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Quality assurance for care of the dying: engaging with clinical services to facilitate a regional cross-sectional survey of bereaved relatives' views
Catriona Mayland ORCID: orcid.org/0000-0002-1440-99531,2,3,
Tamsin McGlinchey2,
Maureen Gambles2,
Helen Mulholland2 &
John Ellershaw2,3
Globally, having the 'patient and /or family voice' engaged when measuring quality of care for the dying is fundamentally important. This is particularly pertinent within the United Kingdom, where changes to national guidance about care provided to dying patients has heightened the importance of quality assurance and user-feedback. Our main aim was to engage with clinical services (hospice, hospital and community settings) within a specific English region and conduct a bereaved relatives' cross-sectional survey about quality of care. Our secondary aim was to explore levers and barriers to project participation as perceived by organisational representatives.
Each organisation identified a consecutive sample of next-of-kin to adult patients who died between 1st September and 30th November 2014. Those who had an unexpected death or were involved in a formal complaint were excluded. The 'Care Of the Dying Evaluation' (CODE™) questionnaire was posted out three months following the bereavement. One-to-one interviews were undertaken with a purposive sample of organisational representatives to explore experiences about project participation.
Of the 30 invited organisations, 18 were able to participate comprising: 7 hospitals, 7 hospices and 4 community settings. There were 1774 deaths which met the inclusion criteria but 460 (26%) were excluded due to inaccurate next-of-kin details. Subsequently, 1283 CODE™ questionnaires were sent out, with 354 completed (27% response rate). Overall, most participants perceived good quality of care. A notable minority reported poor care for symptom control and communication especially within the hospital. Nine interviews were conducted - levers to project participation included the 'significance of user-feedback and the opportunity to use results in a meaningful way'; the main barrier was related to 'concern about causing distress to bereaved relatives'.
Overall, being able to engage with 18 (60%) organisations within the region and conduct the bereaved relatives' survey showed success of this initiative and was supported by interview findings. The potential to be able to benchmark user-feedback against other organisations was thought to help focus on areas to develop services. This type of quality assurance project could form a template model and be replicated on a national and international level.
Calls to ensure the 'patient and family voice' is encapsulated into the measurement of quality of care for the dying is well-established [1]. Hence, on a global basis, bereaved relatives' evaluations (both using surveys and telephone interviews) form a key part of the evaluation of end-of-life care, especially within North America, Japan, and parts of Europe [2,3,4,5,6]. To ensure the highest level of care provision, it is important to be able to robustly evaluate the quality of current care [7].
This evaluation is especially pertinent within the United Kingdom (UK), as within recent years, care for dying patients has featured heavily within public and professional forums. Additionally, significant changes have occurred to national guidance underpinning the way that care should be provided [8, 9]. The Liverpool Care Pathway for the Dying Patient (LCP) [10], an integrated care pathway aiming to improve quality of care in the last days of life, came under intense media scrutiny. The LCP was a nationally endorsed document and used internationally to support the provision of care when it was recognised that an individual may be in the last days of life. A subsequent review of care for the dying advised that the LCP should be phased out by July 2014 [8]. Forty-four key recommendations were provided within the report, including the need for more individualised care and improving skills and competencies for clinical staff caring for dying patients [8]. Following this, the 'One chance to get it right' report identified five 'priorities for care' and highlighted that clear, sensitive, and timely communication is fundamental to ensure good quality of care is provided to dying patients and their families [9]. A recommendation for 'individualised end-of-life care plans' was made and the recent publication of the NICE guidelines for End-of-life care helped provide a framework for best clinical practice [11].
The most recent National UK 'End of Life Care Audit – Dying in Hospital' based on data collected in 2015, demonstrated improvements compared with the previous audit in 2013: a higher proportion of patients were recognised to be dying in a timely manner and for 95% of these, there was a documented discussion about this recognition with those identified as important to the patient [12]. There was, however, a reduction in the rates of anticipatory prescribing for symptoms commonly seen in the last days of life. While this could be perceived as positive and in keeping with NICE guidelines about individualised prescribing, a regional survey of first year doctors reported one of their main needs was for formal guidance with symptom control. These doctors reported difficulties with remembering doses of anticipatory medication [13]. Importantly, the 2015 National audit also highlighted variability in the results between individual hospitals and the continued limited availability of 24/7 palliative care services [12].
In view of these major changes in end-of-life healthcare policy, a quality assurance project was undertaken within a specific English region to assess current care provided to dying patients and their families in three healthcare settings: hospital, hospice, and community. In order to focus on care in the last days of life and immediate post-bereavement period, we used the 'Care Of the Dying Evaluation' (CODE™) questionnaire [14] as our post-bereavement tool. CODE™ seeks perceptions about quality of patient care and level of family support and contains sections on symptom control; nursing and medical care; communication; provision of fluids; place of death; and emotional and spiritual support. It is a shortened version of the original questionnaire, 'Evaluating Care and Health Outcomes – for the Dying (ECHO-D), which was developed, validated and used within a hospice and hospital setting [15,16,17]. CODE™ has also been assessed for validity and reliability [14], has been used nationally within the National Care of the Dying Audit – Hospitals [18], and is currently the focus of an international project involving seven European and Latin American counties [19].
Undertaking robust research for those who are dying is challenging due to the sensitive and emotive area of enquiry. Ethical, moral and practical challenges exist, influencing recruitment, retention, difficulty in identifying suitable outcomes measures and the level of investment in research [20,21,22,23,24]. With this in mind and key for the context of this quality assurance project, it is important to identify a distinction between measurement for judgement and measurement for improvement. It has been argued that in order to facilitate the process of service improvement "we need just enough information to take a next step in learning" [25]. Benchmarking methodology offers a way in which to generate 'just enough information', through facilitating assessment, comparison and reflection of 'relevant' information on care delivery, to identify both gaps in performance and examples of best practice [26, 27]. This methodology promotes a collaborative rather than competitive approach to assessment focussing on sharing information, which is integral to continually improving the quality of care [27]. This ethos underpins the methodology of this reported quality assurance project.
Within a specific English region, the primary aim was to engage with clinical services across hospital, hospice and community settings to explore the current quality of care provided to dying patients and their families, from the perspective of bereaved relatives. In order to achieve this aim, we undertook a cross-sectional regional survey of bereaved relatives' using the CODE™ questionnaire. The project was known as the Regional CODE™ survey and the conduct and results from this survey represents the main focus of this manuscript.
As a secondary aim, we wanted to explore views on project participation as perceived by representatives from individual organisations. To achieve this aim, one-to-one evaluation interviews with organisational representatives were undertaken. Within the context of this manuscript, we will focus on summarising key feedback about the levers and barriers to project participation.
Cross-sectional survey of bereaved relatives' views
Participating organisations compiled a consecutive sample of the patients' next-of-kin (NOK) according to eligibility criteria (Table 1) [28]. Organisations posted CODE™ information packs to the NOK three months following the patient's death. The information pack included a:
CODE™ questionnaire with unique identifier
freepost envelope for returning the questionnaire
information about accessing the web-based tool if on-line completion preferred.
Table 1 Eligibility criteria for Regional CODE™ survey
To remain ethically sensitive and, as this was the first time a survey of this nature had been conducted regionally, no reminder letters were sent.
Evaluation interviews with named organisational representatives
A purposive sample of 'named organisational representatives' were approached to represent service leads from all three care settings (hospice, hospital and community). A letter of invitation and a Participant Information Sheet was posted to potential participants. Following written informed consent, those willing to participate, undertook a one-to-one semi-structured interview conducted by one of three experienced researchers (MG, HM, TM). Using an evaluation interview, where a 'narrative', conversational approach [29, 30] was employed, rather than a researcher developed evaluation form with a set of pre-determined questions and response options, was believed to promote a more participant led assessment. At the same time, it offered the opportunity for clarification and elaboration of important elements of feedback to aid understanding. These conversations were largely focused into: the current process for gaining and dealing with patient and relative feedback and complaints; reasons for participating in the project; general perspectives on taking part in the project (positives and negatives). Interviews were conducted prior to publication of the overall final report. However, an automated report of the CODE™ survey results for individual organisations was available to download via the data entry tool. This provided an opportunity for all participants to review the results for their individual organisation(s) and begin the process of action planning ahead of the final report.
An interview 'topic guide' was used to encourage the conversational 'flow' if this was not naturally occurring. Some specific areas covered were:
Role of the interviewees
Existing bereaved relative feedback processes within organisation (e.g. including the management and feedback of these user-views)
Perceived levers and barriers to project participation (e.g. team format, operational processes, anticipated barriers and overcoming these).
Depending on preferences, interviews were conducted either face-to-face or via the telephone.
Bereaved relatives' survey
CODE ™ data was analysed using descriptive statistics (number, percentage) for each individual question. Median (M) and Inter Quartile Ranges (IQR) were used where appropriate. All missing data is presented within the tables (but excluded from the descriptive analysis). In terms of project feedback, each participating organisation was given their own report detailing results from their bereaved relatives' survey. Subsequently, they were also given a report detailing how their own results compared with other organisations within the region. Within this manuscript, we provide an example of how individual organisations' results for the key outcomes could be compared with regional and national results.
Evaluation interviews
Each interview was audio-recorded, transcribed and analysed with a thematic approach using the "substance of the interview" [31] to formulate overarching themes and categories. One of the researchers (MG) read, and re-read the data from all 9 interviews, recorded initial impressions and developed thematic codes. Further discussion of codes was conducted with the wider team (TM, CM) to reach overall agreement on substantive categories representing the data as a whole. For the purposes of this manuscript, the codes relating to levers and barriers to project participation form the main focus.
From 30 eligible organisations, 19 initially agreed to participate (7 hospitals; 7 hospices; 5 community settings) although one community organisation subsequently was not able to participate due to resource issues. Of those who declined, the main reason was because they were already undertaking a bereaved relatives survey (n = 8); other reasons being 'too few deaths' within the inclusion period (n = 2) and one organisation simply reported that they were unable to participate on this occasion.
From 3402 deaths, just over half (52%, n = 1774) met the initial inclusion criteria. Approximately a quarter of these (n = 491, 28%) could not subsequently be included, with the main reason due to inaccurate NOK data (Fig. 1). From 1283 CODE™ questionnaire packs sent out, 354 returned completed questionnaires (28% response rate). The hospice setting had the largest response rate (82/225, 36%) compared with other settings (hospital 218/849, 26%; community 54/209, 26%).
Flow chart – Response rate within the Regional CODE™ survey
Demographics (Table 2)
Overall, deceased patients were evenly split in terms of gender (n = 170 males, 52%) and, except for the hospice, tended to be from an older age group (n = 259, 70 years or older, 77%). More hospice (n = 74, 90%) and community (n = 44, 81%) patients had a cancer diagnosis compared with the hospital (n = 70, 32%).
Table 2 Demographic data for deceased patients and bereaved relatives within the Regional CODE™ surveya
Participating bereaved relatives tended to be female (n = 225, 67%) and aged between 40 and 69 years (n = 196, 59%). Participants tended to be the spouse or partner to the patient (n = 160, 59%), with the exception of the hospital setting, where participants tended to be the 'son / daughter' (n = 87, 42%) completing the questionnaire. The majority of relatives and patients in this sample were 'White British' and of a 'Christian' religious affiliation.
CODE™ questionnaire results
Key outcomes (Table 3)
Overall, about three-quarters of respondents reported the patient was 'always' treated with dignity and respect by both doctors and nurses (doctors: n = 245, 72%; nurses: n = 257, 75%). A notable minority, primarily from the hospital setting, reported the patient was 'never' treated with dignity and respect by doctors (n = 12, 6%) and nurses (n = 9, 4%). The majority of bereaved relatives (n = 272, 82%) reported they were adequately supported in the last days of life.
Table 3 Key outcomes as perceived by bereaved relatives within the Regional CODE™ surveya
Symptom control (Table 4)
The most commonly reported symptom was 'restlessness' with 225 respondents (65%) perceiving their family member appeared restless 'some' or 'all of the time'. A small but notable minority perceived their family member had the following symptoms 'all of the time' in the last days of life ('pain' n = 37, 11%; 'restless' n = 51, 15%; 'noisy rattle' n = 57, 17%). Pain and restlessness being present 'all of the time' was most commonly reported by hospital respondents and 'noisy rattle' by hospice respondents.
Table 4 Symptom control and communication as reported by bereaved relatives within the Regional CODE™ surveya
For those reporting that their family member had experienced pain, almost three quarters responded that enough had been done by the healthcare team to control this symptom (n = 214, 71%). This proportion reduced, however, to around half for restlessness and noisy rattle (n = 139, 53% and n = 90, 48% respectively). For all three symptoms, respondents perceived that symptom control was best optimised by the hospice healthcare team and least likely by the hospital healthcare team.
Communication (Table 4)
Overall, the majority of respondents perceived that nurses (n = 268, 78%) and doctors (n = 274, 81%) had time to listen and discuss the patient's condition with them (answered 'agree' or 'strongly agree'). Around one-fifth of hospital respondents either disagreed or strongly disagreed to the statement about nurses having time to listen (n = 43, 20%) and a similar proportion about doctors (n = 37, 18%).
In terms of detecting areas of unmet need, discussions about the appropriateness of giving clinically assisted hydration (CAH) were not routinely undertaken and occurred least frequently within the community setting. Overall, for those who hadn't had a discussion about CAH (n = 245), 124 (51%) would have found these types of discussion helpful.
Around half of all respondents (n = 176, 51%) were told what to expect when their family member was dying. Of those who weren't told (n = 187), just over three quarters (n = 144, 77%) perceived that these types of conversation would have been helpful.
Cross-comparison analysis of results between organisations
Each Clinical Commissioning Group (CCG) (the organisation responsible for commissioning health services for a particular area within the region) was provided with a report of the results for its responsible provider organisations. An example of the CODE™ results for the key outcome questions for two hospitals (within a single CCG) is shown in Fig. 2.
Comparison of hospital results (within one CCG) with National Care of the Dying Audit Hospital (NCDAH) and overall Regional CODETM results
Responses were also compared with CODE™ results from the National Care of the Dying Audit – Hospitals (NCDAH) 2013/2014 and with collated results from all participating hospitals within this Regional CODE™ survey. Comparisons suggest that perceptions about quality of care within Hospital 'A' tended to be higher compared with Hospital 'B', with NCDAH data and with collated regional results. Each organisation was then tasked with using the CODE™ results to develop action plans to help further develop clinical services.
Views of representatives from participating organisations
Nine individual interviews were conducted representing views across 11 services (4 hospices, 4 hospitals and 2 community settings) as one representative came from an integrated service (combined hospice / hospital /community). The interviewees' roles were: Consultant in Palliative Medicine (n = 2); Clinical Nurse Specialist & Team Leader (n = 2); Clinical Services Manager (n = 2); Outreach Services Manager (n = 1), and Senior Manager (for End-of-life care / evaluation and quality) (n = 2). Two interviews were conducted face to face with the remainder by telephone. Interviews lasted between 35 and 60 min.
The main themes identified as 'levers' to present and future project participation were: 'lack of existing feedback processes' to obtain user-representation views about the service; 'clear operational processes', including a user-friendly electronic tool, written guidance and a telephone helpline; 'significant user-feedback and opportunity to use results in a meaningful way' which would help inform future care provision. The main theme relating to 'barriers' was the 'fear of causing distress to bereaved relatives' (which was subsequently not found to be the case in this project). Additional themes were: current 'organisational systems not set up to capture information'; lack of organisational 'buy in' and lack of administrative support (Table 5).
Table 5 Summary of interviewees feedback about 'Regional CODE' – levers and barriers for participation
Overall, this was the first bereaved relatives' survey spanning across three healthcare settings undertaken within this specific English region. The ability to engage with 18 (60%) of all organisations, and the fact that the main reason for non-participation was due to current participation in bereaved relatives' surveys, was testament to the success of this quality assurance initiative. This model of providing quality assurance is one which could be replicated within other regions and across countries as a whole. Providing opportunities for user feedback towards services is a key health care priority both nationally and internationally. Within the UK, this commitment is outlined within the NHS constitution [32] and NHS Mandate [33]. Improving support to and engagement with bereaved relatives is also a key objective within the Next Steps On The NHS Five Year Forward View [34]. Results from this project confirm that the majority of these regional organisations did not have formal mechanisms to capture bereaved relatives' views. CODE™ is a valid and reliable tool which could bridge this clinical need and support organisations to obtain feedback of this nature. Interviewees reported that the data generated was perceived to provide valuable local information to better understand experiences of care in the last days of life. Additionally, the opportunity to subsequently benchmark their results with others regionally was seen as a positive outcome.
Generally, the majority of bereaved relatives reported good perceptions of care, although a small but significant minority reported poor experiences. Those who experienced care within the acute hospital settings were more likely to report issues in terms of the care received or the level of family support provided. Motivations for organisations' participation could have been influenced by the expectation that bereaved relatives' perceptions were likely to be favourable. Responses, however, demonstrated variability in the care provided, implying that the motivation was to genuinely seek user-feedback about their service. Although concerns were raised by interviewees about potential distress to bereaved relatives, in reality there were few complaints from bereaved relatives who participated in this project. This finding would reinforce previous research suggesting that bereaved relatives are keen to be given the opportunity to engage in research due to a number of different motivations [35, 36].
The project was not without limitations. There was a high proportion of missing or inaccurate NOK details and, as it was imperative the CODE™ questionnaire was sent to the most appropriate individual, this limited the total number of potential participants. Additionally, this may have led to selection bias as, within some organisations, those who were engaged with Specialist Palliative Care services were more likely to have their details documented accurately. The wider implications of inaccurate details include the potential impact on providing bereavement support if NOK can't be accurately contacted. By being involved with the quality assurance project, however, this helped highlight to individual organisations some of the limitations of their internal reporting mechanisms and facilitated the potential development of solutions in these organisations.
Overall the response rate of returned and completed CODE ™ questionnaires (27%) was lower than expected (estimated to be 35–40%). It was also lower compared with previous studies of this nature including those which have used CODE™ [14, 18]. One reason for the lower response rate was the decision at the project outset not to use reminder letters, a method recognised to increase response rates [23]. Ongoing developments for the CODE™ questionnaire include further Public and Patient engagement to ascertain the best methods to approach and recruit potential participants for these types of surveys [19].
We did not obtain the demographic details of non-responders. This would have enabled a comparison between respondents and non-responders and provided information about the representativeness of our sample compared with the population as a whole. This is especially pertinent due to the fact that most participants were of white ethnic origin and stated they had a 'Christian' religious affiliation. The key element of the project, however, was to assess whether it was possible to engage with clinical services and hence a balance needed to be met between making it sufficiently feasible for individual organisations to participate versus the ideal methodology for conducting a survey of this nature.
Overall, perceptions about hospital care were poorer compared with hospice and community settings especially in terms of symptom control and communication. These areas are recognised themes from patients and family carer feedback [37] although for pain control, findings from previous studies have varied. One recent study demonstrated that those who died in hospital were more likely to have experienced pain compared with those who died at home [38] but others have not supported this finding [39]. It is noteworthy, however, that the deceased patient populations differed between care settings, with hospitals having a greater prevalence of non-cancer patients. In the most recent UK National VOICES survey, findings also suggested that pain control was potentially better met for those with a cancer diagnosis compared with those dying from non-malignant disease [5].
The greatest proportion of discussions about fluids at the end-of-life was reported by the hospital participants and the lowest within the community setting. This may relate to the fact that it is more challenging to provide clinically assisted hydration (CAH) in home or care home facilities. And in turn, healthcare professionals may not have broached this issue due to these types of concerns. The greatest degree of unmet information need about CAH was in the hospital setting, although across all settings, participants would have appreciated discussions. This may be in part due to the generally positive views of CAH by family members [40, 41] and the symbolic meaning that it brings [42]. It is important to understand that making 'blanket' assumptions about the appropriateness of engaging in such discussions cannot be supported, and sensitive communication, using open screening questions is likely to be required to promote the provision of individualised and responsive care [43].
CODE™ specifically focuses on care of patients in the last days of life and family support, and this is the first time it has been used to assess the quality of care in a number of different healthcare settings (hospice, hospital and community). Due to the methods of questionnaire administration, the survey allows each organisation to have individual and personalised feedback about bereaved relatives' perceptions of care. Previous national surveys of this nature have tended to feedback at a regional or CCG area level [5]. Additionally, the project subsequently enabled individual organisations to 'benchmark' themselves with findings from other similar organisations which offers the opportunity to facilitate cross-site learning. Although not conducted within the scope of this project, future follow-up interviews with the representatives from participating organisations would be beneficial to establish the key actions undertaken to help improve their clinical services. Additionally, future developments may include the opportunity to repeat the post-bereavement survey to assess the impact of changes over time. By assessing the feasibility that an evaluation such as this was possible within this region, a future post-bereavement evaluation would offer the opportunity to undertake more robust survey methodology to help further address any confounding factors.
Some of the real strengths of this project include the ability for individual organisations to:
demonstrate active engagement with bereaved relatives and have user-views about their service; this is particularly pertinent to provide evidence for the regulator organisations such as the 'Care Quality Commission' within the UK
have a quick 'at a glance' report to highlight the strengths of the organisation and areas that require further development
compare their own findings with other similar organisations as a whole and with others within their locality; additionally, for hospitals being able to 'benchmark' their data with previous national findings
utilise the CODE™ findings to create action plans to enact service improvement initiatives as well as facilitate learning from other organisations [26, 27].
With the national recommendations to use individualised care plans for dying patients, the optimal way to evaluate the impact of these and provide assurance that care is being delivered in a timely and sensitive manner should be determined. Post-bereavement questionnaires are recognised to be a useful way to do this and CODE™ represents a valid and reliable outcome measure to use. The successful engagement with the project is testament to the commitment of staff and organisations with the clear desire to seek user-feedback to improve care. The model of evaluation and the use of a 'benchmarking' approach, could be used at a local, national and international context to help drive an ongoing continuous quality improvement programme to improve care for dying patients.
CAH:
Clinically Assisted Hydration
CCG:
Clinical Commissioning Group
Care Of the Dying Evaluation
ECHO-D:
Evaluating Care and Health Outcomes – for the Dying
IQR:
Inter Quartile Ranges
LCP:
Liverpool Care of the Dying Pathway
Median (M)
NCDAH:
National Care of the Dying Audit – Hospitals
NOK:
next-of-kin
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Robinson J, Gott M, Ingleton C. Patient and family experiences of palliative care in hospital: what do we know. An integrative review. Palliat Med. 2014;28(1):18–33.
Escobar PLC, Claus M, Zepf KI, et al. Symptom prevalence in the last days of life in Germany: the role of place of death. Am J Hosp Palliat Care. 2012;29:43107.
Gomes B, Calanzani N, Koffman J, et al. Is dying in hospital better than home in incurable cancer and what factors influence this? A population-based study. BMC Med. 2015;13:235.
del Rio MI, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, et al. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psycho-Oncology. 2012;913–21(8):21.
Davies A, Waghorn M, Boyle J, et al. Alternative forms of hydration in patients with cancer in the last days of life: study protocol for a randomised controlled trialTrials. 2015;16:464.
Gent MJ, Fradsham S, Whyte GM, Mayland CR. What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ Support Palliat Care. 2015;5(3):223–31.
General Medical Council. Treatment and care towards the end of life. London, UK: General Medical Council; 2010.
We would like to express our sincere thanks to the individual relatives and friends who participated in this project for taking the time to complete the Care of the Dying Evaluation (CODE™) questionnaire and sharing their views on the care provided. We would also like to thank all the hospitals, hospices and community trusts that participated in this service evaluation project, with particular thanks to members of staff who submitted their data.
Availability of data and material
The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Permissions would also need to be obtained from the Palliative Care Institute, University of Liverpool and Cheshire and Merseyside Strategic Clinical Network for Palliative and End-of-life Care.
Funding was provided by the Cheshire and Merseyside Strategic Clinical Network for Palliative and End-of-life Care. Local advice, where appropriate, was sought from the funding body as to the design of the study but they did not contribute to the collection, analysis and interpretation of the data nor in the writing of the manuscript.
Department of Oncology and Metabolism, University of Sheffield, Broomcross Building, Whitham Road, Sheffield, S10 2SJ, UK
Catriona Mayland
Palliative Care Institute, University of Liverpool, Cancer Research Centre, 200 London Road, Liverpool, L3 9TA, UK
, Tamsin McGlinchey
, Maureen Gambles
, Helen Mulholland
& John Ellershaw
Royal Liverpool & Broadgreen University NHS Hospitals Trust, Prescot Street, Liverpool, L7 8XP, UK
Search for Catriona Mayland in:
Search for Tamsin McGlinchey in:
Search for Maureen Gambles in:
Search for Helen Mulholland in:
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CM, TM, MG, HM and JE all contributed to the design of the study. TM, MG and HM conducted the interviews. MG analysed the data and interviews. CM, TM, and MG interpreted the data. CM was a major contributor to the overall writing of the manuscript and TM specifically contributed to the sections on the interviews. All authors read and approved the final manuscript.
Correspondence to Catriona Mayland.
In keeping with Health Research Authority Guidance, the bereaved relatives' survey was deemed to be Service Evaluation, and so formal ethical approval was not sought. Ethical approval was obtained from the University of Liverpool to undertake the interviews. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and it later amendments or comparable ethical standards. The project was formally registered though the Royal Liverpool University Hospital Clinical Effectiveness department. For this type of study, formal consent is not required and is implied by those who completed and returned the CODE™ questionnaire. Interview participants provided written informed consent.
Quality of healthcare


L-com Global Connectivity (www.l-com.com) has released a new series of IP68-rated cable glands and couplers. Typical applications for these new products include enclosures, outdoor plants, wired LAN connections and wireless installations.
This new product line consists of three models of feed-through couplers, IP68-rated cable glands and couplers: a cable gland with 12-inch RJ45 cable, a one-way-type panel mount cable gland and two-way-type couplers. All three series are available in Cat6a, Cat6 and Cat5e styles. These cable glands and couplers are IP68-rated when fully assembled to a cable and have rubber gaskets and grommets to protect connections from moisture and dust.
All models in this series feature a shielded internal coupler and easy installation with two included grommets that are sized for cables up to 0.323 inches (8.2mm). These cable glands and couplers operate in temperatures ranging from -40°C to +80°C, depending on model.
The new IP68-rated cable glands and couplers provide a versatile solution that is ideal for running RJ45 (8×8) connections into enclosures and panels. They're in stock and available for immediate shipment.


text:
Q: Getting the pixel under the mouse in TImage with Stretch. Proportional and Center all set to true I have got a form with a TImage on it. That TImage is set to Align=alClient, Stretch=True, Proportional=True and Center=True.
At runtime I load a bitmap into that TImage. It gets displayed a bit smaller than the original size but without distortion, as I expect it.
Now I want to get the coordinates of the pixel under the mouse when I press the Mouse button. This is the code assigned to im_Input.OnMouseDown:
procedure Tf_ColorAdjustment.im_InputMouseUp(Sender: TObject; Button: TMouseButton;
  Shift: TShiftState; X, Y: Integer);
begin
  im_Input.Picture.Bitmap.Canvas.Pixels[X - 1, Y - 1] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X - 1, Y] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X - 1, Y + 1] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X, Y - 1] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X, Y] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X, Y + 1] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X + 1, Y - 1] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X + 1, Y] := clYellow;
  im_Input.Picture.Bitmap.Canvas.Pixels[X + 1, Y + 1] := clYellow;
end;

(This is just testing code to see where the mouse click ends up. I know that using the Pixels property is very slow but it was the easiest way to make the affected pixels visible.)
This would work fine if all of these flags were set to false, but because the bitmap is shrunk to match the window, the pixels appear moved to the left and up.
I know that I need to adjust the coordinates, but how do I do it? Is there RTL/VCL support for that? Something like a CalcStretched method of the TImage (I couldn't find it but maybe I just overlooked it). Or do I really have to program the calculation myself?
(I can't believe that Google didn't find a ready made solution for this. This must have been a commonly encountered problem for decades.)

A: Well, you only need a few subtractions and divisions:
function TForm1.ClientToBitmap(const P: TPoint): TPoint;
var
  cW, cH: Integer;       // width and height of control
  bW, bH: Integer;       // width and height of bitmap
  Origin: TPointF;       // top-left pixel of bitmap in the control
  ZoomW, ZoomH: Double;  // required zoom factor to make bitmap fit horisontally or vertically
  Zoom: Double;          // zoom factor
begin

  cW := Image1.Width;
  cH := Image1.Height;
  bW := Image1.Picture.Bitmap.Width;
  bH := Image1.Picture.Bitmap.Height;

  ZoomW := cW/bW;
  ZoomH := cH/bH;
  Zoom := Min(ZoomW, ZoomH);

  Origin.X := (cW - bW*Zoom) / 2;
  Origin.Y := (cH - bH*Zoom) / 2;

  Result.X := Round((P.X - Origin.X) / Zoom);
  Result.Y := Round((P.Y - Origin.Y) / Zoom);

end;

Now:
procedure TForm1.Image1MouseUp(Sender: TObject; Button: TMouseButton;
  Shift: TShiftState; X, Y: Integer);
begin
  with ClientToBitmap(Point(X, Y)) do
  begin
    Image1.Picture.Bitmap.Canvas.Pixels[X - 1, Y - 1] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X - 1, Y] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X - 1, Y + 1] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X, Y - 1] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X, Y] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X, Y + 1] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X + 1, Y - 1] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X + 1, Y] := clBlack;
    Image1.Picture.Bitmap.Canvas.Pixels[X + 1, Y + 1] := clBlack;
  end;
end;

redpajama_set_name: RedPajamaStackExchange


Children as young as three dressed to impress at a special parade held at the independent school in Higham, to celebrate World Book Day.
The nursery classes joined the Kindergarten and Junior students at a catwalk show in the school hall where classmates, and their teachers, took a turn on the runway dressed as book characters.
Many of the outfits had been hand crafted by the students themselves and one form opted to dress as their favourites from a book they had been reading in class.
Headmaster David Craggs said: "Reading really helps bring imaginations to life.


Integrity Doctors has been a lifesaver to our clinic. We spent the first five years in practice, just surviving. Yes we could pay the bills, but it felt like a revolving door of patients in and patients out. Every month felt like we were starting over. Integrity helped us to understand the importance of systems to help educate our patients and ourselves to understand that patients who took preventative measures with their health had better long-term effects. It was easy to get caught in the trap of we are busy lets just skip something for now or lets just do half of something. It became apparent very quickly just how detrimental this could be. While we are far from perfect, we try to stress and remember the disservice we are doing for our patients if we don't follow all of the systems. It is up to us to help educate our patients. No one else will do it for us. If we don't follow through, a patient may drop care and will therefore miss out on the progress we could have made as well as live a life with aches and pains they shouldn't have to live with. On top of that, they may have an unfair impression of Chiropractic and what it can do for them. Integrity helps to keep us on track when we get side tracked with other distractions and this has been the key to our success. While there are so many good products available for the public, we realize that our specialty is Chiropractic. We want to be the best we can at what we know best and we do our best to stay focused on just that. Integrity helps us to keep that focus and as a result, I really do feel that we are able to be the best Chiropractic Office we can be. We have been fortunate to be recognized by our Community by being voted People's Choice and Best of the Red River Valley two years in a row. We thank Integrity Doctors from the bottom of our hearts.


text:
Стахановский завод ферросплавов — промышленное предприятие в городе Стаханов.

История
Решение о начале строительства было принято в 1952 году. Завод строился с 1959 по 1962 год в степи на окраине города.

В строительстве завода участвовали свыше 500 предприятий и организаций СССР (в том числе, 17 предприятий Луганской области).

В марте 1962 года на сушку поставили первую печь, 10 апреля 1962 года была проведена первая плавка ферросплавов, к началу августа 1962 года на заводе работали две электропечи, производившие электроферросилиций. На проектную мощность завод вышел в ноябре 1962 года, когда в эксплуатацию были введены печи № 7 и № 8.

В целом, в советское время завод входил в число крупнейших предприятий города.

После провозглашения независимости Украины государственное предприятие было преобразовано в открытое акционерное общество. В августе 1997 года завод был включён в перечень предприятий, имеющих стратегическое значение для экономики и безопасности Украины.

С весны 2014 года завод контролируется Луганской Народной Республикой. В ходе войны в Донбассе завод был разрушен и остановился.

В 2018 году завод перешел под внешнее управление юго-осетинской компании ЗАО «ВНЕШТОРГСЕРВИС» и получил название филиал № 13 «Стахановский завод ферросплавов» ЗАО «Внешторгсервис».

Современное состояние
У завода восемь ферросплавных печей, производительностью около 2 тысяч тонн в месяц каждая. Основная продукция: ферросилиций, ферромарганец и ферросиликомарганец. Большая часть производимой предприятием продукции (около 75 %) экспортируется.

Завод является специализированным предприятием по производству ферросилиция марок ФС20, ФС25, ФС45, ФС65, ФС75, ФС90, ферромарганца марки ФМн78, электродной массы марки «Б» и улучшенного качества марки «А», ферросиликомарганца марок МнС17РБ, МнС17Р45, а также модификаторов и лигатуры на его основе.

Руководство
 Управляющий филиалом № 13 «Стахановский завод ферросплавов» — Тарабан Игорь Владимирович
 Первый заместитель управляющего филиалом № 13 «Стахановский завод ферросплавов» — Гордиенко Владимир Петрович

Примечания

Предприятия чёрной металлургии СССР
Предприятия Стаханова
Приват (финансово-промышленная группа)
Производители ферросплавов

redpajama_set_name: RedPajamaWikipedia


text:
https://www.niagaraparks.com/visit/nature-garden/queenston-heights/
Nestled high atop the Niagara Escarpment, Queenston Heights Park combines leisure and history in one scenic location. At the entrance to this historic park, visitors are greeted by grand carpet bedding displays that surround both the Brock and Laura Secord Monuments. Facilities include two picnic pavilions, washrooms, a children's splash pad, tennis courts, a band shell, snack bar, playground and seasonal fine dining at Queenston Heights Restaurant.
Snack Bar Available
14184 Niagara Parkway, Niagara-on-the-Lake, L0S 1J0
Southern Terminus of the Bruce Trail
Queenston Heights Park is the southern terminus point of the Bruce Trail, which winds it way northward over several hundred kilometres to Tobermory. This trail passes through the Niagara Escarpment, which has been recognized as a world biosphere by U.N.E.S.C.O.
Brock's Monument
Brock's Monument is owned by Parks Canada and is located in Queenston Heights Park, which is maintained year-round by Niagara Parks.The monument is open for an interpretive programmes daily from May until Labour Day weekend. Parks Canada staff at the monument can be contacted at (905) 262-4759.
Landscape of Nations
The Six Nations and Native Allies Commemorative Memorial can also be found in Queenston Heights Park. The memorial commemorates the significant sacrifices and contributions made by First Nations during the War of 1812 and also recognizes the historic ceremony of peace and reconciliation held in Niagara on August 31 and September 1, 1815 that restored peace among the Native nations who fought on opposing sides.
Experiences to Inspire

redpajama_set_name: RedPajamaCommonCrawl


Pogo - UPular from Nikki Albertyn on Vimeo.
We were required to pick any artist and make a music video for one of their tracks. I chose the Australian (originally from South Africa) artist, Pogo's, song UPular. All characters were illustrated in Adobe Illustrator and later taken into Adobe AfterEffects to animate.


Geometric Regression Library (GeoRegression) is an open source Java geometry library for scientific computing with a focus on 2D/3D space. GeoRegression provides the ability to estimate the closest point/distance between geometric primitives, best-fit shapes, and best fit geometric transform between sets of objects. It is designed for high performance and ease of use. GeoRegression has been release under an Apache v2.0 license for both commercial and non-commercial use.
Limited support for integers types.


text:
Stephen Reeder Donaldson
www.SFBookcase.com
Write both fantasy novels and science fiction. With characters that are realistic and not very heroic, their actions are sometimes disturbing. I would not recommend the books for young children, but for adults it is interesting to see what events actually form the characters.
Born in Cleveland, Ohio, in 1947.As a child he lived in India with his father, an orthopaedic surgeon. His fathers work with lepers during this period inspired the character of Thomas Convenant. Graduated from College of Wooster, in Ohio, in 1968.Received an MA in English, from Kent State University. He resides in New Mexico.
Is currently working on the third, and final, Chronicles of Thomas Covenant.
Qtuoe from SciFi Wire (21st Jan 2000)Author Stephen R. Donaldson said there is no truth to a recent rumor that he is working on a new installment of his best-selling fantasy series The Chronicles of Thomas Covenant the Unbeliever. Donaldson said that rumor has been kicking around for 15 years, but that "it's no more true now than it was in 1985--which is to say, not at all."
However, Donaldson didn't rule out the idea of writing more Covenant books at some point. "The possibility exists that I will someday write what I call The Last Chronicles of Thomas Covenant," he told SCI FI Wire. "But I've given the idea no serious consideration yet."
The Chronicles of Thomas Covenant, the Unbeliever
1. Lord Foul's Bane
2. The Illearth War
3. The Power that Preserves
- Fantasy series about the leper Thomas Convenant, transported to magical land to save it from destruction. Thomas Convenant is an anti-hero, determined to not believe that the Land exists, and only wanting to return to his normal life. Brilliant trilogy. The main character is not very likable, but makes an interesting change from a generic hero.
The Second Chronicles of Thomas Covenant
1. The Wounded Land
2. The One Tree
3. White Gold Wielder
- Sequel fantasy series. Thomas Convenant is once again transported back to the land to save it from a new threat, only to find it transformed from all it was in the first series. Excellent.
Mordant's Need
1. The Mirror of her Dreams
2. A Man Rides Through (1989)
- The young woman Terisa is transported from New York to the kingdom of Mordant, where mirrors have magical powers. Not as good as the Thomas Convenant books, but in a very similar style.
The Gap Series
1. The Gap into Conflict: The Real Story
2. The Gap into Vision: Forbidden Knowledge
- Science fiction series. I have tried the first volume and found that it disturbed me and put me off from reading any other of the books.
Daughter of Regals and Other Tales - Short stories.
Gilden-Fire - The story, set during The Illearth War, of the journey to find out why the giants have lost contact with the Land.
Stephen Donaldson Page on www.SFBookcase.com.
HarperCollin's Interview with Donaldson
Go back to the authors archive, Updated Authors list
Paul Farris 1997


to define the status and phenology of all the species. The wetlands in SoukAhras area were found to be exploited by the birds for overwintering, as a waypoint during the migrations and for reproduction. A total of ten migratory species was counted and four other species are sedentary breeders (the White-headed Duck, Oxyura leucocephala, the Ferruginous Duck, Aythya nyroca, the Mallard, Anas platyrhynchos and the Common coot, Fulica atra). The species-richness presents inter-site and interyear variations. In addition to hosting a significant proportion of wintering and breeding birds for a large number of species, the numbers at some wetlands meet the criteria for Ramsar designation (Criterion 6) for one wintering and one nesting waterbird species, namely the Ferruginous duck Aythya nyroca and the White-headed duck Oxyura leucocephala.
duck, Aythyanyroca, White-headed duck, Oxyura leucocephala, Marbled Teal, Marmaronetta angustirostris, and the Shelduck, Tadorna tadorna. The impact of anthropogenic factors on the waterbird populations at SoukAhras wilaya was very evident during the four seasons.
Despite these negative impacts, the sites of this area still present a great ornithological value.


A group of scientists from across the globe have revealed the stunning details of a submarine canyon on the edge of the country's continental shelf, after mapping an area twice the size of Malta.
The expedition, led by Dr. Aaron Lim of UCC's School of Biological, Earth and Environmental Sciences (BEES), utilises the Marine Institute's Holland 1 Remotely Operated Vehicle (ROV) and state-of-the-art mapping technologies to reveal the nature of the canyon.
"This is a vast submarine canyon system, with near-vertical 700m cliff in places and going as deep as 3000m. You could stack 10 Eiffel towers on top of each other in there," said Dr. Lim (BEES-UCC), "So far from land this canyon is a natural laboratory from which we feel the pulse of the changing Atlantic."
According to Dr. Lim, this discovery coupled with recent findings on the Irish-Atlantic margin shows the advances in both Ireland's marine technology and scientific workforce. "Ireland is world-class, and for a small country we punch above our weight."
This is all about transporting carbon stored cold water corals into the deep. The corals get their carbon from dead plankton raining down from the ocean surface so ultimately from our atmosphere," said Professor Andy Wheeler, School of BEES, UCC, and the Irish Centre for Research in Applied Geosciences (iCRAG).
"Increasing CO2 concentrations in our atmosphere are causing our extreme weather; oceans absorb this CO2 and canyons are a rapid route for pumping it into the deep ocean where it is safely stored away."
"We took cores with the ROV, and the sediments reveal that although the canyon is quiet now, periodically it is a violent place where the seabed gets ripped up and eroded," added Professor Wheeler.
The new mapping data shows a rim feature along the lip of the canyon at approximately 600m water depth. "When we sent down the ROV, we saw that this rim is made of a profusion of cold water corals, which appears to extend for miles along the edge of the canyon," said Professor Luis Conti, University of Sao Paulo.


Check your bio-parameters in real-time.
Reduce stress and increase energy.
It's love at first beat.
When the first HELO Classic was released it created shockwaves in the wearable technology market. The newly designed HELO LX is even more disruptive, and includes powerful upgrades under the hood.
It even has built-in GPS with a panic button if you are in trouble. Plus, new features will continually be released through the Helo App Store, further increasing the functionality of the HELO.
*Some features are made available through the Helo App Store.
HELO's hypo-allergenic band contains replaceable and removable titanium plates, with stones of pure Germanium at 99,99% purity.
Advise your loved ones if your measurements are not in the correct range*.
Guardian offers you an amazing feature: alerting your loved ones through SMS and in-app messages if your measurements are too high or low.
Advanced sensors continuously measure your body's vitals and syncs the data to your phone or tablet via Bluetooth. The reports on the app help you analyze the data, track your progress, and obtain a complete overview of your lifestyle: sleep quality, exercise, blood pressure, heart rate and ECG. And with WeCare, you can monitor and check the bio-parameters of your loved ones remotely.
Get instant notifications and alerts.
LifeLog keeps a history of your heart rate, blood pressure, breath rate, EKG, mood, steps, sleep and many other details every day. You, your loved ones, your physical trainer or your doctors can check, compare and analyse your data to improve your health!


text:
Guns/2A
DC Clothesline Airing Out America's Dirty Laundry
Receive an Obamacare Subsidy? Surprise! You May Owe the IRS Money
Lily Dane
Remember those Obamacare subsidies, the ones that were supposed to make healthcare "affordable" for Americans?
6.8 MILLION people received those subsidies under the ACA in 2014.
A nasty surprise is in store for about half of those people – an estimated 3.4 million Americans – when they file their taxes.
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Over 400 San Francisco Restaurants Closed in 2019. Liberal Solution? Fine Empty Storefronts With a "Vacancy Tax"
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That's because – OOPS – they received subsidies that were too generous. This means that the people impacted will either receive smaller tax refunds than they expected, no refund at all, or will actually OWE the IRS money.
Last Thursday, the Wall Street Journal reported that the tax preparation firm H&R Block did some number crunching and came up with the disturbing calculation:
"The ACA is going to result in more confusion for existing clients, and many taxpayers may well be very disappointed by getting less money and possibly even owing money," the president of a tax preparation and education school told the Journal.
The reason this is happening (aside from the ACA being a seriously flawed policy in just about every way) is because the subsidies are based on PAST income. In other words, taxpayers got their subsidies prior to knowing exactly what their total income for 2014 would be. They had to estimate their income for the year when they signed up for insurance months ago – enrollments for 2014 began in October 2013. Many people didn't know exactly what they'd earn in 2014. Experts say some guessed based on their income as far back as 2012.
And we aren't talking pocket change here, as Tami Luhby of CNN Money explains:
Those who applied through the federal exchange received an average monthly subsidy of $264, according to the most recent figures reported by the Obama administration. They only had to pay $82 a month, on average, for coverage, Roughly 85% of total enrollees received help with insurance premiums. The administration last month said 2014 enrollment was 6.7 million.
Those who underestimated their earnings could owe thousands of dollars, though there is a $2,500 cap for those who remain eligible for subsidies. The threshold for eligibility is based on income – $45,900 for an individual and $94,200 for a family in 2014.
To add insult to injury, subsidy recipients will have to complete the mind-boggling IRS form 8962. To do this, they will use information on their insurance, subsidies, and income that will be supplied to them on Form 1095-A, which they should receive from their exchange by January 31.
If they were not enrolled in Obamacare for the entire year, they will have to break down the subsidy payments by month.
Here's what that form looks like:
Timothy Jost, a law professor at Washington and Lee University, said things could get confusing:
"It will be very difficult for those individuals who received premium tax credits to prepare their taxes on their own and get this straight."
Also concerning is whether the Form 1095-As will contain accurate information and whether the exchanges will send them by the end of January, said Jost, who writes about Obamacare for the Health Affairs blog.
And taxpayers can forget about calling the IRS for help. In November, IRS Commissioner John Koskinen said the upcoming filing season will be one of the "most complicated" ever. He also said that IRS funding reductions "will pose serious challenges to our customer service, enforcement efforts and information technology projects," he said. Koskinen added that telephone service could drop from the 2014 service level of 71 percent to 53 percent in 2015, unless the IRS is provided the funds to hire staff to handle the volume of calls.
Oh, remember when some Obamacare navigators were caught telling applicants to lie about their income to get more subsidies and lower premiums? No one is sure how often that happened, but if people actually took that advice, they may end up paying dearly for it.
But all of this may not matter much come March, when the Supreme Court will decide whether the subsidies issued to residents of states that did not set up their own Obamacare exchanges are legal at all.
As Mac Slavo reported in November:
Should the Supreme Court rule against federal Obamacare subsidies the Affordable Care Act would fall apart almost instantly, as five million low-income Americans would see their health premiums jump nearly $3000 per year, making it too costly for just about everyone who depends on the subsidies.
Obamacare Architect Extraordinaire Jonathan "Foot in Mouth" Gruber said it himself:
"I think what's important to remember politically about this is if you're a state and you don't set up an exchange, that means your citizens don't get their tax credits."
Some are promising to do what they can to repeal Obamacare and replace it with affordable, free-market options. One notable politician who is working to do just that is Mia Love, a Republican member of the U.S. House of Representatives from Utah who assumed office on January 3:
Let's hope that by some miracle, the ACA is repealed as soon as possible, because premiums and penalties are going to increase significantly in 2015.
Lily Dane is a staff writer for The Daily Sheeple. Her goal is to help people to "Wake the Flock Up!"
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text:
Q: Can i have the same name for both vps server and domains? Can a server name be the same name as a domains? Will this lead to problem when configuring server block?

A: Although the question is vague, this might be the answer you're looking for: Assume you have a domain name "example.com" which you have registered with a domain provider. You want to attach that domain name to a server called "www" so people can access a website hosted at "www.example.com."
When you configure the domain, you create a DNS "A" record which points to the IP address for the "www" host of "example.com." This is the "external" name of the server, the domain name. In other words, the FQDN of the server is www.example.com.
The local machine "hostname" of the server at that IP Address can be "www" or anything else. Although it sometimes can be anything else, almost always, the internal hostname and the external domain name of the server should match.
So, with this example, yes, the server name can and should be the same as the domain's name of the server: www.
To find out what an internal server name is, in Linux, type "hostname" and it will show you the server name. In Windows, you can look at System information and look for Computer Properties, Computer name, or sometimes "Device Name"


text:
Cosmetic Surgery and Laser Center of Cerritos
On this blog, Dr. Gregory T. Fisher, MD, FACS, provides useful intormation to his patients. Please contact us with your inquiries. You may also make an appointment by calling Dr.Fisher's office at 562-865-9600.
Otoplasty etc.
First of all, let us remind the readers that all the operations Nadia underwent are performed by Dr. Fisher at one-third of the cost. Nadia Ilse is now looking forward to the new school year, when she will no longer be called "Dumbo" by her peers for her "elephant ears."
To ward off school bullies who began taunting her in the first grade for her ears, Nadia begged her mother at the age of 10 for an otoplasty — an operation to pin her ears back.
The teen, now 14, was recently granted her wish by the Little Baby Face Foundation, a charity that provides free corrective surgery to children born with facial deformities.
Nadia told CNN that the bullying turned her talkative self into a withdrawn, antisocial girl. The taunting "hurt so much,"
When the Little Baby Face Foundation was contacted by Nadia's mother, the organization brought the duo to New York City from Georgia and did more than just pin her ears back. The organization's founder, Dr. Thomas Romo, III. also performed reduction rhinoplasty, reducing the size of the nose, and mentoplasty, altering the chin.
The foundation covered the estimated $40,000 cost of surgery.
Avoiding school bullying by going under the knife is on the rise among American teens. In 2007 alone, about 90,000 youth underwent cosmetic surgery — though not all cases were the result of teasing.
While Nadia says she knows she should have been accepted as she was before the surgery, she also knew the bullying wouldn't end and has no regrets following the procedure.
"I look beautiful, this is exactly what I wanted, I love it," she said.
Nadia must still start counseling as part of her treatment to overcome the years of psychological distress from bullying, but Little Baby Face board member Don Moriarity told MailOnline that Nadia's new outlook demonstrates the group's mission.
"We like to say that Baby Face transforms the lives of these children and gives them newfound confidence," Moriarity said.
Nadia's story emerges months after 13-year-old Nicolette Taylor was featured on ABC's Nightline for her nose surgery to overcome online harassment and name-calling at school. There was also global outcry when 7-year-old Samantha Shaw had her ears pinned back to escape name-calling and harassment last year.
So through all this, what advice would you give parents? Gupta asked Nadia.
"Give your children a lot of love and affection and tell them that they're beautiful every single day," she said.
Most states now have bullying laws that require schools to adopt bullying policies, and efforts to combat school bullying have escalated over the last decade, according to a report released in December by the U.S. Department of Education.
Between 1999 and 2010, more than 120 bills were adopted by state legislatures to introduce or amend legislation that address bullying, harassment or similar behavior in schools. By the time of the Education Department study's conclusion, there were 46 states with enacted anti-bullying laws, 36 with regulations that work against cyberbullying and 13 that give schools the authority to monitor and address bullying behavior even when it occurs off school grounds.
This entry was posted on July 28, 2012. Bookmark the permalink.	2 Comments
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2 thoughts on "Otoplasty etc."
plasticsurgerycerritos says:
I really enjoy reading your articles. Thank you. They are very well written. Dr. Fisher, thank you for responding to my question.
The more I read it, the more I like it!


Summary – For a nation that cherishes its history, it is remarkable how little is known in Ireland about Irish involvement in the Papal War of 1860. Although identifiable Irish units existed within the British army, this was a unique situation for that era, as fledgling Irish recruits fought with bravery and aplomb in Italy alongside men from Europe's military super-powers.
They garnered praise from all, friend and foe, who witnessed their actions. However, to the victors the spoils, and, understandably, surviving statues and memorials in Italy only honour those who achieved Italian reunification. Although treated like heroes on their return to Ireland, the deeds of the Battalion of St. Patrick have dissipated with the passing of time. However, as American historian, Brian C. Pohanka, once insightfully remarked, 'Without memory, we have no deeds'.
Speaker – A public health official by necessity and historian by vocation, Robert Doyle is a native of Baltinglass, Co Wicklow. He has studied the life and career of Myles Keogh for many years and is the co-creator of http://www.myleskeogh.org. He is also a frequent speaker on military history, has written for popular history periodicals including, Military Illustrated and History Ireland and is a contributing editor for the Irish heritage website, http://www.thewildgeese.com.
This entry was posted in Lectures and tagged History, Ireland, Italy, Military, Papal Army, Papl War. Bookmark the permalink.


text:
Richard Strauss: A Lifetime of Lied Composition
DOI link for Richard Strauss: A Lifetime of Lied Composition
Richard Strauss: A Lifetime of Lied Composition book
ByBarbara A. Petersen
BookGerman Lieder in the Nineteenth Century
Richard Strauss (1864-1949) composed lieder throughout his long career, from the 14-measure "Weihnachtslied" of December 1870 to his crowning achievement of 1948, the orchestral songs now known as the Vier letzte Lieder.1 His more than two hundred songs stand at the end of the great nineteenth-century German lied tradition. Perhaps because Strauss enjoyed a long composing career and lived nearly to the halfway mark of the twentieth century, he is sometimes viewed less as a nineteenth-century figure than as a transitional or even a twentieth-century one (if, toward the end, something of an anachronism). Yet, three-quarters of his lieder-112 songs published in groups with opus numbers, forty-five early songs, and a handful of occasional pieces-were composed by 1904.


text:
Q: Is this C++ [out] parameter a pointer to an enumeration, or just a single value? Currently I'm working with DirectShow.NET, an unofficial .NET "port" for Microsoft's DirectShow (C++).
Both IAMAnalogVideoDecoder and IAMTVTuner declare the method get_AvailableVideoFormats. This is how the method is defined in the official docs:
HRESULT get_AvailableTVFormats(
  [out]  long *lAnalogVideoStandard
);

It's not clear to me if this parameter is a pointer to a single AnalogVideoStandard, or a enumeration. Unfortunatelly I'm too inexperienced with C++ to fully understand the docs. Because of the methods name, I would expect it to be a enumeration, but is it?
The reason I'm asking this, is because in the .NET library, this parameter is not a enumeration, just a single value. I find this very strange, since I'm expecting to get multiple "available video formats" here.

By the way, AnalogVideoStandard is an enum.

A:
It's not clear to me if this parameter is a pointer to a single AnalogVideoStandard, or a enumeration.

It's neither1:

Pointer to a variable that receives a bitwise OR of zero or more flags from the AnalogVideoStandard enumeration.

It's a pointer to a value that represents zero or more AnalogVideoStandards.
This answer should explain the rest. You should be able to apply this answer to your .NET code.
1 Technically it could be an enumeration value in C# because enum types can have a FlagsAttribute applied to them but there's no equivalent in C++, you just | values together with no special fanfare.


Dietary intake in Japanese patients with kidney transplantation.
One patient was CKD G1 stage, five in G2, 17 in G3a, 24 in G3b, 14 in G4, and one in G5.
METHODS AND RESULTS: Apolipoprotein M (ApoM) transgenic (Apom-Tg) mice, in which plasma S1P is increased by 296%, and wild-type (WT) mice were subjected to in vivo I/R.
AIM: To investigate whether apoM is excreted in urine of children undergoing heart surgery and the potential of apoM as early biomarker of acute kidney injury (AKI).
Among 225 participants with available Core-E2 sequence (ATAHC, n=113; HITS-p, n=90; and HITS-c, n=22), HCV genotype prevalence was: G1a: 38% (n=86), G1b: 5% (n=12), G2a: 1% (n=2), G2b: 5% (n=11), G3a: 48% (n=109), G6a: 1% (n=2) and G6l 1% (n=3).
Meta-Analysis on the Correlation Between APOM rs805296 Polymorphism and Risk of Coronary Artery Disease.
BACKGROUND The present meta-analysis aimed to summarize the inconsistent findings on the association of apolipoprotein M gene (ApoM) rs805296 polymorphism with the risk of coronary artery disease (CAD), and to obtain a more authentic result about this topic.
Apolipoprotein M: Research progress, regulation and metabolic functions (Review).
Apolipoprotein M (ApoM) is a novel lipoprotein-associated plasma protein of the apolipoprotein family.
Although the majority of plasma S1P is bound to apolipoprotein M (ApoM) in the high-density lipoprotein (HDL) particle, the immunological functions of the ApoM-S1P complex are unknown.
Apolipoprotein M (ApoM) is a novel apolipoprotein that was discovered in 1999 and is bound primarily to high-density lipoproteins (HDLs) in the plasma.
The necessity and effectiveness of mineralocorticoid receptor antagonist in the treatment of diabetic nephropathy.
However, in category G3a and higher, sufficient attention must be paid to hyperkalemia.
HDL-S1P: cardiovascular functions, disease-associated alterations, and therapeutic applications.
The main binding partner of S1P in HDL is apolipoprotein M but others may also exist particularly under conditions of acute S1P elevations.
Network-assisted analysis of primary Sjögren's syndrome GWAS data in Han Chinese.
Of these pSS candidates, 14 genes had been reported to be associated with any of pSS, RA, and SLE, including STAT4, GTF2I, HLA-DPB1, HLA-DRB1, PTTG1, HLA-DQB1, MBL2, TAP2, CFLAR, NFKBIE, HLA-DRA, APOM, HLA-DQA2 and NOTCH4.
[Investigation by young members--comprehensive remarks as a chairman].
The first speaker was Dr. Kurano from The University of Tokyo, and he discussed the crucial role of apolipoprotein M in "sphingosine 1-phosphatology".
ABCA1 upregulating apolipoproein M expression mediates via the RXR/LXR pathway in HepG2 cells.
The present study demonstrated that apoM expression could be elevated by ABCA1 via the RXR/LXR pathway and LRH1 does not involve in the regulation of apoM by the activation of ABCA1, although the direct regulative pathway(s) between ABCA1 and apoM gene is still unknown yet.
Apolipoprotein M binds oxidized phospholipids and increases the antioxidant effect of HDL.
Plasma levels of sphingosine-1-phosphate and apolipoprotein M in patients with monogenic disorders of HDL metabolism.
Report plasma levels of sphingosine-1-phosphate and apolipoprotein M in patients with monogenic disorders of HDL metabolism.
Single Nucleotide Polymorphism at the promoter region of the APOM gene is associated with rheumatoid arthritis.
Enchanced levels of apolipoprotein M during HBV infection feedback suppresses HBV replication.
Apolipoprotein M is required for prebeta-HDL formation and cholesterol efflux to HDL and protects against atherosclerosis.
Induction of MHC class I expression by the MHC class II transactivator CIITA.
The G3A cell line, which is defective in CIITA induction, does not induce MHC class I antigen and promoter in response to IFNgamma.
Molecular analysis of G1B and G3A IFN gamma mutants reveals that defects in CIITA or RFX result in defective class II MHC and Ii gene induction.
Using one IFN gamma mutant cell line (G3A) that is selectively defective in HLA-DR and Ii induction, four lines of evidence are presented to show that CIITA mediates the IFN gamma induction of HLA-DR and Ii genes.


text:
import { useState, useRef, useEffect, SyntheticEvent } from 'react'

import { Menu, Transition } from '@headlessui/react'

import Map from 'ol/Map'
import VectorLayer from 'ol/layer/Vector'
import VectorSource from 'ol/source/Vector'
import Geometry from 'ol/geom/Geometry'

import { EyeIcon, EyeOffIcon } from '@heroicons/react/outline'

// Manage annotation layers
const Layer = (props: {
	layer: VectorLayer<VectorSource<Geometry>>
	index: number
	active: boolean
	map: Map
}) => {
	const { layer, index, active, map } = props

	// Utilities for editing layer name
	const [isEditingName, setIsEditingName] = useState(false)
	const nameInputRef = useRef<HTMLInputElement>(null)
	const [nameInputValue, setNameInputValue] = useState(layer.get('id'))
	const handleNameChange = (e: SyntheticEvent) => {
		const newName = (e.target as HTMLInputElement).value
		setNameInputValue(newName)
		layer.set('id', newName)
	}

	// Utilities for toggling opacity
	const [isVisible, setIsVisible] = useState(layer.getVisible())
	const opacityCache = useRef(layer.getOpacity())
	const toggleOpacity = () => {
		if (layer.getOpacity() === 0) {
			layer.setOpacity(opacityCache.current)
		} else {
			opacityCache.current = layer.getOpacity()
			layer.setOpacity(0)
		}
	}

	// Utilities for context menu
	const [contextMenuPos, setContextMenuPos] = useState([0, 0])
	const contextMenuRef = useRef<HTMLButtonElement>(null)

	// Attach a listener for opacity changes (the opacity of this layer may also
	// be changed by the activeLayer control slider). Need to do this inside a
	// useEffect hook so we can return a cleanup function and avoid a memory leak.
	useEffect(() => {
		const listener = () => {
			setIsVisible(layer.getOpacity() !== 0)
		}
		layer.on('change:opacity', listener)
		return () => {
			layer.un('change:opacity', listener)
		}
	}, [layer])

	// Set layer active
	const setLayerActive = (layer: VectorLayer<VectorSource<Geometry>>) => {
		map.getLayers().set('active', {
			layer,
			index,
		})
	}

	return (
		<div
			className={`${
				active ? 'text-teal-800 bg-gray-100' : 'text-gray-700 bg-white'
			} flex justify-between w-full text-sm overflow-hidden`}
			onContextMenu={(e) => {
				e.preventDefault()
				if (contextMenuRef.current) contextMenuRef.current.click()
				setContextMenuPos([e.clientX, e.clientY])
			}}
		>
			<button
				type="button"
				className="m-1 inline-flex items-center text-gray-500 hover:text-gray-800 focus:outline-none focus:ring-2 focus:ring-offset-1 focus:ring-teal-500"
				onClick={toggleOpacity}
			>
				{isVisible ? (
					<EyeIcon className="h-4 w-4" aria-hidden="true" />
				) : (
					<EyeOffIcon className="h-4 w-4" aria-hidden="true" />
				)}
			</button>

			{/*
        This feels like a bit of a hack. We need to display the text input
        on doubleClick. But we also want to automatically focus the input.
        Since you cannot apply focus to an unmounted/hidden DOM element it's not
        easy to toggle between them. Settled on a hack where we instead change
        the element widths. Likely there is a cleaner solution.
      */}
			<input
				type="text"
				name="layer-name"
				ref={nameInputRef}
				className={`${
					isEditingName ? 'w-full m-1' : 'w-0'
				} block focus:outline-none focus:ring-2 focus:ring-offset-1 focus:ring-teal-500 focus:border-teal-500 border-gray-300`}
				placeholder={layer.get('id')}
				onBlur={() => {
					setIsEditingName(false)
				}}
				value={nameInputValue}
				onChange={handleNameChange}
				onKeyUp={(e) => {
					if (e.key === 'Enter' && nameInputRef.current) {
						nameInputRef.current.blur()
					}
				}}
			/>

			<button
				type="button"
				className={`${
					isEditingName ? 'w-0' : 'w-full m-1'
				} truncate text-left w-full hover:bg-gray-50 focus:outline-none focus:ring-2 focus:ring-offset-1 focus:ring-teal-500`}
				onClick={() => setLayerActive(layer)}
				onDoubleClick={() => {
					setIsEditingName(true)
					if (nameInputRef.current) nameInputRef.current.focus()
				}}
			>
				{layer.get('id')}
			</button>

			{/* Context menu */}
			{/*
        This seems like a poor way of doing this - there is likely a better
        solution. We are using a hidden button to open the context menu. We are
        activating that button via an onContextMenu event (see above). This is
        because headlessUI do not expose the open state of their menu so we
        cannot easily create a controlled component. It's a workaround.
      */}
			<Menu>
				<Menu.Button ref={contextMenuRef} />

				<Transition
					enter="transition duration-100 ease-out"
					enterFrom="scale-95 opacity-0"
					enterTo="scale-100 opacity-100"
					leave="transition duration-75 ease-out"
					leaveFrom="scale-100 opacity-100"
					leaveTo="scale-95 opacity-0"
				>
					<Menu.Items
						className={`absolute w-28 mt-2 origin-top-right -translate-x-full bg-white divide-y divide-gray-100 rounded-sm shadow-lg ring-1 ring-black ring-opacity-5 focus:outline-none`}
						style={{ left: contextMenuPos[0], top: contextMenuPos[1] }}
					>
						<div className="px-1 py-1 ">
							<Menu.Item>
								{({ active }) => (
									<button
										className={`${
											active ? 'bg-teal-500 text-white' : 'text-gray-900'
										} group flex rounded-sm items-center w-full p-1 text-sm`}
										onClick={() => {
											map.removeLayer(layer)
										}}
									>
										Delete
									</button>
								)}
							</Menu.Item>
						</div>
					</Menu.Items>
				</Transition>
			</Menu>
		</div>
	)
}

export default Layer

redpajama_set_name: RedPajamaGithub


text:
Q: Schwarz space $S(\mathbb{R})$ is dense inside $L_p(\mathbb{R})$-spaces I was wondering why the schwarz functions $S(\mathbb{R})$ are dense inside the $L_p(\mathbb{R})$ spaces and I was reading this answer, but I don't understand why the $g_t$ are in $S(\mathbb{R})$. Could someone explain this?

A: Note the following first:

The convolution with any function with compact support is given by an integral on a compact interval.

So now you can establish the second point:

The convolution with any $C^\infty$ function given by an integral on a compact interval gives a $C^\infty$ function (basically you can take the derivatives inside).


Mirror Jewelry Box Armoire Picture bottom is part of the best post in Jewelry Armoire category, published on Monday, March 19th, 2018 .
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Can you help bring a touch of colour to Ipswich railway station?
Do you have green fingers and fancy turning Ipswich railway station into a green oasis? If so Greater Anglia bosses want to hear from you.
They are appealing for more "station adopters" to help improve the environment of stations across the region by developing station gardens or introducing planters or hanging baskets to make it more attractive for passengers beginning or ending their journeys.
Many stations – mainly small halts serving local communities – have already been adopted. Some larger stations, including Cambridge which is the busiest station outside London in the region, have also had adopters step in.
Now Greater Anglia is looking for individuals or groups to adopt stations including Ipswich, Westerfield, Needham Market and Thurston.
Greater Anglia's Community Engagement Manager, Alan Neville, said "We are hoping that individuals, community organisations or local councils, who have an interest in improving their local rail station and bringing it into the heart of the community, will come forward with their ideas.
Greater Anglia provides some funding via the scheme which can help adopters cover the costs of small projects, such as the creation of station gardens and the purchase of flowers, tubs, hanging baskets, tools and materials to help improve the station environment.
The voluntary scheme was originally created in 2003 to improve lines of communication between the train operator and station users.
Station adopters now playing an active role in keeping stations looking good through inventive gardening projects, creative community art schemes, or by being the eyes and ears of their station.
Greater Anglia now has 93 of its 133 stations "adopted", with over 200 volunteers across the region helping to make their station an impressive gateway to their local community.


We got bogged down in our bathtub project for a few different reasons. First, the weather turned cold, so we had more staying-alive issues to deal with (firewood, frozen water). Second, home renovation doesn't involve living things, so I don't tend to prioritize it (lazy garden-obsessed homesteader!). And, finally, we had so many interesting comments on my planning post that I needed to digest for a while.
Speaking of dragging our heels, I guess I should give you at least the cliff notes version of why we don't currently have a working bathtub. One came with the trailer, of course, but when you start from scratch with untraditional home-plumbing, it simply makes more sense to concentrate all of the influent and effluent at a single location. In our case, the chosen location was the warmest spot in the winter trailer --- the kitchen, where we use water constantly for dishes, cooking, and washing. As a result, we ripped the entire bathroom out and turned that area into chicken-waterer-building central.
So how have we been bathing for the last decade? In the summer, a hose outdoors is top notch (says Anna --- Mark prefers his water to be more temperate). In the winter, though, I go for water heated on the stove and poured into a galvanized washtub while Mark prefers bird baths. As you can tell, anything we build will be a major step up.
Okay, now you're back up to date on the next building project. Time to start thinking of the newest bathing apparatus once again!
Thought you might like to know about this battery-powered shower. It works brilliantly & the rechareable battery lasts forever.
Your comment about heating water on the stove and then using a washtub to bathe reminded me of my grandmother's house in what is now the East Village of NYC. She lived in one of those buildings that used to be called a tenement on the top floor, if I remember correctly. They did the same thing: heated water on the stove and then poured it into a washtub to bathe. This was in the early 1950s. Flash forward to 1960 when I visited an aunt in Jersey City, NJ, across the river from NYC. I was there for a weekend and we did our bath the same way: heated water on the stove and then poured it into a washtub. So your solution to bathing is a time-honored one!
I like the picture of the folding tub. Did you notice that they had a hot water heater(?) reservoir right above the tub? Talk about using space efficiently! Since NYC has now given the green light to builders to make ultra small (400 square feet! which would be about a room about 20 feet by 20 feet) this sort of thing would be useful. I have seen some pics of potential "apartments" there that depict the bed folding up into the wall and table being attached to same to fold down so one can eat. I wonder if they got their ideas from Japan where space is very very tight?