Clinicians and professional caregivers aren't used to being on the receiving end of care -- and typically don't like the vulnerability that comes with being a patient. Instead they're often taught to be tough. They work long hours, eat on the go, and balance life and death decisions - in order to deliver care to others. In other words, the culture of medicine is to not care for yourself in as you work to care for others. It's a zero-sum game. Every minute spent getting rest, eating well, enjoying a hobby, or exercising is a minute that's not spent doing patient care.
What if it's not a zero-sum game?
There's ample evidence that how doctors look, feel and behave may affect patient care. Studies show that many doctors and nurses fail to promote healthy behaviors in their patients, particularly if they themselves aren't eating well, getting exercise and are stressed. And who isn't stressed?
Clinicians who are healthier are more likely to talk with their patients about lifestyle choices and patients in turn may feel more comfortable receiving and following their advice.
So much of health care spending and disease burden is tied to behaviors: smoking, diet, activity, and stress. And if the ones who provide care can't make changes in their own lives, can we expect patients to make those changes?
A Johns Hopkins study found that normal weight doctors are more likely to counsel their patients about obesity and weight loss than physicians who are overweight. Today, roughly 6 in 10 doctors and nurses are overweight or obese, a level approaching that in the general population. That's not great news, but it's also an opportunity.
Consider the dramatic decline in smoking rates over the past 50 years. Clinician behavior helped lead the way. In the 1950s about half of physicians smoked. By the 1980s the rate was below 20%. Today its down around 3%. In the culture of healthcare, being a smoker became unacceptable, and the clinicians who quit smoking themselves knew what it took to quit and could help patients get over the hump.
So even though doctors may make lousy patients, embracing that experience might be exactly what they have to do to help their patients get over their own hurdles, vulnerabilities, and fears.
In the words of Nobel Peace Prize-winning physician Albert Schweitzer: "Example is not the main thing in influencing others. It is the only thing."
Make a promise to yourself and those you care for.
If this resonates with you, read more about The Patient Promise. Commit to your own health and creating the best version of yourself, so you can help others do the same.
Recently, a friend had a minor surgery. Once he was safely home, he was surprised that he burst into tears. This was transient, but that's not always the case.
We know it's normal for people to feel anxious before surgery, but do we help them understand that some people experience depression afterward?
People expect pain and other challenges during recovery, but for those who also experience depression, not knowing this can happen creates confusion, embarrassment, and isolation.
Depression has been documented after many procedures coronary artery bypass graft, joint replacement, bariatric surgery, colon surgery. While it may be more common after certain procedures, there's a risk with any surgery. And getting comfortable with identifying and addressing it can only improve patient experiences, engagement and outcomes.
Many factors may contribute: the body has been through a trauma (even if a planned trauma), effects of anesthesia, a post-op let-down effect, opioids, poor sleep, and depression or anxiety before surgery.
This makes it much harder for them to participate in their recovery and rehab.
It lowers their threshold for pain, and can create a pain-depression feedback loop.
Educate patients and family caregivers about post-op depression so they can recognize it, report it, and put it in perspective.
Help people understand what happens during surgery and set realistic expectations about recovery. Knowing what to expect reduces anxiety and gives people a sense of control. And less anxiety before surgery may mean less afterward.
Screen for depression during follow-up visits and calls.
People can only participate in their care when they have energy; unfortunately, depression robs them of this. And including it as part of patient and family education can help people identify it, destigmatize it, and address it.
2. Thombs BD, de Jonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA. 2008;300:2161–71. doi: 10.1001/jama.2008.667.
At age 12, I was diagnosed with a chronic condition, and with a second one 11 years later. I'm not unique. According to a 2017 RAND study, 60% of Americans had at least one chronic condition, and 42% had multiple. With decades of patient experience under my belt, I recently had a bump in my health journey. My medications stopped working and I developed new symptoms. I've had flares in the past, including 5 surgeries, but this time was different. Now I work full time, I'm married, and mom to a toddler. Flaring this time meant missing work, hospitalization, weekly appointments, guilt and depression.
What struck me most was how there wasn't time to discuss these life stressors with my doctors. It was important for them to know how my life was being impacted, and how my life may be impacting my illnesses. It was also important that my multiple specialists understood each others' recommendations and treatment plans - and that I get connected with resources.
While clinicians want to be collaborative,15 minutes makes it difficult. People need to feel they trust their clinician, but they often need resources beyond the encounter, too.
Help patients prepare for their visit.
Be specific! Beyond current symptoms and medications, help patients prioritize questions or concerns that may be outside the traditional conversation about their illness. For example, could your office send a few questions for people to fill out in advance? These could be personal, life-related questions that can be uncomfortable to bring up or answer off the cuff when face to face. How is your health affecting your work? ...hobbies? ...relationships? And vice versa? This way, you can hone in on important topics that can really impact their life, wellbeing, and their ability to follow a new treatment plan.
Then, extend your time and reach.
Most people can benefit from resources or community health connections. But this takes time and often some research.
This is when you can lean on health educators and health education specialists. Separate from RNs and clinical staff, who have set duties in a practice, health educators are trained to focus on how people can best understand what's needed to care for their condition(s), incorporating learning theories and health literacy best practices. With backgrounds in public health and education, they can help bridge the gap by providing what you'd like to be able to give to your patients (resources and a confirmed understanding of conditions and care).
In a health system, ask about the availability of health educators to support you.
In a private practice, when thinking about new roles, consider a health educator or those with a public health background when creating job descriptions.
We're all working towards more positive provider-patient relationships. It's challenging, for both sides, to keep a firm grip on all the details while still trying to stay hopeful. Continuing to work together and continuing to better understand each other's perspectives will help create a path to get us there.
Do we have a heard mentality?
With all the efforts to communicate better with patients— do you ever wonder if they can hear you? Not metaphorically, but literally.
Hearing is a baseline essential for engaging in care and navigating the healthcare system, but how often do we take it for granted that patients can hear what we say?
Only about 15% of people who need hearing aids have them. We also tend to assume hearing is only an issue for seniors. But over 60% of people with hearing loss are under age 65. And while cost is an issue, so is diagnosis and awareness of the other problems it contributes to.
Right now, many people nod along and didn't quite hear what you said about their medication or follow-up care. They're embarrassed. Or they think they understood enough and want to move the conversation along, especially if they know you're pressed for time.
Do they have trouble hearing you when you're facing away from them? Even if they can't lip read, people often supplement auditory information with visual clues.
Do they ask fewer questions? They may stop asking if they won't be able to make out the answer.
Do they seem less social or more withdrawn? People often stop going to social gatherings and restaurants when they can't hear well enough to follow or join conversations.
It's no wonder hearing loss is associated with social isolation in older adults, which also contributes to health problems. Untreated hearing loss is also associated with cognitive decline and diseases of isolation, so higher rates of depression, anxiety, and other psychosocial disorders.
With the health risks piling up, why isn't screening more common?
One issue is recognition. Too many seniors and families may see it as "just part of aging." But there's also social stigma. People are both embarrassed they may have a disability, and they're often in denial as a result. It often takes 7 to 10 years from the time that someone first realizes that they have hearing loss to the time that they first get a hearing aid.
Once people get diagnosed and fitted for hearing aids, there are still challenges. Even though hearing aids are now smaller and less noticeable, people still need to adapt to them. It's important to encourage people to wear them every day for a month. This helps people get used to a new and more "digital" hearing experience. And it gives their brain a chance to remodel around this new information input. Unfortunately, many hearing aids end up in a dresser drawer or returned because people don't give their brain a chance to acclimate. So follow-up to find out if they're being used.
Only when people can hear well can they be part of the conversation.
For more, also check out this brief interview about best practices when talking to someone with hearing loss.
While we all look forward to the day when a family member is told they can go home from the hospital, taking someone home and feeling you can take care of them well is daunting.
And it's often on that last day that family caregivers are told what they need to do and shown how to do it. So, while people are anxious, their minds crowded with questions and concerns, and working memory is less than ideal, we try and tell them what to do.
Michelle Van De Graaff's experiences led her to pilot a way to involve families in care at the hospital. When in the Peace Corps in the Republic of Kiribati, she noticed that family members provided much of the care for their loved ones while in the hospital. After returning from the Peace Corps, when caring for her own child with a congenital heart problem, she noticed how calmly the baby tolerated treatments when she or her husband held the child. As parents, they actually provided a sort of palliative care the clinicians couldn't.
Many family members want to help, but often feel intimidated by doing hands on care. Michelle began a program called "Partners in Healing" to invite family members to become part of the care team. Most accept, then get training on things like monitoring fluids, understanding why and how often to use an incentive spirometer, or in the ICU they may help apply lotion. They get a badge and a checklist where they can help record what they do (like helping with passive motion exercises). They're also shown where things like ice and pillows are, so they can help themselves.
This process also gives family caregivers a chance to ask questions they may not know they have until they start caring for a loved one. When home is the first place family caregivers do hands on care, they often have a lot of questions and no one at hand to guide them.
Family members often experience time in the hospital as endless waiting and anxious watching. They are present, but often don't know how to help or when to chase down a nurse. Utilizing this time in the hospital to train family caregivers, changes those interactions. And it gives them agency both at the hospital and as they bring their family member home.
Catch up with Geri Lynn November 9-10 at the National Caregiving Conference in Chicago. She's cohosting 2 panels and a participatory lab at the Family Caregiving & the Workplace Summit.
Nurse family caregivers, CNOs and CXOs will discuss the impact on nurses and the organizations that employ them. If you're a nurse, nurse manager, director, CNO or work in hospital leadership, you can participate in the surveys here.
It's often challenging for people to express the often complex and confusing experiences of illness, surgery, recovery, or caregiving. And not all of us have a place we can turn to like a piano or canvas to express ourselves. Even asking people to draw a simple image can be daunting.
Consider "Caroline." She has bipolar disorder and struggles to help her son and family understand how she feels during a manic cycle. She was part of an clinician-moderated outpatient group at McLean Hospital that was sharing personal experiences with other patients.
One way to change the conversation and make it more engaging is to have people create and share expressive images. People can start with a stock photo or take their own photo.
Next, she used an app that made it easy to transform that photo into an expression of an experience, thought, or feeling. As you can see below, she transformed the photo from everyday wires on a floor to an expressive image of her experience of mania.
Caroline shared the image with the group and her family. It helped her show and express how she felt. And it allowed her to describe and speak to the image in a very personal, novel, and meaningful way.
"It's instrumental in helping deliver more effective treatment.
It's as though creating the image is a window into what they're experiencing. And it helps them to describe and articulate what previously seemed indescribable.
These images can be printed, turned into slideshows, or used to create a digital recovery plan the patient can take home. The app, called MyMoments, is licensed to healthcare organizations along with training and support from a nonprofit organization called the EDI Institute. It's then available to patients, clinicians, and others for ongoing use.
Others in this small group of colleagues saw and created entirely different storylines from the same image. One spoke of gratitude, another of self care -- but all reconnected with purpose and in the process of self rediscovery recognized all that they shared in common. This proved to be a deep and meaningful discussion that brought all the members of the team closer than they were when they entered the room.
This is one way an easy-to-use resource helps people express their stories, fears, and perspectives on where they are so they can communicate and share it with their clinicians, peers, and families.
How else do you help your patients and caregivers get out of the standard ruts to express themselves so they can engage in new and meaningful conversations?
Dr. Michael Bennick is the Medical Director of the Patient Experience and Chairman of the Patient Experience Council for Yale-New Haven Health System. He is an Associate Clinical Professor, Department of Medicine at Yale University School of Medicine and a Fellow of Trumbull College at Yale University. He began his professional life as a sociologist interested in how individuals find meaning within the communities they reside. This led him on a journey which brought him to internal medicine. The patient has been the focus of his attention for more than 3 decades.
I spend a lot of time in hospitals, but it's not where I was planning to spend Memorial Day. An older relative hit her head ad broke a couple of ribs – and so there we were.
I sat in the room as a nurse explained how and when to use the incentive spirometer to prevent pneumonia. Then something simple, yet amazing happened. He took an extra minute to explain that the pain of the broken ribs would prevent her from taking full breaths. And how using the spirometer to take deep breaths in would expand more of her lungs. That way, those small air sacs in her lungs wouldn't collapse, fill with fluid, and get infected.
It was like hearing the last puzzle piece snap into place.
She got it, she understood the importance of the deep breaths, how her participation is what would make the difference -- and she was on it. She even started to explain it to the doctor when he came by.
We often THINK we're connecting the dots for people. But are we giving them what they need?
Is it enough to tell people an incentive spirometer will prevent pneumonia? Probably not. I don't think it's about giving a full A&P lecture – but enough information to give people that insight into why and how – so their brain gets it.
Obviously, people want to have a smooth recovery. And I kept explaining one of the reasons these things help with healing are because they improve blood flow. But most people were still a bit stymied. They think of their bones as needing calcium, but not blood. It seems like a different system. It just wasn't clicking. So starting with a little more on how the bones need blood put that extra piece in place so it made sense.
People were surprised and confused by the recommendation to get a dental checkup before joint replacement surgery. Telling people that gum disease or things in their mouth could lead to an infection in a hip or knee joint didn't resonate. But explaining that any bacteria in their mouth could travel through their blood to their new joint helped it come together.
Are there best practices or instructions people rarely follow?
If so, take a step back and ask why it isn't clicking for them. What's missing in the explanation to them that we often take for granted? We forget what it's like not to know the why or how of so many things we ask people to do.
Share your insights where you've seen it click for patients and families.
A core challenge health systems and services providers face in patient engagement is attention. Thinking about one's health care proactively requires thinking about one's mortality, and who wants to do that?
Consequently, most patient engagement and patient experience centers around the few moments when people are required to think about their health: medical appointments, hospitalizations, discharges, and pharmacy visits.
Lately, a new touchpoint in the care journey is emerging as an important opportunity to build patient experience and drive greater patient engagement: non-emergency medical transport (NEMT). NEMT is any transportation service for people who aren't in an emergency situation, but who need more assistance than a taxi service provides. It is a fast-growing segment in the healthcare workflow, where stakeholders can capture the attention of the patient or family member while they are already thinking about their care.
The recent entrance of Lyft and Uber into healthcare, Ford Motors' GoRide, as well as several venture backed startups such as Circulation Health and RoundTrip provide solutions for the over 3.6M Americans who miss at least one medical appointment each year. The annual cost of missed appointments in the U.S. is $150B (including lost revenues and idle labor). And the Centers for Medicare and Medicaid Services (CMS) will begin to reimburse NEMT for medicare advantage beneficiaries. This new touchpoint in the healthcare experience is here to stay.
If stakeholders are able to solve transportation for the patient during appointment scheduling and reminders, the focus of outreach can shift to preparation. Scheduling can transform a neutral process to a positive one, with patients able to focus more on their care. Hospitals could take information from the medical record and send SMS or email reminders along with tailored questions for patients to consider as they get ready for their upcoming appointment.
The ride itself is a valuable, defined window of opportunity to provide patients with information about their condition, community resource information via their own app, or utilize the NEMT provider app. During the trip, patients and family members could interact with chatbots, or take a call with a healthcare professional to provide basic information to make the appointment more productive, or enable hospital labor to be more effective during the appointment. For example, Circulation is currently rolling out pilots to prove the effectiveness of healthcare engagement during transportation. Patients are a captive audience during these trips, presenting stakeholders with the opportunity to engage them with important healthcare information such as pre- and post-visit data, or content to promote vaccine awareness.
The NEMT ride back from an appointment may present an even greater patient engagement opportunity than the ride there. During this time, patients are in a mindset to reflect, and could digitally record or answer any questions people have. They could review their care plan and go over next steps. After all, how many times have you thought of a really important question after you have left the doctor?
NEMT is not free of challenges when it comes to engagement. It requires coordinating multiple stakeholders, whether it's the health system, the NEMT provider, or even the driver, to make the experience work. When it comes to drivers, NEMT requires training a new labor force of transportation drivers that are prepared to provide not just a ride-sharing experience, but a healthcare experience.
Creating an effective NEMT patient engagement experience requires both a time and capital investment with results that must be quantified. However, NEMT presents a rare opportunity to create new experiences, and gain valuable information and access from patients while they are in transit.
• I feel guilty taking vacation because I know we're understaffed right now.
• Do I feel safe walking from the parking lot to the hospital?
• Do I feel safe at work from injuries, falls, equipment issues…?
• Is my job secure?
• If I report this problem, will I get blamed for it?
• I don't know which is harder: taking care of patients all day at work, or caring for my sick loved one every other waking hour.
These are some examples of concerns that come up on safety culture surveys at hospitals. Caregivers and staff are often on alert or surveillance mode throughout their shifts, not just for their patients' safety, but for their own safety and well being. In some organizations, this includes going to or coming from work: crossing through dangerous intersections on their way in.
At first, it may sound trivial – but it's not a good way to start or end your day – dodging traffic and worrying about your own safety. While we remove carpets to reduce patient falls and add checks to ensure the right intervention is being offered to the right patient, how to we ensure our caregivers and staff feel safe?
We all know patient-centricity doesn't work without attention to person-centricity of employees who deliver an experience where people feel safe and cared for. Sometimes the lowest hanging fruit to improve patient safety is to improve the physical and psychological well being of the caregivers. Healthcare is about relationships and complex interactions, so staff can only interact well with patients and families if they feel safe and at ease. It allows them to focus on the needs of others.
A nurse suggested that every month they celebrate a useful safety report and the person who reported it.
A physician suggested someone should be available to who staff can talk to confidentially for emotional support when they feel burned out.
While some suggestions might be on the organization's to-do list, hearing what's important to the caregivers can help prioritize where to start. Staff who feel cared for provide better and safer care.
Here's question: when a patient comes in for an appointment, a test, procedure, to the ED, or is diagnosed with a new condition — how many patients are in the room?
If a family caregiver or care partner came with them, there's probably at least 2. We now know that informal caregivers don't just have problems like poor sleep and depression, but are at risk for a large range of health issues: injuries, social isolation, substance abuse, strokes, heart attacks, chronic conditions, and increased frailty. They often skip their own medical appointments, stop eating well, or getting regular exercise, and they're often stressed. Studies show that years of caregiving stress can impact their immune systems for up to 3 years after caregiving ends,1 take many years off their life,2 with a number of caregivers pre-deceasing the person they care for.
The more I think about it - because we can know when caregiving begins or escalates, it's a discrete moment in time when we can both give the caregiver the support and resources they need to prevent serious health issues and help ensure patients get good care and support at home.
Unfortunately, people often don't self-identify as family caregivers. And they don't ask for help, because they don't realize how their life is about to change. I work in healthcare, and it took me a few years to recognize that I was also a caregiver for my dad — let alone that it was having an impact on my health and well being.
How might we better understand who cares for the patient, and who cares for the caregivers?
Talking with people is helpful, but the Atlas of Caregiving found that when you have people draw their caregiving situation, it adds dimension and details they often haven't thought about. This can reveals surprising insights — and it's a way to introduce the topic and help people identify as a "caregiver." It can help normalize it. After all, people often assume the chaos they experience with caregiving is unique to their family.
• Do they live with the patient, nearby, or do they caregiver from a distance?
• What does their support network look like?
• What's their relationship to the medical caregivers?
• Are there others in their network who aren't being leveraged and could help provide support?
CareMaps can be done with paper and pencil or with a new, free desktop app. And they provide surprising insights. A CareMap for a woman who had been caring for her husband for many months revealed she was also caring for a disabled child at home. The care team had no idea, and realized when they were asking her to bring him for appointments or other tasks, they were creating other challenges.
CareMaps are a snapshot in time.
Have people update their CareMap over time. This can also provide valuable insights. I've spoken about my own distance caregiving experiences for many years and only after drawing my own CareMap did I realize that my mom's best friend (who is a fierce advocate for her locally and often gives her rides, etc.) usually goes away for the winter. But we didn't recognize, let alone plan for this.
I also realized my mom, who is in her 80's, is a key caregiver for many of her friends. So when she's out of commission, it's nontrivial for many other families who rely on her to look in on their parents or aunts in her senior residence. But I also hadn't thought about how much of her identity and sense of worth comes from the care she gives.
A couple short videos can quickly walk you through how to create a CareMap. Do one, and see what you learn. Then try it with the informal caregivers you work with.
• Catch her in a panel on family caregivers and care transitions with MaryAnne Sterling, Danny vanLeeuwen, and Amy Cain at the Beryl Conference in Chicago.
• Also on April 17: join Geri, MaryAnne and Danny for the Chicago Participatory Medicine Reception in the Living Room at the Chicago Hyatt.
1. Glaser, J. & Glaser, R."Chronic stress and age-related increases in the proinflammatory cytokine IL-6." Proceedings of the National Academy of Sciences, June 30, 2003.
2. Epel, E.S. et al, From the Proceedings of the National Academy of Sciences, Dec 7, 2004, Vol 101, No. 49.
We are social beings. And social connectedness makes us feel safe so that we can relax, sleep, grow, and maintain our health. When people are isolated from others, research shows this leads to a variety of health issues including depression, being ill more often, and having longer-lasting illnesses.
But it's a personal and sensitive topic, so people are often don't volunteer that they're isolated. People can become isolated at any age for a number of reasons and life changes -- for family caregivers of any age: their social network contracts and as they focus on their family member. And young adults who are heavy users of social media often feel socially isolated. Now that we know social isolation is an underlying contributor and cause of un-health — how might we address it?
"Karen" age 55, takes care of her husband "John," who has Parkinson's. For both of them, it became hard to go out, to see friends, and even good friends came by less. Both Karen and John became more isolated at home. John's doctor recommended a seated exercise class. They went, and not only did it help his muscle tone and function, but he met others coping with Parkinson's, and she met other care partners. Soon they were finding other classes and going to 3, even 4 classes a week. Would they have gone to a support group? Maybe, but certainly not as frequently. And it was more natural social connection, and less stigma of needing support.
How can clinicians and care providers address social isolation?
While it feels like there's not enough time in the day to really get to know patients, just asking 2 or 3 questions at intake can create connection, insights and help identify socially isolation.
1. What are your favorite activities/hobbies and how often do you get to do them?
2. Who do you most look forward to spending time with?
3. Do you volunteer anywhere or are you interested in volunteering?
You could also ask a new question each time patients come in — or have them fill out a 3 question survey in reception. This can help you suss out who is in the patient's social circle (and potentially circle of care) as well as what they care about to proactively make it part of their care plan.
Does your patient garden, cook, read, play cards or love old movies? Any of these can be leveraged for new social connections. Social workers, websites, the library, or religious organizations often have lectures, book clubs, cooking classes, or volunteer opportunities. No one can be versed in all the local goings-on, but knowing a few organizations that provide free social gatherings can help you know where to point patients, without geography or cost becoming a barrier.
Also, keep in mind that people usually need some help or a good excuse to show up the first time. After all, you need to feel safe to socially engage. So just like you'd help someone set a health goal, action plan this with them. Could a friend or neighbor go with them? Might another patient with similar interests meet them or start a book club with them? Do they need help figuring out how to get there?
These are another great way to bring people together in the name of health and have them meet, interact, and support each other. What about hosting a stress reduction or better sleep class? New friendships grow out of groups - and people feel they're not the only ones dealing with a chronic condition or challenge.
How will you help address social isolation with your patients? Share what you try or are thinking of trying.
Diana Deibel is a Senior Voice UX Designer who has worked for years in the healthcare space, crafting connections between patients and clinicians and helping motivate patients on tough topics. You can find her on Twitter, ready to chat @dianadoesthis.
Time For Your Social Network's Colonoscopy: Helping people take action and gleaning new insights.
Preventive medicine is a great way to prevent and treat problems early. But there's a problem: while clinicians recommend flu shots and screening colonoscopies and insurers often pay for them, participation rates are low.
Are people aware of the risk?
Do they understand the guidelines regarding who should get screened?
And do they have any sense of urgency to take action now?
And a colonoscopy is an embarrassing ordeal, right?
People don't usually think of clinicians as experts in these topics and look to their peers. And their peers are only a click away.
At age 63, David Ron was diagnosed with colorectal cancer. Sadly, it took his life 3 years later. David created a one minute video that posted to Facebook when he passed away. In it, he talks about why he postponed screening for 13 years. He felt healthy and thought his risk for colon cancer was remote. So he didn't see the point. Then symptoms appeared, and it was too late. He encourages people to get screened and avoid his fate.
The video (which can be viewed here) went viral. In Israel, it was adopted by organizations fighting cancer; they created Arabic, Russian and French subtitles and boosted it across Facebook. It's been seen by over 400,000 people in the past year. Many younger people asked their parents if they'd been screened and nudged them to go. It's hard to assess the impact on actual screenings, but initial measures showed that at least 1% of people who saw the video were motivated to get screened. And it contributed to the larger task of normalizing the conversation.
A personal story is always compelling, but most people don't talk about their colonoscopy or stool test over drinks or dinner. However, on social networks people are more comfortable posting, commenting, "liking" and sharing about uncomfortable or controversial topics. They vocalize their opinions, get feedback from their peers and friends, and influence other people's minds.
So, in a world where people don't get to spend much time with their doctor and where clinician recommendations can be seen as checking a "good patient" box -- or may even be suspect as unsafe (think vaccines), people turn not just to Dr. Google, but less consciously to the their social networks. They learn if others are getting the flu shot this year, or getting colonoscopies or mammograms at age 50. They may not go online looking for this, so much as absorb it in the chatter and conversations.
Turns out, this is a big deal. Because if you come to believe an action is thought of as standard or normal in our culture (a social norm) and you believe your peers and people you respect think you should engage in a behavior (subjective norms) those both play a critical role in your decision to take action. Yep, you're more likely to do what your friends and peers are doing. And social networks are now a major place where people get those insights.
A network like Facebook is a good source of data. Every like, share comment, video view, and click is aggregated and segmented. Artificial Intelligence or "AI" can sift through the data and identify patterns and provide insights.
For example, the African American population has a higher risk for colon cancer and should get screened earlier, at age of 45. Yet, screening rates are low. To understand why, 30 different interventions were used to educate people about colon cancer screening and collect data on Facebook. Some were short videos of a local doctor talking about: risk of colon cancer, pros of colonoscopy, the prep, sedation, time off work, costs, etc. These were delivered to people over 45 in a geographical area (250K people fit criteria). The AI picked up a pattern revealing that young African American males in the 45-50 age range responded especially well to messages about sedation during colonoscopy and open access, which reduces time off work.
Anyone working in a hospital or clinic can be both a professional and a peer. Want to normalize advanced directives or flu shots? Have anyone on staff who's gotten the vaccine or done their directives wear a button or badge that says they got or did theirs.
Conversations from peers can help normalize, reassure, and encourage others in the group to take action.
Consider how to use social networks as part of your patient engagement strategy.
Do you have a Facebook page, Twitter chats, or other social media presence? The combo of AI and social networks can lead to important insights on what people are saying and what messages resonate with various groups.
It was a question Victoria never expected to hear from a surgeon, before engaging in a dialogue about his recommended treatment plan. In that moment, she was in control. In a vulnerable situation, she had the opportunity to be the author of her own story.
Just a month before this conversation, I'd been rapidly intubated while still awake to secure my airway, which was closing due to an infection called Ludwig's Angina. Maybe it was genetics, maybe it was the intubation, or both, but a tremendous amounts of scar tissue formed on my vocal cords. This left my voice sounding raspy -- like I was a chain smoker or always sick.
The recommended course of treatment was 6 months of speech and vocal therapy, followed by surgery if my voice hadn't improved. Six months of vocal and speech therapy passed and surgery was still on the table.
My physician laid out both options for me and explained the pros and cons of each. For me, the recent memory of being intubated while awake was still fresh my mind. So, the idea of choosing to go through surgery, was frightening. While he explained that I'd be fully asleep for the surgery, he also took the time to understand my emotions. He saw that information alone wasn't going to change my mind. And he respected my emotions, which created trust.
It helped to know that it wasn't a limited or forced suggestion, but simply an option for my own personal quality of life. His opinion wasn't interjected, or I didn't feel like it was. He shared his knowledge, and I had the opportunity to share my thoughts and emotions and make a choice. I feel like people can never have too much information. Knowledge is power when making a decision about your life. That said, our experiences and emotions are important.
So, I had to answer that quality of life question. What did I want? And How did I feel? I decided it wasn't right for me.
There's a lot of research and articles on patient reported outcomes and personalizing care leading to overall improved outcomes. I believe that personalizing care is essential. When we switch to the paradigm of person-centered care, we give individuals the ability to decide their own destiny. When you take the time to truly develop relationships with individuals, you have the opportunity to learn what's important to them and to personalize care to fit their dreams and aspirations.
So, will I ever have surgery on my vocal cords? Well that's to be determined! For one thing, I like sounding like Nora Jones -- being able to sing like her would be even better.
For me, my voice is also a reminder that I survived an obstacle I wasn't expected to see the other side of. But more importantly, my voice is a reminder of a surgeon who put down his pen, looked me in the eyes, considered my thoughts and emotions, and let me determine my future -- a situation and dialogue I did not know or believe I would ever experience.
The experience changed my voice both literally and figuratively. I lose my voice frequently. It used to be a deterrent for me in loud situations because I couldn't talk to people, so I just wouldn't go to parties or events. But I talk every day for work, I do public speaking, and I interact with people daily. It causes challenges, but Throat Coat® tea and voice exercises have helped me through those challenges. But I found my patient voice, articulating and advocating for the patient experience.
Patients, clinicians, and healthcare organizations all want people to feel better so they can live their lives to the fullest. Unfortunately, the side effects of treatment can get in the way.
When first diagnosed with complex regional pain syndrome (CRPS) Mia's physiatrist prescribed five medications. Not surprisingly, it was confusing which medication was supposed to help with what symptoms. By the time Mia came back the following week she was more miserable: agitated and unable to sleep, she had a rash on her face, and was sick to her stomach.
Turns out, she was sensitive to a lot of medications. Although she wanted to be a "good" patient, she couldn't keep taking the meds. But her doctor was hesitant to make any changes and didn't offer alternatives. Mia left feeling scared, frustrated and like the side effects she experienced weren't being taken seriously.
Mia was diagnosed with chronic migraines. She got relief from medication, yet it also made her dizzy, nauseous, and tired. This time the side effects conversation was different. Her neurologist worked with her through many rounds of medications and figured out if she took them as needed just on really bad days it helped her avoid the side effects, while still providing pain relief.
As a family caregiver, Geri had a similar experience when medications her dad was on in the last years of his life caused his skin to thin and itch.The itching drove him crazy and kept him and those taking care of him from getting decent sleep. As a family caregiver, it was frightening to scratch his back, hoping to give him relief but not tear his fragile skin. When the family brought up the itching with his team, it was discussed as more of a nuisance -- the cost of treating his conditions.
Side effects are challenging, especially when patients take more than one medication. But even with a single medication one study that looked at statin side effects, found that 87% of patients reported telling their physician about side effects, and unfortunately physicians often rejected a possible connection to the medication. What would you do? Keep taking the medication ...or become "non-adherent"?
It doesn't take much to change the tone of the conversation and affirm a symptom may be due to a medication and that it's a real issue. Even when complaints don't fit into documented side effects, if we want people to engage in their plan of care, working this out can make all the difference to their peace of mind, quality of life (QOL), and participation. Letting people know you'll work with them to find the right treatment where their QOL is improved builds trust.
Patients can also report side effects to the FDA on MedWatch. This can also help people know they're contributing to a better understanding of side effects for everyone.
People want to feel better and it's hard when treatment makes them feel worse or causes a new problem. People don't like to challenge their care team or seem like complainers, so by the time they tell you about a side effect, it's probably really bothering them.
rushed to the ER. A CT scan of her brain showed a large mass, and after a nine-hour brain surgery she was diagnosed with a gemistocytic astrocytoma -- a slow growing, but malignant brain tumor with a high rate of recurrence.
Six months after Salmi's first surgery her tumor grew back sending her into a whirlwind of treatments over the next two years, including a second brain surgery, struggles with seizures, a rigorous schedule of physical and occupational therapy, and 24 months of chemotherapy.
Fortunately, Salmi received excellent care through her neuro-oncology nurse practitioner.
But Salmi never knew the kind of care she was receiving had a name until five years after she completed treatment and started working for a healthcare nonprofit advocating for access to palliative care for all people facing serious illness.
Why did Super Awesome Nurse never tell Liz she was receiving palliative care? We asked her!
"While I, as the healthcare provider, may have viewed much of the care that was being rendered as palliative in nature, not all patients are ready or willing to consider that most types of brain tumor care is palliative," said Mady Stovall, NP, former neuro-oncology nurse practitioner and current PhD student at Oregon Health and Science University.
Avoiding the term "palliative" initially is understandable. After all, there's a lot of confusion between palliative care and hospice. And no one wants to cause panic that a condition is more serious or has suddenly become more serious.
However, if Salmi had changed health systems or had to find a new provider, she would not have had the words to translate the care provided by this "super awesome" nurse to make sure it continued or was re-initiated as needed. She didn't have the language to ask for that care and advocate for herself.
While we shouldn't overwhelm patients with clinical language, helping them understand what things like palliative care ARE and ARE NOT improves their ability to advocate for themselves.
In fact, it was only after her recurrence that Salmi learned about oncology social workers. Had she known about this role, she would have asked for it when going through surgery and treatment for her initial tumor.
Not everyone is going to become an expert patient in health communications, but educating patients and families as they get and make decisions about care can help them tell us what is most important to them.
*As an additional note we are proud to announce that Liz and Geri will be part of a panel at Stanford Medicine X on advance care planning. Joining them will be palliative physician Dr. Michael Fratkin, researcher Rebecca Sudore, and MD/JD: Dr. Aretha Delight Davis.
Frieda knew she'd recovered from what would have been an epic patient engagement fail. Instead, she used that 15 seconds to establish credibility, value, and concern, but most importantly, to get at why a medication review was meaningful for Monica. She picked a common side effect that would instantly grab Monica's attention. Otherwise, the call might have been seen not as a service, but a nuisance — a call to update records. Or Monica may have suspected the call was gathering information to see if her insurance should keep paying for her medication. But a "medication review" didn't immediately sound like something that would benefit her.
We often assume patients and families know why we're asking them certain questions or to do certain things: We repeatedly ask them about pain levels, tell them to avoid salt if they have heart failure, or recommend caretakers rotate bedridden patients frequently. But the value we recognize and take for granted is often not immediately obvious to patients, and that makes it even more important that we, as provider, articulate those benefits up front.
Even when a patient is admitted and we ask them to repeat and confirm information, patients often don't see the value. Instead, the repeated questions can seem annoying or even incompetent. But opening the conversation with, "To make sure we're keeping you safe, I'm going to re-ask you a few questions…" can shift patients' reluctance to cooperation and trust.
How can we present ourselves as approachable?
There is no cookie-cutter approach to establishing rapport. A tactic like the side effect question can quickly engage a patient who otherwise might not see a medication review as beneficial; but there are other ways.
Reframing this question into a more insight format kills two birds with one stone. Not only can a provider further improve patient rapport by demonstrating compassion and insight, but it creates an opportunity to develop a more open and fluid dialogue. And in a world where providers are pressed for time to connect, this can go a long way.


He was caught for drug dealing in 2007 and was sentenced to 151 months in prison. It was at that time he pleaded guilty to bail jumping in order to get a deal that would limit his stay in prison to no more than two years.
The judge wasn't going for that, however. He claimed the bail jumper had made a "mockery of the constitutional right to bail" and made sure he got more than twice the two years – five years in total.
An appeal was made, but the Second Circuit Court of Appeals in Manhattan upheld the decision.
In other news, a fight between a former student and a school aide near a middle school in Queens resulted in hospitalization for one person and a sprained ankle for a dean who attempted to break up the fight, sources have revealed to New York Criminal Lawyers.
The argument between the two women started inside the school and moved outside, where their confrontation turned violent. During the fistfight on the playground, the dean attempted to intervene, but fell down as the others continued to fight.
Both of the fighters were arrested and charges are still pending.
One of the combatants was taken to the hospital, bleeding from the head. Authorities told N York Criminal Lawyers that none of the wounds were serious.
There is no criminal charge a New York Criminal Lawyer is not prepared to defend against. It is your right to have a swift and fair trial. You can accomplish this with a New York Criminal Lawyer at your side.


Dr. Skibba is a cardiologist in the Hartford area. He is affiliated with Owensboro Health Regional Hospital and Ohio County Hospital.
Dr. Skibba saw more cardiovascular disease (CVD) patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba treated prostate cancer screening patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for prostate cancer screening in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated home-based physical therapy patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for home-based physical therapy in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated glycosylated hemoglobin (A1C) test patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for glycosylated hemoglobin (A1C) test in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated X-ray patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for X-ray in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated cholesterol test patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for cholesterol test in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated more SPECT scan patients than 75% of similar doctors in the Owensboro area for 2014–2018. Learn more.
Dr. Skibba treated complete blood count (CBC) patients in 2014–2018, but we couldn't determine from our database whether he was was a top doctor for complete blood count (CBC) in the Owensboro area during 2014–2018. Learn more.
Dr. Skibba treated more echocardiogram patients than 75% of similar doctors in the Owensboro area for 2014–2018. Learn more.
Dr. Skibba treated more electrocardiogram (EKG) patients than 85% of similar doctors in the Owensboro area for 2014–2018. Learn more.
Dr. Skibba saw more pain patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more obesity patients than 95% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more heart disease patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more vascular disease patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more shortness of breath patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more heart valve condition patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more high cholesterol patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more costochondritis patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw weakness patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw more coronary artery disease (CAD) patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more swelling patients than 85% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more irregular heartbeat patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more diabetes patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw type 2 diabetes patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw more atrial fibrillation (Afib) patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw more fainting patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw lung condition patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw dementia patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw venous insufficiency patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw congestive heart failure (CHF) patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw heart failure patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw peripheral vascular disease (PVD) patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw more peripheral artery disease (PAD) patients than 75% of similar doctors in the Owensboro area in 2014–2018. Learn more.
Dr. Skibba saw headaches patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw anxiety patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw digestive tract conditions patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw cardiomyopathy patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw deep vein thrombosis (DVT) patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba saw acid reflux patients in 2014–2018, but we couldn't determine whether he was a top doctor for the condition in the Owensboro area. Learn more.
Dr. Skibba sees patients and can be reached at the following locations.
Dr. Skibba is able to admit and treat patients at the following hospitals.


Taylor Swift may have a new boyfriend, but she's going to great lengths to keep the relationship private. The 27-year-old pop star is reportedly dating British actor Joe Alwyn, according to E! News.
Taylor is reportedly renting a house in London, but she has gone to great lengths to maintain her privacy. The Sun (a British tabloid) reports that the relationship is pretty serious at this point.
Sources say Swift is just trying to prevent the hype that surrounded her 2016 relationship with Tom Hiddleston. In fact, there are rumors that Taylor is using wigs and disguises to stay under the radar when she goes out with Alwyn.
Alwyn is a 26-year-old theater and film actor who lives at home with his parents. He is currently co-starring in The Favourite. Emma Stone is also starring in that movie. Stone and Swift are, of course, pretty close friends.
Taylor's reps have not commented on the relationship. She was spotted in public this weekend (May 14) for the first time since January. Taylor was photographed at her mother's home in Nashville.
We heard last week that Taylor has been spending her days working on new music. In fact, reports say that we may get to hear new music from Taylor this year.


text:
3 minute readJanuary 24, 20237:48 AM UTCLast Updated ago
Myanmar activists, victims file criminal complaint in Germany over alleged atrocities
BANGKOK, Jan 24 (Reuters) - Myanmar activists and 16 alleged victims of abuse have filed a criminal complaint in Germany, accusing top generals of instigating genocide against Rohingya Muslims and other atrocities since a military coup two years ago.
The filing is the latest in a series of international legal efforts to try to hold the Myanmar military accountable for alleged atrocities against the country's Rohingya minority and democracy supporters and civilians opposed to the coup.
Fortify Rights, a human rights group backing the complaint, said Germany was picked because of its recognition of the principle of "universal jurisdiction", which holds that a national court can try individuals accused of serious international crimes.
"The complaint provides new evidence proving that the Myanmar military systematically killed, raped, tortured, imprisoned, disappeared, persecuted, and committed other acts that amount to genocide, crimes against humanity, and war crimes," Matthew Smith, chief executive officer and co-founder at Fortify Rights, told a news conference in Bangkok.
A spokesman for Myanmar's military government did not answer a call seeking comment on the complaint filed in Germany. The military has in the past denied rights abuses.
Fortify Rights hopes German authorities will take up the complaint and launch an investigation.
A German court last year jailed a Syrian ex-intelligence officer for life for murder, rape and crimes against humanity, marking the first conviction for state-backed torture committed during Syria's civil war.
The German embassy in Myanmar could not immediately be reached for comment.
The 16 individual complainants in the Myanmar filing include ethnic Rohingya and others who survived or witnessed crimes in Myanmar since the coup, Fortify Rights said.
'TOTAL IMPUNITY'
The International Court of Justice has been hearing allegations that Myanmar committed genocide in a case brought by Gambia after hundreds of thousands of Rohingya fled to Bangladesh to escape a Myanmar military offensive launched in August 2017.
Last year, another civil society group, the Myanmar Accountability Project, said Turkish authorities had initiated a preliminary investigation after it filed a case against members of the Myanmar junta over alleged atrocities since the coup.
In the case of the Rohingya, Myanmar authorities have previously said security forces were carrying out legitimate operations against militants who attacked police posts.
The junta has also denied the military had carried out atrocities since the coup, disputing casualty figures given by activists and terming opponents "terrorists".
Akila Radhakrishnan, president of the U.S.-based Global Justice Center, welcomed the filing of the complaint in Germany saying that, along with other accountability processes, it could help "pierce the total impunity the military has been afforded for far too long".
The military ruled the former British colony with an iron fist for years before a decade of tentative reform from 2011, during which Nobel Peace Prize laureate Aung San Suu Kyi led a civilian government.
Suu Kyi has been in detention since her government was overthrown in 2021.
Fortify Rights is an independent non-profit organisation based in Southeast Asia and founded in 2013, funded by donations from Europe, Asia and the United States, including from private foundations.
Reporting by Panu Wongcha-um and Poppy McPherson in Bangkok; Writing by Ed Davies; Editing by Robert Birsel
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redpajama_set_name: RedPajamaCommonCrawl


I can see you in all you do.
You tried to bring me down once.
But it was you who fell.
You thought you could be higher than me.
But it is I who is above all.
This time as the Mighty Roaring Lion.
You will be put asunder.
Thrown away in fire forever and all eternity.
Know this: It is but for a short while.
Your time is almost run out.
Then you will have your time.
Then Heaven and all its hosts will descend.
Then I will come for you.
In all my glory and blinding countenance.
You will burn in the Lake of Fire.
Then the Day of the Lord.
There will be peace never ending.
I, on my Throne of Glory.
I shall reign, I shall reign!


It is 900 years after the Great Nuke and civilisation is in a state of barbarism. There are small communities (Komes) of frals (women) who keep plugots (men) subservient either as seeders (breeders) or machos (slaves). Korvis leads a group of men in an escape from the Frisco Kome. They set up their own community Camp Reagan, frequently venturing forth to raid the women's Kome. Fleeing after one sortie, Korvis discovers an ancient nuclear missile silo. He returns with a ghetto blaster, weapons and wearing a contamination suit and is thought so fearsome that he is declared the mythic President who it is believed will one day return to reunite humanity. He and the Camp Reagan men begin a ruse to fool the frals into believing that he is The President. Korvis discovers a mutual desire for the Fral Tiara (leader) Vena. At the same time, visiting frals from other Komes are conspiring to overthrow Vena and establish her more warlike sister as Tiara so as to eliminate Camp Regan.
During the 1980s, Israeli-born, American-based producers Menahem Golan and Yoram Globus made a good many films, which were released under their Cannon distribution label. Most notably, they gave an entire career to Chuck Norris during this time in the likes of Missing in Action (1984), Invasion U.S.A. (1985), The Delta Force (1986), Firewalker (1986) and Hero and the Terror (1988). They also made a number of bad sword-and-sorcery films – the Italian-made Hercules (1983), Sword of the Valiant: The Legend of Sir Gawain and the Green Knight (1983), The Seven Magnificent Gladiators (1985), The Barbarians (1987), Gor (1987) and Masters of the Universe (1987); various Charles Bronson vehicles; several Tobe Hooper productions – Lifeforce (1985), Invaders from Mars (1986) and The Texas Chainsaw Massacre 2 (1986); a series of cheaply fairytale adaptations; and one or two others such as the excellent Runaway Train (1985) and the ghastly King Solomon's Mines (1985).
America 3000 was a bizarre oddity that emerged during this time. Golan-Globus shot the film on the cheap in their native Israel. The only recognisable name in the cast line-up was Laurene Landon who seemed almost in danger of becoming a B-budget heroine in the mid-80s. America 3000 was one of a whole host of films that came out imitating the success of Mad Max 2 (1981), which created a fad for post-holocaust action movies – amid this genre, Golan-Globus also made the more conventional Cyborg (1989). As the Mad Max imitators became legion, some filmmakers started conducting more tongue-in-cheek versions with efforts like Cherry 2000 (1987), Hell Comes to Frogtown (1987), Warlords (1988) and A Nymphoid Barbarian in Dinosaur Hell (1990). America 3000 was certainly one of the strangest to emerge from this mini-fad.
America 3000 is an almost likeable film. If nothing else, it is one of the few films to attempt to realistically portray a future language and recognise the fact that what would emerge would be a decayed variation of the language we speak today. The whole film is spoken in a strange half-recognisable argot – "the world was woggos", "everything was going hot plastic," or people invoking the "Red Cross" as a prayer and the wait for the return of the near-messianic President. In terms of ideas, the film falls somewhere between Gene Roddenberry's tv pilot Planet Earth (1974), with its all-women society that keep men as subservient prisoners, and the Star Trek episode The Omega Glory (1968) wherein an alien society existed as a satirically exaggerated version of the present, enacting decayed, half-understood versions of the Cold War. As such, it all proves vaguely amusing, if an exercise that leaves one scratching their head at the end of it. Certainly, as a concept, it is probably not enough to stretch to a full film. Instead, what one ends up watching are the at least energetically directed fight sequences. The sheer strangeness was far too bizarre for most audiences who ignored America 3000. The film was seen cinematically in only a few places and then released directly to video.
America 3000 is discussed in the Golan-Globus documentary Electric Boogaloo: The Wild, Untold Story of Cannon Films (2014), which holds the amusing scene of Laurene Landon burning her dvd copy of the film in protest against Golan and Globus's employment practices.


Here is a photo we just received from Nate, one of our customers, installing C9 incandescent bulbs along his roofline. He's installing 200 feet of lights on his 3-bedroom two-baths 1750 square foot home.
How many lights do I need to outline my roof?
The long and most accurate answer is measure and calculate your required linear footage along your roofline and gutters. The easy answer is, if you don't want to take time to measure, start with 200 feet of lights and add on if you need to.
The lights are installed across the front of the house, including a small extra area of elevation and wrap around the sides plugging in at each of the back corners of the house. Easy, peasy. This is a great place to start for most folks.
Now Nate just needs a few curtain lights on those fences…..
Enjoy our Christmas lights preparation tutorial as you plan your Christmas light display.
The first key to installing Christmas lights like a pro is to measure before purchasing.
Take proper precautions as you measure and if you find heights unsettling, you might consider calling a local roofing company to help with installation since winter is usually the offseason for many contractors. Tie yourself off when appropriate and practice good "ladder habits" to avoid unnecessary and dangerous falls.
Let's pretend you choose 15 inch spacing bewteen bulbs for 300 feet of lighting.
Second, divide your total project length in inches by the distance in inches between the bulbs.
If you are ordering glass bulbs, be sure to order an extra box to account for breakage during replacement.
Consider adding 10% to your calculations if you have done any guestimating or to account for small changes of plans during install. "Let's run fewer lights than we planned", said no one ever.
If you are using mini lights, LED string lights that are pre-wired, led or incandescent icicle or net lights just divide the lit length of the light string in feet into the total numer of feet. Be sure to round up to the next whole set of lights and consider adding an extra set for good measure.
Sketch out a quick drawing of all the places you are planning to install lights.
Make note of where outlets will be located and note where you need to roll up a light string to tuck it away at the end of a run. If you are using 18 AWG wire C7 or C9 cords, note where you will need to cut your cords. Plan for any plugs, outlet adapters and terminations you might need to have on hand.
An hour or two in planning will save 10 times the time in extra trips to the hardware store and waiting on 2nd and 3rd packages to arrive.
While you are out measuring, take a look at your surfaces to get an idea of what kinds of clips, stakes and hook you'll need.
We've gathered our hardware into easy to shop categories. Check out our application table for clips and hooks to choose the clip that's tailored to your job.
A good choice of hardware can make your job go smoothly and easily.
We hear every day from folks who are installing lights for the first time or for the first time on a new home. Take a few steps before you purchase to make installation simpler and easier.


The University of Washington is looking for subjects to participate in a new study exploring how different genetic events impact behavior in children with an Autism Spectrum Disorder. Participants between the ages of 8 and 17 years old with and without a diagnosis of ASD are eligible to participate.
The study will involve 8 hours of testing at the University of Washington. Subjects will participate in a neurocognitive assessment, neurological exam, EEG, blood draw, and provide a detailed developmental history.
Expenses related to the study visit (meals and lodging) will be covered by the study and subjects will be reimbursed $100 for their participation.


Rules of Survival game continues to experience a new update on Jan 17 with new stuff to find out. So make sure you won't skip this new update because there are lots of nice things you should learn. But before getting deeper into the update, don't forget to check the maintenance times to see when it will happen in your area.
The accomplishment time is an approximation. It can take longer than it said above. But the developers will attempt to get back up sooner.
You are able to rename your character now! With this rename feature, you can switch your names under Rank in the Stats tab easily. But you should remember that you are allowed to alter your name once a month. Let's start to set a new name now!
You can lean left and lean right easily! The lean feature can be allowed in the Operation settings tab, also, you can change the position of every button, size, and transparency in the Custom tab too.
Chicken Grenades were included in the game. They will deal higher damage in a broader range compared to the common grenades. Also, they are armed with special explosive effects.
There are more two ways for earning Tokens. You can get them by sharing a look or trying to rank first in any mode.
The Token Store now has some brand new items, also, the buying limit rules of the Token Store were enhanced.
Elite Supply Boxes were included, this is a brand new kind of supply to get advanced looks. You can get Butler Set pieces through Elite Supply Boxes.
Now you can check out a specific winter event Down Coat sale! Be sure to obtain nice discounts on down coats so you can stay warm during this winter. Remember that it has a limited time!
There are two tabs added to the discount store, including Packs and Looks. Both of them will have common updates.
The advanced supplies underwent an update! The Punk and Dark Rose Sets were gotten rid of from the advanced supplies. The Pure Preppy and Plaid Preppy Sets were included.
More boat spawn points by the shores of the island were included.
The seating capacity of several vehicles was altered. SUV and Cars: developed to 5 players. Three-Wheeler: developed to 11 players.
The throwing distance of throwable items was so much developed. Already solved a bug making the throwables unable to inflict damage on the vehicles.
Made an optimization to the Spectate feature. The players are able to watch over the enemies who destroyed them.
Grown the time the game operates in your devices background before disconnecting it.
Solved some issues caused by Auto Pilot.
Somewhat reduced the definition of cores left by the players who got killed already.
Improved the image of pistol ammo.
The Backpacks, Meds, and Throwables now have some customization options in the Custom settings tab.
Made an optimization to the showing of the teammate markers on the map. You can see the number and status markers of the teammates easily.
Developed the restriction of friends requests.
Made an optimization to the random poses of the character in the lobby.
Now, the players are able to log in the PC version and pay via scanning a QR code.
Solved the bug making the players experience the module loading errors and giving them invisible collisions.
Solved an error making the bulletproof unable to be shown after the players took off the headwear.
Solved a bug making the explosion effects of flash grenades not be obstructed by the modules in the game.
Solved a bug when some meds were shown continuously in the shortcut of meds.
Solved a bug making the real number of some throwables unable to reduce after being utilized.
Solved an error when the meds that were being utilized obstructed the sight of scope.


First held in June 2009, The Saturday Club Women & Children's Consignment sale is a popular bi-annual event held each fall and spring. All proceeds benefit The Saturday Club and our philanthropic support of women's and children's charities.
The 2019 Consignment Sale will be held May 8th through May 11th, 2019. New and returning consignors are welcome! Consignor space is limited, so register soon to guarantee your spot.
For complete information about the Consignment Sale, and to register as a consignor, please visit our Consignment Sale section.


text:
Aleksandrovo (Bulgaars: Александрово) is een dorp in Bulgarije. Zij is gelegen in de gemeente Svisjtov,  Veliko Tarnovo. Het dorp ligt hemelsbreed op 45 km afstand van Veliko Tarnovo en 187 km afstand van Sofia.

Bevolking
De bevolking van het dorp Aleksandrovo bestond in 1934 uit 695 personen. Het inwonersaantal bereikte een maximum in 1946, toen er 766 inwoners werden geregistreerd. Daarna is de bevolking vrij snel afgenomen tot 443 mensen in 1985, 216 in februari 2011 en 194 personen in december 2019.

Van de 218 inwoners in 2011 reageerden er 189 op de optionele volkstelling. Van deze 189 respondenten identificeerden 170 personen zich als etnische Bulgaren (89,9%), 10 Bulgaarse Turken (5,3%), 8 Roma (4,2%) en 1 persoon was ondefinieerbaar.

Plaats in Veliko Tarnovo

redpajama_set_name: RedPajamaWikipedia


text:
Головна News Director of the CUESC Dmytro Bielov hosted the delegation from the North...
Director of the CUESC Dmytro Bielov hosted the delegation from the North University Centre of Baia Mare (Romania) in Uzhhorod National University
In the context of cooperation of the Center for Ukrainian and European Scientific Cooperation with the Faculty of Philology and Cultural Studies of the North University Centre of Baia Mare (branch of Technical University of Cluj-Napoca), the delegation from the education institution was present on October 8–21. Dean of the Faculty of Philology and Cultural Studies Mircha Farkas and Ligia Tomoyaga were among guests. In particular, Ligia Tomoyaga gave lectures students of the Faculty of Foreign Philology of Uzhhorod National University on a topic "Application of modern technologies in learning the English language as a foreign" (Mrs Ligia told students about new approaches, the methodology of learning a foreign language and their importance) as well as "Gender roles in fairy tales: non-ideological approaches".


text:
The Degrassi Legacy and why it matters
In a time when the world was over exposed to glamorised American teenage dramas where teens were being played by thirty years olds a dramatic shift happened. The seeds of this shift were sown in 1979's (although not screened in the UK until 9th July 1984) The Kids of Degrassi Street. Developed by Playing With Time Inc., a production company owned by Kit Hood and Linda Schuyler, the show was like a breath of fresh air to its young audience. Whilst the U.K. had Grange Hill to follow, Canada and soon the rest of the world were introduced to a group of teenagers who looked like them, acted like them, and had the same issues they did.
Initially four short after school TV specials were made: : Ida Makes a Movie, Cookie Goes to the Hospital, Irene Moves In and Noel Buys a Suit, but the genius behind them was that they were interconnected. Allowing the audience to become part of the world they were watching. Long before the MCU and the Arrowverse, Playing With Time Inc. discovered a secret ingredient that others were missing: don't talk down to your audience! As a result, these four specials were lapped up and a series soon followed that ran for twenty-six episodes until January 1986.
This was by no means the end of Degrassi though!
On January 18th 1987 Degrassi Junior High debuted. DJH contained many of the same actors that were seen in the Kids of Degrassi Street but they now had new names and characters. Any confusion was soon forgotten as Playing With Time Inc. followed the same rules that made their first series a success. There was no one star, every character had their chance in the spotlight and we the audience wandered the school corridors with them. Most importantly the show never spoke down to the audience especially as it dealt realistically with bullying, drug use, child abuse, Spike's teenage pregnancy, eating disorders, homosexuality, homophobia, racism, and divorce. Unlike a number of teen dramas at that time, a number of issues were not necessarily wrapped up with a bow by the end of an episode instead they played out realistically over a number of episodes and show real consequences to a characters actions – positive or negative. This realism proved an issue when the show began being broadcast in the UK on 5th April 1988. Parents complained to the BBC that the show was "too strong" in what it was portraying, and it was soon moved from it children's tv slot on BBC 1 to after 6pm on BBC 2. Certain episodes were pulled from being screened before DJH vanished from the schedules by the end of the year.
After three seasons of 48 episodes DJH came to an end as the kids moved onto Degrassi High! Degrassi High was a direct continuation to DJH with the kids now older and dealing with high school issues. The series opened with a pregnancy scare that leads to an abortion and featured storylines around relationship abuse, working and study, dysgraphia, drug addiction, HIV, parents having affairs, sexual abuse, and suicide amongst other issues. Degrassi High ran for two seasons (twenty-eight episodes in total) and led to the Degrassi Talks magazine show where the actors discussed the issues in the show with other teenagers. Once again showing how much those behind the show valued their audience. Throughout both DJH and Degrassi High the issues were dealt with in a respectful way and not in a sensationalist headline grabbing way that many soaps and drams would deliver such an issue.
On January 5th 1992 came the TV movie Degrassi: School's Out. This movie marked the end of the initial Degrassi generation we had followed for the last five years. Rather than keep the characters at school and drag it on longer (which they easily could have) Playing With Time Inc. once again respected the audience enough to let the characters grow up and go on with their lives. Degrassi: School's Out defiantly went out with a bang! Including a scene where Snake (played by Stefan Brogan) makes Canadian television history by being the first person to ever say the word "f**k" on broadcast television!
The Degrassi franchise would remain dormant for a number of years but then it was announced that a new show Degrassi: The Next Generation would pick up ten years later after Degrassi: School's Out. Debuting on 14th October 2001, D:TNG opened with the two part episode "Mother and Child Reunion." The hook of the new generation was Emma Nelson (Miriam McDonald) – she was the daughter of Christine "Spike" Nelson (Amanda Stepto) whose pregnancy and life we followed years before. Through Emma and Spike we are introduced to the new generation of Degrassi children as well as catch up with the old ones, many of whom or now parents or in the case of Snake – now a teacher at the school! Like its predecessors the actors remained within their age range and the issues were plenty and dealt with in a manner that showed respect to the audience and to what was being portrayed. D:TNG ran for fourteen seasons (387 episodes) although from Season 10 it was retitled simply as Degrassi. This in turn was followed up by Degrassi: Next Class that ran for four seasons (40 episodes) until July 2017.
Whilst there is no new Degrassi currently on the horizon I feel it is safe to say that Degrassi will rise again at some point. It's legacy is to rich to be left on a shelf. Kit Hood and Linda Schuyler's Playing With Time Inc. captured teenagers for over 40 years. Three generations have now grown up with Degrassi and the entire time Degrassi has remained faithful to its audience by always considering them as equals to the characters that were magnificently portrayed on screen. In a time of rich 30 year old teenagers in flash cars in Beverly Hills dominating airwaves, through to over produced "reality" television, the audience always knew the Degrassi was a place that kept it real and that is why they always keep going back there.
Thanks to all involved.
Zenon: Girl of the 21st Century (1999)
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Created by Eileen Gallagher and directed by Jane Prowse, The Fugitives was a seven part show from 2005 that follows fourteen-year-old Jay Keaton (Alex Roe). A teenager with a high Read more
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Tags: Degrassi High Degrassi Junior High Degrassi: Next Class Degrassi: School's Out Degrassi: The Next Generation featured The Kids of Degrassi Street
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You have acquired interest in forex trading, have done the necessary reading and training and now you feel you are ready to get some skin into the game. To do this, you will need to identify a trusted and reputable forex broker that falls under legal regulation where you are from. This ensures that you do not put your money in the increasing number of forex scam.
Rakuten forex is one of the most reputable forex brokers the world over. It has a solid financial footing and has a slew of customers from all around the world.
To start forex trading, you need a fx trading account to ensure that you can easily access the online forex market, view the market conditions, place a trade of your choice, make profits and withdraw the profits into your pocket.
Unlike trading in securities and other financial assets, forex brokers will not charge fees or commissions directly. This is because, as the entity that allows you access to the forex market they are the market markers. Rather than charge a direct fee or commission, forex brokers gain from spreads.
In forex trading, the difference between the ask price and the bid price is known as a spread. This spread is how brokers make their money from every trade conducted through them.
You should therefore ensure that the spreads offered by your broker are not reasonable so as to make a reasonable profit on after your trades.
Leverage in financial terms usually refers to a loan. In forex, the term leverage refers to a loan that brokers of traders using their accounts to control a larger portion of their market than their actual cash allows.
Usually, brokers offer leverage from 50 times your initial cash up to 250 times. Leverages helps you optimize tour trading sessions and make superior profits than you would have made with your initial capital. On the other hand, when the market is against you a large leverage position can clear out your account although most forex brokers have strategies to mitigate against that occurrence.
Before you open a trading account with a forex broker, ensure that they are well known with a good reputation and a strong financial background. Also make sure that they fall under the financial regulators in region to guard and protect your money.
Ensure that your forex broker is a reliable and well known broker in the forex circles.
After you have selected your broker, you can now choose the type of account you want to use to trade. Different forex brokers offer different types of FX trading accounts. There are two main types of accounts. The first is a personal account which will be registered under your name while the second is a corporate account which is an account option for companies that want to trade in the forex market.
Some brokers also have different accounts depending on the amount of starting capital you have to trade with.
The third step in opening a forex trading account is registering your account. To do this successfully, your broker will require that you supply them with your personal information among other details. This is an important part of the account opening process that allows the broker to know their customer and confirm the validity of the information provided for security and safety purposes.
After the forex broker is satisfied that the personal information provided is true and valid, they will then send you information that will allow you access to your account. You will then need to deposit your initial capital to start trading.
Finally, you can now start trading with your new live forex trading account.


----- Paul George scores 36 points as the Oklahoma City Thunder top the Portland Trail Blazers 123-114 Tuesday night at Chesapeake Energy Arena in Oklahoma City, OK.
The Thunder offense was too much for the Blazers on Tuesday night.
Paul George poured in a game-high 36 points and Russell Westbrook added a triple-double with 29 points, 10 rebounds, and 14 assists as the Thunder top the Trail Blazers 123-114 at Chesapeake Energy Arena in Oklahoma City.
The Thunder torched the Blazers shooting 50.6% from the field including 11-for-23 from three-point range with all five starters scoring in double-figures. Steven Adams scored 14 points and pulled down eight rebounds and Terrance Ferguson added 14 points on 6-for-8 shooting.
Portland (29-20) got a team-high 34 points from Damian Lillard and CJ McCollum rediscovered his shooting touch to add 31 points connecting on 7-of-12 from three-point range.
After five-straight games scoring in double-figures, Jake Layman had just four on 2-for-7 shooting in 17 minutes. Terry Stotts elected to play Maurice Harkless and Al-Farouq Aminu down the stretch for their defense on George. The two combined for four points on 1-for-11 shooting including 0-for-5 from downtown.
Portland had the second-fewest turnovers in the NBA (12.2) over the previous 12 games, but had 20 against the Thunder leading to 29 points.
Up Next- The Trail Blazers will travel to Phoenix to meet the Suns on Thursday night. The game is scheduled to tip off at 6:00 PM.
Chad's Take- Harkless and Aminu combined for four points on 1-for-11 shooting. Not good enough.


text:
package android.text.method;

import android.graphics.Rect;
import android.text.Editable;
import android.text.GetChars;
import android.text.Spannable;
import android.text.Spanned;
import android.text.SpannedString;
import android.text.TextUtils;
import android.view.View;

/**
 * This transformation method causes any newline characters (\n) to be
 * displayed as spaces instead of causing line breaks, and causes
 * carriage return characters (\r) to have no appearance.
 */
public class SingleLineTransformationMethod
extends ReplacementTransformationMethod {
    private static char[] ORIGINAL = new char[] { '\n', '\r' };
    private static char[] REPLACEMENT = new char[] { ' ', '\uFEFF' };

    /**
     * The characters to be replaced are \n and \r.
     */
    protected char[] getOriginal() {
        return ORIGINAL;
    }

    /**
     * The character \n is replaced with is space;
     * the character \r is replaced with is FEFF (zero width space).
     */
    protected char[] getReplacement() {
        return REPLACEMENT;
    }

    public static SingleLineTransformationMethod getInstance() {
        if (sInstance != null)
            return sInstance;

        sInstance = new SingleLineTransformationMethod();
        return sInstance;
    }

    private static SingleLineTransformationMethod sInstance;
}

redpajama_set_name: RedPajamaGithub


text:
Yurii Fedorovych Shchyhol (born 5 November 1983) is a brigadier general, candidate of legal sciences, and head of the State Special Communications Service of Ukraine (Ukrainian: DerzhSpetsZviazku). He calls the current Russian-Ukrainian cyberwarfare to be the first world cyberwarfare.  He also defines Russia as a legal target for Ukraine's cyber attacks.

Biography
He was born on November 5, 1983, in the village of Zazymia, Brovary Raion, Kyiv Oblast.

In 2006, he graduated from the National University of the State Tax Service of Ukraine, majoring in law.

In 2017 he finished Alfred Nobel University, majoring in finance and credit.

From 2007 to 2008, he worked in the Baryshivka tax inspectorate of the Kyiv Oblast.

From 2008 to 2009, he studied at the National Academy of the Security Service of Ukraine.

From 2008 to 2020, he served in the military in operational and managerial positions in the Security Service of Ukraine.

On July 8, 2020, by order of the Cabinet of Ministers of Ukraine No. 822-r, he was appointed the Head of the State Service for Special Communications and Information Protection of Ukraine.

Shchyhol also highlighted the importance of Starlinks provided by Elon Musk to Ukraine in renewing the communication to liberated areas of Ukraine from Russian occupiers.

References

1983 births
Living people
Security Service of Ukraine officers


text:
Mouse brain mapped with single-cell resolution
The level of detail in the map will help researchers to understand how the mouse brain functions.
By James Lloyd
Published: 10th May, 2020 at 08:00
A new 3D reference atlas of the mouse brain will enable researchers to zoom down to the level of a single cell. By studying the mouse brain's structure in such detail, neuroscientists will be able to advance their understanding of how the mouse brain functions, and how this functioning can go wrong.
The atlas – called the 'Allen Mouse Brain Common Coordinate Framework', or 'CCFv3' – was created by researchers at the Allen Institute for Brain Science in Seattle, USA.
A virtual section of the 3D mouse brain atlas © Allen Institute for Brain Science
They averaged the brain scans of 1,675 mice, made using a technique called 'serial two-photon tomography'. This works by shining a laser on the brain tissue and measuring how the tissue emits light, or 'fluoresces', in response.
Each point on the atlas's 3D grid was labelled according to the brain structure it belongs to. In total, the researchers labelled more than 800 structures, including several that hadn't featured in previous mouse brain atlases.
Read more about brains:
Brain cells' ability to work as a team strengthens memories
Exercise and the brain: why moving your body matters
Brain atlases are useful for neuroscientists because they provide a reference when studying brain disease. For instance, this atlas will allow researchers to compare the 3D volumes of different brain structures in healthy and diseased mouse brains.
This could in turn lead to insights into the human brain, as mice are often used as a model for understanding human neurological disease – partly because our genomes are so similar (around 90 per cent of genes associated with disease in mice have counterparts in humans).
Mouse Brain Cortex © Allen Institute for Brain Science
"We hope the wider neuroscience community will use it as a new standard reference atlas," said co-senior author of the study Dr Lydia Ng.
"By making our atlas and related tools open access, new data and data types generated across our community can be more easily integrated and compared in the same spatial context, and the atlas in turn can be modified as our knowledge about brain structure evolves."
How does an MRI scanner work?
Magnetic Resonance Imaging (MRI) takes advantage of the fact that the nucleus of a hydrogen atom (a single proton) behaves like a weak compass needle. In the presence of a strong magnetic field, the hydrogen atoms will align themselves, but a radio signal of the correct resonant frequency will cause them to deflect slightly.
When the signal is removed, the atoms return to their equilibrium state and emit a radio signal of their own. An MRI scanner can detect these signals and use them to map the distribution of molecules with lots of hydrogen atoms – ie, water and fat. In this way, it can create detailed images of the inside of the body.
Scanning table: The patient can only be scanned from inside the magnetic coil, so a motorised table slides them in and out.
RF system: An antenna produces a radio signal to 'nudge' the hydrogen nuclei and listen to the answering radio wave they emit.
Liquid helium: Liquid helium is pumped through an enclosing jacket to cool the superconducting magnets almost to absolute zero.
Main magnet: Superconducting magnetic coils produce a magnetic field of 1.5 teslas – that's about 300 times stronger than a fridge magnet.
Patient: The high magnetic fields mean that patients with cochlear implants, pacemakers or embedded shrapnel usually can't be scanned.
Gradient system: A second coil distorts the main magnetic field so that the resonant frequency of the protons varies according to position.
How can we be sure that medical body scans are safe?
Who really invented the MRI machine?
James Lloyd
Staff writer, BBC Science Focus
James is staff writer at BBC Science Focus magazine. He especially enjoys writing about wellbeing and psychology.