Sean Paul is a well-known rapper from Jamaica who is also a songwriter and singer. In 2000, he released his debut studio album entitled 'Stage One'. Paul has successfully released 6 studio albums and 24 singles. Additionally, he has also released 1 mixtape and 1 compilation album. Now let's have a close look at Sean Paul's net worth in 2019.
Sean Paul Ryan Francis Henriques was born on 9 January 1973, in Kingston, Jamaica to his parents Frances Henriques and Garth Henriques.
He went to Wolmer's Boys' School and was a part of the Jamaican water polo team from 13 till 21. He later went to Hill Academy High School. After his school, Paul attended the University of Technology (formerly known as College of Arts, Science, and Technology). Initially, he wanted to do hotel management and did training in commerce.
Sean Paul was raised as a Catholic, and many of his extended family members are swimmers. He was interested in music from a young age, and also possessed a good athletic and academic record.
In 2012, Sean Paul got married to Jamaican television host Jodi Stewart, after dating each other for a long time. The couple welcomed their first child named Levi Blaze in February 2017.
In March 2000, Sean Paul released his first album called 'Stage One'. In September 2002, he released his second studio album 'Dutty Rock'. It went on to become a multi-platinum certified album and peaked at No. 1 on the U.S Rap charts.
His third studio album called 'The Trinity' got released in September 2005. This too became a commercial success. This was followed by 'Imperial Blaze' in 2009. In January 2012, he released the album 'Tomahawk Technique'. His last studio album called 'Full Frequency' was released in February 2014.
Sean Paul released the compilation album 'Dutty Classics Collection' in June 2017. He has also released the mixtape entitled 'The Odyssey Mixtape' in December 2009.
Some of the popular singles released by Sean Paul includes "Get Busy", "Like Glue", "We Be Burnin'", "Ever Blazin'", "Temperature", "Never Gonna Be the Same", "So Fine", "Got 2 Luv U", "She Doesn't Mind", "Other Side of Love", and "No Lie".
He is planning to release his seventh studio album and has already released singles from the album including "Body" and "Crick Neck".
In 2004, Sean Paul won the Grammy Award for Best Reggae Album. In 2017, he was nominated in three categories at the Brit Awards. He has won four MOBO Awards and has won the 2006 American Music Awards. He has won the Soul Train Award in 2009 and is also the winner of the Source Awards in 2003. Other awards won by Sean Paul include MTV Music Awards, MuchMusic Video Awards, and MTV Romania Music Awards.
Sean Paul has an estimated net worth of more than $14 million. He made this fortune from the sale of his albums. Sean Paul has successfully released many singles and albums in his career, and two of his albums have certified multi-platinum. He is the most successful artist from Jamaica in the US charts. His singles have also peaked inside the top ten in many countries including Austria, France, and Canada. Paul had also appeared in the film 'Belly' in 1998.
Sean Paul is considered one of the most popular rappers in the world. He found considerable success after the release of his album 'Dutty Rock'. The album shaped his career and made him a popular reggae star. He is also a dancehall who rose to prominence after releasing his albums. He was born into an athletic family, and he is a good swimmer.


Enter the Kentucky Exposition Center (KEC) through Gate 6 on Preston Highway located between Thorntons Gas station and Sleep Inn 3320 Preston Highway, Louisville, KY 40209. Proceed to where the road comes an intersection and you will see the event site. We will only have 100 free parking passes. Once their gone you will have to pay for parking to enter the site, so get there early. Karts are allowed at this site.
Karting participants must register through MotorsportReg.com so we know you are coming can make appropriate accommodations.
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"We do not have fruit"
The answer should be " hatuna tunda" because " tunda" is singular for fruit.
No, not really. In English, "fruit" is generally an uncountable noun. It's normally only used countably when it means "a kind of fruit" (eg. "yoghurt with three fruits" means three kinds of fruit) but most of the time we just say fruit. If we want to specify number, we say "piece of fruit", so we can think of tunda as "(a piece of) fruit" and matunda as "(pieces of) fruit". Just because something is singular in English doesn't mean it has to be in other languages and vice versa.
That being said, because "fruit" is ambiguous about the number of pieces of fruit and it doesn't really matter when it's negative anyway because if you don't have "a cat", you definitely also don't have "cats", it should probably accept tunda too, if that is something Swahili speakers feel is idiomatic and equivalent to the English.
very well explained and understood thank you!!


Three Its All Just Relative Or Is It?
Wilfrid J. Waluchow is a Professor in the Philosophy Department at McMaster University. His many other works include Inclusive Legal Positivism (Oxford University Press, 1997) and Well and Good: A Case Study Approach to Biomedical Ethics (Broadview Press, 3/e 1998).


Students will learn one of Abraham's servants was Hagar.
Students will learn In Bible times servants were much like slaves and had to do whatever their master asked of them.
Students will participate in an activity to show their appreciation for those whose job it is to serve them in various ways.
Guiding Question: How should we show our appreciation to those who have jobs like servers, flight attendants, nurses, maids and many others who do things for us but often go unnoticed and unappreciated?
Procedure: Review the story of Abraham, God's promises to him and Hagar and Ishmael. Explain to students that in Bible times servants were more like what we would call slaves. Although they were cared for and may have received some sort of wage, their employment opportunities were very limited. This meant they had to do whatever their employer required of them. It was not uncommon for a servant to be required to become the concubine of her master. (Note: Concubines were not mistresses, but rather secondary wives in this culture.) Sarai had Abraham take Hagar as his concubine so he could have a son. Tell students they will find out in another lesson, Hagar was not appreciated for giving birth to Ishmael and was treated rather badly. Ask students who today "serves" them in any way. They will probably come up with servers in a restaurant, but remind them of other service occupations like garbage collection, mail delivery, nursing, teaching, store clerks, etc. Ask them how they have seen these people be treated poorly or well by those they are serving. Have the students think of people who serve them who they may not have appreciated properly. Ask students to make them cards and put together a small goodie bag to give to these people the next time they see them. The goodie bags don't have to contain more than a couple of small items. The value is in the note and the very act of being appreciated for their work. Encourage students to deliver their notes and packets within the week. Have them come to class prepared to share what happened when they gave the notes and packets to people. Discuss how becoming more appreciative of others can reflect God's love and point others to Him.
What do customers do that irritates those who serve them the most?
Supplemental Activity: Have more advanced students interview people who are in various service type jobs. What do customers do that irritates them the most? How would they like to be treated by those they serve as they are doing their job? Have students share their findings with other and create a campaign to encourage others to treat those in service occupations with more respect and appreciation.


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Office Cupboards from York Railway Carriage Works.
Several other numbers are available. These are pine carcass and have been restored with new mahogany plinths and tops. 33" (84cm) wide, 17 ¾" (45 ½ cm) deep, 48 ¾" (124cm) tall. We have more of these available in different sizes and configurations.


Serious grilling can sometimes lead to the occasional oil slick. Preserve your expensive decks, balconies, and patio surfaces in style with our stain-resistant, rubberized grill pad. Made specifically to fit Traeger Residential Models, the large, 32 by 40 inch surface area provides superior protection against grease, drips, scuffs, stains and saucy spills.
Barbecue is not for the faint of heart. From sauce splashes to drips and drops, when it comes ot porch protection, it's better safe than sorry. Mark your grill's parking spot on the patio with a Traeger Grill Pad.


Although the actual scale of the issue is arguable, it's well established in the Project Management community that a very significant proportion of failed projects are due to poor requirements gathering in the early stages of defining project.
There are many approaches, and no magic solutions - but I'll outline one approach that we take, utilising a Mindmap to reduce the technobabble, and assisting the site builder and client to come to terms on a shared set of expectations.
We'll walk through using a small business website scenario to illustrate the process.
A very useful method to bridge the communication gap between business/management and design/techies.
An idea I will be more that happy to implement myself.


Pocket sized designed to fit into 'pockets'!
This style of Tinder pouch was becoming very popular in the late 18th to early 19th Century especially in countries like Tibet and they were elaborately decorated. Small stones and Tinder would be added into the pouch and carried around in the pockets. We've taken one of our most popular leather pouches, the 'Mini Pocket Pouch' and have added a Striker to the exterior of the Pouch . The Striker has actually been securely stitched into the seam of the pouch and is surprisingly easy to use. We've added in a few appropriate sized pieces of Norfolk Flint , some Amadou and some Jute Twine for the makings of a small Tindle Bundle. You can add your own pieces of tinder if you wish but we wanted it to reflect the time of that era by making it simple. Each of these Leather Mini Pocket Tinderboxes have been hand stitched, hand dyed to give them an aged rustic patina and some of our designs have been hand tooled to give them a slightly individual touch.
This high quality Pocket sized Pouch has been hand stitched, wet moulded, hand dyed and then hand tooled to give the pouch some authentic character. The whole idea is that it is pocket sized and tough!! Its just big enough to contain all your basic needs for a small Tinder Pouch. This little Mini Pouch has been handmade by us at Beaver Bushcraft and we have carefully let the texture of the leather show to add a little bit of character and patina.
The Pocket Tinderbox contains 12 Inches of Jute Tinder Cord that has been made from natural plant fibres, which are loosely twisted into a 3-yarn cord. It is the best jute that there is for traditional 'Flint & Steel' fire lighting. it is easy to carry a few of these cords in your tinderbox ready to make a Tinder Bundle without having to scavenge around for dried bulky grasses, plant downs and other materials to make your Tinder Bundle. It takes just one piece of Jute Tinder Cord to create a fire.
Untwist one piece of Jute Tinder Cord into its constituent fibres.
Fluff the fibres up and roll into a loose ball to make a small Tinder Bundle.
Place a glowing ember into the Jute Cord Tinder Bundle.
Gently wrap the fibres around the ember.
Wave the Tinder Bundle in the air, or gently blow on it until it starts to produce a thick greenish smoke.
Give it a few hard short puffs of air and it will burst into flames.
Place burning Tinder Bundle into a previously prepared Fire Lay and hey presto you have a nicely burning camp fire.
Amadou is made from the Horse's Hoof Fungus, which has a fine, velvety layer resembling suede leather. This suede-like trama layer is sandwiched between a tough nut-like, outer, layer called the Cuticle and the pores, which are thousands of tiny tubes all packed together. The Horse's Hoof Fungus is mainly found on dead trees such as the Birch and Beech, and it resembles a horse's hoof – hence its common name. Amadou is very hard to source, and even more difficult to make well.
Amadou was used by our ancient forefathers because it makes excellent tinder able to catch even the vaguest of sparks, it is probably one of the best tinder that can be found in nature. It is has a beautiful velvet feel and is as resilient as suede leather and can be stored indefinitely. Amadou has been used for fire-making for thousands of years, and would have been found in virtually every travellers tinder box because of its great reliability.
Once your Amadou has caught a spark, it will begin to glow and gently smoke. This newly formed ember is very hard to extinguish since it burns so INCREDIBLY HOT. Any wind or breeze that blows on it will cause it to get even hotter!
Once the ember has become established, to your satisfaction, you have more than ample time to place the Amadou ember into the centre of a previously prepared tinder bundle – and then blown into a flame. Whilst Amadou burns very hot it burns at a steady and slow pace; a small piece, about the size of your thumb nail will burn for a good minute or so.


SureTwist flat roofing nails for fixing 6mm plywood composite warm roof insulation boards such as Celotex or Kingspan. The helical configuration of the roofing nails provide maximum performance when fixing warm roof insulation boards. For insulation boards with SureTwist warm roof fixings you only need a hammer.


text:
Q: Limit of the absolute value of a general function Given the function $f: X \rightarrow \mathbb{R}$ with $\lim_{x\rightarrow a}f(x) = L$. Prove that $\lim_{x\rightarrow a}|f(x)| = |L|$.
$\forall \epsilon > 0 \exists\delta>0 s.t. 0<|x-a|< \delta \Rightarrow ||f(x)| - |L||\leq |f(x) - L| < \epsilon$.
I'm not really sure regarding this step
$$||f(x)| - |L||\leq |f(x) - L| < \epsilon$$
Is it correct?

A: you have it nearly correct. the inequality you need is (with $a=f(x)$ and $b=L$)
$$
||a|-|b|| \le |a-b|
$$
which holds in fact for any complex numbers $a,b$. it states that the minimum distance between two concentric circles is no greater that the distance separating any two points, one on each circle.

redpajama_set_name: RedPajamaStackExchange


Faraos Copenhagen Store Championship Dash and Miranda Write up.
Store Championship Preview, what will i expect Saturday July 29th.
What list will i bring to Faraos Store Championship Things has changed, Wave 11 is out. But i am still going to hold steadfast in a variation of my list from the last Store Championship. Where i managed to finish in top 6 of the day.
I was going to the Fanatic Store Championship in Star wars X-wing miniature game. With Dash and Miranda. And as i said to myself, a good succes would be to win a couple of games, and a great succes would be ending in top 8 to get those nice Range ruler for distance the Orange one.


This booklet is the 7th spouse quantity to 'An creation To utilizing GIS In Marine Biology'. it really is designed to reinforce the data on utilizing GIS in marine biology supplied in that ebook, and, certainly, for use along it instead of for use independently as a stand-alone quantity. accordingly, this e-book should be of so much curiosity to those that have already learn 'An advent To utilizing GIS In Marine Biology'.
This supplementary workbook comprises 5 workouts protecting the sensible use of GIS in marine biology. those routines objective to introduce marine biologists to utilizing QGIS (or Quantum GIS), a freely-available, open-source GIS software program package deal, and variety from creating a uncomplicated map of the destinations the place a species used to be recorded for inclusion in a e-book, or presentation to making grids of species presence-absence, richness and abundance, and grids of environmental variables. The routines are designed to be within the order they're offered, and paintings with a selected facts set which are downloaded individually for free.
Working via those 5 workouts may help the beginner GIS consumer receive event in operating with GIS and so advance their GIS abilities. not like such a lot different GIS tutorials, this knowledge is particularly provided in a marine organic context and the entire workouts use genuine info from a marine organic learn. for this reason, those routines usually tend to give you the type of adventure in utilizing GIS that marine biologists will locate necessary and appropriate to their very own research.
These workouts are provided within the related easy-to-follow stream diagram-based layout first brought within the 'How To...' portion of 'An creation To utilizing GIS In Marine Biology'. they're followed via photographs which convey the person how their GIS venture should still glance as they growth during the workouts, letting them evaluate their very own paintings to the predicted results.
This is a part of the PSLS sequence of books which use Task-Oriented studying (TOL) to coach the sensible program of analysis talents to the existence sciences. This consists of demonstrating how those talents can be utilized within the particular conditions within which they're more likely to be required instead of targeting instructing theoretical frameworks or on instructing abilities in a standard or summary demeanour. through seeing how the same techniques are used to accomplish numerous assorted targets inside of a selected box, it turns into more uncomplicated for the reader to spot the final ideas at the back of the sensible software of those strategies and, as a result, to move them to novel events they might stumble upon within the future.
2. the way to Use The QGIS 2.4.0 software program consumer Interface.
3. workout One: making a Map Of Species Distribution For A Publication.
4. workout : making a Presence-Absence Raster info Layer.
5. workout 3: making a Species Richness Raster information Layer From Survey Data.
6. workout 4: making a Polygon Grid Sata Layer Of Abundance in step with Unit attempt From Survey Data.
7. workout 5: growing Raster info Layers Of Environmental Variables.
Experiences of Environmental infection and Toxicology makes an attempt to supply concise, serious experiences of well timed advances, philosophy and critical components of finished or wanted exercise within the overall box of xenobiotics, in any section of our surroundings, in addition to toxicological implications.
Derived from an unheard of study attempt masking over 70 box years of box information in a chain of stories, Trophic association in Coastal platforms represents another method of coastal study that has been effectively utilized to coastal source administration matters. This exact e-book is predicated upon a chain of long term, interdisciplinary reports of a chain of coastal areas within the NE Gulf of Mexico that come with nutrient loading, habitat definition, quantified collections of organisms from microbes to fishes, and the selection of the trophic association that defines the approaches that form the productiveness of those parts.
An important element of many alternative ecosystems, cyanobacteria occupy nearly each area of interest of the earth, together with clean and salt waters, rice fields, sizzling springs, arid deserts, and polar areas. Cyanobacteria, in addition to algae, produce approximately part the worldwide oxygen, making evaluation in their ecophysiologies very important for knowing weather affects and capability remediation.
This ebook specializes in the ecological affects of the good East Japan Earthquake and ensuing tsunamis, an extraordinary and intensely huge disturbance occasion, on numerous coastal ecosystems in Japan's Tohoku region, together with sub-tidal and tidal animal groups, sand dune plant groups and coastal forests.
Next Next post: Download e-book for kindle: Nitrogen in the Marine Environment by Douglas G. Capone,Deborah A. Bronk,Margaret R.


The softball team beat Harnett Central in the 1st round of a State Playoffs tonight. Ashley had 6 runs 10 hits 0 errors, HC 4 runs 7 hits 2 errors. AHS scored 2 in 1st, 1 in 2nd and 3 in 3rd. HC had 2 in 2nd and 2 in 5th. Robyn Kerr was winning pitcher and Halee Grodi was losing. Person Yopp had triple and Lauren Brooks had a double. Taylor Carter 2-4 with 2 RBI, Schae Dickson 2-3 with 1 RBI, Lauren Brooks 2-3. Next game Friday vs South View.


For the first time in English comes a remarkable literary discovery. In 1928, Turkish author Ali Rıza Seyfioğlu pirated Bram Stoker's Dracula, rewriting it with new material, patriotic overtones, and Islam. A rare example of a "bootleg" novel, it's also the first adaptation to plainly identify Dracula as the historical warlord Vlad the Impaler.
Now you can be one of the first to read it outside its home country.
New essays by scholars Şehnaz Tahir Gürçağlar and Iain Robert Smith on the history of the book and its 1953 film adaptation, Drakula İstanbul'da.
Rarely-seen publicity stills from the film adaptation, Drakula İstanbul'da.
The Bram Stoker Award-winning author of the Anno Dracula series pens a personal introduction.
Copyright © 2017 Neon Harbor Entertainment, LLC. All rights reserved.


An opportunity for a Client Accountant job has become available within an established leading property company based in Dublin City Centre. This is an excellent opportunity for a qualified accountant looking to progress their career in a busy finance department.
Complete monthly management accounts and reporting packs as well as maintenance of all financial data.
Assist with accounts payable and receivable ensuring all issues are dealt with and resolved.
Deal with internal and external auditors.
Assist with projects and identify opportunities for improvement within the business.
Practice trained would be desirable.


text:
Economy|Financial Markets
China slashes one-year interest rates to help virus-hit firms
People's Bank of China is trying to make it easier for companies affected by coronavirus to borrow funds.
China's central bank has injected liquidity into financial markets several times to support businesses affected by the virus outbreak [File: Jason Lee/Reuters]
China's central bank cut the interest rate on its medium-term lending facility on Monday as policymakers sought to ease the pain on businesses caused by a coronavirus outbreak that has severely disrupted activity.
The move is expected to pave the way for a reduction in the country's benchmark loan prime rate (LPR) – the rate that commercial banks charge their best customers – which will be announced on Thursday, to lower borrowing costs and ease financial strains on companies hit by the virus epidemic.
The People's Bank of China (PBOC) said it was lowering the rate on 200 billion yuan ($28.65bn) worth of one-year medium-term lending facility (MLF) loans to financial institutions by 10 basis points (bps) – 0.10 of a percentage point – to 3.15 percent from 3.25 percent previously.
MLFs allow banks and other financial institutions to borrow from the central bank using securities as collateral.
The interest rate cut helped Chinese stock markets rally on Monday, which in turn lent support to other Asian bourses.
The central bank attributed the move to keep banking system liquidity "reasonably ample" to counter factors including the maturity of previous stimulus measures, but it did not address the specific reason for the rate move.
No MLF loans were due to mature on Monday.
Earlier this month, the PBOC unexpectedly lowered the interest rates on reverse repurchase agreements, also known as reverse repo operations, by 10 basis points as the virus outbreak escalated. In reverse repo operations, the central bank buys bonds and other securities from financial institutions and sells them back in the future at a slightly higher price. A lower reverse repo interest rate makes it cheaper for commercial banks to borrow from the central bank.
Traders and analysts said cutting the MLF rate following a similar move in the reverse repo rate would help the reduction in rates to feed through to longer-term lending.
Fresh headaches
The coronavirus outbreak has hit the Chinese economy just as it was starting to show some signs of stabilising after 2019 growth cooled to its slowest pace in nearly 30 years.
The virus has already killed more than 1,700 people and infected more than 70,000 and is yet to show convincing signs of peaking with more than 2,048 new cases reported on Monday.
Some analysts believe China's economy could contract in the first quarter compared with the previous three months due to the shock to business and tough public health restrictions.
With transport curbs still in place in many parts of the country, economic activity in China remains subdued, although there are reports that more factories are slowly resuming production.
"An imminent V-shaped recovery is looking less likely than a few days ago," Capital Economics said in a note on Friday.
When compared with a year earlier, first-quarter growth could slump to 4.5 percent from 6 percent in the fourth quarter, according to the latest Reuters poll.
Most analysts expect a sharp rebound in the second quarter if the disease can be contained soon, but they warn that disruptions could continue to ripple through manufacturing and service sectors for months to come.
"The central bank will shift its focus to support firms' mid- to long-term financing needs rather than short-term stabilisation," Yan Se, chief economist at Founder Securities in Beijing said, noting the PBOC's large fund injections via reverse repo operations in the last two weeks.
He now expects a targeted reduction to bank's reserve requirement ratio, which is the amount of cash that commercial banks must maintain with the PBOC.
Further cuts in China's key lending rates are widely expected in coming months to ensure a recovery takes hold. More fiscal spending is also believed to be on the cards, along with measures to boost domestic consumption.

redpajama_set_name: RedPajamaCommonCrawl


text:
Restored Prisoner's Letter Uncovers Horrific Details of Life at Auschwitz Death Camp
Filed to:history
Photo: Michel Zacharz AKA Grippenn via Wikimedia Commons
In 1944, Marcel Nadjari—a Greek Jew who was forced to remove bodies from the Auschwitz gas chambers—buried a letter in a forest near the camp. The text was rediscovered in 1980, but it was virtually unreadable. Using a new imaging technique, scientists have finally reconstructed the letter, and it's providing harrowing new details of the Holocaust—and what it was like to work as a forced laborer in a Nazi extermination camp.
As reported in Deutsche Welle and Spiegel, a restoration effort headed by Russian-born historian Pavel Polian has brought the handwritten text of a document buried by Auschwitz-Birkenau prisoner Marcel Nadjari back to life. The letter, enclosed in a thermos and wrapped in a leather binding, was buried by Nadjari in November 1944 just outside the extermination camp, where it lay buried for 36 years. It was accidentally unearthed by a student in 1980, but most of the text was unlegible. Using a technique called multispectral analysis, Polian, with the help of Russian IT expert Aleksandr Nikitjaev, managed to decipher upwards of 90 percent of the document. The details of this work are set to be published by the Munich-based Institute of Contemporary History (IfZ) in November.
Nadjari, a Jew from Thessaloniki, Greece, had the misfortune of working as a member of the Auschwitz-Birkenau Sonderkommando. These forced laborers had to perform the unthinkable, removing the bodies from the gas chambers, extracting teeth, shaving off their hair (which was processed into yarn), delivering the bodies to the crematorium, and disposing the ashes into rivers. Members of the Sonderkommando were frequently killed and replaced with new arrivals; out of the estimated 2,200 Jews assigned for this task, only a few hundred managed to survive the war.
Nadjari's secret note represents one of nine similar records written by five Sonderkommando members, though his is the only one written in Greek (the others being in Yiddish). Only 10 to 15 percent of the surviving document was originally legible. Nikitjaev was able to read the badly smudged text by taking multi-spectral recordings of the document at various optical wavelengths. This non-invasive technique allows researchers to map and identify the pigments (in this case ink) on badly worn documents and visualize the reflections that characterize a letter. Working for an entire year, Nikitjaev progressed through the document, turning the blurred script into outlines of letters that could be made visible again.
"When you read what work I did, you will say, how could I...or anyone else do this work and burn his fellow believers...many times I thought of coming in with them [into the gas chambers] to finish, but I have always kept my revenge."
Nadjari had written the letter in the hopes that whoever found it would deliver the document to a diplomatic representative of Greece, who would subsequently hand it over to either friends or family back home. Reading the recovered text, it's clear that Nikitjaev was distraught by the nature of his work, and even contemplated suicide. But it was his thoughts of vengeance that kept him going.
"When you read what work I did, you will say, how could I...or anyone else do this work and burn his fellow believers...many times I thought of coming in with them [into the gas chambers] to finish, but I have always kept my revenge: I wanted to live to avenge the death of Papa and Mama, and that of my beloved little sister, Nelli," wrote Nadjari in the restored document.
Image: Pavel Polian
His accounts of life as a member of the Sonderkommando are particularly harrowing.
"Our work was to receive them first, most of them did not know the reason...the people I saw when their destiny was sealed, I told the truth, and after they were all naked, they went further into the death chamber, where the Germans had laid pipes on the ceiling to make them think they were preparing the bath, with whips in their hands, the Germans forced them to move closer and closer together, so that as many as possible could fit in, a true Sardinian death, then the doors were hermetically sealed," wrote Nadjari. "After half an hour, we opened the doors [of the gas chamber], and our work began. We carried the corpses of these innocent women and children to the elevator, which brought them into the room with the ovens, and they put them in there the furnaces, where they were burnt without the use of fuel, because of the fat they have."
He also participated in the spreading of the ashes, which the Nazis did to cover their tracks. Nadjari figured that his days were numbered and that he'd eventually be killed in the gas chambers. "We have to leave the earth because we know so much," he wrote.
Nadjari managed to survive his experience at Auschwitz-Birkenau, where around 1.1 million people, the vast majority of them Jews, were killed during the Second World War. He returned to Greece after the war, and eventually moved to the United States. Nadjari died at the age of 54 in New York, before his document was rediscovered.
[Institute of Contemporary History—Munich, Berlin (IfZ) via Deutsche Welle and Spiegel]
Gas Chambers Uncovered By Archaeologists At Sobibor Death Camp
Archaeological dig at Concentration Camp reveals what the Nazis tried to hide
Historic Holocaust Escape Tunnel Discovered in Lithuania


How to keep the text in vector in Photoshop without rasterizing it or flattening the layers when exporting to PDF?
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How to punch through all the layers in Adobe Illustrator?
How to ensure scalability of logo design?
How can I make my logo suitable for all purposes, from webpages to very large printed banners? I currently use use Photoshop.
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text:
Der Hunsrückhöhenweg ist ein 166 km langer Wanderweg, der die Städte Boppard und Bernkastel-Kues verbindet. Somit überquert der Wanderweg zweimal den Hunsrück: Im ersten Abschnitt vom Rhein an die Nahe und im zweiten Abschnitt von der Nahe an die Mosel. Unter anderem führt der Weg über den Erbeskopf, der mit einer Höhe von 816 Metern die höchste Erhebung in Rheinland-Pfalz darstellt. Derzeit wird der Wanderweg durch den Hunsrückverein e.V. betreut und gepflegt. Der Wanderweg wird durch ein weißes "H" auf grünem Grund gekennzeichnet.

Charakteristika

Der Hunsrückhöhenweg führt größtenteils über asphaltierte Wege, auf Grund der Vielzahl an zu überwindenden Steigungen gilt der Schwierigkeitsgrad jedoch als hoch. Einige der Sehenswürdigkeiten entlang des Wanderweges sind unter anderem die Weinberge entlang des Rheins und der Mosel, das Naturdenkmal Teufelsfels, die historische Altstadt von Herrstein und das Thonet-Museum (Boppard) in Boppard.

Streckenverlauf
1. Etappe: Boppard – Gondershausen (ca. 15 km)

2. Etappe: Gondershausen – Kastellaun (ca. 19 km)

3. Etappe: Kastellaun – Sohren (ca. 26 km)

4. Etappe: Sohren – Rudolfshaus (ca. 22 km)

5. Etappe: Rudolfshaus – Kirn (ca. 16 km)

6. Etappe: Kirn – Kempfeld (ca. 25 km)

7. Etappe: Kempfeld – Deuselbach (ca. 30 km)

8. Etappe: Deuselbach – Morbach-Heinzerath (ca. 16 km)

9. Etappe: Morbach-Heinzerath – Bernkastel-Kues (ca. 16 km)

Literatur

Einzelnachweise

Wanderweg im Hunsrück
Wanderweg in Rheinland-Pfalz

redpajama_set_name: RedPajamaWikipedia


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Fluoroscopy and C-Arm Market
Request Free Sample Copy
/ Market Insight
Published On : Oct 2022
Code : CMI510
Industry : Medical Imaging
Fluoroscopy and C-Arm Market Analysis
Fluoroscopy and C-Arm Market, by Product Type (C-Arms, (Full Size C – arms, Mini C – arms), Fluoroscopy Devices), by End User (Hospitals, Specialty Clinics, Diagnostic Centres), and by Region (North America, Latin America, Europe, Asia Pacific, Middle East, and Africa)- Size, Share, Outlook, and Opportunity Analysis, 2022 - 2030
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Fluoroscopy and C-Arm Market to Surpass US$ 5,552.2 Mn by 2030
Free Insights Infographics Description Table of Content Segmentation Methodology
C-Arms are imaging devices that work on the principles of X – ray technology. C-Arms have two key components: X – ray detector and X – ray source. C-Arms provide high resolution real time X – ray images, which help physicians monitor the surgery and make critical corrections where necessary and reduce the chances for follow up surgeries.
Global fluoroscopy and c-arm market is estimated to be valued at US$ 3,872.1 million in 2022 and is expected to exhibit a CAGR of 4.6% during the forecast period (2022-2030).
Figure 1. Global Fluoroscopy and C-Arm Market Share (%), by Product Type, 2022
Increasing product launch by the key market players to expand product portfolio is anticipated to propel the global fluoroscopy and c-arm market growth
Increasing product launch by the key market players to expand product portfolio is anticipated to propel the global fluoroscopy and c-arm market growth, over the forecast period. For instance, on November 16, 2021, FUJIFILM Holdings America Corporation, a diagnostic and enterprise imaging solutions company announced the launch of its compact mobile c-arm imaging system, the Persona CS mobile fluoroscopy system, which is intended for quick and smooth positioning in operating room and other environments. The robust and portable system is made to offer improved real-time image guiding for a variety of surgical operations including orthopaedic, difficult surgical, pain management (anaesthesia), and emergency procedures.
Global Fluoroscopy and C-Arm Market Report Coverage
Market Size in 2022:
Historical Data for: 2017 to 2020
Forecast Period:
Forecast Period 2022 to 2030 CAGR: 4.6%
2030 Value Projection:
Geographies covered:
North America: U.S. and Canada
Latin America: Brazil, Argentina, Mexico, and Rest of Latin America
Europe: Germany, U.K., Spain, France, Italy, Russia, and Rest of Europe
Asia Pacific: China, India, Japan, Australia, South Korea, ASEAN, and Rest of Asia Pacific
Middle East: GCC Countries, Israel, and Rest of Middle East
Africa: South Africa, North Africa, and Central Africa
Segments covered:
By Product Type: C-Arms (Full Size C – arms, Mini C - arms), Fluoroscopy Devices
By End User: Hospitals, Specialty Clinics, Diagnostic Centers
Companies covered:
GE Healthcare, Koninklijke Philips N.V., Siemens Healthineers, Hologic, Inc., and Ziehm Imaging
Growth Drivers:
Increasing product launch by key market players
Restraints & Challenges:
Adoption of alternative techniques, to fluoroscopy such as ultrasound
Figure 2. Global Fluoroscopy and C-Arm Market Share (%), by Region, 2022
Increasing adoption of fluoroscopy and c-arms is expected to propel growth of the global fluoroscopy and c-arms market.
Increasing adoption of fluoroscopy and c-arms is expected to propel growth of the global fluoroscopy and c-arms market over the forecast period. For instance, in November 2018, Agfa US Corp., a developer and manufacturer of imaging systems and IT solutions, was awarded a group purchasing agreement with Premier, which allowed Premier members, at their discretion, to take advantage, of special pricing and terms pre-negotiated by Premier for Agfa's comprehensive line of Direct Radiography (DR) systems.
Global Fluoroscopy and C-Arm Market– Impact of Coronavirus (COVID-19) Pandemic
Since the COVID-19 virus outbreak in December 2019, the disease has spread to over 100 countries across the globe and the World Health Organization had declared it a public health emergency on January 30, 2020.
COVID-19 has affected the economy in three main ways: by directly affecting production and demand of medical devices, by creating disruptions in distribution channels, and through its financial impact on firms and financial markets. Due to nationwide lockdowns, several countries, such as China, India, Saudi Arabia, U.A.E., Egypt, and others, faced problems with regard to the transportation of drugs and vaccines from one place to another. Additionally, there were delays in hospitalization and surgical procedures as number of patient visits decreased, which affected the global fluoroscopy and c-arm market over the forecast period.
Global Fluoroscopy and C-Arm Market: Key Developments
On July 14, 2022, FUJIFILM Europe GmbH, a subsidiary of Fujifilm Holdings Corporation, Launched New Hybrid C-Arm and Portable X-Ray Device. Hybrid C-Arm and Portable X-ray machine planned to offer high quality fluoroscopic and static x-ray images during surgery and other medical procedures. The technology offers a more effective and streamlined workflow by capturing radiography and fluoroscopic images on a single platform.
Global Fluoroscopy and C-Arm Market: Restraint
Adoption of alternative techniques, to fluoroscopy is expected to hinder growth of the global fluoroscopy and c-arms market. Fluoroscopy techniques allow surgeons to perform minimally invasive surgical procedures. However, fluoroscopy involves risk from ionizing radiation due to which several physicians prefer use of alternative techniques such as ultrasound, which provides similar modalities. For instance, according to an article published in August, 2021, by Egyptian Journal of Radiology and Nuclear Medicine, ultrasound is the perfect initial imaging modality for imaging of urinary tract without ionizing radiation.
Major players operating in the global Fluoroscopy and c-arm market include GE Healthcare, Koninklijke Philips N.V., Siemens Healthineers, Hologic, Inc., and Ziehm Imaging
Fluoroscopy is an imaging technique that uses X-ray technology for taking real-time images of the body, allowing physicians to visualize internal organs, muscles, and bones. Fluoroscopy devices use flat panel detectors for digital image processing that reduces the radiation dose administered to the patient. A fluoroscopy and C-Arm is a device used by physician to guide a needle to specific area with live X-ray screen. A fluoroscopy and C-Arm consist of two units, the image detector and X-ray generator on moveable C-Arm. Increasing prevalence of chronic diseases, new product approvals and launches along with increasing healthcare infrastructure during the forecast period is expected to assist the market growth.
Key market players are involved in inorganic growth activities such as partnership to increase product portfolio, is expected to drive the growth of global fluoroscopy and c-arm market, over the forecast period. For instance, on April 19, 2021, Ziehm Imaging GmbH, a developer, manufacturer of mobile X-ray-based imaging solutions, entered into a partnership with Carestream Health, a medical imaging company, announced the addition of a mobile C-Arm into its product portfolio. This surgical imaging system, the Ziehm Vision RFD C-Arm, will improve Carestream's mobile and fluoroscopic product. Moreover, increasing prevalence of musculoskeletal impairments in the world is expected to propel the growth of global fluoroscopy and c-arm market. For instance, according to data published on July 14, 2022, by the World Health Organization, around 1.71 billion people have musculoskeletal problems worldwide. Musculoskeletal impairments include more than 150 different diseases or conditions such as impairments in the muscles, bones, joints, etc. Musculoskeletal fluoroscopy is a nuclear radiology procedure used for detecting musculoskeletal abnormalities.
Key features of the study:
This report provides an in-depth analysis of the global fluoroscopy and c-arm market, and provides market size (US$ Million) and compound annual growth rate (CAGR%) for the forecast period (2022–2030), considering 2021 as the base year
It elucidates potential revenue opportunities across different segments and explains attractive investment proposition matrices for this market
This study also provides key insights about market drivers, restraints, opportunities, new product launches or approval, market trends, regional outlook, and competitive strategies adopted by key players
It profiles key players in the global fluoroscopy and c-arm market based on the following parameters – company highlights, products portfolio, key highlights, financial performance, and strategies
Key companies covered as a part of this study include GE Healthcare, Koninklijke Philips N.V., Siemens Healthineers, Hologic, Inc., and Ziehm Imaging
Insights from this report would allow marketers and the management authorities of the companies to make informed decisions regarding their future product launches, type up-gradation, market expansion, and marketing tactics
The global fluoroscopy and c-arm market report caters to various stakeholders in this industry including investors, suppliers, product manufacturers, distributors, new entrants, and financial analysts
Stakeholders would have ease in decision-making through various strategy matrices used in analyzing the global fluoroscopy and c-arm market
Detailed Segmentation:
Global Fluoroscopy and C-Arm Market, By Product Type:
C-Arms
Full Size C - arms
Mini C - arms
Fluoroscopy Devices
Global Fluoroscopy and C-Arm Market, By End User:
Global Fluoroscopy and C-Arm Market, By Region:
Rest of Middle East
By Region/Country
GE Healthcare *
Hologic, Inc.
Ziehm Imaging
"*" marked represents similar segmentation in other categories in the respective section.
What is the current market size and compound annual growth rate (CAGR) of the global fluoroscopy and C-Arm market during the forecast period (2022-2030)?
Global Fluoroscopy and C-Arm market size is estimated to be valued at US$ 3,872.1 million in 2022 and is expected to exhibit a CAGR of 4.6% between 2022 and 2030.
What are the major factors driving the market growth?
Factors such as increasing product launch by the key market players, increasing adoption of fluoroscopy and c-arms are expected to drive the market growth.
Which is the leading product type segment in the market?
Full Size C – arms is the leading product type segment in the market.
What are the key factors hampering growth of the market?
The major factors hampering growth of the market include adoption of alternative techniques, to fluoroscopy such as ultrasound.
Which are the major players operating in the market?
Major players operating in the market include GE Healthcare, Koninklijke Philips N.V., Siemens Healthineers, Hologic, Inc., and Ziehm Imaging.
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Scottish Liberal Democrats In the UK. In the EU.
Spokesperson Team
Flagship tax avoidance rule has never been used
Posted by Media Team | Updated 2018-07-22
Scottish Liberal Democrat Leader Willie Rennie has today revealed the general anti-tax avoidance rule (GAAR) introduced by Scottish ministers has never been used as a compliance tool, despite being described as a "key feature" of the new rules which allow Revenue Scotland to take counter action against artificial tax avoidance schemes.
The rule was established by Revenue Scotland and the Tax Powers Act of 2014.
The GAAR is a specific compliance tool which operates as a deterrent against tax fraud and tax avoidance. It is recognised by stakeholders as being significantly wider than the UK General Anti-Avoidance Rule, which is based on the narrower test of 'abuse' rather than 'artificiality' of tax arrangements.
Willie Rennie commented:
"The General Anti Avoidance Rule was paraded as the magical solution to tax dodging in Scotland. Either there has been a miraculous change in the attitudes of tax dodgers or this rule is less effective than we were told.
"When ordinary families are paying their fair share of tax they expect the government to ensure the wealthy and large companies are doing the same.
"If the Scottish Government claim is serious about tackling tax avoidance head on why has it neglected to use one of the mechanisms it claimed was key to doing so? The quality of our public services rest on tax payer contributions. The SNP have the tools to ensure that happens. Why is this sitting on the shelf?"
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text:
Cross-sectional study of patients with type 2 diabetes in OR Tambo district, South Africa
Oladele Vincent Adeniyi1,
Parimalaranie Yogeswaran2,
Benjamin Longo-Mbenza2,
Daniel Ter Goon3,
Anthony Idowu Ajayi4
1Faculty of Health Sciences, Department of Family Medicine, Walter Sisulu University, East London, South Africa
2Faculty of Health Sciences, Department of Family Medicine, Walter Sisulu University, Mthatha, South Africa
3Department of Nursing Science, School of Health Sciences, University of Fort Hare, East London, South Africa
4Faculty of Social Sciences & Humanities, Department of Sociology, University of Fort Hare, East London, South Africa
Correspondence to Dr Oladele Vincent Adeniyi; vincoladele{at}gmail.com
Objectives South Africa has pledged to the sustainable development goal of promoting good health and well-being to all residents. While this is laudable, paucity of reliable epidemiological data for different regions on diabetes and treatment outcomes may further widen the inequalities of access and quality of healthcare services across the country. This study examines the sociodemographic and clinical determinants of uncontrolled type 2 diabetes mellitus (T2DM) in individuals attending primary healthcare in OR Tambo district, South Africa.
Design A cross-sectional analytical study.
Setting Primary healthcare setting in OR Tambo district, South Africa.
Participants Patients treated for T2DM for 1 or more years (n=327).
Primary outcome measure Prevalence of uncontrolled T2DM.
Secondary outcome measure Determinants of uncontrolled T2DM (glycosylated haemoglobin (HbA1c) ≥7%).
Results Out of the 327 participants, 274 had HbA1c≥7% (83.8%). Female sex (95% CI 1.3 to 4.2), overweight/obesity (95% CI 1.9 to 261.2), elevated low-density lipoprotein cholesterol (95% CI 4.4 to 23.8), sedentary habits (95% CI 7.2 to 61.3), lower monthly income (95% CI 1.3 to 6.5), longer duration of T2DM (95% CI 4.4 to 294.2) and diabetes information from non-health workers (95% CI 1.4 to 7.0) were the significant determinants of uncontrolled T2DM. There was a significant positive correlation of uncontrolled T2DM with increasing duration of T2DM, estimated glomerular filtration rate and body mass index. However, a significant negative correlation exists between monthly income and increasing HbA1c.
Conclusions We found a significantly high prevalence (83.8%) of uncontrolled T2DM among the patients, possibly attributable to overweight/obesity, sedentary living, lower income and lack of information on diabetes. Addressing these determinants will require re-engineering of primary healthcare in the district.
EDUCATION & TRAINING (see Medical Education & Training)
Primary healthcare study on glycaemic control in individuals treated for diabetes in a predominantly rural South African setting.
Epidemiological data on patients and health system determinants of glycaemic control were explored.
Owing to the cross-sectional design, the causal relationship with the determinants could not be ascertained.
We were cautious with overgeneralisation of the findings, due to the convenience sampling of participants and under-representation of men in the study.
South Africa has pledged to the sustainable development goal of promoting good health and well-being to all residents. While this is laudable, paucity of reliable epidemiological data for different regions on diabetes and treatment outcomes may further widen the inequalities of access and quality of healthcare services across the country. Diabetes, an incurable chronic non-communicable disease, imposes a significant burden on the health services and has become a global public health problem.1 ,2 Although diabetes was considered the disease of the affluent, however, a paradoxical shift in rural–urban lifestyles means that populations from low socioeconomic communities too are affected.3–5
According to the International Diabetes Federation6 estimates, 371 million individuals were living with diabetes worldwide in 2012, accounting for a prevalence rate of 8.3%. The prevalence of diabetes ranges from 4.3% in sub-Saharan Africa (SSA; lowest), 6.7% in Europe, 10.5% in North America and the Caribbean to 10.9% in the Middle East and North Africa (highest).7 About 2 million people are living with diabetes mellitus (DM) in South Africa alone.1 It is, however, projected that the number of individuals with diabetes will double in SSA over the next 20 years (110% absolute increase by 2035),6 due to rapid nutritional and epidemiological transitions in the rural and urban communities.8 ,9 Going by the report of the International Diabetes Federation,7 SSA is ill prepared to deal with the astronomical increase in prevalence and incidence of diabetes and its complications in affected individuals.
Despite the scientific discoveries in diagnostic and treatment modalities, it appears that treatment outcomes of individuals with confirmed diabetes are generally suboptimal in SSA. The prevalence of uncontrolled diabetes ranges from 62% in Nigeria,10 66.7% in South Africa1 to 79.2% in Uganda11 and 82% in Botswana.12 These figures are in agreement with the findings of Diabcare study which reported good glycaemic control in only 29% of treated individuals in six African countries.13
Several reasons have been advanced for the suboptimal glycaemic control of diabetes in SSA. Lack of an operational diabetes programme, inefficient healthcare systems, inadequate staffing, stock-out of essential drugs and lack of patient empowerment14 ,15 were highlighted as reasons for suboptimal treatment outcomes documented in the majority of African countries. Likewise, the high level of unemployment, poor access to health facilities, lack of knowledge about diseases, perceptions and practices, poor attendance and failure to keep appointments at diabetes clinics could have impacted the poor health outcomes in Africa.16
In addition, the total health expenditure for diabetes in Africa (<1% of the total global health expenditure allocated for diabetes) is inadequate to cope with the health demand of diabetes,17 hence the poor treatment outcomes. There seems to be consensus among scholars that patient-related factors,4 ,5 ,18–22 disease-related factors and health system factors5 ,23 ,24 are the major determinants of poor glycaemic control. However, variation of factors influencing uncontrolled diabetes exists across regions and health facilities.4
In order for the South African Government to meet the sustainable development goal of promoting good health and well-being for all residents, data on the prevalence, treatment and glycaemic control of diabetes in rural and urban communities are needed for strategic planning on quality health service delivery. These epidemiological data are not available for OR Tambo district, an underserved region of South Africa. This study therefore bridges this gap by estimating the prevalence of uncontrolled diabetes, as well as identifying its sociodemographic and clinical determinants in individuals attending care in rural and semiurban communities of OR Tambo district, South Africa.
Study design and setting
This cross-sectional study drew participants from over 15 community health centres (primary care centres) in OR Tambo district, South Africa, to Mthatha General Hospital between June and November 2013. This district (level 1) hospital is located in a semiurban area and provides supervision for the referring community health centres in the rural communities surrounding Mthatha. Patients often receive diagnosis and treatment at Mthatha General Hospital with follow-up care at the nearest rural clinics where outreach clinicians provide monthly reviews.
About two-thirds of individuals with diabetes were not achieving glycaemic control in South Africa.1 Erasmus et al25 also reported a 79.9% prevalence of uncontrolled diabetes in the study setting in the past decade. Daramola et al26 reported a prevalence of 71% in a primary healthcare setting in Western Cape, though in a different province and periurban setting. The sample size was estimated with the formula for a cross-sectional study:
Using the formula;
Z1−α=Z0.95=1.96, P=precision to an acceptable approximation of the study population at 95% CI, P is the proportion of patients with uncontrolled type 2 DM (T2DM). P is therefore taken to be 70% in order to achieve the maximum sample size. D is the absolute precision, and is taken as 0.05. The total sample size (n=323) was adjusted by a factor of 10% in anticipation of incomplete medical data.
Using the formula27 1÷(1−adjusted factor) multiply by the estimated sample size.
A total of 360 participants were included in the study.
Participants and inclusion criteria
Participants were invited from community health centres to attend the outpatient clinic at Mthatha General Hospital during the study period. They were included if age ≥30 years at diagnosis of DM and they had been on treatment for at least 1 year prior to the study. Exclusion criteria include type 1 diabetes, recent diagnosis of diabetes (<1 year), acutely ill and debilitated patients. A consecutive sample of 360 participants participated in the study.
Study instrument and pilot study
A structured questionnaire was designed in accordance with the main objectives of the study. A pilot study was conducted with 20 individuals living with diabetes who were excluded in the main study, at the Mthatha General Hospital, following which adjustments were made to the study instrument.
The Chief Executive Officer of the hospital granted permission for the study. All participants provided written informed consent to participate in this study.
Data collection procedure
Data were recorded by personal interview and abstraction from medical files. The following independent variables were obtained from an investigator-aided interview: sociodemographic characteristics (gender, age, marital status, type of residence, and monthly income, level of education and employment status) and lifestyle habits (smoking, excessive alcohol consumption and physical activity). Type of residence was categorised as semiurban (if participants resided in Mthatha) or rural (if participants resided in the neighbouring communities outside Mthatha). Smoking history was categorised as current smoker (smoked at least one cigarette within the past month), never-smoker and former smoker (having quit smoking more than 1 month prior to the study). Participants' consumption of alcohol was categorised as never drink, quit drinking (having quit drinking for more than one month prior to the study) and currently drinking (drank at least one unit of alcohol within the past month).1
Physical activity assessment focused on activities during work and leisure times in accordance with the Society of Endocrinology, Metabolism and Diabetes of South Africa;1 light to moderate activities without increase in respiratory frequency and heart rhythm (self-reported sedentary behaviour). Also, duration of diabetes and current medications was abstracted from the medical files. Duration of diabetes was defined as interval of diagnosis till the period of study. Other information obtained included sources of diabetes information, prior hospitalisation for hypoglycaemic episodes, self-reported adherence to medications and dietary contents. Evidence of diabetes complications: stroke (evident on clinical examination and prior documentation in the medical record), heart failure and renal failure (prior assessment documented in the medical record of the participants).
Body weight in light clothes was measured to the nearest 0.5 kg in the standing position using a Soehnle Scale (Soehnle-Waagen Gmbh Co, Muurhardt, Germany) and height was measured by a stadiometer in standing position with closed feet (without shoes to the nearest 0.5 cm), holding their breath in full inspiration and Frankfurt line of vision.28 Body mass index (BMI) was calculated for each participant. BMI was categorised in accordance with the WHO criteria (2000) as <18.5, 18.5–24.9, 25.5–29.9 and >30.0 kg/m2 as underweight, normal, overweight and obese, respectively.
Blood pressures (systolic and diastolic) were measured in accordance with standard protocols29 with a validated Microlife BP A100 Plus model. Fasting venous blood (after an 8 or more hours overnight fast) was obtained for lipid profile, which includes total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TGs). Creatinine level was assayed from the blood sample and the glomerular filtration rate was estimated using the chronic kidney disease epidemiology collaboration equation. The dependent (outcome) variable is the glycosylated haemoglobin (HbA1c) level, which was performed in accordance with the international reference values and quality assurance criteria using stringent laboratory assays.1 Glycaemic control was categorised as: good (HbA1c≤7%), poor control (HbA1c>7%), moderately poor (HbA1c=7–8.9%) and critically poor (HbA1c≥9%).
Data were expressed as mean values±SDs for continuous variables. Counts (frequency=n) and proportions (%) were reported for categorical variables. Percentages were compared using χ2 test. Student's t-test was used to compare means between groups. Univariate OR using Mantel-Haenszel and multivariate OR using logistic regression analysis were calculated with their 95% CIs to define any association between uncontrolled T2DM (dependent variable) and its associated factors (independent variables). The logistic regression model was also adjusted for confounding factors. A p<0.05 was considered for significant difference. Data were analysed by Statistical Package for Social Science (SPSS) V.21 for windows (SPSS, Chicago, Illinois, USA).
Out of the 360 recruited, 33 had incomplete data (blood results and medical information). Total participants included in the analysis were 327. Table 1 describes the study participants according to the sociodemographic characteristics.
Sociodemographic characteristics of participants
The majority of participants were females (70.3%), lived in rural communities (88.7%), achieved at least secondary education (67%), never drank alcoholic beverages (71.3%) and never smoked cigarettes (77.1%). All participants consumed the prevalent diet: pap, porridge, meat, rice, bread and fast food items (all energy-dense foods).
Some participants had suffered diabetes complications: stroke (n=11), renal failure (n=80) and heart failure (n=7). Prevalence of uncontrolled T2DM was 83.8% in the studied population: male 75.3% (n=73/97) and women 87.4% (n=201/230). Figure 1 describes the glycaemic control according to sex distribution and categories of HbA1c level.
Glycaemic control according to sex distribution. HbA1c, glycosylated haemoglobin.
In univariate analysis, there was a significantly higher risk of poor glycaemic control among individuals with longer duration of T2DM, obesity, lower estimated glomerular filtration rate (eGFR), higher TG levels and, paradoxically, elevated HDL-C (table 2).
Determinants of uncontrolled T2DM: univariate analysis
Furthermore, the risk of poor glycaemic control was higher among those on a combination therapy of insulin and metformin (91.2%, n=83/91, OR=2.4, 95% CI 1.1 to 5.4; p=0.024). Also, a higher risk of poor glycaemic control was found among patients on insulin (91.7%, n=88/96, OR=2.7, 95% CI 1.2 to 5.9; p=0.013) in comparison with those without insulin. The majority (97.5%, n=315/323) of participants reported poor adherence with treatment.
The risk of uncontrolled diabetes was lower among individuals with prior hypoglycaemic episodes (68.4%, n=26/38, OR=0.4, 95% CI 0.2 to 0.8; p=0.006). Significant positive associations were observed between elevated levels of HbA1c (uncontrolled T2DM) and BMI, T2DM duration, LDL-C and eGFR levels. However, a paradoxical association was found between elevated levels of HbA1c and monthly income (table 3).
Significant associations of uncontrolled T2DM and independent determinants
The final model of the multivariate logistic regression (LR) method shows that the significant determinants of uncontrolled T2DM were longer duration of T2DM, overweight/obesity, female gender, sedentary lifestyles, higher LDL-C, lower monthly income and source of diabetes information from non-health workers after adjusting for other variables (residence, monthly income, alcohol intake, smoking status, medications, previous hypoglycaemic episodes, HDL-C and eGFR; table 4).
Significant determinants of uncontrolled T2DM: multivariate analysis
This study sought to determine the prevalence of uncontrolled T2DM and its sociodemographic and clinical determinants among individuals attending primary healthcare in OR Tambo district, South Africa. We found a significantly high prevalence (83.8%) of uncontrolled T2DM in the study population. This prevalence is slightly higher than the previously reported prevalence of 79.9% more than a decade from the same setting.22 The rate of uncontrolled T2DM from this study is higher than the rates from a similar level of care in Western Cape Province (71%)26 and Northwest Province (69.3%),30 respectively, within South Africa. However, it is comparable with another South African report from KwaZulu-Natal Province (83%) reported by Igbojiaku et al.31 Poor glycaemic control has been documented in different parts of Africa: Congo DRC32 (68%), Nigeria10 (62%), Uganda11 (79.2%) and Botswana12 (82%). There seems to be a trend of poor glycaemic control among the indigenous Africans irrespective of their location, which portends danger for their health.
It should be noted that the influence of nutritional transitions, changing lifestyles and decline in health system performance in the past decade might contribute to variations comparable to those found in this study. Nevertheless, the high prevalence rate of uncontrolled T2DM observed in our sample is worrisome, given the deleterious health implications of uncontrolled T2DM. Several underlying issues may contribute to uncontrolled diabetes among the population studied. It might be possible that many patients do not truly understand the health implications of having uncontrolled T2DM. However, this supposition is only speculative. Therefore, a study examining the perception and knowledge of patients attending healthcare centres concerning uncontrolled T2DM is imperative.
It should be noted that predominantly rural communities in South Africa and the rest of Africa are faced with the similar problem of poor access to quality healthcare services.15 Patients travel long distances to townships for hospital visits; they are largely poor, unemployed and live in rural communities. The rural communities lack functional health facilities; there is a regular stock-out of medications and lack of doctors and nurses. Further access to quality healthcare becomes unattainable due to poverty.32 ,33 The relationship of poverty and health indicators cannot be ignored in these rural communities. Significant patient-related factors: female gender, rural residence, obesity, unemployment, poor monthly income and diabetes information from non-healthcare workers were associated with uncontrolled T2DM in our study. There was a high representation of women (70.3%) among the study participants, which reflects the overall higher level of usage of health facilities by women in South Africa.34 Although the association of poor glycaemic control had been documented in the literature,4 ,20 it is likely that fewer men (29.7%) in this study were using their medication and following dietary advice. Therefore, a population-based study in these communities would help determine the true prevalence of uncontrolled T2DM among men in the region.
The majority of participants were unemployed (89.2%) and had a monthly income of <R1200 (<US$100), which suggests the glaring level of poverty in this region. This impacts directly on the health-seeking behaviour of patients, such as cost of transportation to hospitals for routine check-up and pick up of medications, money for glucometer and other basic needs. These social determinants of health were reported in SSA previously.15 ,16 Also, poverty impacts on the food contents of the participants, which are limited to energy-dense food and thus could contribute to poor glycaemic control. The current study found no association between the age of patients and level of glycaemic control. However, this finding is in contrast to the systematic review by Sanal et al4 which reported a strong association between increasing age and good glycaemic control. Obesity is an independent determinant of uncontrolled diabetes in this study. Many other studies have reported a similar association between obesity and uncontrolled diabetes.19–21
Despite the fact that a high proportion (66.7%) of the study participants achieved at least secondary education, the level of education was not statistically significant (p>0.05) in this study. Ismail et al22 had reported no relationship between level of education and level of glycaemic control among patients with T2DM. Physical inactivity was an independent and significant determinant (p<0.0001) of uncontrolled T2DM in the study. The benefits of exercise in reducing cardiovascular risks have been documented.35 ,36 Aerobic exercises improve insulin sensitivity and metabolic control. However, the rural residence and age of participants may explain why formal exercises might be unattainable; hence, aerobic exercise should be appropriate for age, gender and social environment of each patient.
Diabetes information from non-healthcare workers is an independent determinant of uncontrolled diabetes in this study. Sources of diabetes education are crucial for gaining relevant lifestyle changes required to improve glycaemic control. It is observed that the majority of participants reported poor compliance with treatment. Patient education is crucial to improve compliance with medications. Education provided by a trained diabetes educator is more significant for good glycaemic control.21 ,37 Inadequate staffing with doctors and nurses and lack of diabetes educators in the local health facilities are some of the reasons for the poor treatment outcomes in our setting. Patients' education on their clinical condition therefore comes from unverified sources.
The paradoxical association of uncontrolled T2DM and insulin therapy in the study warrants further investigation. Further clarity on the suboptimal glycaemic control in participants on insulin therapy could not be ascertained due to lack of data on the timing of initiation and dosing schedule of insulin therapy in the participants. Nevertheless, the possibility of clinic inertia such as delays in initiating insulin therapy, failure of optimisation of insulin doses and inadequate follow-up of patients cannot be ignored as the reasons for our results. Early initiation of insulin within 3 years of diagnosis of diabetes would preserve the β-cells of the pancreas.35 In addition to clinic inertia, access to clinic follow-up for optimisation of insulin doses may probably be unattainable due to costs of transport to hospital as a result of poverty.
Also, our study reported a significant association between uncontrolled diabetes and longer duration of diabetes. Individuals with diabetes for at least 9 years have higher odds of having poor glycaemic control (OR=35.8). Long duration of chronic hyperglycaemia is associated with β-cell loss and further deterioration of glucose homoeostasis.35 Chronic hyperglycaemia is a precursor to diabetes nephropathy and thus further deterioration in glucose metabolism.35 Also, a significant association (p=0.002) was observed between uncontrolled diabetes and LDL-C, with elevated levels in participants with HbA1c≥9.0%. The risk of uncontrolled T2DM was higher (twofold) in participants with LDL-C≥2.2 mmol/L. Chronic intracellular lipids in the liver are associated with deterioration in the functions of β-cells and development of non-alcoholic hepatic steatosis.35 The paradoxical increase in HDL-C in individuals with uncontrolled T2DM warrants further investigation.
Association of LDL-L, renal failure and long duration of diabetes with uncontrolled diabetes has been reported previously.4 ,5 ,19 There was a positive linear association between uncontrolled diabetes and declining GFR level; participants with HbA1c≥9.0% were more likely to have renal impairment. This has clinical implications for management of patients. Metformin (biguanide), one of the commonly used oral hypoglycaemic drugs, is associated with lactic acidosis in the presence of renal failure.35 Therefore, clinicians need to regularly monitor the renal functions. It should also be noted that some participants had already developed complications: stroke, heart failure and renal failure. This is, however, not surprising, based on the high prevalence of uncontrolled T2DM.
The inherent limitations of a cross-sectional study cannot be ignored. Indeed, only prospective studies might demonstrate a causal association between the determinants and uncontrolled T2DM. Besides, the self-reporting of participants could not rule out the possibility of bias in the participants' responses, such as under-reporting of cigarette smoking and alcohol consumption. Also, the under-representation of men did not allow for a good understanding of glycaemic control in our studied population. The convenience sampling of participants coupled with a health facility-based study may have introduced bias. Besides, the glycaemic control in this study may have underestimated the true prevalence at the population level in the communities.
Notwithstanding the limitations, the study provides epidemiological data on glycaemic control of diabetes in an understudied region with poor access to quality healthcare services. The findings might help inform future healthcare decisions on resource allocations (human and material) with a priority for improvement in diabetes care services in the underserved communities.
This study indicates that uncontrolled T2DM is high among the rural, poor socioeconomic communities of OR Tambo district, South Africa. This is worrisome, given the health implications of uncontrolled T2DM. Also, obesity, longer duration of T2DM, poverty, lack of diabetes education, sedentary lifestyle and dyslipidaemia are identified as the most important and independent determinants of T2DM in the setting. Clinicians should pay attention to the determinants of uncontrolled diabetes and overcome their inertia to initiate and optimise insulin therapy in the management of individuals living with diabetes. There is an urgent need for re-engineering of primary healthcare with prioritisation of diabetes care and other non-communicable diseases in the rural underserved communities.
The authors thank the staff of Mthatha General Hospital for their involvement in the successful completion of the research work.
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Contributors OVA and PY conceived and designed the study protocol, coordinated the data collection and drafted the manuscript. BL-M and AIA participated in the study design and performed the statistical analyses. DTG participated in data collection and drafting of the manuscript. All authors read and approved the final version of the manuscript.
Ethics approval Ethical approval was obtained in accordance with the Helsinki II Declaration from the Walter Sisulu University Ethical Committee and Eastern Cape Department of Health, South Africa.
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