRQoL outcomes for the telehealth group; and the usual care better marginally better outcomes on the disease-specific and psychological distress scales. However, overall these differences did not reach statistical significance, with the results suggesting that telehealth, relative to usual care, does not significantly impact upon patients HRQoL (generic and disease-specific) or their psychological distress over a period of 12 months. Nor does the status of these participants' PROMs greatly alter over the 12-month period, regardless of their treatment group.
The only significant effect across the analyses of the PROMs was found on the DHP disinhibited eating subscale—where a significant trial arm effect was detected. Parameter estimates indicated that being a member of the telehealth intervention trial arm provided an approximately 10-point increase on the DHP disinhibited eating scores. This may have indicated that with telehealth patients are more likely to undertake disinhibited eating (eg, lack eating control, emotional eating), perhaps as a response to knowing that should any effects of lacking eating control become extreme, they are being monitored and health care professionals will be able to suitably intervene. The provision of telehealth has the potential to increase individual's empowerment and self-care behaviors to manage their conditions through remote monitoring, rather than leading to a reliance of health care professional control. The mechanisms of such unexpected negative effects need further investigation in relation to theoretical constructs of behavioral change. Furthermore, effect-size estimates revealed this effect on disinhibited eating to be a small to medium effect, with large CIs that crossed the 0 border, indicating poor reliability in this estimate.
The only outcome with an effect size CI that appeared robust was with the EQ5D measure. However, the magnitude of this effect indicated that it would unlikely be clinically significant. The lack of effects on these PROM could also be because patients with diabetes are used to monitoring their conditions, in terms of checking blood glucose, monitoring their diets, and activity levels [32,33], and the potential benefits of the additional remote connections to health care professionals do not add value to their self-monitoring behaviors.
Despite lack of effects on PROMs, the WSD diabetes cohort showed modest gains in glycemic control [21], which was similar to another UK-based RCT [7]. There was also evidence that the telehealth trial was effective at reducing hospital admissions and mortality [34]. There were no differences on diabetes specific QoL, self-care behaviors, self-efficacy, which is consistent with recent pragmatic multicenter RCT in the UK [7], and other long-term conditions in the WSD trial [8,35]. However, these results demonstrated no substantial decreases in these outcomes either. To gain improvement in PROMS, the telehealth system may need to be broader than self-monitoring of blood glucose and designed to target the behavioral antecedents to these PROMs in individuals with impaired mood and HRQoL. Telehealth services may need to be more tailored to the individual, so that there is a match between the person and the technology to increase its impact.
This study also examined the use of novel social functioning with diabetes scales of social marginalization and social conspicuousness. Overall, the results showed that there are only small impacts in these 2 areas of social life and that they are not impacted upon by telehealth as delivered in this study. However, it may be the case that non–home-based remote monitoring, other technology-enabled care systems or mobile monitoring [3-6] would have a greater impact in these areas.
This clustered RCT addresses many of the methodological limitations identified in previous studies and adds evidence to an important gap in the literature. However, caution is required as although this was a relatively large sample of patients with diabetes compared with past studies, in the available cases analyses, the sample size did fall short of the recommended number required to detect a small effect. Despite recruiting 455 patients at baseline, the required number was not met due to attribution. This highlighted the difficulties in recruiting and maintaining participants in a trial of this size and complexity; nevertheless, a larger sample may help narrow the CIs of effect sizes and identify further statistically significant effects.
Also, the WSD trial was a pragmatic trial, but with associated limitations. While it has good ecologic validity, 1 potential criticism is the number of confounding factors (eg, the nature of the telehealth intervention delivered at each of the regional WSD sites/participating). Like other studies in this area, there is a high risk of selection bias given that the numbers of eligible patients the study sample were drawn from is unknown. Nevertheless, the WSD trial recruited a large number of patients with diabetes, is 1 of very few UK-based studies conducted in the National Health Service, and benefits from high generalizability across different centers, given the inclusion of a many general practices (n=204) delivering telehealth or standard care to patients with diabetes. However, in his study we did not examine differences between patients using insulin as well as oral medication and those who were only using oral medication. It is likely that insulin use will have a greater effect on HRQoL than medications alone, and thus insulin users may have a greater potential for the support via telehealth. This potential impact requires further investigation, especially in relation to the timeframes within which telehealth may have positive impacts upon HRQoL and psychological distress in each group of patients with diabetes.
Importantly, as an RCT, this study did not aim to specifically examine the mechanisms by which telehealth may impact PROMs. The differences in the types of telehealth and how they may differentially affect outcomes needs better investigation—as they likely use different mechanisms for action on HRQoL and psychological distress, making it problematic to compare the effectiveness of trials. Telehealth solutions also need to be described in sufficient detail, to determine how their use in the complex health care environment of diabetes management, may lead to improved HRQoL outcomes. Monitoring and interpreting readings in diabetes self-management is only 1 domain of a complex set of behaviors patients are advised to follow. Thus, the complexity of interventions, including the integrated role of telehealth across services, need to be adequately described with the mediating and moderating variables also examined. Furthermore, additional types of technology that patients with diabetes may use in addition to the telehealth services provided by the general practitioner/local authority also need to be considered, as they may mask effects specific to these services.
Implications and Future Research
The findings have implications for mainstreaming telehealth. Providing telehealth alone, in the absence of monitoring and enhancing the mediating mechanisms (eg, self-care behaviors, self-efficacy [Cartwright et al. Unpublished data], acceptability [20], and reducing dropout [36]) will not necessarily lead to improvements in HRQoL. In the future, further improvements to these complex interventions maybe required for telehealth to be used as a tool to improve patients' self-care and HRQoL. For example, evidence-based self-management interventions could be delivered via telehealth to facilitate the management of long-term conditions, such as diabetes and the capability of mobile monitoring may need to be integrated into home-based telehealth packages.
This study found no substantial impacts of telehealth on either generic or disease-specific HRQoL measures in a population with diabetes. However, this study also demonstrated that there were no substantial decreases in HRQoL with the introduction of telehealth. Coupled with moderate improvements in glycemic control, there is potential promise for telehealth interventions, but more effective telehealth interventions aimed specifically at improving outcomes measured by PROMs are needed. Self-monitoring using telehealth is insufficient to improve PROMS by itself, but we recommend using evidenced based self-management techniques targeting self-care and QoL delivered via telehealth, as a tool to facilitate the delivery of the intervention.
A special thanks to Alan Glanz and Professor Chris Ham (Kings Fund) for the support throughout the study.
We are extremely grateful to all the individual participants for their time and interest in the study, all the managers and professionals in Cornwall, Kent, and the London Borough of Newham in the Health and Social Services and to the participating case study organizations for their help. Participants are not named to preserve anonymity. We are also grateful to members of the remote care community for their continuing support, and the reviewer of the manuscript for their insightful comments.
This is an independent report commissioned and funded by the Policy Research Programme in the Department of Health. The views expressed are not necessarily those of the Department.
SN was the chief investigator of the Whole Systems Demonstrator Trial. SH, MC, MB, and LR were responsible for the day-to-day running of the trial. SH ran the analysis and all authors contributed to the preparation of the manuscript.
None declared.
Unadjusted mean scores (with 95% confidence interval) for each patient-reported outcome by trial arm. BL: base line; ST: short term; LT: long term.
JPG File, 653KB
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CESD-10: Center for Epidemiologic Studies Depression scale
CI: confidence interval
DHP: diabetes health profile
EMM: estimated marginal means
EQ5D: EuroQual 5D
HRQoL: health-related quality of life
IQR: interquartile range
MCS: mental component summary
PCS: physical component summary
PROMS: patient-reported outcomes
RCT: randomized controlled trial
SE: standard errors
SF: short-form
STAI: state trial anxiety inventory
WSD: whole systems demonstrator
Edited by G Eysenbach; submitted 08.12.16; peer-reviewed by B Larsen, E Murray, J Hanley; comments to author 26.01.17; revised version received 25.05.17; accepted 22.06.17; published 01.09.17
©Shashivadan P Hirani, Lorna Rixon, Martin Cartwright, Michelle Beynon, Stanton P Newman, WSD Evaluation Team. Originally published in JMIR Diabetes (http://diabetes.jmir.org), 01.09.2017.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Diabetes, is properly cited. The complete bibliographic information, a link to the original publication on http://diabetes.jmir.org/, as well as this copyright and license information must be included.
Hirani SP, Rixon L, Cartwright M, Beynon M, Newman SP, WSD Evaluation Team
doi: 10.2196/diabetes.7128 PMID: 30291060 PMCID: 6238866


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