The Eye Safety Card has been gaining very positive feedback from colleagues who have ordered and seen the card.
One of the main themes of feedback is that it would be a very useful tool for staff training sessions covering the area of how to detect and appoint patients with significant ocular problems. It provides a very clear and visual template for this type of staff training session. This would then lead well onto to it's everyday use which is be available as a prompt/reminder to reception staff when faced with a patient who may have significant signs or symptoms.
This type of training would be well suited to both independent or multiple practice, and would compliment any existing systems which practices may have in place.
As usual please get in touch for any further information and I am always grateful for any feedback and suggestions!


KONG BraidZ Fuzzy Monkey Dog Toy, Small (Colors Vary) - Each monkey squeaks and is available in three sizes (small, medium and large) and sold in an assortment of three vibrant colors (blue, purple, orange). Braidz fuzzy monkey toys are tightly braided for strength yet stretchy for a great game of tug and fetch. Your dog will love you for it. Fuzzy monkeys have long, soft fuzzy limbs which dangle in a way dogs find tough to resist.
Zanies Plush Funky Monkey Dog Toy, 14-Inch, Orange - Features four different textures, a half plush body, a half nubby body, bungee limbs, and rubber ears for hours of playtime fun. Brightly colored funky monkey with cute design is a must-have dog toy. Available in orange color. Measures 14-inch length. Made of plush, rubber, elastic material.
Huge Monkey Stick Dog Toy-20IN-TAN - Lead free dog toy. All parts of this monkey squeak- hands feet ears nose and body. Sizing 20 in. Pets should be supervised when playing with toys as no toy is completely indestructible. For dogs whose bark is worse than their bite great for mammoth chewers. 26 in. Plus there is a squeaker for every mood- the monkey's body squeakers sound more primate than the high-pitched perimeter squeakies. Stuffed monkey dog toys are great for big dogs. . Made with plush and thick berber fleece. Chew and chomp our huge monkey stick is such a great option for big dogs.
Coastal Pet Products 827982 Li L Pals Latex Monkey Dog Toy – Pink, 4 in.
Coastal Pet Products 827982 Li L Pals Latex Monkey Dog Toy – Pink, 4 in. - Ng with toys as no toy is completely indestructible sizing 20 in 26 in. Pet supply.
Petstages Just For Fun No Stuffing Plush LiL Squeak Monkey Dog Toy for Small Dogs by Petstages - 5 h. Provides safe, squeaky fun with no messy stuffingchambers maintain shape and squeak even if puncturedtwo squeak chambers with two fun soundsmeasures 7 l x 2 w x 1.
KONG Bendeez Monkey Dog Toy, Large - Ideal for interactive or solo play, kong bendeez are made of soft fleece that cleans and polishes teeth. Kong bendeez are flexible and fun for playtime. . There are many ways to play-bend, twist or shake for squeaky fun.
Boss Pet FatHedz Monkey Dog Toy - Tons of fun playtime for you and your dog, or just your dog. Dogs love them. Soft and cuddly, this darling plush monkey has an oversized head that squeaks. Collect them all.
Babble Buddies Holiday Monkey Dog Toy – Small - Babble buddies holiday monkey with holiday hat makes realistic animal sounds when squeezed. . This plush dog toy featurea a removable voice box for safety.
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Multipet International 48084 4″ X 3.8″ X 10″ Sock Monkey Dog Toy - Pets put a new twist on what it is to have fun with this classic handcrafted sock toys with a squeaker this classic poly-filled sock material toy is bound to please with squeakers for added interaction. Size, 10 in medium. Color, brown. Materials, plush toy with squeakers.
JW Pet Company Crackle Heads Canvas Monkey Dog Toy, Large - A squeaky belly adds to the fun. Our patent pending bottle ball is placed inside the durable fabric to provide the crackle sound and crunch that dogs love. The canvas fabric covers the bottle ball providing a protective layer that allows the crunchy sound to still come through. The crackle heads canvas monkey large toy is a timeless character made from canvas material with crackle heads technology inside. The bottle ball has no cap or sharp rings that can harm soft mouth areas. Crunchy and safe fun that dogs love wrapped up in an appealing classic stuffing free design. Suitable for medium, large and giant breeds. .
KONG BraidZ Monkey Dog Toy, Small - Minimal stuffing for minimal mess. Kong braidz small are approximately 8-inches long. Kong braidz help polish your dogs teeth and remove plaque. Cutest tug toy on the market. Kong braidz soft but strong non-toxic material is tightly braided for strength.
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KONG BraidZ Fuzzy Monkey Dog Toy, Medium (Colors Vary) - Braidz fuzzy monkey toys are tightly braided for strength yet stretchy for a great game of tug and fetch. Your dog will love you for it. Fuzzy monkeys have long, soft fuzzy limbs which dangle in a way dogs find tough to resist. Each monkey squeaks and is available in three sizes (small, medium and large) and sold in an assortment of three vibrant colors (blue, purple, orange).
17″ Plush-filled, Multicrew Monkey Dog Multi-Colored Toy - Great for fetching and tugging games, this plush monkey toy is made to last. This stuffed multi-colored toy features a unique shaggy outer fabric that is easy for pets to grab. . Give your pet a new playtime companion with the walmart plush multicrew monkey dog toy. This canine companion squeaks when squeezed and is designed to delight just about any furry friend.
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Li L Pals Latex Monkey Dog Toy by Coastal Pet - Li l pals latex monkey dog toy. Color blue.
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Super Colossal 45 inch Monster Max Monkey Stick Plush Chew Toy For Dogs - The love monkey monster max colossal monkey stick dog chew toy is perhaps the biggest dog toy on the market petlou's monster max comes in bright orange and features four squeakers and a loud grunt in the belly. Of course monster max is perfect for your large dogs, but small dogs love him too.
Zanies Plush Fuzzy Monkeys Dog Toy, Orange - A squeaker inside each toy will drive dogs bananas. Each includes a hangtag and a hanging loop. Each monkey toy is made with brightly colored plush and features a big smile and a squeaker inside. Available in orange color. This fuzzy monkeys are plush monkey toys for dogs that are tons of fun at playtime. Measures 5-inch length.


Longitudinal analytical approaches to genetic data.
Background: Longitudinal phenotypic data provides a rich potential resource for genetic studies which may allow for greater understanding of variants and their covariates over time. Herein, we review 3 longitudinal analytical approaches from the Genetic Analysis Workshop 19 (GAW19). These contributions investigated both genome-wide association (GWA) and whole genome sequence (WGS) data from odd numbered chromosomes on up to 4 time points for blood pressure–related phenotypes. The statistical models used included generalized estimating equations (GEEs), latent class growth modeling (LCGM), linear mixed-effect (LME), and variance components (VC). The goal of these analyses was to test statistical approaches that use repeat measurements to increase genetic signal for variant identification. Results: Two analytical methods were applied to the GAW19: GWA using real phenotypic data, and one approach to WGS using 200 simulated replicates. The first GWA approach applied a GEE-based model to identify gene-based associations with 4 derived hypertension phenotypes. This GEE model identified 1 significant locus, GRM7, which passed multiple test corrections for 2 hypertension-derived traits. The second GWA approach employed the LME to estimate genetic associations with systolic blood pressure (SBP) change trajectories identified using LCGM. This LCGM method identified 5 SBP trajectories and association analyses identified a genome-wide significant locus, near ATOX1 (p = 1.0E−8). Finally, a third VC-based model using WGS and simulated SBP phenotypes that constrained the β coefficient for a genetic variant across each time point was calculated and compared to an unconstrained approach. This constrained VC approach demonstrated increased power for WGS variants of moderate effect, but when larger genetic effects were present, averaging across time points was as effective. Conclusion: In this paper, we summarize 3 GAW19 contributions applying novel statistical methods and testing previously proposed techniques under alternative conditions for longitudinal genetic association. We conclude that these approaches when appropriately applied have the potential to: (a) increase statistical power; (b) decrease trait heterogeneity and standard error; (c) decrease computational burden in WGS; and (d) have the potential to identify genetic variants influencing subphenotypes important for understanding disease progression.
Chiu, Y. and Justice, A. and Melton, P. 2016. Longitudinal analytical approaches to genetic data.. BMC Genetics. 17 (S2): 4.


S1E12: Releves 何が起こるか興味があった - Eat the Rude.
HANNIBAL: I was curious what would happen. I was curious what would happen when I killed Marissa. I was curious what you would do.
ABIGAIL: You wanted me to kill Nick Boyle.
ABIGAIL: How many people have you killed?
HANNIBAL: Many more than your father.
ABIGAIL: Are you going to kill me?
HANNIBAL: I'm so sorry, Abigail. I'm sorry I couldn't protect you in this life.


text:
package com.siyeh.igtest.imports;

import java.util.*;
<warning descr="Single class import 'import java.io.File;'">import java.io.File;</warning>

public class SingleClassImport
{
    public HashMap m_map;
    public File file;
}

redpajama_set_name: RedPajamaGithub


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We ventured out west to one of our favorite local breweries, Adroit Theory. As one of their Black Heart Society club members, it was time to pick up our latest stash of beer so we thought we'd get some cheese pairings done.
For those who haven't been to Adroit, their line up of beer changes all of the time. They are a nanobrewery, making small batches of excellent brews. But this also means that by the time you read about these pairings, some of the beers discussed won't be on the menu! But we recommend you have fun with it. Take some of our suggestions, pair it with newer beers, and let us know what you think. Oh, and you should know all of their beer is high ABV. Adroit is not for the faint of heart.
We ordered a complete flight and ended up with 12 little goblets of goodness to drink and pair with our cheese selection. All of the cheeses were purchased at Wegman's, but you are likely to find similar items at Whole Foods or any other high-end store. We are going to focus on the best pairings we found this time around rather than give a pairing suggestion for all 12 beers.
First Circle Barrel Aged Blend (Ghost 049): We paired this with all three cheeses and the brie was just phenomenal. It drew out the sweetness of the barrel aging without being too sweet. But we were surprised at what happened with the pont l'eveque. The funkiness of the cheese mixed with the beer and then we experienced a cocoa finish and it gave the beer a very boozy punch.
Ortolan Bunting Strong Ale (Ghost 154): Brie, brie, brie. The only cheese you will need with this beer. Really makes the caramel/toffee notes of the malts stand up and be counted. We never got past the brie so can't tell you what the other cheeses will do.
What Evil Lurks Imperial Pumpkin (Ghost 044), Aged in Rum Barrels: We won't repeat what was said the minute we put the Jasper Hill cheddar and this beer together. It's not very ladylike. But we can tell you this: the sweet of the pumpkin is mixed with the sweetness of the rum and an explosion of flavor overwhelms your palate. This was our favorite pairing of the day.
Love of the Damned Brandy Barrel Aged Old Ale (Ghost 040): Once again, the cheddar cheese was our pick to accompany this beer. With the cheese, the beer takes on a port wine flavor, which is not unexpected considering this beer was aged in brandy barrels.
We had a lot of fun trying to pair our cheeses with all of these beers. We will definitely be back when their lineup changes. If you're interested in seeing what's coming next at Adroit, check out their webpage www.adroit-theory.com or follow them on Facebook.


Scopia Gulliver Blue Sensation Bacopa is covered in stunning sky blue star-shaped flowers with yellow eyes along the stems from mid spring to late fall. Its small serrated round leaves remain green in color throughout the year. The fruit is not ornamentally significant.


text:
Artiés y Garós es un tersón tradicional del Valle de Arán, (Cataluña, España) utilizado como circunscripción territorial para las elecciones al Consejo General de Arán. Resultado de la división del antiguo tercio de Garòs, su territorio se corresponde con la parte sur del municipio del Alto Arán: Artiés y Garós.

Elecciones
Desde la restauración de la estructura administrativa tradicional del Valle de Arán de 1990, elige 2 de los 13 Consejeros del Conselh Generau d'Aran.

Referencias

Tercios del Valle de Arán

redpajama_set_name: RedPajamaWikipedia


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redpajama_set_name: RedPajamaCommonCrawl


Wrecks was "Guest of Honor" at a recent dedication ceremony in Crockett Texas. Wrecks is pictured with the statue of Lightnin' Hopkins, which can be seen in the Crockett Park.
Lightnin' Hopkins grew up in nearby Centerville, TX.


text:
Q: Is there a collection of measurable not necessarily nested but converging sets such that we cannot permute measure and limit We know that for $\{E_n\}_{n\geq0}$ Lebesgue measurable sets s.t. $E_0\subset E_1\subset...$ we have $\lim\limits_{n\rightarrow\infty}E_n=\bigcup\limits_{n=0}^{\infty}E_n$ and $\mu(\lim E_n)=\lim(\mu(E_n))$
Similarily if $E_0\supset E_1\supset...$ and $\mu(E_0)<\infty$ we have $\lim\limits_{n\rightarrow\infty}E_n=\bigcap\limits_{n=0}^{\infty}E_n$ and $\mu(\lim E_n)=\lim(\mu(E_n))$
But what if we lose the property of nestedness? What would be some interesting examples of collections of sets where we cannot permute limit and Lebesgue measure?

A: An example: $E_n=[n,n+1]$
Then $\mu(E_n)=1$ for every $n$ but $\lim_{n\to\infty}E_n=\varnothing$ so that $\mu(\lim_{n\to\infty}E_n)=\mu(\varnothing)=0$.

edit:
With the lemma of Fatou it can be shown that:$$\mu(\liminf E_n)\leq\liminf\mu(E_n)\tag0$$
If some $c>0$ and some integer $n_0$ exists such that $n>n_0\implies E_n\subseteq[-c,c]$ then this can also be applied on the sets $[-c,c]-E_n$ leading to: $$\mu(\liminf E_n)\leq\liminf \mu(E_n)\leq\limsup\mu(E_n)\leq\mu(\limsup E_n)<\infty\tag1$$
You are dealing with a convergent sequence of measurable sets iff $\liminf E_n=\limsup E_n$ so in that case $(1)$ implies that: $$\mu(\lim E_n)=\lim \mu( E_n)$$

This shows you that it is somehow inevitable to come up with "sets that dissapear to infinity" for an example that you ask for.

redpajama_set_name: RedPajamaStackExchange


text:
Changes in Opioid Prescribing for Chronic Pain in Washington State
Gary M. Franklin, Deborah Fulton-Kehoe, Judith A. Turner, Mark D. Sullivan and Thomas M. Wickizer
Gary M. Franklin
From the Departments of Environmental and Occupational Health Sciences (GMF, DF-K) and Health Services (GMF), University of Washington School of Public Health and Community Medicine, Seattle; the Washington State Department of Labor and Industries, Olympia (GMF); the Departments of Neurology (GMF), Psychiatry and Behavioral Sciences (JAT), and Rehabilitation Medicine (JAT), University of Washington School of Medicine, Seattle; and the Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, OH (TMW).
Deborah Fulton-Kehoe
Judith A. Turner
Mark D. Sullivan
Thomas M. Wickizer
Purpose: To conduct a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in Washington State (WA) focused on changes in practice patterns and use of support tools in the prescription of opioids for the treatment of chronic noncancer pain (CNCP).
Methods: A convenience sample of primary care providers in WA was obtained from diverse geographic regions and health care organizations. The web-based anonymous survey was conducted in March-August 2011.
Results: Among 856 provider respondents, 623 reported treating patients with CNCP and served as the analysis sample. Most providers (72%) reported concern about opioid overdose, addiction, dependence, or diversion. Only 25% indicated concern about regulatory scrutiny. Only a small proportion of providers overall (3.3%) reported that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians (MDs and osteopaths) (2.1%) reported this. A greater proportion of physicians (70.9%) than ARNPs (40.1%) reported familiarity with the Washington State opioid dosing guidelines. Physicians in a large health plan with substantial infrastructure support reported less concern about opioids compared with providers in other settings. Of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation. The vast majority of providers reported a need to access more efficient, innovative means of support and education related to treating patients with CNCP, such as telemedicine consultation.
Conclusions: Overall, prescribing providers in WA reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a health care organization with opioid prescribing guidelines and access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.
A public health epidemic of morbidity and mortality related to prescribed opioids has engulfed the United States over the past decade, leaving in its wake approximately 15,000 deaths per year.1 More citizens in the United States have died since 1999 from unintentional overdoses of prescription opioids than died in the Vietnam War.2 Morbidity and mortality are increased in patients prescribed high daily doses of opioids (ie, >100 to 120 mg/day morphine-equivalent dose [MED]).3⇓–5 Although the vast majority of opioid use is short term, recent data suggest that the majority of patients receiving at least 3 months of continuous opioids continue to take opioids at least 2 years later.6 Patients taking high doses and showing signs of opioid misuse are the most likely to proceed to years of use.6 These data suggest that long-term opioid therapy may be a self-perpetuating or even lifelong therapy that may have a significant adverse financial effect on state Medicaid and workers' compensation systems.7 In response to these serious problems, public agencies in the state of Washington (WA) implemented in 2007 the first opioid dosing guideline in the United States,8; in 2010 the state passed the first new laws repealing earlier permissive laws,9 and implemented regulations10 reflective of widely agreed upon best practices for the safe and effective prescription of opioids for chronic noncancer pain (CNCP).
The principal prescribers of opioids for adults with CNCP are primary care providers. These providers—prominently MDs, osteopaths, and, in some states, advanced practice nurses—are in a particularly difficult position, often facing patients with complex pain-related problems and demands. In a survey of WA primary care physicians in early 2009, the majority of providers reported serious concerns about the development of dependence, addiction, or diversion in their patients with CNCP who were treated with opioids.11 Moreover, up to a third of primary care physicians report having experienced severe adverse events, including death, among their patients with CNCP who were treated with opioids.12,13 At the same time, one third of WA primary care physicians report difficulty accessing pain consultation to assist in caring for these patients.11 These converging circumstances may contribute to the reluctance of primary care providers to initiate opioid therapy in patients with CNCP or to accept new patients into their practices who are already receiving chronic opioid therapy.12 Medical students report that treating complex patients with CNCP and opioids is a reason for them not to enter a primary care field.14
To better understand current practice patterns related to opioid prescribing for patients with CNCP in the rapidly changing policy and regulatory landscape in WA, we conducted a survey of primary care prescribers in the state, including nurse practitioners. In particular, we sought to examine (1) changes in physician practice patterns regarding opioid use for CNCP compared with an earlier survey, 2) differences in practice patterns between advanced registered nurse practitioners (ARNPs) and physicians, and 3) differences between prescribers across regions and health systems likely to have disparities in resource support. In our survey, we paid particular attention not just to identifying recognized problems, but also to identifying potential solutions to the current crisis.
Study Design and Survey Development
The current survey was adapted from a prior survey11 of primary care physicians (N = 655) conducted in WA from October through December 2009. We revised the 21 items used in the prior survey11 and added questions assessing other areas. The final survey consisted of 39 items and took 15 minutes on average to complete. In this survey, we focused largely on how practice patterns may have changed since implementation of the WA Opioid Dosing Guideline in 2007.8 As an example of question format, we asked, "Has the frequency of your opioid prescribing for chronic, noncancer pain changed over the past 3 years?" Response choices were (1) "Yes, I prescribe opioids to more of my chronic pain patients now"; (2) "Yes, I prescribe opioids to fewer of my chronic pain patients now"; (3) "Yes, I stopped prescribing opioids"; (4) "I have not prescribed opioids in the past 3 years"; and (5) "There has been no change in the number of chronic pain patients for whom I prescribe opioids."
We approached numerous organizations and asked either clinical pain specialists/leaders or administrative personnel in those organizations to assist in disseminating the survey. Organizations that agreed to participate included the Washington State Medical Association (by sending out a link in their monthly newsletter); Group Health (GH), a large integrated health plan serving more than 400,000 members in WA (via listserv E-mail distribution by a pain specialist/leader); the Everett Clinic, a large multispecialty clinic in an urban area north of Seattle (via listserv E-mail distribution by a pain specialist/leader); the Washington Academy of Family Practice (via listserv E-mail distribution by administrative personnel); and the Spokane County Medical Society (via direct mail, E-mail, and web/newsletter notification by administrative personnel). The Spokane County Medical Society was added at their request because of perceived concerns regarding opioid use in the county. In addition, a current mailing list of actively practicing ARNPs was accessed through the WA Department of Health, and invitations were mailed from our research office to ARNPs regarding potential participation. Once distributed in each organization or group, the survey was available for up to 120 days. Like the earlier survey, our adapted survey was anonymous and web-based, using Survey Monkey (http://www.surveymonkey.com/). The current survey was conducted from March through August 2011. The project was approved by the University of Washington Human Subjects Review Committee.
The analysis sample consisted of survey respondents who said that they treated patients with CNCP. We used descriptive statistics to characterize the sample and survey responses. We used χ2 tests to compare responses of different types of providers and providers in different settings. In particular, we compared responses of physicians and ARNPs. We also compared responses of providers in Spokane, the largest city in Eastern WA (county population of 451,000) with those of providers in other regions of the state. Finally, we compared responses of providers affiliated with GH, a nonprofit health care system in WA that in 2010 implemented a multifaceted risk mitigation initiative and guideline targeting management of patients receiving long-term opioid therapy.15 Statistics were analyzed using 2-tail tests, and we considered statistical significance to be P < .05. SPSS version 15.0 (SPSS, Inc., Chicago, IL) was used to conduct the analyses.
A total of 856 providers completed the survey. Response rates varied somewhat across the organizations: Group Health, 10.8% (63 of 584 providers on the E-mail distribution list); Washington Academy of Family Practice, 6.3% (169 of 2700 providers on the E-mail distribution list); and ARNPs, 8.5% (425 of 5000 who were mailed invitations to participate). Of these respondents, 623 said that they treated patients with CNCP; the respondents are the focus of this report. Among these respondents, 253 self-identified as an MD (40.6%), 243 as an ARNP (39%), 32 as an osteopath (5.1%), and 16 as a physician assistant (2.6%). Respondents with missing data for provider type (n = 79) were excluded from analyses by provider type. For analyses related to physicians, MDs and osteopaths are combined.
Overall, physician responses were similar to the responses in the prior survey,11 with the exception that 71% of physicians in the current survey reported that they had read and/or applied the WA Opioid Dosing Guideline8 compared with 62% in 2009 (P = .01). Compared with the 2009 survey, the current survey sample included a greater proportion of female providers (62.5% vs. 40%) and a smaller proportion of MDs (41% vs. 88%).
Table 1 summarizes the providers' reported opioid prescribing practices. Physicians were more likely than ARNPs to report prescribing opioids to ≥50% of their patients with CNCP (39.8% of physicians vs. 21.7% of ARNPs; P < .01). Fewer GH providers (18.8%) than non-GH providers (42.7%) reported prescribing opioids to ≥50% of their patients with CNCP (P = .008). Although 44.4% of respondents overall reported prescribing opioids to fewer patients with CNCP than in the past, the majority of both GH (60.4%) and Spokane providers (63%) reported this. More than twice as many ARNPs (5.8%) as physicians (2.1%) reported having stopped prescribing opioids altogether (P = .03). No GH providers reported that they stopped prescribing opioids. A majority of both GH (57.4%) and Spokane (58.9%) providers reported prescribing higher doses of opioids less often. A majority of providers (72.3% overall; 73.1% of physicians) reported being very concerned about overdose, addiction, dependence, or diversion. In the 2009 survey, 54% of physicians reported those concerns. In the current survey, a somewhat smaller proportion of GH providers (61.7%) reported being very concerned about those opioid-related problems compared with non-GH providers (73.2%; P = .09). A minority of all survey respondents who saw patients with CNCP (25.3%) indicated that they were very concerned about regulatory scrutiny. Only 12.8% of GH providers were so concerned, compared with 26.4% of non-GH providers (P = .07).
Table 1. Opioid Prescribing Practices of 623 Primary Care Physician and Advanced Registered Nurse Practitioner (ARNP) Survey Respondents, Overall and by Physician, ARNPs, and Two Large Practice Site Subgroups*
Table 2 provides information about the use of the WA Opioid Dosing Guideline and other resources. Compared with physicians, fewer ARNPs had read and/or applied the guideline (40.1% of ARNPs vs. 70.9% of physicians; P < .01). The majority of providers (87%) felt that the 120 mg/day MED yellow flag dose in the guideline was reasonable (71%) or too high (16%). More physicians compared with ARNPs reported having access to opioid prescribing policies and tools in their clinics (68.1% vs. 48.5%; P < .01) and electronic prescription records linked to electronic health records (84.1% vs. 62.5%; P < .01) that could assist in supporting appropriate opioid use. Spokane providers were the most likely to report "never or almost never" successfully obtaining a pain consultation compared with non-Spokane providers (42.5% vs. 12.8%; P < .01). Only 3.3% of GH providers reported such difficulty compared with 16.7% of non-GH providers (P < .01).
Table 2. Availability/Use of Guidelines, Tools, and Consultation, by Group*
The great majority of all groups thought that specific innovative methods of consultation or assistance, such as telephone or video consultation with experts, would be helpful. Nearly 90% reported that web-based continuing medical education training would be useful. Only a minority of providers overall (17.6%) reported participating in collaborative therapy arrangements with pharmacists, but 47.7% of GH providers reported this capacity versus 14.9% of non-GH providers (P < .01).
Primary care providers in the United States find themselves at an important crossroads concerning opioid therapy for CNCP. For more than a decade, pain experts and organized medicine called for more adequate treatment of pain with opioids, which increased prescribing by physicians and other providers who treated patients with CNCP.16 Rates of use and daily doses of the most powerful schedule II opioids then rose dramatically.17 These increased rates of use—especially increased rates of high-dose use—have contributed to the public health epidemic of overdose morbidity and mortality that has occurred over the past decade.3⇓–5
In 2007, WA was the first state or jurisdiction to implement specific dosing guidance for opioids in the treatment of CNCP.8 It was also the first state to repeal the "Intractable Pain" laws that had legalized long-term opioid therapy without a dosing ceiling and to implement new laws and regulations reflecting generally agreed upon best practices.9,10 In a 2009 survey primary care physicians in WA reported that they rarely used most of these best practices and that they thought that more guidance and community resources, including dosing guidance, was needed.11 WA agencies and our collaborating clinical and academic advisors responded with an updated Opioid Dosing Guideline in June 2010, which contained tools needed to implement most of the best practices.8
When the WA Opioid Dosing Guideline was first published online in April 2007, it received strong negative feedback from professional pain organizations and patient advocacy groups and a lawsuit was filed but was subsequently overturned. However, in the 2009 survey of WA primary care physicians, 86% reported that a yellow flag dose of 120 mg/day MED was reasonable (75%) or too high (11%), which is similar to the results of the current survey (71% and 16%, respectively).11 Of primary care prescribers who responded to the 2009 survey, 54% were concerned about dependence, addiction, and diversion. In the current survey, an even larger proportion of providers (72%) reported similar concerns. These concerns are consistent with survey data collected from primary care physicians in low-income clinics in the United States,12 Canada,13 and Veterans Affairs medical clinics.18 Thus, while primary care physicians generally express confidence in their ability to use opioids to treat CNCP,12,13 potential risks of dependence and addiction and lack of community and system resources are significant concerns.
In the current survey, providers in a large WA integrated health plan (GH) that has a long tradition of innovation in chronic care reported fewer concerns regarding opioid prescribing for CNCP. This is likely because of strong institutional support throughout the organization for adoption of best practices regarding opioid prescribing, including a risk mitigation initiative and prescribing guideline targeting patients receiving chronic opioid therapy that was implemented in October 2010.15 Although 3.3% of all providers statewide reported they had stopped prescribing opioids for CNCP, no GH provider in our survey reported doing so. While 16.7% of non-GH providers and 42.5% of Spokane providers reported that they "never or almost never" can access a pain consultation, only one GH physician reported such difficulty. When WA passed new opioid laws early in 2010,9 concern was expressed regarding regulatory scrutiny and potential overreach by the government. However, in the current survey, conducted about 1 year after passage of the law, only a minority of WA providers overall (25.3%) reported being very concerned about regulatory scrutiny. Among providers at GH, only 12.8% reported such concern. In Spokane, a community with less support for opioid prescribing and chronic pain management best practices, 29.2% expressed concern.
Although ARNPs may prescribe controlled substances in WA and in most states,19 this is the first report of opioid prescribing practices specific to ARNPs. Of the respondents in this survey, 39% were ARNPs. Overall, in our survey, ARNPs, as compared with physicians, were less likely to report prescribing opioids to the majority of their patients with CNCP, to have read/applied the WA Opioid Dosing Guideline, or to have available opioid policy tools or electronic health records in their clinical setting. Compared with WA physicians, ARNPs were more than twice as likely to have stopped prescribing opioids altogether to their patients with CNCP. The reasons for these differences are not clear.
Limitations of this study include the use of a convenience sample and a low response rate. The 2009 survey focused on acceptance and diffusion of the 2007 Opioid Dosing Guideline, whereas the current survey was expanded to include a focus on changing practices and needed resources. The addition of ARNPs to the survey sample and different methods of accessing respondents resulted in differences between the 2009 survey and the current survey that precluded ability to directly compare results.
Although questions remain concerning the long-term effectiveness of opioid therapy in people with CNCP, there is little question that more community-based resources will be necessary to effectively treat patients with CNCP. In this survey, the great majority of all prescribers reported enthusiasm for the diffusion of tools to help them manage patients with CNCP, including phone consultations with experts, web-based tools, web-based continuing medical education, and other advanced training, patient decision aids, and computerized programs to monitor prescription drugs. The current results also suggest a pressing need to increase capacity in the majority of communities that do not have the substantial resources required to effectively address chronic pain.16
We have begun to develop such capacity through payment incentives for best practices and improved care coordination among injured workers in WA20 and by offering more efficient means of consultation, such as the use of video-linked consultations with panels of university-based experts.21 The prevention and adequate treatment of chronic pain should be considered in the same conceptual framework offered by leaders of integrated care management for other chronic diseases.22 As such, a medical home model to address chronic pain as a community-wide health delivery innovation should be considered. Insurers will be critical in developing incentives for best practices that could be effective alternatives to opioids in preventing and treating chronic pain, such as reducing patient avoidance of fear and promoting patient participation in customary activities, graded exercise, cognitive-behavioral therapy, and multidisciplinary intensive rehabilitation.23 In addition, incentivizing balanced, evidence-based provider education on these best practices will be necessary to help ensure their dissemination.
Opioids have not turned out to be the effective and "not as addicting as we used to believe" treatment that some pain champions and pharmaceutical companies promised, based on no good scientific evidence, in the late 1990s.24 We were told that there is no ceiling on dose and that the best way to treat tolerance is to keep increasing dose. We have now learned that dose is highly related to morbidity and mortality3⇓–5; implementation of more clear-cut dosing guidance and other best practice tools are needed at this point.8,15 Practitioners are clamoring for more guidance and community resources to deal with the multitude of patients now receiving long-term opioid therapy and the many other patients with chronic pain who are not taking opioids. There is a particularly urgent and critical need for research that will generate the information necessary to prevent the next cohort of patients from getting potentially lethal but ineffective doses of opioids and to shed light on effective ways to improve the suffering and function of those who already are dependent on or addicted to opioids and are still in pain.
We thank Kathleen Egan for survey administration, Rae Wu for data management and analysis, and Laura Black for manuscript preparation.
This article was externally peer reviewed.
Funding: Funding was provided by the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (grant no. 5R21CE001850-02).
Conflict of interest: none declared.
Received for publication October 4, 2012.
Accepted for publication January 19, 2013.
Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92.
Warner M,
Chen LH,
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Anderson RN,
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. Drug poisoning deaths in the United States, 1980–2008. NCHS Data Brief 2011;(81):1–8.
Dunn KM,
Saunders KW,
Rutter CM,
. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85–92.
Bohnert ASB,
V M,
Bair MJ,
. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305:1315–21.
Gomes T,
Mamdani MM,
Dhalla IA,
Paterson JM,
Juurlink DN
. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011;171:686–91.
Martin BC,
Fan MY,
Edlund MJ,
Devries A,
Braden JB,
Sullivan MD
. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med 2011;26:1450–7.
Meier B
. Pain pills add cost and delays to job injuries. The New York Times. June 2, 2012. Available from: http://www.nytimes.com/2012/06/03/health/painkillers-add-costs-and-delays-to-workplace-injuries.html?pagewanted=all. Accessed September 5, 2012.
Washington Agency Medical Director's Group. Opioid dosing guideline for chronic noncancer pain. Available from: http://www.agencymeddirectors.wa.gov/opioiddosing.asp. Accessed September 5, 2012.
Washington Engrossed Substitute House Bill 2876. an act relating to pain management. March 26, 2010. Available from: http://apps.leg.wa.gov/documents/billdocs/2009-10/pdf/bills/session%20laws/house/2876-s.sl.pdf. Accessed September 5, 2012.
Washington State Department of Health. Pain management. Adopted rules. Available from: http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/AdoptedRules.aspx. Accessed September 5, 2012.
Morse JS,
Stockbridge H,
Egan KB,
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Franklin GM
. Primary care survey of the value and effectiveness of the Washington State Opioid Dosing Guideline. J Opioid Manag 2011;7:427-33.
Leverence RR,
Williams RL,
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. Chronic non-cancer pain: a siren for primary care-a report from the PRImary care MultiEthnic Network (PRIME Net). J Am Board Fam Med 2011;24:551-61.
Wenghofer F,
Wilson L,
Kahan M,
. Survey of Ontario primary care physicians' experiences with opioid prescribing. Can Fam Physician 2011;57:324-32.
Corrigan C,
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. What can we learn from first-year medical students' perceptions of pain in the primary care setting? Pain Med 2011;12:1216-22.
Trescott CE,
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Von Korff MR
. Group Health's initiative to avert opioid misuse and overdose among patients with chronic noncancer pain. Health Aff (Millwood) 2011;30:1420-4.
Committee on Advancing Pain Research, Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press; 2011. Available from: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx. Accessed May 15, 2013.
Franklin GM,
Turner JA,
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. Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002. Am J Ind Med 2005;48:91-9.
Dobscha SK,
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. Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med 2008;9:564-71.
Nurse practitioner prescriptive authority. Available from: http://nursinglicensemap.com/advanced-practice-nursing/nurse-practitioner/nurse-practitioner-prescriptive-authority/. Accessed September 5, 2012.
Wickizer TM,
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UW Pain Medicine Patient Care: TelePain. Available from: http://depts.washington.edu/anesth/care/pain/telepain/index.shtml. Accessed September 5, 2012.
Coleman K,
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. Evidence on the chronic care model in the new millennium. Health Aff (Millwood) 2009;28:75-85.
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. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.
. A World of Hurt: Fixing Pain Medicine's Biggest Mistake. New York: New York Times e-book; 2013.
You are going to email the following Changes in Opioid Prescribing for Chronic Pain in Washington State
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Common Illnesses, Patient Physician Interactions, Continuity, and Practice Organization


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Audio report Palestine
Palestine Today 08 16 2017
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Welcome to Palestine Today, a service of the International Middle East Media Center, www.imemc.org, for Wednesday, August, 16, 2017.
Israeli clashes leave 26 injured civilians in the West Bank as the navy attack Gaza fishermen These stories, and more, coming up, stay tuned.
Israeli soldiers invaded, on Wednesday at dawn, the village of Kobar, northwest of the central West Bank city of Ramallah, and demolished a home belonging to the family of a Palestinian who stabbed, last month, three Israelis to death, in their home at a nearby colony. The soldiers also injured 26 Palestinians during ensuing clashes.
Medical sources in Ramallah said the soldiers shot 26 Palestinians during the clashes; one of them is a cameraman, identified as Mohammad Radi, who works for Palestine TV. The cameraman was shot with a rubber-coated steel bullet in his face, after a soldier shot him from a close range, while he was filming the clashes.
The sources stated that thirteen Palestinians were shot with rubber-coated steel bullets, and thirteen others suffered the effects of teargas inhalation. It is worth mentioning that the soldiers have recently abducted the parents, and uncle, of Omar al-'Abed who carried out the stabbing attack last month.
Also on Wednesday, Israeli soldiers abducted, four Palestinians in Abu Dis town, and one in at-Tour, in occupied East Jerusalem, in addition to abducting another Palestinian near Jenin, in the northern part of the West Bank, and three in Hebron, in southern West Bank.
Elsewhere, Israeli navy ships opened fire, on Wednesday morning, targeting several Palestinian fishing boats near the coast of Beit Lahia, in the northern part of the Gaza Strip. The attack did not lead to casualties, abductions or property damage, but forced the fishermen back to shore without being able to fish and provide for their families.
And that's all for today from the IMEMC News; this was the Wednesday , August, 16, 2017, news round-up from the Occupied Palestinian Territories. From more news and updates, please visit our website at www.imemc.org today's report has been brought to you by George Rishmawi and me Ghassan Bannoura.
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Money Food Health.com
Labor market recovery halted with few silver linings in sight
The labor market recovery came to a screeching halt in December, and the few data points that look promising for some of the most vulnerable working Americans are actually deeply troubling upon further inspection.
Driving the news: The recovery was interrupted as the coronavirus raged and the government was slow to move on fiscal support.
Reality check: Average hourly pay has been consistently rising since May and it rose by another 23 cents in December. That's actually a bad thing.
The measure has been distorted by the outsized number of lower-paid workers out of a job. When lower-paid people drop off payrolls, it inflates the overall wage figure for people who are still employed.
Case in point: At the onset of the pandemic — as the economy lost a record number of jobs — hourly pay soared by $1.34. That's a massive move, considering the hourly figure typically fluctuates by mere cents.
Another false hope narrative exists in the gap between white and Black unemployment. It narrowed last month, as the Black unemployment rate fell to 9.9% from 10.3%.
But that's in part because the number of Black workers considered in the labor force shrunk — i.e. gave up looking for work altogether. More white workers re-entered the workforce last month.
Whites were the only group to see a net rise in employment in December. Latinos fared the worst by far, with 252,000 fewer considered employed in December. There were 40,000 fewer employed Asians, and 26,000 fewer Black workers.
The professional and business services sector — think lawyers, accountants or consultants — saw the biggest job gains last month (161,000), helping offset the nearly 500,000 jobs shed in the leisure and hospitality sector.
But over 40% of the gains were in temporary help services, limited gigs that may or may not turn into longer-term work.
Of note: Economists say if there's a silver lining in the report, it's that the labor market pain was largely limited to the leisure and hospitality industry while most other sectors continued to add jobs.
Yes, but: The fate of restaurant, hotel, casino and other hospitality jobs rests on the virus path and mass vaccinations. The dynamic contributes to the economy's K-shaped recovery: workers in some of the lowest paid industries are out of work, while less virus-sensitive industries aren't feeling the same economic pain.
Source: www.axios.com
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Reclining Nude
Signed lower left: Renoir
Metropolitan Museum of Art, New York
The Walter H. and Leonore Annenberg Collection, Bequest of Walter H. Annenberg, 2002
Arsène Alexandre, Paris, until 1903
his sale, Georges Petit, Paris, 18-19 May 1903, nr. 53, to Viau
George Viau, Paris, 1903-7
his sale, Durand-Ruel, Paris, 4 March 1907, nr. 54, to Bernheim-Jeune
with Bernheim-Jeune, Paris, 1907-10, sold on 18 January 1910 to Bernheim
Emile Bernheim, from 1910
?with Bernheim-Jeune, Paris, until 1911, sold to Cassirer
with Paul Cassirer, Berlin, 1911, purchased from Bernheim-Jeune on 20 June sold to Meirowsky
Dr. Max Meirowsky, Cologne, then Berlin, still later Geneva, 1911-died 1949
his estate, 1949-52, on deposit at Musée d'art et d'histoire, Geneva, 16 February 1950-21 March 1952, sold to Wildenstein
with Wildenstein, New York, 1952-53, sold 27 January 1953 to Haupt
Mrs. Ira (Enid A.) Haupt, New York, 1953-83, sold to Annenberg
her brother and his wife, Walter H. and Leonore Annenberg, Rancho Mirage, Calif., 1983-his d. 2002
Metropolitan Museum of Art, New York, The Walter H. and Leonore Annenberg Collection, Bequest of Walter H. Annenberg, 2002
Metropolitan Museum of Art Accession number 2003.20.12
Other works by Pierre-Auguste Renoir
Girl with a basket of oranges
Man on a Stair
Apples and Flowers
Seated Nude


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Nicole Corris
AEA / SAG-AFTRA
Andre Copher Nicole Corris Sean Ferguson Ian Ross
Albatross Air flies again! Join us this summer on the NCL Joy.
After an action packed five months on the NCL Epic, we're headed back our to sea this summer on the newly renovated NCL Joy. See you in Alaska!
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Andre Copher (Drums, Percussion) is a Los Angeles based musician and has been playing drums and percussion since age 10. He has traveled the world performing and studying a wide variety of musical styles including jazz, rock, classical, and traditional West African music. His eclectic musical interests led to a collaboration with International Franz Liszt Piano Competition winner Rudolf Budginas on his album "Ambient Romance." As a student at the Bob Cole Conservatory in Long Beach he had the opportunity to accompany the award winning vocal ensemble Pacific Standard Time. He continues to perform actively with cruise ships, local theaters, and co-leads his experimental band Three Rooms.
Sean Ferguson (piano/keyboards, harmonica, guitar, bass, vocals) is an experienced pianist, musical director, arranger, and orchestrator. He has traveled the world as a pianist and bandleader for various cruise lines, including Cunard, Crystal, Princess, and NCL. While earning a Bachelor of Music in Jazz Studies from Capital University in Columbus, Ohio, Sean performed with the Capital University Big Band at internationally acclaimed jazz festivals including Montreux, North Sea, and Umbria. When on land, Sean works in NYC as an accompanist for Inside Broadway and for Walker Clark Studio, with students on Broadway, national tours, and tv/film. Sean and Nicole have been performing together since 2002.
Nicole Corris (vocals, Moog bass, keyboards) is a New York City based singer, actress, and producer. She has performed around the world on Regent, Princess, and Celebrity Cruise Lines. Theatrical highlights include BC/EFA's 28th Annual Easter Bonnet Competition at Broadway's Minskoff Theatre, The Wizard and I chorus for Stephen Schwartz with the NY Pops at Carnegie Hall, and most recently performing as a soloist with Banda Sinfónica de Montevideo (Uruguay) in Wonderlust Theatre Company's Memory: Los Musicales de Andrew Lloyd Webber. She also works regularly in NYC's busy tv and film industry.
Ian Ross (guitar, bass, vocals) is an ohio based musician, arranger, and composer. He received a bachelor's degree in jazz guitar performance from the College Conservatory of Music at the University of Cincinnati in 2006 and was named "Cincinnati's Best Guitarist" by East Side Vibe Magazine in 2010. Ian has studied privately with guitar legends Pat Martino and Scotty Anderson and has shared the stage with such musical luminaries as Jeff Healey, Will Ray and Robert Lockwood jr. recording his first album of original material with grammy award-winning producer Jim Gaines. From 2012-2016 Ian worked as houseband guitarist with Princess Cruise Lines and as Fleet Arranger with the company from 2016-2018.
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This paper may be regarded as a new numerical method for the analysis of triangular thin plates using the natural area coordinates. Previous studies on the solution of triangular plates with different boundary conditions are mostly based on the Rayleigh-Ritz principle which is performed in the Cartesian coordinates. Consequently, manipulation of the geometry and numerical calculation of the integrals are time consuming and tedious. In this paper a new approach is developed to analyze triangular plates by the Ritz method, using interpolation functions in the area coordinates. The geometry is presented in a natural way by mapping a parent triangle and the integrals are evaluated analytically. In this approach, the convergence is always assured due to the completeness of interpolating polynomials. Several examples are presented and the results are compared with other available data.


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Daniël Francois Malherbe or (as he is generally known) D.F. Malherbe (28 May 1881 – 12 April 1969), was an Afrikaans-language novelist, poet, dramatist, and scholar.

He was born in Dal Josafat in the Cape Colony, now Western Cape Province, South Africa.

Malherbe is most noted for having written what is regarded as the first novel of artistic value in Afrikaans, Vergeet niet (Do Not Forget). His Biblical novels--Die Hart van Moab (The Heart of Moab, 1933), Saul die worstelheld (Saul the Struggle Hero, 1935), and Die profeet (The Prophet, 1937) draw a parallel between the Afrikaners and the Israelites of the Old Testament, yet today they are lightly regarded. Malherbe was also active in the promotion of Afrikaans.

The D.F. Malherbe High School in 14th Avenue, Walmer, Port Elizabeth, South Africa is named after him as well as the D.F. Malherbe Primary School in Vanderbijlpark, South Africa.

References

1Lindenberg, E., et al. "Inleiding tot die Afrikaanse Letterkunde". Pretoria and Cape Town: Fifth edition, 1980.

External links
Picture and biography

1881 births
1969 deaths
Afrikaans-language poets
South African male poets
Afrikaner people
Hertzog Prize winners for prose
20th-century South African poets
20th-century South African male writers