text:
Improving adherence to hepatitis C screening guidelines
BMJ Quality improvement report
Jane Trinh1,2,
Nicholas Turner1,2
1 Internal Medicine, Duke University Health System, Durham, North Carolina, USA
2 Pediatrics, Duke University Health System, Durham, North Carolina, USA
Correspondence to Dr Jane Trinh; jane.trinh{at}duke.edu
Background Hepatitis C (HCV) is a viral liver disease that can result in cirrhosis, hepatocellular carcinoma, liver transplantation or death. The Centers for Disease Control (CDC) estimates that 2.7–3.9 million Americans are living with HCV, yet the majority are unaware. Starting in 2013, both CDC and US Preventative Services Task Force guidelines agreed in recommending HCV screening for all those born between 1945 and 1965 yet many clinics have been slow to adopt screening.
Objective We designed a quality improvement project seeking to improve HCV screening rates among patients seen for new or annual visits to ≥90% over a 3-year period in an academic primary care clinic.
Methods Screening rates were assessed through repeated review of charts (50 per cycle or 300 charts total, roughly 35% of eligible visits) as a series of interventions were executed. Sustainability was assessed by repeating an additional 50-chart analysis 1 year after completion of the study interventions. At the conclusion of the study, a post hoc analysis of socioeconomic factors was undertaken to determine whether gender, income or ethnicity might affect screening rates.
Results Over 6 cycles of interventions, screening rates improved from 24% to ≥90%. Screening rates remained at 88% 1 year after completion of the interventions. The most effective interventions used reminders built into our electronic medical record and informed providers of their personal HCV screening rates relative to the clinic as a whole. Our post hoc analysis found that lower socioeconomic standing and white race were associated with reduced likelihood of screening.
Conclusions Provider adoption of new HCV screening guidelines can be markedly and sustainably increased with electronic medical record prompts as well as directed feedback informing providers of their personal screening rates compared with colleagues.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
http://dx.doi.org/10.1136/bmjoq-2017-000108
There has been ongoing uncertainty among primary care providers about the new Centers for Disease Control (CDC) and US Preventative Services Task Force (USPSTF) recommendations for hepatitis C virus (HCV) screening. In contrast with many targeted recommendations, the CDC and USPSTF has recommended universal screening based on a birth cohort, patients born between 1945 and 1965. The recommendation for screening despite absence of reported risk factors has posed a particular barrier in primary care settings, in physician's considering screening, and potentially in patients accepting screening due to stigma surrounding a disease primarily spread via intravenous drug abuse.
This quality improvement (QI) project sought to quantify baseline HCV screening rates in our primary care clinic on release of the guidelines in 2013 and to propose interventions to improve screening rates in our clinic. Our clinic is an academic practice based in Durham, North Carolina, and consists of combined internal medicine and paediatrics physicians. It is a combined faculty-resident primary care clinic, with 23 resident physicians and 4 faculty physicians.
We aimed to increase the proportion of patients born between 1945 and 1965 who are appropriately screened for hepatitis C infection at annual or new patient visits to >90% over a 3-year period in our combined internal medicine-paediatrics primary care clinic.
HCV is an RNA virus which can cause chronic infection leading to hepatic cirrhosis, hepatocellular carcinoma and liver failure requiring transplantation—yet the vast majority of patients are asymptomatic following acute infection.1 2 The CDC estimates that 2.7–3.9 million Americans are living with HCV infection, with 45%–85% unaware they were ever infected.3 Traditionally, HCV screening targeted only those patients with documented risk factors for HCV infection, yet data from the National Hepatitis Screening Survey show that targeted screening misses 31%–47% of cases of HCV in the USA.2 Screening has become particularly important with the advent of highly effective direct-acting antiviral agents, which can prevent development of cirrhosis, hepatocellular carcinoma or need for transplantation.4 5
Epidemiologists identified a particular birth cohort, those born between 1945 and 1965, which carries the majority of the HCV burden in the USA with 67% of all cases.6 As a result, both the CDC and USPSTF recommend HCV screening for all those born between 1945 and 1965, in addition to those at increased risk based on traditional risk factors.7–9 Screening consists of an initial HCV antibody test followed by confirmatory PCR if positive. The release of the updated CDC and USPSTF guidelines on HCV screening presented an opportunity to evaluate the adoption of new guidelines within an academic primary care clinic.
Baseline measurement
Baseline data on HCV screening within the combined internal medicine-paediatrics primary care clinic were obtained through a retrospective chart review of annual or new patient visits between January and April 2013. Records of 51 patients seen for annual or new patient visits in this time frame were examined. Annual or new patient visits were examined alone rather than return visits or acute care visits since these are typically the visits where screening test indications are reviewed. Each patient's complete laboratory records within the institutional electronic medical record (EMR) were reviewed so that HCV testing would be detected even if not discussed at the specified annual clinic visit.
We defined the HCV screening rate as the number of individuals with a laboratory-documented HCV serology divided by the number of individuals seen for annual or new patient visits. Screening rates for HCV were assessed at regular 6 months interval for about 3 years (the duration of the QI project) by direct chart review of approximately 50 consecutive annual or new patient visits for each interval (300 charts total, comprising roughly 35% of eligible clinic visits).
Baseline data on provider knowledge of and comfort with the new screening guidelines were obtained through an online survey.
Baseline HCV screening rates
Among the 51 patients examined, only 12 (23.5%) had received HCV testing in accordance with CDC and USPSTF screening guidelines. Among the 12 patients who had been tested, only 1 was tested for a true screening indication as intended by the CDC and USPSTF.
In a baseline pre-intervention survey conducted, when presented with four screening scenarios, providers only correctly elected to screen in 50%–62.5% of instances in which CDC and USPSTF guidelines would prescribe HCV serologies. Similarly when asked to recall whether they had offered HCV screening to an actual clinic patient within the preceding 6 months, just 62.5% answered yes while very few (12.5%) reported a patient refusing testing if the conversation was initiated by the provider. This suggests providers offering screening likely posed the greatest barrier to screening.
This QI project was conducted in an academic, combined internal medicine and paediatrics (Med-Peds) primary care clinic in Durham, North Carolina. There are 23 Med-Peds residents and 4 practising Med-Peds faculty members. The study was launched in July 2013, shortly after CDC and USPSTF guidelines came into agreement on universal HCV screening for those born between 1945 and 1965. Patients born between 1945 and 1965 who were seen by one of our clinic providers (either resident or faculty physicians) for either an annual visit or a new patient visit were included in the study. Patients with active or known liver disease were excluded as their HCV screening may not have been obtained for screening purposes. We aimed to develop a QI project in clinic, using the 'plan, do, study, act' (PDSA) Model for Improvement, with a goal of improving HCV screening rates to ≥90% over 3 years. Interventions were targeted to first identify provider-related factors responsible for missed screening, to increase provider knowledge of current screening guidelines, to increase documentation of HCV screening discussions and to increase provider comfort with discussing HCV testing with patients, based on preintervention survey results. Within this framework, six total PDSA cycles were executed, with six interventions including: (1) a baseline survey of provider knowledge, (2) distribution of guidance for providers for discussing HCV screening with patients, (3) addition of an EMR prompt in the clinic's annual visit template to remind providers to screen for HCV, (4) a petition to the institution's EMR management board to include HCV as an automatic, age-specific, prompt within the Health Maintenance section and the addition of a modified prompt in the EMR that would 'force' a response to screening, (5) incorporation of HCV screening in the health maintenance section of the EMR and (6) individualised audit of provider's HCV screening rates with rewards for those with the highest screening rates. The project protocol was reviewed by Duke's institutional review board (IRB) and granted exempt status as a QI project.
The goal of this QI project was to improve the proportion of patients born between 1945 and 1965 who were appropriately screened for HCV infection in a primary care clinic. Many providers were not aware of the new guidelines when they were first published, and resistance to universal screening was evident in the clinic due to provider knowledge and comfort with screening, as well as patient discomfort with universal screening. It was also not part of the standard health maintenance discussion by providers. The PDSA cycles were aimed at improving overall rates of screening in the clinic, thereby improving adherence to CDC and USPSTF guidelines and enhancing preventative health maintenance care.
PDSA cycle 1
The providers in clinic were administered a preimplementation HCV screening knowledge, skills and attitude survey. Data were recollected following administration of the initial survey, and 50 consecutive annual exams or new patient exams were evaluated for whether or not patients born between 1945 and 1965 were up to date on HCV screening. There was no change from the presurvey data, with only 24% of patients having HCV results available in the EMR. Interestingly, there was an increase in documentation noted in which HCV testing was at least mentioned to be discussed at a future visit (an additional 4% of visits). Efforts at improving knowledge alone helped recognition of the screening recommendation but did not increase screening rates.
The intervention for this cycle involved providing physicians with scripted text to help guide physicians in counselling patients about the importance of HCV testing. This was based on initial survey results suggesting that in addition to lack of awareness, there is some lack of comfort in understanding the reasons behind the new HCV screening as well as being able to convey these indications to patients. Consequently, the intervention involved the construction of scripted text in the institution EMR outlining the reasons behind the new recommendations with special focus on the reason behind screening by birth cohort, blind to other risk factors. The release of this scripted text that was readily accessible within the EMR to be inserted into patient instructions was announced via e-mail, and was intended to improve awareness and also to encourage discussion of HCV screening with patients. The postintervention screening rates remained essentially unimproved with just 30% screened. Given the absence of any effect by providing discussion assistance tools, it was clear that screening could only be improved by targeting interventions more directly at a provider's decision to screen.
The next intervention focused on provider prompts in the note template used in clinic for annual and new patient visits. Review of screening rates at this interval showed no real improvement in HCV screening rates at annual visits with just 30% tested. A slight improvement was seen however in documentation with 36% of clinic providers now at least documenting a discussion of HCV screening.
Presuming that improved documentation ought to precede improved screening rates, the second survey was designed to investigate the sources used by providers in selecting appropriate screening tests at each annual visit. The majority of providers (67%) reported relying on the health maintenance section of the EMR (among the remainder, 17% relied on their own reminder system and 17% relied on memory alone), consequently any intervention seeking improved HCV screening rates would best target the health maintenance section of the EMR.
The second survey also included a repeat 'test question' seeking to determine how many providers would correctly screen for HCV according to the new guidelines. Compared with the first iteration in which 60% of respondents correctly screened according to birth cohort, the rate of correct responses improved to 83%—suggesting awareness of the new guidelines was gradually improving.
A proposal was drafted to the EMR management board to include HCV screening in the next edition of health maintenance prompts built into this section of the EMR, but there was a time delay in the response and implementation. In the interim, an additional line was added to the annual clinic visit template used in our clinic, listing HCV screening for those born between 1945 and 1965 with choices of 'not indicated', 'declined' or 'complete' to follow. Compared with the last cycle in which 30% of patients were tested and 38% of charts included appropriate documentation of HCV screening discussion, the addition of HCV testing to the annual template correlated with a slight improvement in screening rates to 38% and documentation rates to 40%. Scrutiny of failure to document or screen suggested that in the majority of cases, providers were using their own custom templates which did not include an HCV prompt. In fact, in 83% of cases where HCV status was undocumented, a private template had been used which lacked an HCV prompt phrase. Cases in which an HCV prompt existed in the note accounted for only 17% of failed screenings—in most cases providers listed 'n/a' or 'discussed' without a clear conclusion on why screening was not pursued.
Increased documentation rates revealed a second interesting trend. Among cases in which HCV screening was offered but not pursued, 40% of charts indicated that the patient declined screening.
Based on the above information, there were two clear avenues for further improvement. First was updating the EMR health maintenance section to include HCV screening, which would not depend on the note template the provider chooses to use (private or clinic-wide).
Additionally, the majority of templates import the health maintenance section from EMR. Second, because improved documentation has revealed a trend of patients declining HCV screening, it became necessary to improve education for both providers and patients on the indications and benefits of HCV screening.
The proposal to incorporate HCV screening in the health maintenance section of our institution's EMR was accepted and implemented by the EMR management board. Following formal addition of the HCV screening task to the health maintenance tool within our institution's EMR, screening rates improved to 60%, documentation rates improved to 64% and patients declining testing accounted for only 3% of missed opportunities to screen according to chart documentation. While addition to the formal health maintenance tab clearly improved screening rates on the whole, missed screening opportunities continued to cluster among providers who relied on their own privately created templates, accounting for a full 61% of missed screening opportunities.
As a substantial proportion of failed screening opportunities could be attributed to the use of privately created clinic note templates which did not incorporate the updated HCV screening prompt or the EMR health maintenance section, providers were individually notified of their HCV screening rates relative to the clinic as a whole, and for those with lower screening rates a reminder was given to update their clinic templates. Following individualised email feedback, the per cent of patients screened improved to 74%, and documentation rates improved to 84%.
With significant effect following individualised feedback, it seemed that providers were certainly motivated to make improvements when aware of their own screening rates relative to the rest of the clinic. For the next stage, rewards were offered for the highest screening rates in clinic.
Given the improvements seen after individualised feedback, an announcement was next sent out via email to all clinic providers noting the overall clinic HCV screening rates along with notification that a reward would be offered for the providers with the highest screening rate for the next intervention cycle.
Using funding from a prior QI project, Sanford Guides and American Academy of Pediatrics Redbooks were obtained as incentives for the providers with the highest screening rates. At one of the residency programme meetings, it was announced that the providers with the top four screening rates were identified and rewarded for their efforts.
Following the offer of rewards, screening rates finally reached 90% and documentation rates surpassed 96%.
At baseline, the prevalence of HCV seropositivity measured within our clinic population as a whole was 3.2%. Initial HCV screening rates were 24% and survey data indicated that 75% of providers were uncomfortable explaining the rationale behind the current CDC and USPSTF guidelines for HCV screening. Over the first few PDSA cycles (directed largely at increasing provider knowledge of HCV screening guidelines), improvements in screening rates were limited. Once interventions were focused on providing EMR-triggered reminders for HCV screening, and providers were given individualised feedback based on audits of their personal HCV screening rates, clinic-wide screening rates exceeded 90% after multiple PDSA cycles (figure 1). Similarly, documentation rates improved from 4% to 96%.
Stepwise improvement in hepatitis C virus (HCV) screening rates with each subsequent quality improvement intervention. A key to interventions is offered corresponding to the cycles of intervention. EMR, electronic medical record; PDSA, plan, do, study, act.
One year after completion of the six cycles of intervention, an additional 50 consecutive charts were reviewed to assess durability of the HCV screening interventions. The screening rate remained at 88% while the documentation rate had decreased slightly to 80%.
To investigate barriers to screening in the remaining 10% of patients, we conducted a post hoc analysis of all patients born between 1945–1965 seen for an annual visit within our Med-Peds clinic from 2013 to 2016 (n=1430) assessing for differences in screening rates based on gender, race and income quartiles. Socioeconomic quartiles were assessed according the definitions used in the Census Bureau American Community Survey. Univariate logistic regression analysis was conducted using the generalised linear model function in the open-source statistical program R (https://www.r-project.org/). The OR for HCV screening was calculated for each variable of interest. Although preliminary, our results suggest that screening was more likely to be missed among whites (OR 0.76, 95% CI 0.61 to 0.95) and those with lower socioeconomic standing (OR 0.90, 95% CI 0.81 to 0.99, table 1). Of note, determination of socioeconomic standing could only be obtained for 1277 (89%) of examined patients. For the remaining 153 (11%) patients, income data were not available in our database.
Univariate logistic regression analysis of variables affecting HCV screening
Lessons and limitations
Through the course of multiple PDSA cycles, screening rates steadily improved from 23% to 90%. The most effective interventions were those that altered clinic note templates or the Maestro Care Health Maintenance tab, followed by efforts to assure that providers had updated their personal clinic templates to incorporate these changes. The most effective motivators for change appeared to include direct feedback offered to providers on their own screening rates, coupled with rewards being offered to the providers with the highest screening rates.
While screening rates met the 90% goal at the close of this QI project, it remains concerning that 10% of patients are still not being offered HCV screening in accordance with CDC and USPSTF guidelines. As the majority of interventions were focused on providers, consideration was next given to the possible effect of patient demographics on HCV screening rates. In a retrospective pilot analysis (with IRB approval), associations between HCV screening and various indicators of socioeconomic standing were sought. Interestingly, there was a trend towards ongoing inadequacy of screening among the poorest quartile, among males, and among Caucasians and Latinos—suggestive that some patient factors may be playing a role in missed screening opportunities as well. This question is being examined in greater details as part of a separate IRB-approved geospatial epidemiology project intended to verify these preliminary concerns that particular socioeconomic groups are consistently being overlooked in HCV screening attempts. This is especially salient given reports of rising HCV rates in new demographics inclusive of economically disadvantaged rural populations.
Although encouraging that screening rates remained at 88% within a 50-patient sample assessed 1 year after completion of the interventions, it is possible that this reflects accrual of screened patients within our clinic population rather than truly sustained screening efforts. Documentation of screening status with each annual or new patient visit may better reflect ongoing screening efforts, which remained similarly high at 80%.
Following multiple PDSA cycles, HCV screening rates rose steadily from 24% at the outset to 90% in our combined Med-Peds clinic in <3 years. While interventions targeted solely at increasing provider awareness of HCV screening guidelines had minimal positive effects, interventions targeted at the annual clinic visit templates used by providers, or at the Health Maintenance reminders within our EMR were notably more effective. This can be seen in figure 1, where an initial rise in successful documentation of HCV screening status (between cycles 1 and 2), along with the addition of HCV screening to our clinic visit templates (cycle 3) preceded an eventual rise in actual screening rates (between cycles 3 and 4). Additionally, offering individualised provider feedback as simple as emailing their personalised HCV screening rate from the preceding 3 months proved highly effective at ensuring adoption of the updated clinic templates and health maintenance section. This may account for the ongoing rise in screening rates observed between cycles 4 and 6.
We were similarly encouraged that rates of HCV screening remained high at 1 year after completion of the interventions, recognising that this might be slightly biased by accrual of screened patients within our clinic population. Perhaps more reflective of ongoing practice, documentation rates remained markedly improved at 80% as well.
Overall, HCV seropositivity within our clinic mirrored national rates based on the NHANES database, with a prevalence of 3.2% locally vs 3.5% nationally among those born between 1945 and 1965. Among seropositive individuals, 60% were also PCR positive suggestive of active infection for which treatment would be indicated.
Despite successfully increasing screening rates to 90%, a subsequent search for patient factors predictive of missed screening suggested that lower socioeconomic standing and white race might be associated with missed screening opportunities. While these trends were noted in a post hoc analysis and the study itself was not designed to answer this question, we are conducting a larger retrospective cohort study to verify these observations. If confirmed, targeting further screening efforts towards these populations may be helpful given rising rates of HCV within these same populations.10–12
QI interventions can dramatically and sustainably improve HCV screening rates in an academic primary care clinic, especially when using EMR templates or offering individualised provider feedback. While most of our interventions focused on provider factors, preliminary findings from our study suggest that several patient factors, including gender, race and economic standing, might be associated with missed screening opportunities, or perhaps that certain individuals are more likely to decline screening. Research is ongoing to confirm these findings.
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Contributors JT and NT planned the study, and contributed to content of the manuscript. NT conducted the PDSA cycles and data analysis. JT provided data for analysis.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Ethics approval The intent of this work was to improve the quality of care provided to patients in our primary care clinic, and was not a study on patients. As such, the protocol was reviewed by Duke's Institutional Review Board and granted exempt status.
Provenance and peer review Not commissioned; externally peer reviewed.
© Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/


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text:
Enrichment lessens Angelman-like traits in male mice
by Peter Hess / 2 February 2022
Sex differences: Male model mice raised in enriched environments had less severe behavioral problems than their female peers.
Photography by Richard Drury
Angelman syndrome model mice have fewer-than-expected behavioral and motor problems if they grow up in a stimulating enclosure, filled with toys and other enrichments, according to a new study.
The mice are missing a copy of UBE3A — the gene mutated or deleted in people with Angelman syndrome, an autism-linked condition characterized by developmental delay and motor coordination problems. The rodents usually have motor issues, mild cognitive impairments and difficulty with typical activities such as building nests and burying objects.
Past attempts to improve behaviors in UBE3A mice have worked for only a narrow set of traits, says lead investigator Alexander Kloth, assistant professor of biology at Augustana University in Sioux Falls, South Dakota. But male UBE3A mice in the new work benefited more broadly. The female mice, by contrast, did not show the same gains.
"We were surprised that so many phenotypes that typically show up in Angelman syndrome model mice were rescued by environmental enrichment," Kloth says. The lack of responsiveness in female mice came as a surprise, too, he adds.
These results highlight the importance of stratifying model mice by sex for preclinical research, says Lawrence Reiter, professor of neurology at the University of Tennessee Health Science Center in Memphis, who was not involved in the study.
Kloth and his team randomly assigned the model mice and controls to either standard or enriched housing at 21 days of age, when the mice were weaned. The standard housing contained little more than the basics: shaved wood bedding, a cotton nest and containers for food and water. The larger enriched housing, by contrast, contained climbing structures and exercise wheels, bedding of different textures and a variety of toys and treats scattered throughout.
The benefits of this early start are consistent with results of interventions seen in people, Reiter says: "Enrichments starting earlier have better outcomes."
After six weeks, the mice began a series of behavioral tests. Male UBE3A mice raised in the enriched accommodations performed better on nearly every test than UBE3A males raised in standard cages, the researchers found. These mice even performed as well as wildtype mice did on some of the tasks, including a test that measures a mouse's motivation to escape deep water. Female UBE3A mice raised in an enriched environment did not show any significant improvement on the same task.
Enriched male UBE3A mice performed at the same level as standard-housed controls on a test of motor learning, but not as well as wildtype mice raised in enriched environments. Female UBE3A mice performed equally poorly on that test, regardless of their housing.
Angelman model mice tend to be overweight, but both males and females raised in enriched housing showed no difference from wildtype mice in terms of body weight. The findings were published in December in Brain and Behavior.
The findings suggest that some of the Angelman-like traits seen in UBE3A mice, which have been extensively studied and described by other researchers, can be sensitive to environmental changes, says Ype Elgersma, professor of molecular neuroscience at Erasmus University in Rotterdam, the Netherlands, who was not involved in the work. "One should take this into consideration when designing the experiments," he says.
Importantly, male wildtype mice raised in enriched cages performed significantly better on some — but not all — behavioral tests than wildtype mice raised in standard cages, so it remains to be seen which benefits are specific to the Angelman model mice, Reiter says.
And the burning question is why the mice improved, Reiter says.
It's possible that motor issues in Angelman mice have more to do with how their brains process feedback from the environment than with motor function per se, so it would be illuminating to see whether a domain such as gait, which involves this more complex feedback, improves with environmental enrichment, he says.
Differences in the levels of brain-derived neurotrophic factor, which has been shown to be affected by environmental conditions, and stress-related chemical signals in the brain could account for the sex difference observed in this study, Kloth says. "Further understanding these molecules in the context of Angelman syndrome model mice will be key to future work."
To this end, he and his students plan to examine how neuron structure and function are affected by differences in rearing environments.
Cite this article: https://doi.org/10.53053/YIMN2562
TAGS: Angelman syndrome, environment, motor skills, mouse models, sex, UBE3A

redpajama_set_name: RedPajamaCommonCrawl


The Xbox was released on November 15, 2001, in North America, followed by Australia and Europe in 2002. It was Microsoft's first foray into the gaming console market. The sixth-generation console competed with Sony's PlayStation 2, Sega's Dreamcast, and the Nintendo GameCube. It was the first console produced by an American company since the Atari Jaguar ceased production in 1996.


text:
Q: Grafana: Combine/join two different prometheus metrics into one table which share some values I'm using grafana+prometheus+telegraf for monitoring certain web servers. I'm collecting metrics for certificate information: x509_cert_expiry and dns status: dns_query_rcode_value exposed by telegraf for a single web server, say web1, where two websites are hosted, say http://www.myapp1.com and http://www.myapp2.com. Metrics look like this:
x509_cert_expiry{common_name="myapp1.com",env="staging",group="web",host="...",instance="...",issuer_common_name="...",job="web1",public_key_algorithm="RSA",san="myapp.com",serial_number="...",signature_algorithm="SHA256-RSA",source="https://www.myapp1.com:443",verification="valid"} 4898676
x509_cert_expiry{common_name="myapp2.com",env="staging",group="web",host="...",instance="...",issuer_common_name="...",job="web1",public_key_algorithm="RSA",san="myapp.com",serial_number="...",signature_algorithm="SHA256-RSA",source="https://www.myapp2.com:443",verification="valid"} 4897854

dns_query_rcode_value{domain="myapp1.com",env="staging",group="web",host="...",instance="...",job="web1",rcode="NOERROR",record_type="NS",result="success",server="8.8.8.8"} 0
dns_query_rcode_value{domain="myapp2.com",env="staging",group="web",host="...",instance="...",job="web1",rcode="NOERROR",record_type="NS",result="success",server="8.8.8.8"} 0

(values containing '...' are redacted - not an actual label values)
Now, I would like to combine/join/merge/squeze these two metrics x509_cert_expiry and dns_query_rcode_value into a single grafana table just to avoid creating two panels one for certificate information and other for domain probe, in order to display everything in a single panel since these two metrics share some common information (e.g. common_name="myapp1.com" -> domain="myapp1.com") and are scattered across multiple metrics with different labels.
Looking at the collected metrics, there are some similar label values and I would like to use to produce single set of data with specific columns - some of them pointing to label values, some of them having values from metrics.
What I've tried so far:

*

*creating promql expression for joining these two vectors:
dns_query_rcode_value * on (instance) group_left(san) (count by (instance, san)   (x509_cert_expiry{san!=""}))
but that isn't working:
Error executing query: found duplicate series for the match group {instance="..."} on the right hand-side of the operation: [{instance="...", san="..."}, {instance="...", san="..."}];many-to-many matching not allowed: matching labels must be unique on one side

*Messing with grafana transforms as per https://stackoverflow.com/a/65961366/20320365 and https://stackoverflow.com/a/66131801/20320365 but no avail.
Is something like this even possible ?
Thanks.

redpajama_set_name: RedPajamaStackExchange


The National Institute for Health Research Clinical Research Network (NIHR CRN) Portfolio is a database of high-quality clinical research studies that are eligible for support from the NIHR Clinical Research Network in England; these include Industry adopted Commercial studies.
Research funded by the NIHR and partners should be eligible for adoption onto the United Kingdom Clinical Research Network (UKCRN) portfolio. For full details on the eligibility criteria please view the following go to the UKCRN website.
These are studies that do not meet the criteria for adoption by NIHR and are therefore not entitled to network funding or support. It is always worth checking if the funder may be able to become an eligible partner.
Commercial research is defined as research that is funded and sponsored by a commercial organisation. In this contract research the company designs the protocol and own any results and arising Intellectual property. Commercial contract research must be fully funded but may be adopted by the NIHR portfolio and therefore eligible for facilitation from the local networks. For information on national support for commercial research please click here.
Portsmouth Hospitals Trust supports student research, which must be subject to the same quality and ethical review processes as all other research projects within our Trust.


text:
Arthur D. Little launches new 'AFAQ' Program to foster new generation of Saudi consultants
Posted by Mohamed Ghamdi | Dec 19, 2021 | Economy, Education & Training
The 12-month program will prepare local up-and-coming talent for consulting positions
Participants will gain experience by interacting with Arthur D. Little teams and working with clients on projects
AFAQ begins in February 2022 and applications are now open
Riyadh, Saudi Arabia – 19 December 2021: Arthur D. Little (ADL), a leading management consultancy firm with the longest-standing presence in the Middle East region, has announced the launch of AFAQ, a new 12-month program that will prepare upcoming Saudi talent for careers in the consulting industry. With personal growth deeply rooted in the company's culture and the skills, intelligence, and creativity of people long considered key organizational assets, these enduring values will be at the forefront of Arthur D. Little's latest initiative. A new generation of consultants will be guided, developed, and ultimately integrated into the professional landscape, with an engaging and interactive learning agenda facilitating this priority.
Ryan Alnesayan, Principal at Arthur D. Little Middle East, said: "As the Kingdom invests in future leaders and demand from clients increases in the world of consulting, so does the need for influxes of new talent. It's true that success in this area is essential rather than aspirational, yet the nature of these efforts could not be further from being stressful or strenuous. Saudi Arabia today is a market full of growth opportunities for innovative minds and up-and-coming professionals. And at Arthur D. Little, we are excited about the AFAQ program because it represents an advantageous new avenue for us to assist future consults en route to realizing their potential and making invaluable long-term contributions. We see that the national talent pool is certainly promising with the motivation and capabilities required to climb career ladders, something that will be harnessed through AFAQ."
Inspired by a commitment for advancing consulting capabilities, fostering breakthrough innovation thinking, adopting future-oriented leading skills, and questing for change and realization of the national vision, AFAQ will realize each of these objectives, positioning participants to explore growth opportunities in today's evolving marketplace, drive innovation and change, and formulate their own success stories.
Over the program's duration, aspiring consultants will interact with and work alongside Arthur D. Little teams. Research, analysis, knowledge structure, presentation preparation, and project work will all be primary focus areas, collectively offering comprehensive exposure to critical consulting skills through formal development-focused training. Furthermore, participants will also be granted chances to work directly with Arthur D. Little clients and help them discover the most prudent solutions to complex but interesting problems.
Interested in the AFAQ program? Here's what you need to know
This program is dedicated to Saudi Nationals interested in pursuing a career in consulting, from fresh graduates to those nearing bachelor's or master's degree completion. AFAQ will begin in February 2022, and applications are accepted from majors in Engineering, Business, Computer Science, and Economics – with English proficiency and a 3.5+ GPA score both required. Moreover, AFAQ means "horizon" – which is a testament to the new beginnings explorable through the program. People interested are asked to send their CV, cover letter, and transcript tocareers.meast@adlittle.com
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Cecilia still doesn't get the point.
Marla came to America as a stowaway on a ship.
It was obvious that Sri didn't want to do that.
Ernest wants to be with us.
Melinda skipped work to watch the USA-Germany soccer match.
Vladimir said Boston is a nice place to live.
We're no longer working for Cathrin.
Vicky kicked the trash can.
Vidhyanath puts lots of sugar in his coffee.
Mason found the test difficult.
Hein is a kind man.
Morris calls me every day.
I'd like to see King.
I don't love Toby anymore.
Meehan has done his work well.
Brent and Joon have arrived.
Vincent gave me everything I need.
The sheriff told Rajeev to be out of town by sundown.
Justin and Vic know the truth.
If I remember correctly, Antonella used to be a carpenter.
Judith doesn't miss a thing.
I like to dance with Roberto.
Why do you hate Peter?
Why don't you and Derek do it?
Do you think Jochen will believe you?
The coroner is performing an autopsy on Daniel to find out what killed him.
Did Marek ever talk about me?


The car turned around the corner of the mountain road, and Graeve saw the white castle. The airy, dreamlike palace with its slim towers and rounded arches was gleaming white atop a steep peak against the dark background of wild cliffs covered with pine forest. The road was meandering up the mountain, towards the glittering castle, its finely carved lines wonderfully silhouetted against the bright blue sky. Further and further along this steep, winding road Dr. Parzival Graeve went, ascending to his royal patient who was awaiting him in that shining palace on the top of the mountain.
Graeve sat motionless in the back seat of the car, his white forked beard freely lying on his chest, his large, portly frame relaxed and quiet. Only his sharp blue eyes gazed piercingly at the landscape. These vigilant eyes immediately noticed the stark contrast between the magnificent castle and the desolate surroundings. Piles of rubbish on the roadside and across the lonely fields, sick, contorted pine trees with yellow branches, abandoned houses with crumbling roofs, people looking both frightened and utterly depressed--Graeve was making his way through a barren land.
Finally, the castle of Montsalvat lay before him.
There were other cars waiting, perhaps indefinitely, in front of the huge cast-iron gate flanked by two towers. It was closed, but, once Graeve's car turned up, the gate slowly opened, letting him into a courtyard with a beautiful garden. Montsalvat's chiselled beauty looked very different up close. The castle appeared immense, oppressive, its true color not white but rather pale grey. The car drove on to the hall, the oldest part of the palace and its main residential building, a colossal five-storey cubic structure with a high, gabled roof.
Several men were standing in the driveway, waiting for the car. One of them, a courteous, grey-whiskered man, stepped forward and welcomed Graeve with a pleasant smile.
Graeve's room was in the western wing of the hall overlooking the Korbensee, a mountain lake. The stone balcony opened on to a stunning view of it, light blue and misty under the azure sky. The balcony door was open, and crisp, fragrant wind from the alpine meadows was sweeping through the room. Graeve closed the door and stood thinking, looking at the lake.
He knew that the king's realm did not extend beyond the far end of the lake, which was effectively the kingdom's western border. Montsalvat was a tiny state comprising only the castle and a few small mountain villages. For centuries, it had been closed to all foreigners, and little was reported about what had been happening within its impenetrable borders. The only fact known about Montsalvat was that its ruler was ill. He had been ailing for a long time, and nobody was able to help him. There was a time when the king let send after all manner of leeches and surgeons, both unto men and women, and there was none that would behote him the life. As no local medic was able to help, the king started seeking aid from outside. A great many doctors and physicians attended him, but proved powerless to stop his progressing malady.
Graeve had long known that he would eventually be called in to Montsalvat. In his large house on one of Vienna's quietest streets, which had felt so empty after the death of his wife a few years ago, Graeve had been waiting for a distant call. And he'd finally heard this call. The time had come.
Surprisingly, he did not feel tired after his long journey. He was not hungry, either, and did not touch the abundant lunch exquisitely served for him on a little table. Quite the opposite: he was unusually sprightly and focused, as if before an important exam, and he could barely wait until the hour had passed and he could come down to meet Count Von Neumayr.
Finally, a liveried servant turned up and led Graeve through a vaulted, gallery-like corridor to a large, beautifully decorated drawing room where the prime minister and his retinue were waiting for him. The walls were adorned with murals and tapestries depicting various tournament scenes and knights wearing suits of armor.
'These murals are excellent,' said Graeve admiringly.
Von Neumayr nodded in agreement.
'I hope you have managed to have a bit of a rest,' he said.
Graeve looked at Von Neumayr and then at the officials surrounding him.
'I want to ask a few questions before I see the patient, if you do not mind,' he said.
Before Graeve could respond, the door opened and a tall, slender, beautiful woman stormed into the room. She was pale and agitated.
'Well, we have been discussing the methods other doctors used--' said the count.
The king's lodgings were on the upper floors of the eastern wing of the palace, so it took some time for them to walk there from the Hall of the Knights, through numerous corridors and galleries. Inside, the palace seemed even larger than it did from outside--a maze of passages, staircases and private chambers, some looking long abandoned and some incomplete, with unpainted walls and sacks of plaster left lying about. It was already late evening, and it grew dark outside the large windows--but the palace was bright and well-lit, albeit empty. They did not encounter anyone on their way to the eastern wing.
Finally, they reached a high, gilded double door. The queen pushed it forcefully and they came in.
The room behind the door was small and stuffy. The king lay motionless on a bed just opposite the door, his eyes closed, his big, matted beard sticking up in the air. He was breathing noisily. An abominable smell of rotting flesh filled the room.
The king opened his eyes. His gaze was unfocused.
She brought a cup of water for him and he drank it off in one gulp.
'Lutz, the doctor came,' said the queen.
Graeve stepped forward and bowed. The king gave him a long glance.
'I have not seen you before,' he said.
'I have never been here before, Your Majesty,' Graeve responded.
Aided by the queen and the prime minister, he took off the king's trousers, wincing unwittingly at the terrible smell. Underneath was a dirty, pus-soaked bandage. When he removed it, a terrible, swollen wound in the king's groin came to light. Graeve shied away unintentionally.
'What? Don't you like it?' croaked the king.
'For ages,' said the king.
Graeve could not help staring at the wound. He has never seen such dreadful sores in all his long medical practice. The king must have been experiencing horrible pain. He told the king about this.
Graeve helped the king lever himself upright. Once sitting up, he looked better, as if he had already received some treatment and was now recovering. His brown eyes glistened with excitement; his large, hooked nose turned red.
He laughed. Graeve had not yet applied a new bandage to his wound, and the sore was very much visible. However, the king seemed not to notice it. He continued to laugh.
Graeve cast a severe look at him.
He asked the prime minister to send someone for warm water and opened his suitcase. The king was observing him ironically.
'You are just like the others, are you?' he said suddenly.
Graeve could not stand this any longer.
'Oh, of course,' said the king, smiling bitterly.
Graeve started cleaning the wound. The king wailed.
'I told you, Your Majesty,' said Graeve.
Having finished tending to the wound, he straightened and looked at the king.
'What do you think, doctor?' asked the queen anxiously.
Graeve did not respond. He was gazing out of the window, trying to discern – what? It was pitch dark outside and the lake would not be visible from this wing anyway. But he was thinking about it, bracing himself to say the words.
Graeve looked at the queen. She nodded.
'Don't say that, Lutz!' the queen exclaimed.
'Are you sure that the prognosis really is this poor?' the prime minister enquired.
'Which one?' said the queen and Count Von Neumayr with one voice.
Graeve paused, pondering his response.
'The king's fish,' echoed the queen, staring at him in light amusement.
'What about it, doctor?' said the prime minister impatiently.
'It is just--' Graeve started but stopped short, looking at the king.
The king was not listening. He had fallen asleep.
They tiptoed out of the bedroom and stopped in the corridor.
'So what about the fish, Dr. Graeve?' asked the prime minister.
As Graeve turned to head for his room, he met the queen's wary eyes.
Now he felt really tired and hungry. His cold lunch was waiting in his room. Graeve ate the meal and drank a glass of red wine. He found that, despite the tiredness, he was thoroughly enjoying his dinner – the food and especially the wine were superb. Yet he never stopped thinking about his patient. It was astonishing that a man with such a wound was still alive and could survive years of poor care. Apparently not all of those doctors who had been treating him were quacks.
Immediately after the meal, Graeve felt sleepy and barely made it to his bed. He fell asleep once his head touched the pillow.
The Korbinsee lay before him, its dark, smooth water glistening under the bright full moon. He was alone on the shore, a long fishing rod in his hand. It was damp and chilly, but an unusual warmth was emanating from the water, as if the lake were a giant warm-blooded organism. He had been sitting there for a long time, because the fish were shy and were not biting. Shy fish, he thought. What a curious expression. And then he thought, Here I am sitting upon the shore fishing. What do I have behind me? Only the arid plain. The abominable wasteland.
And next moment he felt a nibble. He pulled joyfully, hoping a big, strong fish had just taken his bait. But what was on the end of his line sent chills down his spine.
Graeve woke up with a start and lay awake until the early morning, thinking about eerie dreams and sinister forebodings.
At eight o'clock sharp, he was outside the king's bedroom.
The queen and the count had already arrived and were waiting for him. The queen still looked pale and wary, casting quick, distrustful glances at him.
Surprisingly, the king was somewhat improved in looks. His face had lost its unhealthy flush; his gaze was sharp and focused.
'Here comes the doctor!' he announced gleefully.
Before he answered, Graeve cast a look through the window. He was right--the lake was not visible from this wing of the palace.
He turned to the king.
'They say it has been long extinct,' he said finally.
'So the legends say,' said the king with a sniff--but he was visibly carried away with the idea.
The king looked up at her.
The queen, aghast, raised her hand to her mouth. She did not say a word, just stood there silently.
'Yes, Your Majesty?' said Graeve, stepping forward.
'How did you know about the fish, Dr. Graeve?' asked the king.
Graeve looked at the prime minister. Count Von Neumayr looked down.
'Goodbye, Your Majesty,' said Graeve.
He left the king's lodgings and went straight to his room. He did not see the moment when the king sailed off in his boat. He was still in his room at four o'clock in the afternoon, when heavy rain came down and the entire staff of the castle started to search for the king.
Dr. Graeve was still in his room when darkness fell and the searchers returned from the lake, having found neither the king nor his boat. He did not come down to dinner, either.
Early in the morning, Graeve crept out of his room and walked out of the palace. The rain had stopped. Graeve came down to the lakeshore and looked around.
It was still dark and misty, but he was persistent. He started walking along the shore and soon saw something in the water.
Something he was expecting to see.
It was a dead body, head and shoulders above the shallow water near the shore.
Next moment he heard some voices. It was a search party from the castle. A group of palace servants was coming down to the lake.
Within minutes, Count Von Neumayr, white as ashes, came down along with the castle guards and approached the dead body. He then turned round and looked at Graeve.
'You surely know what has happened, Graeve, do you?' he asked.


Exposing wasteful & discriminatory PLA mandates for all construction jobs. Say "NO" to union-only project labor agreements.
The U.S. Army Corps of Engineers (USACE) has issued a survey soliciting comments from the construction industry about the potential use of a government-mandated project labor agreement (PLAs) for the construction of a General Instruction Building at the Carlisle Barracks of the U.S. Army War College in Carlisle, Pennsylvania.
TheTruthAboutPLAs.com, a project of ABC National, encourages the merit shop contracting community to respond to this PLA survey. Tell USACE government-mandated PLAs reduce competition, increase costs, and impede the economy and efficiency of government contracting.
To review and respond to USACE survey, click here.
Survey responses to Solicitation Number W912DR19R0018 should be sent via email to Ms. Patricia Morrow at patricia.morrow@usace.army.mil by 10:00 a.m. Eastern local time on Friday, February 1, 2019.
Attached is a template contractors can customize to help with their response. Before submission, please rename the document with your company name, pay close attention to the highlighted text and customize it as much as possible.
Please forward ABC Vice President, Regulatory, Labor & State Affairs Ben Brubeck (Brubeck@abc.org) communications to USACE in case ABC National needs to take additional steps to defeat a PLA mandate on this contract.
USACE and other federal agencies have issued more than 260 similar project labor agreement surveys requesting information about the potential use of PLAs on specific construction projects across the country as a result of regulations and federal agency policies stemming from President Obama's pro-government-mandated PLA Executive Order 13502, which encourages federal agencies to mandate PLAs on a case-by-case basis for federal construction projects exceeding $25 million in total cost.
TheTruthAboutPLAs.com has taken the opportunity to respond to all PLA surveys as they are issued and encourages the merit shop contracting community to do the same. Responding with accurate and timely information is critical and effective at creating more work for qualified merit shop contractors and their skilled employees. Due to our collective advocacy, none of these projects have had PLAs mandated on them.
Learn how ABC is still winning the fight against government-mandated PLAs in federal contracting.
To stay up to date on future federal PLA survey alerts, "Like" our Facebook page at Facebook.com/thetruthaboutplas and follow us on Twitter at Twitter.com/truthaboutplas.
To help TheTruthAboutPLAs.com continue to ensure fair and open competition on federal, state and local construction projects funded by taxpayer dollars, make a donation here.
The merit shop contracting community and taxpayers need to help defend free and open competition from special interests. Communicate your opposition to government-mandated PLAs to elected officials here.
© Copyright 2019 : The Truth About Project Labor Agreements. All Rights Reserved.


With 10 years experience running surf camps across the best beaches in Europe, here at Star Surf Camps we know exactly how to make your summer dreams a reality. So, if you like the sound of surfing perfect waves, fun & experienced coaches, camping in beautiful bell tents, feasting on great food, chilling on the beach, unwinding with a yoga session and enjoying good summer vibes a surf camp, then look no further! We are the only truly international surf camp with a warm atmosphere ideal for groups and solo surfers alike.
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Find the right surf camp destination with surf holidays around the world!
*France. *Spain. *Portugal. *Fuerteventura. *Morocco.
We have been running our surf camps for 10 years at some of the best surf beaches in Europe & across the globe. What makes us unique is our focus on fun and expert surf coaching and our dedication to share this passion and the famous surfers lifestyle with all our surf holiday guests. We combine this focus on learning to surf with great healthy food, daily yoga classes in unique locations, live music & DJ's, free wine and cheese evenings, comfortable bell tent accommodation and, of course, a fun and international surf camp team to make you feel welcome and at home.
Renowned for our professional and enthusiastic approach to teaching surfing in our surf camps, with Star Surf Camps, you learn to surf in a safe environment and are looked after every step of the way. With surf camps and trusted partner surf camps around the world, we find the best surf locations and surfing destinations suited to your surfing ability and budget.
Our international surf camp for Teens 15+ near Santander is located on the beautiful beach of Oyambre National Park with fantastic wave conditions for everyone looking to learn to surf or improve their existing surf skills. Besides learning to surf, your surf holiday week here is spent sunbathing, playing beach games, going on SUP safaris, doing yoga and many cool outdoor activities.
Are your surf camps suited to all levels of surfing ability?
Among our surf destinations, we have surf camps catering to different surf ability levels. Whereas some surf camps are suited to first-time and intermediate surfers, other surf trips are exclusive to advanced surfing abilities. Our detailed surf camp descriptions tell you everything you need to know about each trip. Or for more information, simply contact one of our surf travel experts by emailing info@starsurfcamps.com or calling +44 2081 335337.
What sets Star Surf Camps apart from other surf companies?
Here at Star Surf Camps, we all share the same passion: surfing. And we are devoted to sharing that passion with you. We are a team of experienced travellers who know how important it is to find the right waves to improve your surfing skills. If you decide to join us in one of our surf camps, then you can expect a true authentic surf lifestyle created by our multilingual and multinational surf and camp teams, making your stay unique to any other surf camp. You will spend your surfing holidays in a fun, friendly and social environment and make new friends from all around the world.
In your surf camps, do you only work with professional surf instructors?
Yes, in all our surf camps and partner surf camps, we only work with professional, fully licenced and qualified surf instructors. Nothing is more important to us than our surf camp customers' safety in the water. Our qualified surf instructors are also in the water with you for all of your surf lessons.
What is the best way to travel to my summer surf camp holidays? Can you help me find public transportation?
*Rome2Rio.com — This website is a great source to find plane, train and bus as well as car and ferry routes.
*Skyscanner.com — If you're planning on flying to one of our surf camps, check out Skyscanner, an awesome website that compares the cheapest flights (without saving your searches).
*Eurolines.com — This travel website offers bus routes pretty much through all of Europe and, surely, have a bus stop close to your home, too.


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Michigan State to pay Larry Nassar victims $500 million in settlements
The two sides met for the last two days behind closed doors in mediation.
Michigan State to pay Larry Nassar victims $500 million in settlements The two sides met for the last two days behind closed doors in mediation. Check out this story on USATODAY.com: https://on.freep.com/2Io3QCc
David Jesse and Gina Kaufman, Detroit Free Press Published 11:12 a.m. ET May 16, 2018 | Updated 5:59 p.m. ET May 16, 2018
Before the world knew Larry Nassar's name and his crimes, these two women were building their case one voice at a time.
Larry Nassar appears in court on to listen to victim-impact statements prior to being sentenced on January 16, 2018 in Lansing.(Photo: Scott Olson, Getty Images)
Michigan State University has settled hundreds of lawsuits filed against it by the survivors of MSU doctor Larry Nassar's sexual assaults.
The settlement, which covers all 332 current claimants, will cost Michigan State $500 million. The school will pay $425 million now and hold $75 million in reserve in case other Nassar victims come forward. The details on how much money each survivor will get are still being worked out.
MSU will now work on how it will pay the settlement, MSU spokeswoman Emily Guerrant told the Free Press.
Survivor attorney James White said this is a chance for the survivors to begin to move forward.
"I don't think they can ever be made whole, but this is a step in the right direction," he said.
The deal was announced Wednesday, after the Detroit Free Press published news of the settlement, following two days of closed-door mediation sessions between lawyers for the university and the survivors.
Terms of the settlement are as follows:
• $425 million dollars will be paid to all current claimants
• $75 million dollars will be set aside in a trust fund to protect any future claimants alleging sexual abuse by Nassar
The settlement was approved by the MSU board in a conference call Tuesday night.
"There will be no confidentiality agreements or non-disclosure agreements attached to the settlement," according to a joint press release from the survivors and the university. "Additionally, the parties must act to address items necessary to finalize the agreement. The settlement applies to only Michigan State University and MSU individuals sued in the litigation. It does not address claims against USA Gymnastics, the United States Olympic Committee...or any other parties."
Survivors' attorney John Manly said "This historic settlement came about through the bravery of more than 300 women and girls who had the courage to stand up and refuse to be silenced. We appreciate the diligent efforts of ... survivors' attorneys across the nation who worked to obtain this measure of justice and healing. We also thank the mediator and all who participated in crafting this settlement. It is the sincere hope of all of the survivors that the legacy of this settlement will be far reaching institutional reform that will end the threat of sexual assault in sports, schools and throughout our society."
Robert Young, special counsel to MSU, said: "Michigan State is pleased that we have been able to agree in principle on a settlement that is fair to the survivors of Nassar's crimes. We appreciate the hard work both sides put into the mediation, and the efforts of the mediator, which achieved a result that is responsible and equitable."
MSU's board also issued a statement:
"We are truly sorry to all the survivors and their families for what they have been through, and we admire the courage it has taken to tell their stories. We recognize the need for change on our campus and in our community around sexual assault awareness and prevention.
"A successful resolution to the litigation is a positive step in moving us all forward. We will continue working as a Board to address the necessary changes and improvements that are needed at our university."
Penn State University paid out $109 million to 35 victims in the Jerry Sandusky scandal.
Nassar victims want sex abuse laws adopted. Lawmakers have concerns.
John Engler on his Michigan State job: 'I'm ready to go now'
Nassar stands accused of molesting dozens of female student athletes while he was a doctor at MSU. He was sentenced Dec. 7, 2017, to 60 years in federal prison on child pornography charges and is currently in a maximum-security federal prison in Tucson, Ariz. He also faces a 40- to 175-year sentence issued in Ingham County and a 40- to 125-year sentence from Eaton County, where he was charged with a total of 10 sexual assaults. Those sentences will not begin until he finishes the federal sentence.
How MSU will pay for the settlement is under careful scrutiny by parents, students, alumni and financial rating agencies.
Interim President John Engler has long said the costs will be covered by tuition and state aid. Lawmakers have said no state aid should be used.
MSU brought in $859 million in tuition revenue in 2016-17, according to its audited financial statements. That's 29% of its total revenue of $2.9 billion. If MSU's reputation has suffered from the scandal, it could see a drop in the number of students enrolling, which could lower that income.
On the other side of the ledger, the university has $1.1 billion in outstanding debt. Ashley Ramchandani, a credit analyst with S&P Global Ratings, said it considers MSU to be in good shape financially with debt and could likely add some if needed.
MSU also ended the last fiscal year with $1.1 billion in unrestricted net assets. That's money that isn't legally contracted to a certain project, but often is set aside for particular projects.
MSU's credit rating just took a big hit
Michigan State prepares for what could be its largest freshmen class ever
It's like a family's savings account where money is set aside for a new car, a new roof for the house and other projects. It can be switched to something else, or to cover an emergency, but that means those projects can't be covered.
The two biggest chunks of what MSU has set aside are its unrestricted net assets for infrastructure ($557 million) and programs ($400 million).
Earlier this month, Moody's Investor's Service lowered the school's rating, meaning MSU will pay higher interest rates if it borrows money. The rating drops MSU to Aa2 from Aa1, affecting approximately $975 million of rated debt.
And S&P Global Ratings, despite noting that MSU likely can take on more debt, also has lowered its outlook on the university to negative, in response to pending investigations into MSU, along with lots of turnover in senior leadership.
The lowering also reflects a belief that MSU's enrollment could drop, which means less money coming into the university. The firm said it isn't sure how all the fallout will shake out.
Contact David Jesse: 313-222-8851 or djesse@freepress.com. Follow him on Twitter: @reporterdavidj
Read or Share this story: https://on.freep.com/2Io3QCc


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Home » Elephant Conservation in Malaysia
Malaysia is split into two parts by the South China sea. Both of Malaysia's territories are home to two of the sub species of elephants. Peninsula Malaysia is home to the mainland Asian elephant (Maximus elephas indicus) and Borneo is home to the so called pygmy elephants (Maximus elephas borneensis).
Click here for the latest news about elephants in Malaysia
Malaysian Elephant Population Figures:
Elephant Range: 45,000 km² approx (includes Peninsula and Borneo combined)
Country Ranking: 4th of 13
Total Wild Elephants: 2,351 – 3,066
1,251 – 1,466 – Peninsula
1,100 – 1,600 – Borneo
Country Ranking: 4th or 5th of 13
Total Captive Population: negligible
Country Ranking: Joint 10th of 13
Source: R Sukumar – A Brief Review of the Status, Distribution and Biology of Wild Asian Elephants Elephas maximus- International Zoo Yearbook 2006
While this information source is considered the very best available, accurate data on wild elephant populations is difficult to obtain and scientifically verify.
Wild Elephants in Malaysia
Peninsula Malaysia
Historically elephants were found in large numbers throughout the dense forests of the Malay Peninsula. However over the past 100 years, the forests have steadily given way to agriculture for both food and cash crops and the wild elephants have progressively receded from the south and west. Initially forest clearance paid no heed to the need for elephant corridors to allow for trans migration and this gave rise to a considerable rise in human-elephant conflict and the destruction of valuable crops.
The Malay authorities response was to set up the Elephant Management Unit in 1974 under the authority of the Department of Wildlife and National Parks. This unit has established the world-renowned Kuala Gandah Elephant Conservation Centre. The unit has become highly specialised in elephant translocation in response to human elephant conflict, moving elephants to the eastern Malaysian states of Kelantan, Terengganu and Pahang where there is still a large amount of forest, some of which is protected as part of the vast Taman Negara National Park.
Using translocation, elephants have been completely removed from the states of Perlis, Selangor and Negeri Sembilan. In total, some 500 elephants have been translocated over 25 years.
Forest clearance is now much reduced and takes place only after a lengthy planning process, which takes into account elephant migtation pattern and habitat requirements.
The translocation policy appears to have been successful in maintaining a healthy elephant population and reducing human-elephant conflict.
The elephants of Borneo were only accepted as a totally separate sub species in 2003 after scientists concluded that they were genetically different from their mainland cousins. Borneo is still home to large areas of forest which provides real hope that a healthy wild elephant population has a sustainable future. The elephants of Borneo are known to migrate between Malaysia and the Indonesian province of Kalimantan.
Currently, the Department of Wildlife and National Parks are working closely with the WWF to ensure the survival of Borneo's elephants.
Domesticated Elephants in Malaysia
Historically, Malaysia had something of a domesticated elephant tradition based around the palaces of the Malay Sultans. However, this culture began to fade out in the 19th century.
Domesticated elephants were revived in 1974 because of the requirements of the Elephant Management Unit. Six mahouts and four khoonkie elephants (those trained to capture wild elephants) were brought over from Assam to train rangers how to control and capture wild elephants. Today the unit maintains eight elephants to help with its operations.
Malaysia has a registration scheme for all elephants in captivity, mainly in zoos. According to research carried out by the United Nations Food and Agriculture organisation, there are 36 elephants on the register.
Malaysia's approach to elephant conservation has been well thought out, scientifically based and methodical in its approach. The translocation of problem elephants has mitigated the effects of human-elephant conflict found elsewhere and ensured healthy, sustainable elephant populations. In the future, as long as further deforestation is limited, it should be possible for Malaysia to maintain a healthy elephant population on both the Peninsula and in Borneo.


Our coaches are passionate about rowing and sharing their experience. Each one brings a diverse set of skills and knowledge to our team.
Courtney comes to WRA with a long resume of rowing, coaching and administrative accomplishments. Courtney began rowing in Bellingham with WWU. She was at the start of the long run of national championships. After completing 4 year of rowing with WWU, Courtney began a 9 year career of coaching all levels of rowing and helping with administrative work as Program Director with Sammamish Rowing in Redmond. At the 9 year mark with Sammamish, she heard rumblings from the George Pocock Foundation, that they wanted to start a rowing club in Renton. This being Courtney's home town, she jumped at the chance to introduce the locals to rowing. Once Renton Rowing had found stability, she was offered the Assistance Coaching job for the WWU women's team. This brought her full circle and she has enjoyed her three years with WWU. In 2017 the WWU Women's Rowing team captured its 8th NCAA National Championship and Courtney was a part of the Pocock/CRCA Division II Staff of the Year.
Walker grew up on Bainbridge Island and rowed all four years for Bainbridge Island Rowing Club. During senior year his varsity four qualified for the youth national championships where we placed 10th in the nation. After high school Walker rowed for Lewis and Clark College for one year. Walker began his coaching back in his hometown with BIR where he worked on and off as their head novice coach as well as the assistant varsity boys coach. Walker began coaching as a volunteer and took over as the Junior Head Coach during the summer of 2017. Now a member of the Western Washington University Men's Crew Team, Walker spent much of the 2018 season in the stroke seat of the Varsity 8+.
Caleb joins the coaching team this fall, assisting Coach Hauptman with the Junior Team. He will also be assisting with Masters and Sculling Instruction. Caleb rowed lightweight for BIR's Juniors team for four years. Also while at BHS, Caleb was on the baseball and wrestling teams, earning a spot at the wrestling state championships during his senior year. After graduating from Pitzer College in 2016 with degrees in International Political Economy and Organizational Studies, Caleb joined the staff at BIR as both an assistant and head novice boys coach. Besides coaching, Caleb works in the renewable energy field, runs triathlons and marathons, and is an avid traveler.
Henry graduated Western Washington University in 2017, with a degree in mathematics, after rowing with the team for two years. Henry continues to be involved with WWU Men's program as the Novice Coach. Originally from California, Henry joined the WRA Coaching Staff in the summer of 2018 primarily working with our adult Learn to Row program. Outside of coaching, Henry enjoys baking and photography.
Mason has been rowing for six years, at Sammamish Rowing Association and Western Washington University. He has coached every age range from middle school up and is excited to be WRA's Masters coach. Mason studies physics and astronomy at Western and loves to row fast.


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text:
Known informally as the Octagon Building, the redbrick octagonal building at 118 Cooper Street (at the corner of Front Street) in Santa Cruz, California was built in 1882, adjacent to the first (1866) County Court House, to serve as the County Hall of Records. In 1894, a major fire destroyed most of the nearby buildings, including the adjacent courthouse, but the brick Octagon survived.

In 1968, the records were moved to a new County Government Center. Many historic brick buildings on the Pacific Garden Mall were damaged during the 1989 Loma Prieta earthquake, but again the Octagon survived. On March 24, 1971, it was added to the National Register of Historic Places.

Since 1993, the Octagon has been used as the Museum Store for the adjacent Santa Cruz Museum of Art and History (MAH), and later as a coffeehouse. Vacant as of October 2016, the building is administered by the MAH.

See also
 National Register of Historic Places listings in Santa Cruz County, California
 Octagon house

References

External links

 Institutions in Santa Cruz County – 1850–1950
 The History of the Santa Cruz Courthouse by Margaret Souza

Santa Cruz, California
History of Santa Cruz County, California
Octagonal buildings in the United States
Buildings and structures in Santa Cruz County, California
Government buildings on the National Register of Historic Places in California
Government buildings completed in 1882
National Register of Historic Places in Santa Cruz County, California

redpajama_set_name: RedPajamaWikipedia


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