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Q: modern treatment of the triviality of the multiplicator of the finite special linear group Given your favorite version of the Heisenberg group one can prove the Stone-Von Neumann theorem. It is then not to hard to construct a family of representations on a central
extension of $Sp\left(2n, F\right)$ by $\mathbb{C}^{\times}$, where for me $F$ is a local field.
In a past project I constructed such a representation in the case when $n=1$ and $F$ is finite, and I would like to deduce this special construction from the general construction outlined in my first paragraph. I believe this reduces to showing that when $F$ is
finite $H^2 \left( SL_2 \left(F\right) , \mathbb{C}^{\times} \right)$ is trivial when $F$ has odd order not equal to 9.
That said, I've been bouncing back and forth between books and google trying to find a proof of the triviality of this Schur multiplier.Indeed I found one in Schur's 1904 paper
"Uber die Darstellung der endlichen Gruppen durch gebrochene lineare Substitutionen."
However I was hoping that in the more than 100 years since Schur published this there has been a less German and more modern treatment of the triviality of $H^2 \left(SL_2 \left(F\right), \mathbb{C}^{\times} \right)$. So I'm wondering, is there such a treatment? Perhaps, as an alternative to a reference, someone could provide a sketch of the proof.
Edit 1: In the Atlas of Groups one can find an algorithm to calculate the Schur multiplier
of a finite group, given generators and relations. However, I'd hope that there is a less computational proof that better capitalizes on the specific nature of the group $SL_2 \left(F\right)$.
Edit 2:Geoff Robinson and Jack Schmidt have pointed out that the Schur multiplier is nontrivial in the case that $F$ has order 4 or 9. Hopefully, my revised question is answerable.

A: Here is just a partial answer to indicate that one mostly knows the multiplier from basic group theory.
If G = SL( 2, q ) for some prime power q = pk, then the Sylow r-subgroups of G are either:

*

*Quaternion if r = 2 ≠ p,

*Cyclic if 2 ≠r ≠ p,

*Elementary abelian if r = p
In the first two cases, the Sylow r-subgroup already has trivial multiplier, so G has trivial r-multiplier, as in pages 107–108 and 117 of Schur (1907) or page 170 of Aschbacher's Finite Group Theory and pages 123, 151, 153 of Isaacs's Finite Group Theory.

In particular, the multiplier of G is always a p-group.

One can even calculate the multiplier of a nicer group, B, where the relations are easier to understand.

Caveat: I haven't finished the calculation, but perhaps here is one way to approach it.
Since the Sylow p-subgroup P is abelian, B = NG(P) controls the multiplier, that is, the multiplier of G is isomorphic to the multiplier of B.  I think one could simply calculate the multiplier (start with the multiplier of P and the take into account the GF(q)× = B / P action, where it acts as squares; this is done on page 118–119 of Schur (1907)).  Large k should have trivial multiplier because of the large action of GF(q)×, and small k should be trivial since the multiplier of P is already small.  Apparently something goes wrong for medium sized k, at least when q = 4 or q = 9.
When q = 4, one gets B ≅ AGL(1,4) ≅ A4 which has SL(2,3) as a double cover.  When q = 9, one actually gets an action of GF(q)× on an extra-special 3-group as a triple cover of B.
In general you would have to get:
$$ \hat B = \langle a, b_i, z_{ij} : a^{q-1} = b_i^p = z_{ij}^p = 1, b^a = b^{(\zeta^2)}, [b_i,b_j]= z_{ij}, z_{ij} \in Z(\hat B) \rangle$$
and I guess the question is how a can act consistently on both b and z without forcing z = 1.  This appears to be a matrix congruence over GF(q), and so is probably equivalent to Schur's method.  Presumably it is also understandable as looking at alternating forms on GF(q)2, so related to your original Sp(2, F) problem.

At any rate here is a bibliography with some links.

*

*Schur, J.
Über die Darstellung der endlichen Gruppen durch gebrochene lineare Substitutionen.
J. für Math. 127, 20-50 (1904).
JFM35.0155.01
URL:GDZPPN002165511

*Schur, J.
Untersuchungen über die Darstellung der endlichen Gruppen durch gebrochene lineare Substitutionen.
J. für Math. 132, 85-137 (1907).
JFM38.0174.02
URL:GDZPPN00216633X

*Aschbacher, Michael.
Finite group theory.
Cambridge Studies in Advanced Mathematics, 10.
Cambridge University Press, Cambridge, 1986. x+274 pp.
ISBN: 0-521-30341-9
MR895134
Google books

*Isaacs, I. Martin
Finite group theory.
Graduate Studies in Mathematics, 92.
American Mathematical Society, Providence, RI, 2008. xii+350 pp.
MR2426855
Google books:
** p. 118 lemma,
** p. 123 quaternions have no multiplier,
** p. 151 def. of multiplier,
** p. 153 triviality of more multipliers.

A: The trouble is that there can be small exceptions to the general rule: for example, $A_{6} \cong {\rm PSL}(2,9)$, and $A_{6}$ has a triple cover. Hence the Schur multiplier of $A_{6}$ has order $6$, and ${\rm SL}(2,9)$ has a triple cover.


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Diversity, Distribution and Evolution of the Planktonic Diatom Family Chaetocerotaceae
Gaonkar, Chetan Chandrakant (2017). Diversity, Distribution and Evolution of the Planktonic Diatom Family Chaetocerotaceae. PhD thesis The Open University.
PDF (Version of Record) - Requires a PDF viewer such as GSview, Xpdf or Adobe Acrobat Reader
The number and abundance of diatom species in environmental samples are counted traditionally by means of light microscopy (LM). However, recognizing –let alone, counting- species is often challenging because of the existence of cryptic species and intraspecific phenotypic plasticity. Proper characterization requires isolation of cells, growing them into monoclonal cultures, and characterizing the cultures genetically and morphologically. However, not all species grow in culture, featureless ones are less likely to be isolated, and the procedure is laborious. High-throughput sequencing (HTS) metabarcoding bypasses morphology; DNA is collected from environmental samples, a particular marker sequenced, and the resulting sequences sorted into clusters or terminal clades assumed to represent species. Yet, reference barcodes of taxonomically validated species are needed to identify these clades. This exercise is the main aim of my thesis.
Since it is impossible to do this for all the diversity within a PhD thesis project, we selected Chaetocerotaceae, an abundant and diverse family of marine planktonic diatoms, containing two genera: Chaetoceros and Bacteriastrum. Its members uniquely share setae; thin siliceous tubes emerging from the valve corners, facilitating detection in samples. Strains were obtained from the Gulf of Naples (GoN), from Central Chile and Roscoff – at sites for which LTER time series data are available.
A total of 270 strains were obtained from these sites, and their 18S- and partial 28S rDNA sequences and morphological information gathered. The strains grouped into 60 genetically distinct species, thus providing a dataset of validated Chaetocerotacean 18S reference barcodes. Inferred molecular phylogenies showed monophyletic Chaetocerotaceae as well as monophyletic Bacteriastrum inside paraphyletic Chaetoceros, and the presence of cryptic diversity. To start with taxonomic updates, the species C. sporotruncatus and C. dichatoensis were described within the C. socialis species-complex based on spore morphology and sequence differences. Several rDNA sequences contained spliceosomal introns (ca. 100bp) and/or group-I introns (ca. 400bp). Phylogenies inferred from the introns did not corroborate rDNA phylogenies, suggesting horizontal gene transfer. Presence/absence of introns in conspecific strains sampled in different seasons suggests population differentiation between these seasons. A HTS dataset consisting of V4-sequences (part of 18S) from 48 seawater samples taken over the seasons in the GoN revealed 76 terminal clades of which 46 grouped with a reference barcode. Some of these species occur year-round whereas most others are seasonal. Surprisingly, of the 30 clades belonging to unknown Chaetocerotacean species, two appear to be among the most abundant in the GoN.
2016 The Author
genetic markers; bar coding
Faculty of Science, Technology, Engineering and Mathematics (STEM)
Associated Research Centre:
Stazione Zoologica Anton Dohrn
Chetan Chandrakant Gaonkar
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Narrator: Peter Kenny
Play audiobook
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Review of the book
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Again, 9/11 first responders are pleading with Congress to fund their health care. Again, Jon Stewart is joining them.
In December 2015, a retired New York firefighter and Sept. 11 first responder named Kenny Specht sat down with Jon Stewart on "The Daily Show With Trevor Noah."
It was the second time in five years that Specht appeared on the show to talk about Congress's lack of action on a bill that would compensate health-care costs for 9/11 first responders who had developed illnesses related to the toxic fumes they inhaled while clearing rubble and recovering bodies at Ground Zero after the 2001 terrorist attacks. The first time Specht spoke with Stewart, in 2010, he was joined by three other men.
Now, they were joined by three empty chairs.
"Just out of curiosity, where is everybody?" Stewart, a former "Daily Show" host who was appearing as a guest, asked the firefighter.
Since their first appearance, Specht told him, two of the first responders had become too ill to appear. The other had died of cancer.
The sobering moment was punctuated by an infuriated Stewart, who has spent the past decade repeatedly slamming Congress for delays in funding health care for ailing first responders and survivors who risked their lives on 9/11. Stewart's fury on the issue has been nearly unparalleled among other public figures, emerging louder than arguably anyone else on Capitol Hill or in the media each time money for first responders' health care has been at risk of evaporating.
Now he's back again, urging Congress this week to pass new legislation that would permanently fund health care for ailing 9/11 first responders and survivors, as yet again, the 9/11 victims compensation fund is running out of money.
Stewart added, "The idea that 18 years later they're still tugging on the hemline on the government to get this bill through and get it funded properly is truly beyond comprehension."
Senate Minority Leader Charles E. Schumer (D-N.Y.), as well as Sens. Kirsten Gillibrand (D-N.Y.) and Cory Gardner (R-Colo.), announced bipartisan legislation Monday that would ensure that 9/11 first responders who fall ill in the future will be covered under the Victim Compensation Fund, which will expire in 2020.
Last week, the Justice Department's special master who oversees the funds announced that future payouts may be cut by 50 to 70 percent, saying "I am painfully aware of the inequity of the situation ... but the stark reality of the data leaves me no choice." As the fund is running out of money, the special master said, compensation claims are increasing at unprecedented levels as more people become sick.
Congress has revived the compensation fund twice, in 2010 and 2015, but both times gave it only a five-year lifeline, leading public servants to petition their elected officials for a more permanent solution. They are able to seek health-care compensation from the fund because of the James Zadroga 9/11 Health and Compensation Act, which was extended by Congress in 2015 to last 75 years — again in part because of Stewart's aggressive lobbying alongside the New York public servants.
The 9/11 terrorist attacks have always been personal for Stewart, who said in 2001 that he could see the World Trade Center from his apartment in Lower Manhattan. Nine days after the attacks killed nearly 3,000 people, Stewart appeared behind his wooden desk on "The Daily Show," stumbling at first to shirk the awkwardness that comes naturally with a late-night comedy show in the wake of the nation's most unfathomable tragedy. "Tonight's show is obviously not a regular show," he said.
Then came an unforgettable monologue.
Years later, in 2010, Stewart would air another unforgettable 9/11 segment — this time in a comedic sketch aimed at the Republican-led Congress for not funding health care for first responders. He began by satirizing the idea that one would think health care for 9/11 first responders would be an easy bipartisan deal to strike.
"Oh, there's a tax increase to pay for this? I'm sorry, I didn't know they were going to try to pay for the bill to provide health care for those suffering for their heroism with a tax," a red-faced Stewart yelled sarcastically.
Weeks later, when the bill appeared to be hopeless after Republicans tried to filibuster it, Stewart brought on a panel of first responders. Days later, the Senate brought the bill back to the floor as the legislative session drew to a close. It passed.
The legislation passed by Congress was only temporary, however, and so in 2015, as the fund was set to expire and a deal to save it was still up in the air, Stewart returned to the halls of Congress to hound Republican lawmakers who had yet to commit to voting to extend the funding, going door to door and bringing cameras along with him. Then, he persuaded Trevor Noah, his "Daily Show" successor, to let him back on the program.
On Monday, Stewart said it was "beyond my comprehension" why he and the first responders were still singing the same tune.
Wearing a navy blue T-shirt displaying the FDNY Ladder 42 logo, he appeared at a news conference alongside the first responders, as well as Gillibrand, Schumer, Gardner and other lawmakers, and addressed the journalists in the room.
He said he didn't "want to ask you, I just want to beg you," to tell the stories of the men and women suffering from diseases traced back to the fumes of Ground Zero.
Feal, the 9/11 first responder, took the stage after him, pleading that they not be forgotten.


text:
Skala H0 – nazwa skali w modelarstwie kolejowym o podziałce 1:87 i rozstawie szyn 16,5 milimetra.

Historia
Pierwsze modele kolejowe wykonane w skali H0 były zaprezentowane na Targach Lipskich w 1935 roku przez niemieckie firmy modelarskie Trix oraz Märklin. Do 1950 roku były oznaczane jako skala 00 (później w Wielkiej Brytanii oznaczano tak skalę 1:76). Później modele kolejowe w tej skali były produkowane przez wiele niemieckich firm modelarskich. Po drugiej wojnie światowej modele kolejowe były dodatkowo produkowane w NRD przez  firmy Piko oraz Gützold. Modele kolejek w skali H0 były typowe dla Niemiec Wschodnich, ze względu na normatywy mieszkaniowe, które ustanawiały 40 m2 powierzchni mieszkań. Największa makieta kolejowa w skali H0 nosi nazwę Miniatur Wunderland i znajduje się w Hamburgu.

Obecnie H0 jest najbardziej rozpowszechnioną skalą w modelarstwie kolejowym. Jej wielkość pozwala na dobre oddanie szczegółów, a także samodzielne wykonywanie i przerabianie modeli. Liczne firmy modelarskie produkują bogaty asortyment modeli gotowych, poszczególnych części i akcesoriów do makiet w tej skali. Produkowane są w tej skali także modele pojazdów, w tym pojazdów bojowych, gotowe lub do sklejania.  Stosowanie taboru i torów różnych firm sprawia w praktyce pewne problemy związane z różnymi systemami sprzęgów stosowanymi przez dużych producentów, oraz profilami torów.  W skali tej istnieją także dwa systemy zasilania: prądem stałym z dwóch szyn o różnych biegunach, oraz stosowany głównie przez firmę Märklin system trzyszynowy prądu przemiennego.

Pochodnymi skalami w tej samej podziałce 1:87 są H0m o szerokości toru 12 mm, H0e o szerokości toru 9 mm i H0f o szerokości toru 6,5 mm, odpowiadające kolejom wąskotorowym o szerokości toru odpowiednio 1000 mm, 750 mm i 600 mm.

Przypisy

Linki zewnętrzne

 Miniatur Wunderland w Hamburgu

Skale stosowane w modelarstwie

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text:
Gate lock prevents break-in
Posted on October 15, 2016 by Jeannie Knight
A Petworth landowner has praised the robustness of Zedlock gate locks following an unsuccessful break-in attempt on estate land.
A Zedlock was fitted to the gate, which protects an area of forest just outside the town, in 2014, after a number of raves were held illegally in the woods. Neil Humphris, the Head Forester of Leconfield Estates, specified Zedlocks on a number of gates where padlocks had previously been fitted.
The scene that greeted forestry workers on arriving for work
He explained:'On a number of occasions padlocks were cut off and thrown away before the rave organisers moved in. Because there was no evidence that property had been damaged to gain entry, stopping and clearing the rave was much more difficult. Zedlocks are far more difficult to break and very easy to use, don't rust and jam and you can have them all keyed-alike.'
On this occasion a vehicle, probably a 4×4, was used to attempt the break-in. Despite the fact that the gate and gate posts were wrecked during the attempt, the Zedlock held firm, keeping the would-be trespassers out.
Also, the Zedlock was still operational and when forestry workers arrived the following morning, they were able to unlock it.
Zedlock was still operational when workers arrived
Chris Boddington, of CB Forestry, said: "Clearly those responsible had repeatedly snatched at the gate with a rope or chain in attempts to gain access, and both gate posts were pulled over by more than 45 degrees.
"But we were able to unlock the Zedlock to gain access, though opening the gate was a two-man job because it was so bent. I'm certainly impressed with the durability of the Zedlock."
The access is now protected by a new, heavy duty gate, fitted with a Zedlock.
Zedlock was started in 2011 and is based in Petworth, West Sussex. Managing Director, Bruce Robertson, originally designed the Zedlock (Patent No. GB2489293) as a secure and practical alternative to a padlock and chain.
Since its introduction, further models and a range of accessories have been developed to widen the application of the lock. Its gate locks are available to suit the majority of metal and wooden gate and are distributed by Birkdale Sales, a manufacturer of wholesale ironmongery and gate hardwear.
It serves over 3,500 outlets in the UK and Ireland. The full range of locks is also available locally direct from Zedlock. Zedlock Limited, Unit 5, Old Station Yard, Station Road, Petworth, West Sussex, GU28 0JF. www.zedlock.com +44(0)1798 342251 sales@zedlock.com
This entry was posted in From The Horse's Mouth by Jeannie Knight. Bookmark the permalink.


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See Emily, a Saker Falcon, at the North Island Wildlife Recovery Centre.
Exciting things are happening at the Wildlife Recovery Centre: Plan your visit today!
Centre opens year-round with host of events and new activities
It's been a busy winter for the North Island Wildlife Recovery Centre, where plans for 2018 include year-round opening, new exhibits and a host of events on the calendar!
Located on Errington, just 10 minutes west of Parksville on Highway 4A, the centre is a treasure trove of wildlife experiences, education, wild bird watching and wildlife gardening, all on eight acres of immaculately manicured grounds.
Visitors can view and learn about non-releasable wildlife such as eagles, owls, turkey vultures, ravens, falcons, black bears and more.
"We invite the public to the centre to learn and thrill to view these amazing creatures, but also to support our programs," says NIWRA's Jodi Young. "As a rehabilitation centre, education centre and tourist attraction, without you we could not exist – the animals depend on us, but we depend on you."
Rehabilitation of Vancouver Island wildlife is why they exist, but popular events are planned throughout the year:
To start the season, NIWRA has partnered with the Brant Festival and will release an eagle from the centre.
Family Day, a fun-filled wildlife-themed day on June 16, draws hundreds of families to the centre.
During summer, glove-trained birds such as Oliver the owl and Emily the saker falcon are presented Monday, Wednesday and Friday at 1:30 p.m.
Planning is underway for Wild Woman Day on Sept. 15, a celebration of women nurtured by and nurturing nature that should not be missed.
Also for your calendar is NIWRA's annual Mushroom Festival on Oct. 14, it's a fungi day!
And finally, the centre celebrates the Christmas season with the Magical Nights of Light in December, a fantastic display of laser lights that are even better in the rain or snow.
The North Island Wildlife Recovery Association's sole focus is on supporting the animals in their care and sharing with you, the public, how you can help. Part of that is having the centre become a Discovery Campus.
Incredible volunteers greet you from the Bear Den Gift Shop as you enter and can direct you to the Eco Room, with animal displays and NIWRA's award-winning video to view. Venture through the Museum of Nature which leads to NIWRA's treatment centre and eagle flight enclosure.
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NIWRA is a must-see destination. Bring your family, friends and picnic lunch – you'll be amazed!
Plan your visit at niwra.org or visit us on Facebook.
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What is Hiragana?
You are here: What is Hiragana?
=> Hiragana is the basic Japanese phonetic alphabet. It represents every sound in the Japanese language. Therefore, you can theoretically write everything in hiragana. However, because Japanese is written with no spaces, this will create nearly indecipherable text.
=> Hiragana is used along with kanji to write all native Japanese words (including words of Chinese origin). Hiragana is used for verb and adjective endings (okurigana), particles, words that have no kanji, words which are commonly written only in kana, words for which the writer does not know the kanji, and as furigana (hints provided by the writer to the reading of an unfamiliar kanji).
=> Hiragana are used when you can't use kanji, for sound symbolism, particles, help verb, and conjunctions. Hiragana can also be used for adverbs and names for animals and plants. Often you can see them together with a kanji to form a word. Hiragana is used for changing meanings of kanji by adding a hiragana character after the kanji. Hiragana is also used wherever kanji characters wouldn't be used.
=> Hiragana can be used to express and write all Japanese words without the use of kanji since hiragana is like an alphabet. If you can't remember the right kanji for a word, you can just spell it out in hiragana. There are 46 Hiragana to learn. In addition to those 46 hiragana there are some hiragana with different pronunciation.
How many hiragana characters are used in Japanese Language?
->There are 46 hiragana symbols in Japanese, each with a particular sound but with no independent meaning.
How do the 46 hiragana characters behave in the Japanese Language?
->Each Japanese "alphabet" has a particular function. Hiragana characters play two major roles.
*Creating grammatical structure
A major function of hiragana is to add grammatical structure to sentences. One way is in the form of okurigana, the hiragana characters added to the end of words to modify meaning.
*Showing pronunciation
Hiragana characters are often written next to unusual kanji characters to show their pronunciation in the same way that we have added roman characters to the sentence above. In this case the hiragana characters are referred to as furigana or yomigana. In addition, hiragana is also used to write native Japanese words that have no kanji of their own.
Next, you can check out our hiragana chart, play a hiragana game or learn how to write hiragana.
Complete Hiragana Game Reviewer
Japanese Alphabet Matching Game – Hiragana
Japanese Hiragana Typing Game
Hiragana Game
Hiragana Game Reviewer


text:
SNMPTT - SNMP Trap Translator - (traducteur des traps SNMP) est un logiciel permettant de capturer et de traduire de manière compréhensible les messages trap remontés par les agents SNMP.

Ecrit en Perl, ce logiciel s'interface avec le daemon snmptrapd de la suite de logiciel Net-SNMP.

Liens externes
 site officiel

Logiciel réseau et Internet


Few Canadians know that the original vision of Medicare went well beyond public payment for the old system. The original vision of Medicare included new ways of delivering care. But, as then Saskatchewan Premier Tommy Douglas realized in the 1950s, this vision would have to be implemented in two stages.
Saskatchewan led the rest of the country and the continent with its health policy. Before Tommy Douglas became premier in 1944, the province already had a thriving municipal doctor program, provided universal care for patients with tuberculosis, and had established Canada's first cancer control agency. After his victory in 1944, Douglas appointed Dr. Henry Sigerist, an internationally known Johns Hopkins professor of medicine to review the province's health system. Sigerist recommended the establishment of district health regions to which would include hospital and medical care, diagnostics, public health, and home care.
Saskatchewan established the Health Services Planning Commission to continue planning and facilitate implementation of the Sigerist report's conclusions. Southwestern Saskatchewan was keen to move and on January 1, 1946, the Swift Current Health Region was established, providing universal hospital and medical care.
However despite the popularity of the Swift Current plan with local doctors and the initial positive reviews from Canadian organized medicine, opposition from doctors in other parts of the province and country prevented the spread of the Swift Current model.
Eventually the Saskatchewan provincial government, led by Douglas as Premier, moved ahead with Medicare's first stage, providing insurance to people when they got sick. In 1947, Saskatchewan implemented universal hospital insurance and in 1962, medical insurance. However, over 90 per cent of the province's doctors went on strike, refusing to see patients even in an emergency. Eventually, Saskatchewan's doctors essentially settled for what the government had been offering.
Canadian governments were shaken by the bitter strike and were loathe to have a repeat. As a result, Canadian governments did little to challenge physicians on the way health care services were organized. There were some new models of care developed based on group practice and integration of public health. The Saskatchewan community clinics and the Sault Ste. Marie Community Group Health Centre were evaluated in the 1960s and 1970s and shown to have lower overall health care costs because their patients spent 20-25% fewer days in hospital.
The first stage of Medicare has been very good to Canadians. Up until the late 1950s, Canadians and Americans had similar health status and similar health care systems with similar costs. Now Canadians are healthier and spend much less on health care. Despite the world's highest health care spending, nearly 60 million Americans either have no insurance or live with someone who lacks coverage, and tens of millions have such bad coverage that health care bills bankrupt half a million every year. And, Medicare has been good for Canadian business by reducing manufacturers payroll costs by up to $6 per hour per employee.
When Canadians first started debating Medicare one hundred years ago, we were a young country and most health problems were acute. However, today our main health problems are chronic diseases in an aging population. And because Canadian physicians have not integrated their practices with each other or with the rest of the health system, Canadians with chronic diseases frequently develop complications which could have been prevented with better follow up.
Compared with other wealthy countries, Canada has some of the longest waits for primary health care, medical specialists, hospital emergency rooms, and elective surgery. Douglas noted in his day that needless "ping-ponging" between different specialists and diagnostic tests caused many delays. Now the waits are longer because there are more specialties, more tests available, and because modern practices won't allow patients into hospital just to have all their tests and consultations at once. When care processes are updated using the original vision of Medicare, waits plummet. The Saskatoon Community Clinic sees their patients the day they want to be seen and the Saskatchewan Health Quality Council has taken this innovation to 25% of the province's primary health care practices. The Hamilton Shared Care Mental Health Program integrates 145 family doctors, 17 psychiatrists, 80 counsellors to provide primary health care-based mental health services to over 300,000 patients. The program increased the number of patients using mental health services by 1100% while simultaneous reducing referrals to the psychiatry specialty clinic by 70%.
Canadians should also have faster access to elective surgery. For example, the Alberta Bone and Joint Institute Pilot Project reduced wait times for artificial joints from 19 months to less than 11 weeks, all the way from family doctor referral right through to surgery. The key changes included creating orthopaedic surgery group practices.
The Second Stage of Medicare is coming but can we wait?
We have known the broad brush strokes for the Second Stage of Medicare since at least 1946 in Swift Current. The development of the quality agenda in health care has added a lot of detail to the sketch. And, there are more and more Canadian examples of these Second Stage programs with their attendant benefits to health and the health care system. If we could implement the Second Stage of Medicare we could improve the country's health, a lot, including the health of the people who provide care. While Medicare has problems, it's pretty clear that we can fix them all without charging clients or contracting out care to the lowest bidder.
Few Canadians know that the original vision of Medicare went well beyond public payment for the old system. The original vision of Medicare included new ways of delivering care. But, as Tommy Douglas reminded us in the SOS Medicare Conference in November 1979, this vision would have to be implemented in two stages – the first stage was to remove money as a barrier to access but the second, more difficult, stage would be "to alter our deliver system" in order "to reduce costs and put an emphasis on preventative medicine.
Saskatchewan led the rest of the country and the continent with its health policy.2 Before Tommy Douglas became premier in 1944, the province already had a thriving municipal doctor program, provided universal care for patients with tuberculosis, and had established Canada's first cancer control agency. Just months after Douglas was elected premier, the province became the first jurisdictions in North America to cover all cancer diagnosis and treatment.
After his victory in 1944, Douglas appointed Dr. Henry Sigerist, an internationally known Johns Hopkins professor of medicine, to review the province's health system.3 Sigerist recommended the establishment of district health regions to focus on preventive medicine. The district would include hospital and medical care, diagnostics, public health, and home care. To ensure the focus was on prevention, Sigerist recommended that the medical officer of health head up the health region.
here is a successful experiment in the large scale provision of medical care, courageously applied, efficiently managed and remarkably free of attempts to make the facts fit preconceived ideas, financial or otherwise.
Improved coordination of health care delivery focused on prevention through a local integrated health region: The region funded and organized a comprehensive package of services including hospital and physician care, diagnostic services, home care, public health, and children's dental services.
Prepaid funding: Services were available to the public on a universal basis, with little or no charge to users.
Group medical practice: The doctors were in private practice, but the regional medical leadership, including the medical officer of health, exerted significant influence in standards of practice and utilization. The medical office of health and public health nurses worked in tandem with the physicians to deliver preventive services.
Democratic community governance of health care delivery by a locally elected board: The twelve Swift Current board members represented the region's eighty-seven municipalities. Community governance would ensure health care remained responsive and customized to the priority needs of the local population.
Eventually the Saskatchewan provincial government, led by Premier Douglas, moved ahead with Medicare's first stage: providing insurance to people when they got sick. In 1947, Saskatchewan implemented universal hospital insurance. When Saskatchewan launched its medical insurance plan on July 1, 1962, over 90 percent of the province's doctors went on strike, refusing to see patients even in an emergency.10 Eventually, Saskatchewan's doctors essentially settled for what the government had been offering. The settlement of the 1962 Saskatchewan physicians' strike is generally seen as a victory for the government and the birth of Medicare in Canada. However, events belie this interpretation.
In the longer term, Canadian governments were collectively shaken by the bitter 1962 doctor's strike and were loath to have a repeat. The federal government did implement a national hospital insurance plan in 1957 and a national medical insurance plan in 1968. In 1969, the country's deputy ministers of health asked the University of Toronto's Dr. John Hastings to write a report on the reorganization of medical practice and primary health care as it moved to public payment. Hastings' 1972 report recommended a similar system to that suggested by Sigerist twenty-seven years earlier: group medical practice, non-fee-for-service payment, and integration with public health and social services.
Despite a positive reception from nursing groups, public health associations, and several provinces, there was firm opposition from the medical profession. The health system stayed pretty much the same for twenty-five years after Dr. Hastings's report. Canadians had first-dollar coverage for hospital and physicians' services, but the delivery system still looked like the 1950s. Almost all physicians are in private practice, billing the provincial Medicare plans on a fee-for-service basis. There is little group practice or the use of inter-disciplinary teams.
And Medicare has been good for business in Canada by picking up the tab for most health care costs. Our manufacturers have an $8 per hour per employee advantage over their American competitors.24 Medicare keeps hundreds of thousands of our best-paying jobs in this country. By any standard we have done well by adopting Tommy Douglas's first stage of Medicare. But, as Douglas predicted, our health system has developed problems.
All these programs should be designed to keep people well — because in the long run it's cheaper to keep people well than to be patching them up after they are sick.
Financial factors are another driving force for change. Tommy Douglas always said that focusing on prevention would make Medicare more sustainable. And a growing body of evidence indicates Douglas was right.33 For example, a recent Alberta after-care program for congestive heart failure patients leaving hospital reduced future hospital use by 60 percent, with $2,500 in overall net cost savings per participant.34 Home care nurses ensured that patients were taking their medications, were eating properly, and making other lifestyle changes. And the regular follow-up ensured that corrective measures were taken quickly if a patient began to deteriorate.
I have a good doctor and we're good friends. And we both laugh when we look at the system. He sends me off to see somebody to get some tests at the other end of town. I go over there and then come back, and they send the reports to him and he looks at them and sends me off some place else for some tests and they come back. Then he says that I had better see a specialist. And before I'm finished I've spent, within a month, six days going to six different people and another six days going to have six different kinds of tests, all of which I could have had in a single clinic.
Now the waits are longer because there are more specialties, more tests available, and because modern practices won't allow patients into hospital just to have all their tests and consultations at once.37 All these reasons demonstrate the urgent need to swiftly shift to the second stage of Medicare. If we don't do a better job preventing the preventable, the system will collapse from the strain — and many Canadians will suffer needlessly in the process.
Are we providing the safest, most suitable care? Are we investing enough in prevention? Are we reducing inequalities in health? The answer to these questions is no, not yet. But we could. It is the Council's belief that we already have strong evidence and enough experience to pursue a quality agenda.
Over the last fifteen years, reports from many countries on hospital complications have spurred interest in the quality of care.39 A 2004 Canadian study showed similar results to those in other countries. One Canadian in fourteen suffers a complication while in hospital, and over one-third of these could be prevented.40 Somewhere between 9,000 and 24,000 Canadians die annually from preventable complications of their hospital care. That's 5 to 10 percent of all deaths.
Of course, this isn't the fault of any one professional, one profession, or one organization. Most countries face similar problems, although some do better and some do worse. Many jurisdictions have developed quality initiatives. There are health quality councils in Saskatchewan, Alberta, and Ontario. Each of these councils, as well as others in other countries, have developed principles for health system renewal.42,43, 44,45 Their work was used as the basis for the list of principles for the second stage of Medicare (See Box). The principles are divided into essential ones, which are what we want and the instrumental ones, which help us get there. This paper addresses the essential principles. Other speakers at that the meeting dealt with instrumental ones.
Population Health Focus: There should be a determined effort to continuously improve the overall health of the population.
Equitable: There should be continuing efforts to reduce disparities in the health of those groups who may be disadvantaged by social or economic status, age, gender, ethnicity, geography, or language.
Client-Centred: Client-centred care respects individuality, ethnicity, dignity, privacy, and information needs of each clients and the client's family. That respect should pervade the health system. Clients should be in control of their own care.
Effective: The best science and evidence should be used to ensure care is the best, most appropriate possible. Innovations should also be based on best evidence, whether they are new ways of coordinating care, preventing disease, delivering service, or using technology.
Accessible: Clients in need should get timely care in the most appropriate setting. The system should continuously reduce waits and delays.
Safe: People should not be harmed by the care that is intended to help them. The system should monitor and continuously reduce adverse events.
Efficient: There should be continuing efforts to reduce waste, including waste of supplies, equipment, time, ideas, and health information.
Accountable: The system should be highly accountable to clients, their families, and funders. There should be clear quality objectives for all health service providers. The objectives and funding should be aligned at the provincial, regional, and local levels to ensure clients and families experience fully integrated care.
Appropriately Resourced: The health system should plan for appropriately trained human resources; provide a safe and satisfying environment for their work and provide sufficient facilities, instruments, and technology to support productive and effective care.
Non-Profit Delivery: Health care is fundamentally different from commercial good and services. Markets simply are not designed to deal effectively with health care, which is a social function. Health care providers provide the best care when they work in teams, not as competitors.
What Would the Second Stage of Medicare Look Like?
What's wrong with our current approach?
Our current approach to health care and health policy is based upon treating illness after it occurs. We miss opportunities for prevention. Implementing the second stage of Medicare could avert thousands of premature deaths a year and the suffering of tens of thousands of others.
Why do we have this problem?
Our health system was largely designed to treat acute illness. Federal legislation only requires the provinces to cover hospitals' and physicians' services. Our system offers increasingly expensive treatments, but our major health problems continue to be chronic diseases, which cannot be cured but often can be prevented.
Most health problems are related to social, environmental, occupational, economic, and other factors. Governments tend to deal with these health determinants in an uncoordinated fashion. Our country has little in the way of planning for health or social goals as compared with economic ones. If the health system is going to help make Canada a healthier place, it will need to work with other sectors on the non-medical determinants of our health.
Saskatchewan developed the Human Services Integration Forum to coordinate health and social planning across government departments. It is led by a Steering Committee, with senior officials representing seven provincial government departments and the Cabinet Office.
Then provinces need to help health regions work with other sectors at regional and local levels. For example, Saskatchewan's Human Services Integration Forum integrates its work with ten Regional Inter-sectoral Committees (RICs). The committees include representatives from various provincial and federal government departments, municipalities, regional health authorities, housing authorities, educational institutions, tribal councils, police, and Métis organizations.
We need to ensure that we are continuously monitoring and reducing disparities in health and health care. Given that disparities in health arise from a complicated interplay of factors, most of which are not under the control of the health care system, we need to clarify what the system can do itself and where it needs to recruit help.
The Saskatoon Health Region has identified significant disparities in health and health care access within its catchment area.56 For example, there are sixteen times as many suicide attempts in the poorest neighbourhoods than in the wealthiest, but only twice as many physician visits for mental health problems.
We need to involve clients in all aspects of their care and in health services planning. We need to ensure that we build in sensitivity and tolerance to Canada's growing ethnic, racial, and religious diversity as we re-design our health system.
During the 1990s, the London Intercommunity Health Centre developed a highly effective program to deal with diabetes in London's large Latin American population.67 The centre has found that most of the time, when a client's diabetes is out of control, it's due to non-medical factors. So they have a social worker and two community health workers who are part of their team. They help their clients deal with a myriad of problems, from illiteracy to landlord tenant problems.
The evidence doesn't get to where it needs to go. The doctor doesn't have the information at the bedside. The nurse doesn't have it at the client's home.
The health providers know the evidence, but there is a system barrier that prevents them from using it. Family doctors know they should be doing a better job with chronic disease; but few family doctors work with other professionals like nurses, therapists, and others, and fewer have electronic health records.
Canada has fewer doctors per population than almost any other wealthy country, and we are at the low end for hospital beds and diagnostic equipment.73 However, health systems with fewer resources than ours can run smoothly with few waits and delays. One of the big problems in primary health care is the lack of inter-disciplinary care compared with other jurisdictions. Doctors are seeing a lot of patients who would be better off seeing other professionals or managing their own care.
One of the reasons many Canadians face long waits for specialist visits is that the main format hasn't changed in over a hundred years. In most of Canada, specialists schedule their clients for one-hour appointments, after the family doctor has made the referral. But sometimes the visit could have been replaced by a five-minute phone call between the family doctor and the specialist. In other cases, the client and family might need a half-day assessment from a multi-disciplinary specialist team.
We need to focus on clients' needs and use some queuing techniques to ensure timely access. Toronto's Access Alliance Community Health Centre74 improved the access to its maternal child programs for new immigrants and refugees by literally taking services to clients. The centre works closely with settlement agencies to identify the Toronto neighbourhoods into which new immigrants and refugees are moving. Then Access Alliance uses existing community ethno-cultural networks to recruit and hire peer outreach workers. The outreach workers and staff from the CHC deliver up to twenty education programs, including six on parenting. They also facilitate well child and women clinics conducted by the CHC's nurse practitioners and dietitians in community settings.
And we could get needed specialty care quickly, as well. In Hamilton, the HSO Mental Health Program integrates 145 family doctors, 17 psychiatrists, 80 counsellors who are based with the family doctors (most of whom are social workers), and over 300,000 clients.77,78 As a result of the program, 1,100 percent more clients have been seen with mental health problems in primary health care, while referrals to the psychiatry specialty clinic have simultaneously dropped by 70 percent. All clients are given standardized assessments, and the program has documented improvements in depression scores, as well as general health and functioning.
Finally, we could get faster access to elective surgery. For example, the Alberta Bone and Joint Institute Pilot Project79 reduced wait times for artificial joints from nineteen months to less than eleven weeks, all the way from family doctor referral right through to surgery.
When you put it all together, we shouldn't have to spend a lot more money in Canada to get some day access to primary health care, routine specialty care within one week, and elective surgery in a month.
The lack of electronic information systems is a key risk factor for clients. To quote the US Institute of Medicine, "In a safe system, clients need to tell care-givers something once." One of the major complaints by Canadian clients is that they repeatedly have to tell the same stories to many different providers. And if clients are incapable of giving this information, the care team won't have it. This risky situation becomes even more dangerous when a client moves from one health care setting to another, for example, from the operating room to the intensive care unit, or from hospital to home.
We need to ensure that we are using effective services and that there are safeguards in place when things do go wrong. Information systems are a key facilitator for safety. Dr. David Chan and other McMaster University colleagues developed OSCAR, Open Source Clinical Application Resource, an open-source, electronic health record.84,85 Dr. Chan has recently assisted a group of Toronto agencies that deal with the homeless establish an integrated record which will be available online to whatever provider requires the information.
The Client Access to Integrated Services and Information (CAISI) Project aims to reduce the risks of chronic homelessness by enhancing the integration of care between agencies at the individual and population levels, using an electronic information system.86 Providers will not have to search through paper charts or telephone a dozen other agencies to get key information and keep their clients safe.
The Second Stage of Medicare is Coming, But Can We Wait?
But, while there have been many improvements in Medicare, the pace is slow and our public discourse is plagued by the endless debate about privatization. The media have a strong bias against "good news," so they provide almost no coverage of second stage reforms. Google records 300 times as many "hits" for Vancouver orthopedic surgeon Dr. Brian Day than for the Alberta Bone and Joint Institute. Dr. Day offers quicker artificial joint implants for cash on the barrel. But he would have no customers if the Alberta Institute's pilot project were spread across the country.
1C. Schoen, R. Osborn, P,T. Huynh, et al., "Taking the Pulse of Health Care Systems: Experiences with Health Problems in Six Countries," Health Affairs 10 (2005):w5–509–w5–525.
2C.H. Houston, Steps on the Road to Medicare (McGill-Queen's Press: Montreal, 2002).
3M. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions that created the Canadian Health Insurance System (McGill Queens Press: Montreal, 1978), 244; C.D. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance (McGill-Queens University Press: Kingston and Montréal, 1986), 138–9.
4For more details on the Swift Current Region see: http://scaa.usask.ca/gallery/medicare/en_swift-current.php. Accessed 10 April 2007; and also see: Houston, Steps on the Road to Medicare, 77–88.
5M. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions that created the Canadian Health Insurance System (McGill-Queen's Press: Montreal, 1978), 251–2; and Houston, Steps on the Road to Medicare, 85.
6Houston, Steps on the Road to Medicare, 85.
7A.D. Kelly, "The Swift Current Experiment," Canadian Medical Association Journal 58 (1948): 506–11.
8Taylor, Health Insurance and Canadian Public Policy, 252; Naylor, Private Practice, Public Payment, 191.
9Taylor, Health Insurance and Canadian Public Policy, 252; Naylor, Private Practice, Public Payment,178–9, 191.
10This section draws from Taylor, Health Insurance and Canadian Public Policy, 239–330; Naylor, Private Practice, Public Payment, 176–213.
11See: http://www.saskatooncommunityclinic.ca/. Accessed 15 June 2007.
12See: http://www.ghc.on.ca/home.html. Accessed 15 June 2007.
13D. Murray, "The Group Health Centre Model – working to improve continuity, comprehensiveness and responsiveness in primary care," presentation to the Research Group on Equity of Access and Organization on Primary Health Care Services. Found at: http://www.greas.ca/publication/pdf/davidmurray.pdf. Accessed 2 November 2006.
14For example, Group Health was given an award for innovation at the Ontario Ministry of Health and Long-term Care's Expo 2007. See: http://www.ghc.on.ca/news/news.html?ID=59. Accessed 20 June 2007.
15. J.E.F. Hastings, F.D. Mott, A. Barclay, D. Hewitt, "Prepaid group practice in Sault Ste. Marie, Ontario: Part I: Analysis of utilization records," Medical Care 11 (1973): 91–103.
16. F.D. Mott, J.E.F. Hastings, and A. Barclay, "Prepaid group practice in Sault Ste. Marie, Ontario. Part II: Evidence from the household survey," Medical Care 11 (1973): 173–88.
17. G.H. DeFriese, "On paying the fiddler to change the tune: Further evidence from Ontario regarding the impact of universal health insurance on the organization and patterns of medical practice," Millbank Memorial Fund Quarterly 53, no. 2 (1975): 117–48.
18. W.G. Manning, A. Leibowitz, G.A. Goldberg, W.H. Rogers, and J.P. Newhouse, "A controlled trial of the effect of a prepaid group practice on the use of services," New England Journal of Medicine 310 (1984): 1505–10.
19. J.E. Ware, W.H. Rogers, A.R. Davies AR, et al., "Comparison of health outcomes at a health maintenance organization with those of fee-for-service care," Lancet i (1986): 1017–22.
20Organisation for Economic Cooperation and Development, "Frequently requested health statistics 2006," found at: http://www.oecd.org/dataoecd/20/51/37622205.xls. Accessed 21 June 2007.
21S. Woolhandler, T. Campbell, and D.U. Himmelstein, "Costs of health care administration in the United States and Canada," New England Journal of Medicine 349 (2003): 768–75.
22US Institute of Medicine, "Health insurance is a family matter" (18 September 2002), http://www.nap.edu/catalog/10503.html?onpi_newsdoc09182002 (accessed November 17, 2003).
23A. Wordsworth, "Medical bills main culprit in bankruptcies: US study," National Post (27 April 2000).
24B. Purchase, "Health care and competitiveness," background paper for the National Health Policy Summit (Ottawa, 1996).
25T.C. Douglas, "We must go forward," in Medicare The Decisive Year, ed. Lee Soderstrom (Canadian Centre for Policy Alternatives: Ottawa, 1984).
26H. Gilmour and J. Park, "Dependency, chronic conditions, and pain in seniors," Health Reports supplement1 (2005): 21–31. Found at: http://www.statcan.ca/english/freepub/82-003-SIE/2005000/pdf/82-003-SIE20050007443.pdf. Accessed 2 November 2006.
27There is no recent comprehensive study of the cost of chronic disease in Canada but a recent study in Nova Scotia concluded that 60 percent of the province's health care costs were for chronic diseases. R. Colman, K. Hayward, A. Monette, et al., "The cost of chronic disease in Nova Scotia. GPI Atlantic." Found at: http://gov.ns.ca/health/downloads/chronic.pdf. Accessed 2 October 2006.
In 2004, the US Centers for Disease Control concluded that persons with chronic conditions consumed 75 percent of the costs of the system: http://www.cdc.gov/nccdphp/burdenbook2004/. The higher figures could be due to some of the persons with chronic conditions developing unrelated acute problems while the lower figure may be related to the exclusion of acute problems (such as falls in the elderly), which are often related to chronic problems.
28C. Schoen, R. Osborn, P.T. Huynh, et al., "On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries," Health Affairs 11 (2006): w555–w571. Found at: http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w555/DC1. Accessed 2 November 2006.
29M.J. Stampfer, F.B. Hu, J.E. Manson, et al., "Primary prevention of coronary heart disease in women through diet and lifestyle," New England Journal of Medicine 343 (2000): 16–22.
30F.B. Hu, J.E. Manson, M.J. Stampfer, et al., "Diet, lifestyle, and the risk of type 2 diabetes mellitus in women," New England Journal of Medicine 345 (2001): 790–7.
31R. Doll, R. Peto, K. Wheatley, et al., "Mortality in relation to smoking: 40 years' observations on male British doctors," British Medical Journal 309 (1994): 901–11.
32From tabulations constructed from data from the Canadian Institute for Health Information. Found at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=statistics_results_topic_hospital_e&cw_topic=Health percent20Services&cw_subtopic=Hospital percent20Discharges. Accessed 10 November 2006. These conditions were responsible for 950,000 hospital days or roughly 2870 hospital beds (at 90 percent capacity).
33The 2001 Saskatchewan Royal Commission on Medicare chaired by long-time health administrator Ken Fyke noted: "Many attribute the quality problems to a lack of money. Evidence and analysis have convincingly refuted this claim. In health care, good quality often costs considerably less than poor quality." K.J. Fyke, "Caring for Medicare: sustaining a quality system," report of the Saskatchewan Commission on Medicare (Regina: The Commission, 2001).
34R. T. Tsuyuki, M. Fradette, J.A. Johnson, et al., "A multicenter disease management program for hospitalized patients with heart failure," Journal of Cardiac Failure 10 (2004): 473–80.
35C. Schoen, R. Osborn, P.T. Huynh, et al., "Taking the pulse of health care systems: Experiences with health problems in six countries," Health Affairs 10 (2005): w5–509–w5–525.
36Quote from speech by T.C. Douglas entitled "We Must Go Forward" in transcript of Canadian Centre for Policy Alternatives Conference proceedings entitled "Medicare: The Decisive Year" held on 12-13 November 1982 in Montreal. Copies of the 1982 conference proceedings may be obtained from the Canadian Centre of Policy Alternatives or the Canadian Health Coalition.
37For one thing, it's pretty dangerous to be in hospital if you don't really need to be there.
38Found at: http://www.healthcouncilcanada.ca/en/index.php?option=com_content&task=view&id=70&Itemid=72. Accessed 9 April 2007.
39For examples, see the US Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academy Press, 2001).
40G.R. Baker, P, G. Norton, V. Flinthoft, et al., "The Canadian Adverse Events Study," Canadian Medical Association Journal 170 (2004): 1678–86.
41C. H. Rojas-Fernandez, D. Carver, and R. Tonks, "Population trends in the prevalence of benzodiazepine use in the older population of Nova Scotia: A cause for concern?" Canadian Journal of Clinical Pharmacology 6, no. 3 (1999): 149–56. See also, "Therapeutics Initiative. Use of Benzodiazepines in BC. Is it consistent with the recommendations?" found at: http://www.ti.ubc.ca/PDF/54.pdf. Accessed 21 June 2007; and K. Tu, M. Mamdani, J. Hux, and J. Tu, "Progressive Trends in the Prevalence of Benzodiazepine Prescribing in Older People in Ontario, Canada," Journal of the American Geriatric Society 49 no. 10 (October, 2001): 1341–5.
42"Accessible, safe, client-centred, timely, efficient, and equitable," from the Saskatchewan Health Quality Council Annual Report 2004/2005 (Regina, 2005). Found at: http://www.hqc.sk.ca/download.jsp?DB3G1GthpqzpLvJEazdYnX8xfpeDzqbvqhr5yD/Ts9e8cXBjtGTIzA==. Accessed 24 July 2006.
43"Acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety," from the Alberta Quality Matrix for Health (Alberta Health Quality Council). Found at: http://www.hqca.ca/index.php?id=87. Accessed 11 April 2007.
44Ontario Health Quality Council 2006 Annual Report (Toronto, 2006). Found at: http://www.ohqc.ca/pdfs/ohqc_report_2006en.pdf. Accessed 6 June 2006.
45US Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academy Press, 2001).
duquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/S_2_2/S2_2_A.html (accessed 26 September 2003); National Institute of Public Health Act http://publi cationsduquebec.gouv.qc.ca/dynamicSearch/telecharge.php?type=2&file=/I_13_1_1/I13_1_1_A.html (accessed 26 September 2003).
47See Pathways to Education: http://pathwaystoeducation.ca/home-executive.html. Accessed 12 April 2007.
48Health Disparities Task Group of the Federal Provincial Territorial Advisory Committee on Population Health and Health Security, "Health Disparities: Roles of the Health Sector" (2004). Found at: http://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf. Accessed 23 September 2006.
51"A population health strategy focuses on factors that enhance the health and well-being of the overall population. It views health as an asset that is a resource for everyday living, not simply the absence of disease. Population health concerns itself with the living and working conditions that enable and support people in making healthy choices, and the services that promote and maintain health," from Federal Provincial Territorial Advisory Committee on Population Health, "Strategies for Population Health: Investing in the Health of Canadians" (1994).
52M. Lalonde, "A New Perspective on the Health of Canadians" (Ministry of Supply and Services,1974). Found at: http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/perspective.pdf. Accessed 4 November 2005.
53J. Epp, "Achieving Health for All: A Framework for Health Promotion," released at First International conference on Health Promotion (Ottawa, 1986). Found at: http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2001-frame-plan-promotion/index_e.html. Accessed 7 September 2006.
54B. Zimmerman and S. Globerman, (2004) "Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?," in Health Care Services and the Process of Change, ed. P.-G. Forest, T. McIntosh, and G. Marchildon (Toronto: University of Toronto Press), 21–53.
55Health Disparities Task Group of the Federal Provincial Territorial Advisory Committee on Population Health and Health Security, "Health Disparities: Roles of the Health Sector" (2004). Found at: http://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf. Accessed 23 September 2006.
56M. Lemura, C. Neudorf, and J. Opondo, "Health disparities by neighbourhood income," Canadian Journal of Public Health 97 (2006): 435–9.
57See: http://www.saskatoonhealthregion.ca/news_you_need/media_centre/media/2006/news_091106.htm. Accessed 11 April 2007.
58Saskatchewan Hansard, 19 March 2007. Found at: http://www.legassembly.sk.ca/committees/HumanServices/Verbatim/070319HU.pdf. Accessed 11 April 2007.
59W. Langewitz, M. Denz, A. Keller, et al., "Spontaneous taking time at start of consultation in outclient clinic: cohort study," British Medical Journal 325 (2002): 682–3.
60H. B. Beckman, and R. M. Frankel, "The effect of physician behavior on the collection of data," Annals of Internal Medicine 101 (1984): 692–6.
61M.K. Marvel, R.M. Epstein, K. Flowers, et al., "Soliciting the client's agenda: have we improved?," Journal of the American Medical Association 281 (1999): 283–7.
62C.H. Braddock, K.A. Edwards, N.M. Hasenberg, et al., "Informed decision making in outpatient practice: times to get back to basics," Journal of the American Medical Association 282 (1999): 2313–20.
63J. Oxman-Martinez and J. Hanley, "Health and services for Canada's multicultural population: challenges to equity," Canada Citizenship and Immigration, in "Serving Canada's multicultural population for the future," discussion papers (2005). Found at: http://www.pch.gc.ca/multi/canada2017/PDFs/document_e.pdf. Accessed 20 November 2006.
64J. M. Anderson, "Ethnicity and illness experience: Ideological structures and the health care delivery system," Social Science & Medicine 22 (1986): 1277–83.
66C. Schoen, R. Osborn, P.T. Huynh , et al., "On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries," Health Affairs 11 (2006): w555–w571. Found at: http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w555/DC1. Accessed 2 November 2006.
67See the website for the London Intercommunity Health Centre: http://www.lihc.on.ca/; or the Latin American Diabetes Program: http://www.pldiabetes.com/.
68B. Harvey, "The diabetes epidemic from a CHC perspective," presentation to the annual meeting of the Association of Ontario Health Centres (Kingston, 5 June 2006).
69R.S.A. Hayward, G.H. Guyatt, K.-A. Moore, et al, "Canadian Physicians' attitudes about and preferences regarding clinical practice guidelines," Canadian Medical Association Journal 156 (1997): 1715–23.
70B. Hutchison, C.A. Woodward, and G.R. Norman, et al., "Provision of preventive care to unannounced standardized clients," Canadian Medical Association Journal 158 (1998): 185–93.
71Ontario Health Quality Council First Annual Report (Toronto, April 2006).
72Schoen, Osborn, Huynh, et al., "Taking the pulse of health care systems," w5–509–w5–525.
73Organization for Economic Cooperation and Development, "Health data set" (10 October 2006). Found at: http://www.oecd.org/dataoecd/20/51/37622205.xls. Accessed 25 April 2007.
74Ontario Health Quality Council 2007 Report (Toronto, 2007), 42. Also see: http://www.accessalliance.ca/ .
75M.M. Rachlis, "Public Solutions to Health Care Wait Lists" (Canadian Centre for Policy Alternatives: Ottawa, January 2006). Found at: http://policyalternatives.ca/documents/National_Office_Pubs/2005/Health_Care_Waitlists.pdf. Accessed 12 January 2006.
76For more details see the Health Quality Council's website: www.hqc.sk.ca.
77N. Kates, A.-M. Crustolo, S. Farrar, et al., "Mental health and nutrition: integrating specialists' services into primary care," Canadian Family Physician 48 (2002):1898–1903.
78N. Kates, "Managing chronic mental health problems in primary care," presentation to Ministry of Health and Long-Term Care Expo" (Toronto, 19 April 2006).
79Alberta hip and knee replacement project: Interim results (Alberta Bone and Joint Institute, December 2005). Found at: http://www.albertaboneandjoint.com/PDFs/Int_Rep_Dec_19_05.pdf. Accessed 20 December 2005.
80C.M. Hohl, J. Dankoff, A. Colacone, et al., "Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly clients presenting to an emergency department," Annals of Emergency Medicine 38 (2001): 666–71.
81R.M. Tamblyn, P.J. McLeod, M. Abrahamowicz, et al., "Questionable prescribing for elderly clients in Quebec," Canadian Medical Association Journal 150 (1994): 1801–9.
82US Institute of Medicine, To Err is Human: Building a Safer Health Care System, eds. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson (Washington, DC: National Academy Press, 2000).
84See, www.oscarmcmaster.ca for more details.
85D. Chan, "Free/Libra Open Source Software (FLOSS) in Health Care: showcase of OSCAR, a Canadian product," presentation (12 November 2006).
86See: http://www.caisi.ca/wiki/index.php/Main_Page. Accessed 15 December 2006.


I am reading Jules Verne again: last time I was too young and got overwhelmed with his long descriptions and the usage of incredibly exotic units (I was raised as a metric-system mind).
It is a true pleasure to rediscover this author, both in his famous books and in the less known ones. I do not consider Jules Verne as a visionary: he has not foreseen anything like the heavier-than-air vehicles or the usage of oil as a source of energy. He is not such a scientist as well: you can see that he hardly explains what system allows the space travelers to survive the enormous acceleration of the bullet that carries them to the Moon.
But he is very well informed on the state of science and technologies of his time, and extremely good at imagining what could be the most advanced versions of what he was seeing around him. For me, he is more an extrapolative mind than a prophetic one!
But there are of course some interesting coincidences, like the fact that he estimated a lift-off to the Moon would happen either in Texas or Florida, when actually it was from Florida controlled from Texas!
Globally, it is a rejuvenating experience to read his books: his faith in science and engineering, his depiction of righteous men, his fascination for nature are communicative: it makes the grey and gloomy days of winter a little brighter and hopeful.
Moreover his true admiration for the United States, which he considers the land of bold endeavors and true democracy, is also refreshing, because full of genuine tenderness. Can Jules Verne help rediscovering America?
Posted by Unknown at 9:51 a.m.


text:
Sean Lyden
Senior Fleet Advisor
Sean Lyden (www.seanlyden.com) is senior fleet advisor with Nimnicht Commercial Fleet Center in Jacksonville, Fla.
Written by Sean Lyden
The Latest Developments in Hybrid-Electric Medium-Duty Trucks
New developments, technologies, and trends in hybrid-electric, medium-duty trucks could give fleet managers the incentive they need to take a closer look at how hybrid options could help reduce overall costs.
The Latest Trends in Medium-Duty Truck Maintenance
A lot has happened since 2007 to impact medium-duty truck maintenance costs and protocols — for better and for worse.
MPG for Mediums
When we're talking about on-highway trucks, there are opportunities in aerodynamics, low-rolling-resistance tires, "downspeeding" and other strategies to save fuel. But when you're talking delivery trucks, work trucks, vans and the like, the strategies are different. Below are four approaches to improving mpg for mediums.
The test truck was the International TranStar in the new nomenclature - 8600 in the past. But the other new badges, high on the side of the hood, told the story: MaxxForce. This tractor was one of the International validation units for the new big-bore engines, destined for a high-mileage fleet to get fast results before the engine becomes commercially available around mid-year.
Peterbilt's 387 Hybrid
The C15 was very responsive, showed great throttle modulation and made gearshifting a joy. And at the event, the 387 it powered also gave pause. I hadn't driven one in several years and the new dash appealed enormously.


I've created design using Upfront and Fixer theme at my localhost. I was wondering is it possible to export content from that localhost site to my live site? Regular WP export doesn't work.
How to export Upfront theme content?
The theme and its setting will not, furthermore - copying the theme's folder via FTP won't work either.
2. You may want to give our Snapshot plugin a try. Setting this up on both sites should allow you to take a full backup of the original site and then upload it to a target site and deploy, however there might be some minor tweaks (most likely CSS etc) needed afterwards.
Having said all this, I'm moving this thread to our "Features and Feedback" forum. I agree that the "export/import" option for Upfront's settings/layouts would be great so hopefully enough members of our community will support this idea to encourage our developers to include it in one of the future releases!


Why our Wedding Car Hire Shooters Hill Services?
Why our Wedding Car Hire Shooters Hill Services are so special?
With us, you will get a well-uniformed and knowledgeable chauffeur. Our chauffeurs will reach the pickup location before time, to avoid delays. Our Shooters Hill wedding car hire service is ideally the first choice of Shooters Hill Bride and Groom. The Shooters Hill Couples not only love our service but they are highly fond of that how we make their wedding day so memorable and cheerful.


Gangga Express Fast Boat serves sea transfer from Nusa Penida to Bali and return. Gangga Express use Tribuana Port ( Kusamba ) as their transfer port in Bali. Beside serves sea transfers from Bali to Nusa Penida, Gangga Express also provide a boat charter. As known by the public, to cross from Nusa Penida to Kusamba (Tribuana port) is quite difficult due to the waves of Kusamba are quite large so that the boat is tossed around. So, we provide a security alert for our crossing to give a comfortable and safe trip for our customer. We also provide a pontoon to lean and balance a boat from the brunt of the waves when lowering passengers. The Pontoon is connected to the coastal mainland so passengers don't need to jump into the water when going down to the coast of Tribuana. We have more than 40 staff, with experience working in the sea for many years.
Gangga Express 2 uses a Suzuki engine 4 x 175hp (a total of 700 hp) Gangga Express 2 can take you to your destination within 20 minutes.
Gangga Express 3 uses a Suzuki engine 3 x 250hp (total 750hp) Gangga Express 3 can take you to your destination within 20 minutes.
Gangga Express 4 uses a Suzuki engine 4 x 250hp (a total of 1000hp). Gangga Express 4 can take you to your destination within 20 minutes.


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Stan Getz - Getz At The Gate [3LP] (previously unreleased 1961 live recording) (Vinyl)
''Getz At The Gate'' is a previously unreleased 1961 live recording from the historic Village Gate in New York City. This release features an all-star, rarely heard quartet with pianist Steve Kuhn, bassist John Neves and drummer Roy Haynes (aka 'The Boston Band'). Includes extensive liner notes by Boston jazz historian Bob Blumenthal.
1.Announcement by Art D'Lugoff / live recorded Nov. 1961, 1.It's You Or No One / live, recorded Nov. 1961, 1.Like Someone In Love / live, recorded Nov. 1961, 2.It's All Right With Me / live, recorded Nov. 1961, 2.Spring Can Really HangYou Up The Most / live, recorded Nov. 1961, 2.Woody 'N' You / live, recorded Nov. 1961, 3.Blues / live, recorded Nov. 1961, 3.Wildwood / live, recorded Nov. 1961 4.When The Sun Comes Out / live, recorded Nov. 1961, 1.52nd Street Theme / live, recorded Nov. 1961, 1.Impressions / live, recorded Nov. 1961, 1.Where Do You Go / live, recorded Nov. 1961, 2.Airegin / live, recorded Nov. 1961, 2.Jumpin' With Symphony Sid / live, recorded Nov. 1961, 2.Yesterday's Gardenias / live, recorded Nov. 1961, 3.Stella by Starlight / live, recorded Nov. 1961


We are excited to start selling maizopes at the lovely Mt. Pleasant Farmers Market. Visit us every Saturday starting April 30th, from 9 am to 1 pm. We can't wait to meet you! Our menu for this weekend is: Brisket Tinga, Almond Mole with Chicken, Rajas & Mushrooms.


Stilled houses line the shore of Tai O fishing village on Lantau Island Hong Kong China.
Tai O fishing village located on Lantau Island, Hong Kong.
Tai O harbour Lantau Island Hong Kong China.
Street shops in the fishing village of Tai O on Lantau Island, Hong Kong, China, Asia.
Tai O fishing village, Lantau Island, Hong Kong, China, Asia.
Tai O Village, Lantau Island, Hong Kong, China.
Tai O village man drying shrimp in the hot sun.
An ethnic stone exhibit at the fishing village of Tai O on Lantau Island, Hong Kong, China, Asia.
Pink Ladies bicycle outside premises at Tai O fishing village, Lantau Island, Hong Kong, China.
Fishing nets in Tai O Village, Lantau Island, Hong Kong, China.
Souvenir shop in Tai O fishing village, Lantau island, Hong Kong S.A.R.
Hong Kong - April 10, 2011: Houses on stilts above the tidal flats of Lantau Island are homes to the Tanka people in Tai O.
Street food in the fishing village of Tai O on Lantau Island, Hong Kong, China, Asia.
Tai O fishing village, Lantau Island, Hong Kong, China, Asia - view of very old traditional house.
Local seafood cuisine in Tai O Village, Lantau Island, Hong Kong, China.
Old rusted house in Tai O fishing village, Lantau island, Hong Kong S.A.R.
Tai O harbor looking east towards the South China Sea.
Jars of locally produced shrimp paste at the traditional fishing village of Tai O on Lantau Island Hong Kong.