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Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)
Research Protocol ARCHIVED May 1, 2014
Background and Objectives for the Systematic Review
Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) is a condition characterized by a constellation of symptoms, with post-exertional malaise and/or chronic and disabling fatigue being the hallmark. In an attempt to describe the condition based on the proposed etiologies, several other terms have been used, including post viral fatigue syndrome and chronic fatigue immune dysfunction syndrome.1-4 The term ME was first used in the 1930s after an outbreak of neuromyesthenia and CFS was first coined in the 1980s, with both conditions having overlapping features.3-5 Over the years, there has been disagreement on the underlying etiology and whether the conditions represented by these terms reflect a single pathologically discrete syndrome, subsets of the same illness, or a nonspecific condition shared by other disease entities. The two persisting terms, ME and CFS, have more recently been used interchangeably4 despite the ongoing controversy.
The first set of clinical criteria defining the condition were published in 19883 and have been further developed over the years most notably with the 1994 Fukuda criteria,2 the 2003 Canadian clinical case definition,1 and in 2011 with the international consensus criteria.7 (see Table 1). This most recent international consensus report advocates moving away from the term CFS in favor of ME to better reflect an underlying pathophysiology involving widespread inflammation and neuropathology, and to embrace the two terms as synonymous.7 The syndrome that encompasses ME/CFS is characterized by various manifestations of diffuse symptoms including post-exertional malaise and/or persistent and disabling fatigue, pain, sleep disturbance, neurological and cognitive manifestations (i.e., impaired concentration, mental processing, memory), motor impairment, and altered immune and autonomic responses.1,2,7 The variable symptomatology and lack of an identifiable disease process with gold standard of measurement have challenged researchers and clinicians in their attempts to better understand the disease process and its effects on patients.
The prevalence of ME/CFS is also difficult to estimate given the uncertainty of the case definition. The CDC reported a U.S. prevalence of 0.3 percent with over 1,000,000 adults with the disorder in the U.S.8 By using different case definitions, some suggest that the rate is as high as 2.5 percent.4,9 Currently there are no U.S. Food and Drug Administration (FDA) approved medications for the treatment of ME/CFS, but many have been used to treat the associated symptoms. The burden of disease and economic impact from both medical and societal costs may be in the billions of dollars. Thus finding ways to accurately diagnose patients to optimize management has significant public health importance and consequences. Controversies surrounding ME/CFS have led to wide variations in the clinical management of patients, including uncertainty in etiology, diagnosis, and approach to treatment. Identifying treatment interventions and meaningful clinical outcomes is also challenging, given the breadth of symptoms and the uncertainty as to whether specific symptom combinations define subsets of patients that may respond uniquely to different approaches. When patients were surveyed in April, 2013 as part of the U.S. Food and Drug Administration's (FDS's) patient-focused drug development initiative, treatments fell into two broad categories, those intended to treat the underlying cause of the disease and those targeting specific symptoms. The first category included immune modulators such as rintatolimod and rituximab, and antiviral and antibiotic medications. Interventions targeting symptoms included medications to treat pain, fatigue, and sleep dysfunction, and non-drug therapies which included yoga, stretching and relaxation techniques, counseling on pacing strategies, and mental exercises.10 An examination of the comparative effectiveness and harms of treatments for ME/CFS is important to guide clinical practice, which underscores the need for a systematic review on this topic. This report focuses on the clinical outcomes surrounding the attributes of fatigue, especially post-exertional malaise and persistent fatigue, and its impact on overall function and quality of life because these are unifying features of ME/CFS that impact patients.
This topic was nominated by the Office of Disease Prevention (ODP) at the National Institutes of Health to Inform an Evidence-based Methodology Workshop on ME/CFS. The Working Group convened by ODP assisted in refining the topic.
Table 1. Groups With Case Definitions of ME/CFS
Fukuda et al., 19942
Carruthers et al., 20031
Revised Canadian
Jason et al., 201011
International Consensus Statement
Dowsett, 199412
Sharpe, et al. 199113
The Key Questions
What methods are available to clinicians to diagnose ME/CFS and how do the use of these methods vary by patient subgroups?
What are widely accepted diagnostic methods and what conditions are required to be ruled out or excluded before assigning a diagnosis of ME/CFS?
What is the accuracy and concordance of diagnostic methods?
What harms are associated with diagnosing ME/CFS?
What are the (a) benefits and (b) harms of therapeutic interventions for patients with ME/CFS and how do they vary by patient subgroups?
What are the characteristics of responders and non-responders to interventions?
PICOTS
Population(s)
For KQ 1: Symptomatic adults (aged 18 years or older) with fatigue
For KQ 2: Adults aged 18 years or older, with ME/CFS, without other underlying diagnosis
Exclude:
Patients with other underlying diagnosis
For KQ1: Case definitions: e.g., Fukada/CDC, Canadian, International and others
For KQ2: Forms of counseling and behavior therapy, graded exercise programs, complementary and alternative medicine (acupuncture, relaxation, massage, other), and symptom-based medication management (immune modulators, beta blockers, antidepressants, anxiolytics, stimulants, other)
For KQ1: Diagnostic accuracy studies and diagnostic concordance studies with comparators
For KQ2: Placebo or no treatment/usual care, other active interventions (including combination therapies and head-to-head trials)
For KQ1: Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, C statistic (AUROC), net reclassification index; concordance, any potential harm from diagnosis (such as psychological harms, labeling, risk from diagnostic test, misdiagnosis, other)
For KQ2: Overall function (i.e. 36-item Short Form Survey [SF-36]), quality of life, days spent at work/school, proportion working full or part time, fatigue (Multidimensional Fatigue Inventory [MFI] or similar), adverse effects of interventions, withdrawals and withdrawals due to adverse events, rates of adverse events due to interventions
Include: 12 weeks or longer
Include: Clinical settings
Analytic Framework
Figure 1. Analytic Framework for the Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
A. Criteria for Inclusion/Exclusion of Studies in the Review
The criteria for inclusion and exclusion of studies will be based on the Key Questions (KQs) and are described in the previous PICOTS section.
Below are additional details on the scope of this project:
Study Designs: For all KQs we will include randomized controlled trials (RCTs). For KQ 1a we will also include derivation, validation, and cohort studies. For KQ 1c and 2b we will also include cohort studies with comparators. For all KQs we will exclude uncontrolled observational studies, case control studies, case series, and case reports. Systematic reviews will be used as sources of evidence if they address a Key Question and are assessed as being at low risk of bias, according to the AMSTAR quality assessment tool.14,15 If systematic reviews are included, we will update findings by adding primary studies identified in our searches. If multiple systematic reviews are relevant and low risk of bias, we will focus on the findings from the most recent reviews and evaluate areas of consistency across the reviews.16
Non-English Language Studies: We will restrict to English language articles, but will review English language abstracts of non-English language articles to identify studies that would otherwise meet inclusion criteria, in order to assess for the likelihood of language bias.
B. Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies to Answer the Key Questions
Publication Date Range: Searches will begin in January 1988, the year the first set of clinical criteria defining CFS were published.3
Library searches will be updated while the draft report is posted for public comment and peer review to capture any new publications. Literature identified during the update search will be assessed by following the same process of dual review as all other studies considered for inclusion in the report. If any pertinent new literature is identified for inclusion in the report, it will be incorporated before the final submission of the report.
Literature Databases: Ovid MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Health Technology Assessment, National Health Sciences Economic Evaluation Database, and Database of Abstracts of Reviews of Effects will be searched to capture both published and gray literature.
Scientific Information Packets: Scientific information packets (SIPs) will be requested from drug and device manufacturers and a notice inviting submission of relevant scientific information will be published in the Federal Register in an effort to identify any relevant unpublished literature that may contribute to the body of evidence. All interested parties will have the opportunity to submit data for this review using the AHRQ Effective Health Care publicly accessible online SIP portal (https://effectivehealthcare.ahrq.gov/get-involved/submit-sead/).
Manufacturers of currently available and FDA approved anxiolytics, antidepressants, antivirals, beta-blockers, immune modulators, non-steroidal anti-inflammatory drugs, stimulants, and triptans will be invited to provide SIPs.
Hand Searching: Reference lists of included articles and systematic reviews will be reviewed for includable literature.
Contacting Authors: In the event that information regarding methods or results appears to be omitted from the published results of a study, or if we are aware of unpublished data, we will query the authors to obtain this information.
Process for Selecting Studies: Pre-established criteria will be used to determine eligibility for inclusion and exclusion of abstracts in accordance with the AHRQ EPC Methods Guide.14 Abstracts will be included if they fulfill the population, interventions and outcomes of interest, and meets the included study design and duration. To ensure accuracy, all excluded abstracts will be dual reviewed. All citations deemed appropriate for inclusion by at least one of the reviewers will be retrieved. Each full-text article will be independently reviewed for eligibility by two team members, including any articles suggested by peer reviewers or that arise from the public posting process. Any disagreements will be resolved by consensus.
C. Data Abstraction and Data Management
After studies are selected for inclusion, data will be abstracted into categories that include but are not limited to: study design, year, setting, country, sample size, eligibility criteria, population and clinical characteristics, intervention characteristics, and results relevant to each key question as outlined in the previous PICOTS section. Information that will be abstracted that is relevant for assessing applicability will include the method of diagnosis, number of patients randomized relative to the number of patients enrolled, use of run-in or wash-out periods, and characteristics of the population (clinical subgroups e.g., post-exertional malaise, postural hypotension, and others), intervention, and care settings. All study data will be verified for accuracy and completeness by a second team member. A record of studies excluded at the full-text level with reasons for exclusion will be maintained.
D. Assessment of Methodological Risk of Bias of Individual Studies
Predefined criteria will be used to assess the quality of individual controlled trials, systematic reviews, and observational studies by using clearly defined templates and criteria as appropriate. Studies will be evaluated using appropriate criteria developed by the U.S. Preventive Services Task Force.17 Systematic reviews will be assessed using the AMSTAR quality rating instrument.15 Particular attention will be given to the criteria of patient population including ME/CFS case definition and spectrum of patients included in the study, comparability of groups, importance and validity of outcome measurements for the ME/CFS population, adjustment for confounders, and adherence. These criteria and methods will be used in conjunction with the approach recommended in the chapter, Assessing the Risk of Bias of Individual Studies When Comparing Medical Interventions in the AHRQ Methods Guide developed by the Agency for Healthcare Research and Quality14 and the chapter Options for Summarizing Medical Test Performance in the Absence of a "Gold Standard."18 Studies will be rated as "good," "fair," or "poor," or as specified by the particular criteria.
Studies rated "good" will be considered to have the least risk of bias, and their results will be considered valid. Good-quality studies include clear descriptions of the population, setting, interventions, and comparison groups; a valid method for allocation of patients to treatment; low dropout rates and clear reporting of dropouts; appropriate means for preventing bias; and appropriate measurement of outcomes.
Studies rated "fair" will be susceptible to some bias, though not enough to invalidate the results. These studies may not meet all the criteria for a rating of good quality, but no flaw likely to cause major bias. The study may be missing information, making it difficult to assess limitations and potential problems. The fair-quality category is broad, and studies with this rating will vary in their strengths and weaknesses. The results of some fair-quality studies are likely to be valid, while others may be only possibly valid.
Studies rated "poor" will have significant flaws that imply biases of various types that may invalidate the results. They will have a serious or "fatal" flaw in design, analysis, or reporting; large amounts of missing information; discrepancies in reporting; or serious problems in the delivery of the intervention. The results of these studies will be least as likely to reflect flaws in the study design as the true difference between the compared interventions. We will not exclude studies rated as being poor in quality a priori, but poor-quality studies will be considered to be less reliable than higher quality studies when synthesizing the evidence, particularly if discrepancies between studies are present.
Each study evaluated will be dual-reviewed for quality by two team members. Any disagreements will be resolved by consensus.
E. Data Synthesis
We will construct evidence tables identifying the study characteristics (as discussed above), results of interest, and quality ratings for all included studies, and summary tables to highlight the main findings. We will review and highlight studies by using a hierarchy-of-evidence approach, where the best evidence is the focus of our synthesis for each key question.
Qualitative data will be summarized in summary tables as ranges, and descriptive analysis and interpretation of the results will be provided.
Meta-analyses will be conducted to summarize data and obtain more precise estimates on outcomes for which studies are homogeneous enough to provide a meaningful combined estimate. The feasibility of a quantitative synthesis will depend on the number and completeness of reported outcomes and a lack of heterogeneity among the reported results. To determine whether meta-¬analysis could be meaningfully performed, we will consider the quality of the studies and the heterogeneity among studies in design, patient population including method of diagnosis, interventions, and outcomes, and may conduct sensitivity analyses. Meta-regression may be conducted to explore statistical heterogeneity using additional variables on methodological or other characteristics (e.g., quality, randomization or blinding, outcome definition and ascertainment) given enough number of studies.
Results will be presented as structured by the key questions, and any prioritized outcomes will be presented first.
F. Grading the Strength of Evidence (SOE) for Individual Comparisons and Outcomes
The strength of evidence for each key question will be initially assessed by one researcher for each clinical outcome (see PICOTS) by using the approach described in the AHRQ Methods Guide.14 To ensure consistency and validity of the evaluation, the grades will be reviewed by the entire team of investigators for:
Study limitations (low, medium, or high level of study limitations)
Consistency (consistent, inconsistent, or unknown/not applicable)
Directness (direct or indirect)
Precision (precise or imprecise)
Reporting bias (suspected or undetected)
The strength of evidence will be assigned an overall grade of high, moderate, low, or insufficient according to a four-level scale by evaluating and weighing the combined results of the above domains:
High — We are very confident that the estimate of effect lies close to the true effect for this outcome. The body of evidence has few or no deficiencies. We believe that the findings are stable, i.e., another study would not change the conclusions.
Moderate — We are moderately confident that the estimate of effect lies close to the true effect for this outcome. The body of evidence has some deficiencies. We believe that the findings are likely to be stable, but some doubt remains.
Low — We have limited confidence that the estimate of effect lies close to the true effect for this outcome. The body of evidence has major or numerous deficiencies (or both). We believe that additional evidence is needed before concluding either that the findings are stable or that the estimate of effect is close to the true effect.
Insufficient — We have no evidence, we are unable to estimate an effect, or we have no confidence in the estimate of effect for this outcome. No evidence is available or the body of evidence has unacceptable deficiencies, precluding reaching a conclusion.
G. Assessing Applicability
Applicability will be estimated by examining the characteristics of the patient populations (e.g., demographic characteristics; type, duration or severity of symptoms; criteria used for diagnosis, presence of medical and psychiatric co-morbidities); the sample size of the studies; and clinical settings (e.g., primary care, specialty setting) and countries (e.g., patients in developing countries) in which the studies are performed. Diagnostic accuracy or concordance between case definitions may vary by subgroups, and treatment interventions may be more or less effective in specific patient subgroups such as those with post-exertional malaise or postural hypotension. Variability in the studies may limit the ability to generalize the results to other populations and settings.
Carruthers BM, Jain AK, de Meirleir KL, et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. J Chronic Fatigue Syndr. 2003;11(1)
Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994;121(12). PMID: 7978722
Holmes GP, Kaplan JE, Gantz NM, et al. Chronic fatigue syndrome: a working case definition. Ann Intern Med. 1988;108(3). PMID: 2829679
Jason LA, Brown A, Clyne E, et al. Contrasting case definitions for chronic fatigue syndrome, Myalgic Encephalomyelitis/chronic fatigue syndrome and myalgic encephalomyelitis. Eval Health Prof. 2012;35(3). PMID: 22158691
Ramsay M. Myalgic Encephalomyelitis and Postviral Fatigue States: The saga of Royal Free disease. 1st ed. London: Gower Medical Publishing; 1986.
Reeves WC, Wagner D, Nisenbaum R, et al. Chronic fatigue syndrome--a clinically empirical approach to its definition and study. BMC Med. 2005;3. PMID: 16356178
Carruthers BM, van de Sande MI, De Meirleir KL, et al. Myalgic encephalomyelitis: International Consensus Criteria. J Intern Med. 2011;270(4). PMID: 21777306
Reyes M, Nisenbaum R, Hoaglin DC, et al. Prevalence and incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Intern Med. 2003;163(13). PMID: 12860574
Reeves WC, Jones JF, Maloney E, et al. Prevalence of chronic fatigue syndrome in metropolitan, urban, and rural Georgia. Popul Health Metr. 2007;5. PMID: 17559660
Center for Drug Evaluation and Research. The Voice of the Patient: A series of reports from the U.S. Food and Drug Administration's (FDA's) Patient-Focused Drug Development Initiative. Chronic Fatigue Syndrome and Myalgic Encephalomyelitis: U.S. Food and Drug Administration; 2013. Available at: https://www.fda.gov/downloads/ForIndustry/UserFees/PrescriptionDrugUserFee/UCM368806.pdf. Accessed March 22, 2014.
Jason L, Evans M, Porter N, et al. The Development of a Revised Canadian Myalgic Encephalomyelitis Chronic Fatigue Syndrome Case Definition. Am J Biochem Biotechnol. 2010;6(2)
Dowsett E, Goudsmit E, Macintyre A, et al. Report from The National Task Force on Chronic Fatigue Syndrome (CFS), Post Viral Fatigue Syndrome (PVFS), Myalgic Encephalomyelitis (ME). Westcare. 1994
Sharpe MC, Archard LC, Banatvala JE, et al. A report--chronic fatigue syndrome: guidelines for research. J R Soc Med. 1991;84(2). PMID: 1999813
Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Agency for Healthcare Research and Quality. AHRQ Publication No. 10(13)-EHC063-EF. Rockville (MD). Available at: https://effectivehealthcare.ahrq.gov/products/cer-methods-guide/overview/. Accessed March 21 2014.
Shea BJ, Hamel C, Wells GA, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol. 2009;62(10). PMID: 19230606
C. Michael White, Stanley Ip, Melissa McPheeters, et al. Using existing systematic reviews to replace de novo processes in conducting Comparative Effectiveness Reviews. Methods Guide for Comparative Effectiveness Reviews. Agency for Healthcare Research and Quality. AHRQ Publication No. 10(13)-EHC063-EF. Rockville (MD). Available at: https://effectivehealthcare.ahrq.gov/products/methods-guidance-de-novo-processes/methods/. Accessed March 21, 2014.
U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Procedure Manual. AHRQ Publication No. 08-05118-EF. Rockville (MD):July 2008. Available at: https://www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.htm. Accessed March 21, 2014.
Trikalinos TA, Balion CM. Options for Summarizing Medical Test Performance in the Absence of a "Gold Standard". AHRQ Publication No. 12-EHC081-EF. Rockville (MD): Agency for Healthcare Research and Quality; Jun 2012. Available at: https://effectivehealthcare.ahrq.gov/products/methods-guidance-tests-performance/overview/. Accessed March 22, 2014.
Summary of Protocol Amendments
Review of Key Questions
Key Questions were reviewed and refined as needed by the EPC with input from the NIH Working Group and the Technical Expert Panel (TEP) to assure that the questions are specific and explicit about what information is being reviewed.
NIH Working Group
In place of Key Informants, a NIH Working Group Planning Meeting occurred to provide input into identifying the Key Questions and guiding the scope of the report, because this topic was nominated to AHRQ from the National Institutes of Health.
Technical Experts comprise a multi-disciplinary group of clinical, content, and methodologic experts, including the patient perspective, who provide input in defining populations, interventions, comparisons, or outcomes as well as identifying particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore study questions, design and/or methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts provide information to the EPC to identify literature search strategies and recommend approaches to specific issues as requested by the EPC. Technical Experts do not do analysis of any kind nor contribute to the writing of the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.
Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified. Potential conflicts of interest are also managed by not releasing the names of Technical Experts until publication of the final report.
Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodologic expertise. Peer review comments on the preliminary draft of the report are considered by the EPC in preparation of the final draft of the report. Peer reviewers do not participate in writing or editing of the final report or other products. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual reviewers. The dispositions of the peer review comments are documented and will, for CERs and Technical briefs, be published three months after the publication of the Evidence report.
Potential Reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism. Potential conflicts of interest are also managed by not releasing the names of Peer Reviewers until publication of the final report.
EPC Team Disclosures
EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Related financial conflicts of interest which cumulatively total greater than $1,000 will usually disqualify EPC core team investigators.
Role of the Funder
This project was funded under Contract No. HHSA 290201200014I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The Task Order Officer reviewed contract deliverables for adherence to contract requirements and quality. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Sample Search Strategy (Ovid MEDLINE)
exp Chronic Fatigue Syndrome/ (4528)
exp Encephalomyelitis/ (9563)
exp Fatigue/ (20358)
2 and 3 (373)
1 or 4 (4557)
(chronic$ adj3 fatig$ adj3 syndrom$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] (5194)
(myalg$ adj3 encephal$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] (419)
limit 9 to english language (4732)
limit 9 to abstracts (3780)
10 or 11 (5040)
exp cognitive behavior therapy/ (15929)
(cognit$ adj3 behav$ adj5 (therap$ or treat$ or interven$ or regimen$ or counsel$)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] (11111)
13 or 14 (19599)
exp Exercise/ (111374)
((grad$ or therap$ or treat$ or interven$ or regimen$) adj3 exercis$).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] (36939)
16 or 17 (140490)
exp drug therapy/ (1112200)
exp drugs/ (641176)
dt.fs. (1752044)
19 or 20 or 21 (2743222)
((drug$ or pharmac$) adj3 (therap$ or treat$ or adminis$ or prescri$ or interven$ or regimen$)).mp. (539954)
22 or 23 (2871189)
12 and 15 (334)
25 or 26 or 27 (1077)
Diagnosis and Treatment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome
Safety of Vaccines Used for Routine Immunization in the United States
Systematic Review Update: Noninvasive Nonpharmacologic Treatments for Chronic Pain
Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review
Supplemental Project To Assess the Transparency of Reporting Requirements for Studies Evaluating the Effectiveness of Treatment Options for Symptoms of Diabetic Peripheral Neuropathy
Noninvasive, Nonpharmacological Treatment for Chronic Pain
Internet Citation: Research Protocol: Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Content last reviewed December 2019. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/chronic-fatigue/research-protocol


The Computer Science Software Systems Development course aims to deliver graduates that can apply best practice in the application of software engineering to the development of a wide range of information systems in organisations. The course of study covers all the necessary skills you will need to be a computing professional, from idea generation to system implementation.
Each taught year, you will take 120 credit points, which require 1200 hours effort divided into 24 weeks across 2 academic semesters. During the first two years you will build programming skills through modules that teach not only the principles of programming (Programming 1) but also high level programming languages (in Programming 2 and Visual Programming modules). In developing your capabilities to design, build, operate and maintain complex computer and information technology systems modules such as System Analysis-Design, Database Systems, Computer Networks, Web Database Development, Object Oriented Modelling and Interactive Interface Design provide a platform for skill development and practical application. Also, during your second year of study, you will start the process of applying for a placement job in industry, you are supported in this endeavour by the Professional Issues module which dedicates a part of its content to employability.
During the final year, you will get exposed to more advance topics to consolidate your knowledge and understanding of the software development role in industry in preparation for future employment. Modules at this stage include Mobile Technologies, Enterprise Computing, Concurrent and Distributed Systems and Software Engineering. In your final year you will also gain practical experience in the planning, development and implementation of a computing system, this can be used to showcase your skillset to future employers.
Four years, including placement. Each student must complete 120 credits (usually six modules) in each academic year, with the exception of placement year (60 credits). Years 1, 2 and 4 are spent in the University. Modules are taught on campus and are web-supplemented. In Year 3, students undertake a year's work experience.
The GCE A Level requirement for this course is grades BBB. All subject areas considered.
The requirement for this course is BTEC Level 3 National Extended Diploma with overall award profile of DDM to include a minimum of 9 unit distinctions. All subject areas considered.
Successful completion of a Ulster University validated Access route with an overall mark of 70% to include 70% in NICATS Maths (level 2) or GCSE Mathematics grade C (or equivalent) for entry to year 1.
Faculty Prizes can be viewed at: www.ulster.ac.uk/academicoffice/prizes.html.


Our Foreign Skies photo competition aimed to promote views of Scotland and Dundee as seen through the eyes of our international SLS community. It was the brainchild of Ana Agostinho, a student in Anton Gartner's Lab who completed her PhD in 2013 and is now a postdoc at the Karolinska Institute in Stockholm. Ana, herself a prize-winning photographer said, "Through our Public Engagement activities the School has provided the public, in and around Dundee, with an understanding of the excellent quality of life sciences research being carried out here at the School of Life Sciences. Attendance at Doors Open Days and other public engagement events demonstrate the enormous public interest in our research.
The images were displayed in the School followed by public displays at the Mills Observatory and at the McManus Galleries. Click here to view the shortlist.


Also known as The Soldier's Return.
The Mill, Mill O has been added to 2 tune sets.
The Mill, Mill O has been added to 7 tunebooks.
# Added by Crackpot 3 years ago .
From the playing of Conal O Grada. Found on track 6 of the raw bar collective. My transcription.
# Posted by Crackpot 3 years ago .
# Posted by Mix O'Lydian 3 years ago .
"Closely related to this tune…"
An danced the miller's reel, O.


Berker is a leading supplier of high-quality electrical installations - from timelessly classic switch design through to intelligent building management systems.
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text:
Differences between Pelikan M400, M600 and M800
The German brand Pelikan was born in 1832 manufacturing paint and ink. When in 1878 Gunther Wagner took the lead of the company, he incorporated the Pelican, his family's emblem, as the brand's logo.
It was in 1929, after acquiring the fountain pen patents that Pelikan began to produce them and introduced the famous piston system, which differentiated their pens from the rest in the industry.
Since then, the brand has continued to manufacture and market a wide variety of classic and timeless items that drive writing fanatics crazy.
Pelikan Souverän
In 1950 Pelikan launched the model 400, with its green striped body, inspired by the suits of the foreign minister of the Weimar Republic, Gustav Stresemann, who used to wear thinly striped pants.
Image Title: Three Men's Suits, a so-called "Stresemann" to the left, 1924 © bpk - Photo Agency / Kunstbibliothek, Staatliche Museen zu Berlin - Preußischer Kulturbesitz / Dietmar Katz
This model quickly became a worldwide symbol of the brand, with its classic and traditional styling. During the 1980s the series was baptized as Souverän.
The production of the Souverän barrel is a task of extreme delicacy as the material, created exclusively for Pelikan, must be handled with precision.
Pelikan Souverän M605 Stresemann
Pelikan Souverän is considered one of the best in writing instruments, for its solid construction and high quality material. The piston loading mechanism and the handmade nib add the finishing touch to this fabulous collection.
The collection stands out for its variety and practicality, which is why all Souverän pens come with a white carrying case. Among the most popular models are the M400, M600 and M800, but how do they differ?
The main difference between these three models is the size. The M400, which was the first of the 3 to hit the market, is a small pen. Closed, it has an approximate length of 12 cm, and open it has about 14.58 cm.
The M600 is slightly larger, closed at around 13 cm, while open it reaches 15.4 cm.
The M800 is the longest of the three. Its length is 14 cm closed and 16.5 cm open.
Due to the difference in size between the three pens, the weight also varies. However, the real difference is seen in the M800.
The M400 has an approximate weight of 15g, the M600 of 18g. These two pens have an internal plastic mechanism, which makes them extremely light pens.
The M800 has a brass mechanism, reaching a higher weight of around 29g.
The nib is the guide for many when buying a pen, and among these three the nib is significantly different. In comparison the M400 has a shorter and thinner nib, the M600 has a wider and slightly longer one. Both have a 14-karat gold nib of excellent quality.
The M800 stands out for its 18-karat solid gold nib, manufactured entirely in Pelikan, and due to its soft shape and alignment, it has a smoother writing.
Pelikan Souverän M400, M600, M800 nibs detail
Within this same line are the 05, which differ in their ornaments an they are silver instead of gold.
PELIKAN M400
If you require more information or if you would like to place an order, please do not hesitate to contact us or visit our store in Madrid, at Nuñez de Balboa 90.
We will be pleased to help you.
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Edelstein, The Pelikan Gem
WOLF 1834, luxury boxes, cases and winders
Watches for winter sports
GMT watch: What is it and how does it work?
Alpina Alpiner: a classic returns
Montegrappa's Zodiac
Screw-down Watches

redpajama_set_name: RedPajamaCommonCrawl


text:
Donald Trump is one of those _________ U.S. presidents who could not take office for second term.
Ans: 11
49th Vice President of U.S. Kamala Harris is the _________ female V.P. in the history of U.S.A.
Ans: First
Who is Victoria Woodhull in the history of United States of America?
Ans: First Female Presidential Candidate
Which of the following term is used for the current era of Japan's official calendar?
Ans: Reiwa
Who is the Current President of Tajikistan?
Ans: Emomali Rahmon
Tajikistan President Emomali Rahmon has arrived in Islamabad on a two-day visit on_________?
Ans: 2nd June 2021
World's first human case of H10N3 Bird Flu reported in which of the following nation?
Ans: China
Which Nation Becomes The World's First Country To Ban Synthetic Cannabinoids?
After United States, which country has successfully landed a robot on the surface of Mars on 15 May 2021?
Collinet Makosso Appointed New Prime Minister Of Which Nation ?
Ans: Congo
As per June 2nd 2021 meeting, ICC TWorld Cup 2021 is likely to be held in the following country?
Ans: U.A.E.
Which of the following ICC World Cup Twas cancelled in the last year scheduled to be held in Australia?
Ans: Seventh
Which of the following teams did not win ICC World Cup Tso far?
Ans: All of the above are winner
ICC TWorld Cup 2021 will be_____________ event ?
Ans: Eighth
Which of the following sports event(s) cancelled/postponed due to COVID-19?
Ans: All of these
Novak Djokovic won which of the following Australian Open Tennis championship?
Ans: All of the above
Issac Herzog was elected as the 11th president of_________?
Ans: Israel


text:
/*
 * Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except
 * in compliance with the License. You may obtain a copy of the License at
 *
 * http://www.apache.org/licenses/LICENSE-2.0
 *
 * Unless required by applicable law or agreed to in writing, software distributed under the License
 * is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express
 * or implied. See the License for the specific language governing permissions and limitations under
 * the License.
 */
/*
 * This code was generated by https://github.com/googleapis/google-api-java-client-services/
 * Modify at your own risk.
 */

package com.google.api.services.datapipelines.v1.model;

/**
 * A single value in a row. The value set must correspond to the correct type from the row's schema.
 *
 *
 This is the Java data model class that specifies how to parse/serialize into the JSON that is
 * transmitted over HTTP when working with the Data pipelines API. For a detailed explanation see:
 * https://developers.google.com/api-client-library/java/google-http-java-client/json
 *

 *
 * @author Google, Inc.
 */
@SuppressWarnings("javadoc")
public final class GoogleCloudDatapipelinesV1FieldValue extends com.google.api.client.json.GenericJson {

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   * The value may be {@code null}.
   */
  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1ArrayValue arrayValue;

  /**
   * The atomic value of this field. Must correspond to the correct atomic type in the schema.
   * The value may be {@code null}.
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  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1AtomicValue atomicValue;

  /**
   * The enum value of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the schema if that
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   */
  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1EnumerationValue enumValue;

  /**
   * The fixed-length byte collection of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the
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   * The value may be {@code null}.
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  private GoogleCloudDatapipelinesV1FixedBytesValue fixedBytesValue;

  /**
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   * The value may be {@code null}.
   */
  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1IterableValue iterableValue;

  /**
   * The map value of this field. Corresponds to TYPE_NAME_MAP in the schema.
   * The value may be {@code null}.
   */
  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1MapValue mapValue;

  /**
   * The row value of this field. Corresponds to TYPE_NAME_ROW in the schema. This row also holds to
   * its own schema.
   * The value may be {@code null}.
   */
  @com.google.api.client.util.Key
  private GoogleCloudDatapipelinesV1Row rowValue;

  /**
   * The array value of this field. Corresponds to TYPE_NAME_ARRAY in the schema.
   * @return value or {@code null} for none
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  public GoogleCloudDatapipelinesV1ArrayValue getArrayValue() {
    return arrayValue;
  }

  /**
   * The array value of this field. Corresponds to TYPE_NAME_ARRAY in the schema.
   * @param arrayValue arrayValue or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1FieldValue setArrayValue(GoogleCloudDatapipelinesV1ArrayValue arrayValue) {
    this.arrayValue = arrayValue;
    return this;
  }

  /**
   * The atomic value of this field. Must correspond to the correct atomic type in the schema.
   * @return value or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1AtomicValue getAtomicValue() {
    return atomicValue;
  }

  /**
   * The atomic value of this field. Must correspond to the correct atomic type in the schema.
   * @param atomicValue atomicValue or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1FieldValue setAtomicValue(GoogleCloudDatapipelinesV1AtomicValue atomicValue) {
    this.atomicValue = atomicValue;
    return this;
  }

  /**
   * The enum value of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the schema if that
   * logical type represents an `EnumerationType` type.
   * @return value or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1EnumerationValue getEnumValue() {
    return enumValue;
  }

  /**
   * The enum value of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the schema if that
   * logical type represents an `EnumerationType` type.
   * @param enumValue enumValue or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1FieldValue setEnumValue(GoogleCloudDatapipelinesV1EnumerationValue enumValue) {
    this.enumValue = enumValue;
    return this;
  }

  /**
   * The fixed-length byte collection of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the
   * schema if that logical type represents a `FixedBytes` type.
   * @return value or {@code null} for none
   */
  public GoogleCloudDatapipelinesV1FixedBytesValue getFixedBytesValue() {
    return fixedBytesValue;
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  /**
   * The fixed-length byte collection of this field. Corresponds to TYPE_NAME_LOGICAL_TYPE in the
   * schema if that logical type represents a `FixedBytes` type.
   * @param fixedBytesValue fixedBytesValue or {@code null} for none
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  public GoogleCloudDatapipelinesV1FieldValue setFixedBytesValue(GoogleCloudDatapipelinesV1FixedBytesValue fixedBytesValue) {
    this.fixedBytesValue = fixedBytesValue;
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  /**
   * The iterable value of this field. Corresponds to TYPE_NAME_ITERABLE in the schema.
   * @return value or {@code null} for none
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    return iterableValue;
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redpajama_set_name: RedPajamaGithub


text:
Los Billboard Music Awards son unos premios entregados anualmente por Billboard, una revista estadounidense dedicada a la industria musical. Estos premios se han celebrado anualmente desde 1990, primero en el mes de diciembre, hasta el 2006, año en el que se suspendió la entrega hasta su regreso en 2011, a partir de la cual se celebra en el mes de mayo.

Elección
A diferencia de otros galardones, como los American Music Awards, que determinan sus nominaciones de acuerdo a la mayor cantidad de votos recibidos, y los Grammys que se determinan por excelencia musical evaluada por la academia de la grabación, los finalistas de los Billboard Music Awards se seleccionan por su rendimiento comercial en Estados Unidos de acuerdo a los datos registrados por el sistema Nielsen SoundScan a fin de año.

Los premios son otorgados a álbumes, artistas y sencillos de diferentes géneros. Desde 1992, la revista entrega el premio honorífico Billboard Century Award a quien considera que ha realizado un aporte significativo a la industria discográfica en términos de creatividad. Este reconocimiento fue rebautizado en el 2011 como Billboard Icon Award. El rapero canadiense Drake fue la gran estrella de la entrega de los Billboard Music Awards 2019, con 12 galardones, que lo convirtieron en el artista más reconocido de la historia de estas distinciones al sumar ya 27 a lo largo de toda su carrera.

Ceremonia de entrega
Desde que Rick Garson creó los premios en 1989, la ceremonia de entrega fue televisada a través de la cadena de televisión Fox, sin embargo, debido a conflictos contractuales y otras circunstancias, el espectáculo fue cancelado en el 2007. Los planes para una nueva versión de los premios en el 2008 —en asociación con la productora AEG Live— no prosperaron y la ceremonia permaneció suspendida hasta el 2011. En febrero de ese año, Billboard anunció que su show de premios volvería a la televisión, pero esta vez en el mes de mayo y a través de la cadena ABC.

Ediciones

Artistas más ganadores
El récord del artista general con más premios Billboard Music Awards lo tiene Drake con 34, mientras que la artista femenina con más premios Billboard Music Awards es Taylor Swift, quien ha recibido 29 galardones.

Transmisión
Desde su inicio, los Billboard Music Awards (BMA), creados por Rick Garson, Paul Flattery y Jim Yukich, se habían transmitido por televisión a través de la cadena Fox; sin embargo, debido a vencimientos contractuales y otras circunstancias imprevistas, los premios se cancelaron para el año 2007. Los planes para una nueva versión de los premios en 2008 (en asociación con Anschutz Entertainment Group) fracasaron y los BMA se volvieron a cancelar, regresando recién el año 2011.

El 17 de febrero de 2011, Billboard anunció que llevaría los BMA de regreso a la televisión, mudándose de su hogar original en Fox a su nueva cadena, ABC, el 22 de mayo de 2011. Una nueva estatuilla fue creada en New York por la Society Awards. Dick Clark Productions, que es copropiedad de Billboard, comenzó a producir la ceremonia en 2014. El 28 de noviembre de 2017, se anunció que los Billboard Music Awards se trasladarían de ABC a la cadena NBC a partir de 2018, bajo un contrato de un año.

La ceremonia de 2020, originalmente programada para el 29 de abril, se pospuso indefinidamente el 17 de marzo debido a preocupaciones de la asamblea pública relacionadas con el coronavirus. El 14 de agosto de 2020, se anunció que la ceremonia de 2020 se había reprogramado finalmente para el 14 de octubre de ese año.

Véase también
 Los premios Billboard de la música latina

Referencias

Enlaces externos
 Sitio web oficial (en inglés).

Billboard
Programas de televisión de ABC
Series de televisión producidas por 20th Century Fox Television
Series de televisión de Fox
Premios establecidos en 2011

redpajama_set_name: RedPajamaWikipedia


Chromagen are the pioneers of energy efficient hot water systems and have been delivering quality hot water solutions since 1962.
Chromagen is Australian owned and operated. So you can trust that they understand the Australian hot water heating industry and provide long lasting and reliable hot water systems that are well-suited to our ever changing temperatures.
With a focus on sustainable environmental solutions Chromagen has a wide range of hot water systems suited to any household or commercial property.
For an endless supply of reliable hot water you can't go past the compact and durable Chromagen Eternity range. These 6 star energy efficient gas hot water heaters provide a continuous flow of hot water on demand, as and when you need it. With no water storage tank the continuous flow system is an excellent space saver and powered by gas you will benefit from reduced energy bills when compared to an electric hot water heater.
The Chromagen Eternity continuous flow hot water heaters can also be used as a solar booster to a Chromagen solar powered hot water heater to provide a constant stream of hot water 24/7.
The Chromagen ground mounted solar hot water heater is a split configuration with the solar collectors situated on your roof and the water storage tank located at ground level. This highly efficient set up provides greater flexibility in installation and less of a weight load on your roof.
A pump is used to circulate your water through the roof collectors to provide heat, then the water is sent back to the tank to be stored for when you require it.
Use the sun's free energy to your advantage, reduce your carbon footprint and drastically reduce your energy bills.
When ground space is limited there is the option of the Chromagen roof mounted solar hot water heater. The RoofLine system is a close-coupled solar system where the tank and collectors are both situated on your roof. This set up provides very little maintenance as no pump, or other moving parts, are required to heat your stored water. Instead a natural thermosiphon method is used.
If you want all the benefits of a solar powered hot water heater but just don't have the correct property set-up to have one installed then a highly efficient Chromagen heat pump is the answer that you have been waiting for!
The Chromagen heat pump is an all in one, ground mounted, system that heats your stored water by using the ambient outside air, rather than collecting energy from the sun. The heat pump works in much the same way as a refrigerator but in reverse and can provide you with extreme savings when compared to a conventional hot water heating system.
The Chromagen heat pump is also the perfect replacement for an old energy hungry electric storage hot water heater as they have the same footprint design. See more about the benefits, features and available sizes below.
Want to know more about Chromagen hot water?
For a free quote on the supply and installation of the ideal Chromagen hot water system to suit your property and your hot water heating demands, call the hot water experts from Jim's Plumbing.
Should you require repairs or a service to your Chromagen hot water system we can assist here also with our fuss-free same day plumbing service. In a gas or plumbing emergency you can expect to see a friendly Jim's plumber on your doorstep within only an hour* of your call – 24 hours a day, 7 days a week, including all public holidays.
If you've been saving for a hot water heater upgrade then talk to us about our interest free payment plans* on all Chromagen hot water heater supplies and installations.
For a hot water plumber in Adelaide, Melbourne, Perth, Sydney, Brisbane or Canberra you can rely on the team from Jim's Plumbing for your hot water heater repairs, replacements or new installations.
Call us today or complete our easy to use online plumber booking form for an instant call back to discuss your plumbing requirements.


text:
Shooting for the Stars
This client needed one more medal in the Commonwealth Games in Glasgow in 2014 to equal a particular record that he wanted to achieve
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Posted by Jeremy Lazarus on	 March 13th 2019
Due to the nature of the situation, some details are omitted, even though I have permission from the client to explain the situation.
The person was a marksman, with numerous medals from international competition. He needed one more medal in the Commonwealth Games in Glasgow in 2014 to equal a particular record that he wanted to achieve. He was reaching an age where it was obvious to everyone that this would be his last realistic attempt to win a medal.
Having just about reached the final (he shot poorly by his standards), he asked to spend some time with me in the 45 minutes available between the qualifying round and the final. He was, understandably, feeling the pressure, wanting so much to do win a medal, and knowing this was almost certainly his 'last shot' at doing so.
We found as quiet a spot as we could, given that it was the Commonwealth Games! We sat on a bench by an outdoor café on the outskirts of the venue. Having worked with him several times previously, we quickly got down to business. He wanted to feel confident during the final. We did the NLP 'Resource Anchor' process, lasting around 20 minutes, including the essential mental rehearsal afterwards. This mental rehearsal proved invaluable as it aided him to recover from a poor shot at a crucial point in the final.
The client won a medal; words cannot describe the impact on his and his family, achieving such a goal having devoted so much time and energy to it. He writes:
With Jeremy's support, guidance and knowledge I was able to handle the intense pressure of being 60 and going into my final Commonwealth Games (Glasgow 2014), knowing that it was 'now or never'. Although I did not shoot particularly well in the qualifying round, I managed to reach the final, and Jeremy helped me to really focus and relax before the final and win the coveted 18th medal (a bronze) to equal the record.
Jeremy Lazarus
NLP Master Trainer, specialising in NLP for Business, Coaching and Sport.


For most artists, being invited to join a social circle was important, even career-changing, as it brought them into contact with peers and patrons. A few artists have themselves been at the centre of circles, and Edgar Degas (1834-1917) was perhaps one of the most influential. From his meeting with JAD Ingres (1780-1867) in 1855 to his friendship with the young John Singer Sargent (1856-1925), Degas was nothing if not thoroughly sociable.
This article is the first of two summarising some of the more significant artistic friendships of Edgar Degas, and suggests visually some potential influences resulting from them.
One of Degas' longest friendships was with Vicomte Ludovic-Napoléon Lepic (1839-1889), who was persuaded by Degas to associate with the Impressionists and exhibit in the First Impressionist Exhibition in 1874. Lepic's lover was Marie Sanlaville, one of the ballet stars of the Paris Opera who was also well-known to Degas, and appears in some of Degas' paintings of the ballet.
Lepic broke from the Impressionists because of their insistence that members did not show at the official Salon, but appears as a model in several of Degas' paintings, including Count Lepic and his Daughters (1870), below, and Place de la Concorde (1875), which shows Lepic and his daughters, with their dog.
Lepic became a successful marine painter, eventually being appointed as such to the French State in 1883. Some of his paintings of the coast are reminiscent of Degas' small series of coastal landscapes painted around 1870.
Jacques Joseph (James) Tissot (1836-1902) was also a student of Louis Lamothe (1822–1869), and appears to have become a friend of Degas' early in his career, together with the successful portrait painter Alfred Stevens (1823–1906).
Degas is thought to have first met Édouard Manet (1832-1883) in 1862 or 1864, and from then had a close friendship until Manet's death. It was not without its strains, though: in 1868, Degas painted a double portrait of Manet and his wife Suzanne, an accomplished pianist. Manet then slashed the canvas through his wife's image, prompting Degas to ask for its return, so that he could repaint it – which he never did. Nor do we know the reason for Manet's mutilation of the painting.
Degas became a friend of the Rouart family of industrialists, particularly Stanislas-Henri Rouart (1833-1912), who trained as an artist and exhibited in the Salons from 1868-70. During the Franco-Prussian War of 1870, Rouart and Degas served alongside one another in the defence of Paris. When Rouart's work was refused by the Salon in 1873, Degas invited him to take part in the First Impressionist Exhibition the following year, where he showed four paintings and some prints. Rouart was also a friend of Gustave Caillebotte.
With his Italian family origins, Degas was often an important point of contact for Italian painters who moved to Paris, particularly those who associated with the Macchiaioli (sometimes considered as 'Italian Impressionists'). When Giuseppe De Nittis (1846-1884) first came to Paris in 1867, he made friends with Degas, a relationship which remained close until De Nittis' death.
(Jean-Baptiste-)Léopold Levert (1828-1882), about whom we know very little, was a friend of Degas, who also painted his portrait (below). Levert took part in the Impressionist Exhibitions of 1874, 1876, 1877, and 1880.
When Giovanni Boldini (1842-1931) moved to Paris in 1872, he became a good friend of Degas, and was also a friend of John Singer Sargent – sufficient to have painted Sargent's portrait twice. Boldini painted, and De Nittis made a drypoint print of, Degas' portrait.
Another member of the Macchiaioli who moved to Paris in 1873, Federico Zandomeneghi (1841-1917) entered the outer circle of Impressionists, becoming friends with Degas, Pissarro, and Sisley.
Although I don't have dates for them, Zandomeneghi's paintings of nudes were clearly influenced by those of Degas.
Posted in General, Painting and tagged Boldini, de Nittis, Degas, Ingres, Lepic, Levert, Macchiaioli, Manet, painting, Rouart, Sargent, Stevens, Tissot, Zandomeneghi. Bookmark the permalink.


Roughly a year and half ago, US President Donald Trump has called on Qatar to stop the funding of terrorism and the spread of its "extremist ideology", claiming that the nation of Qatar "has historically been a funder of terrorism at a very high level". This came about while Saudi Arabia and its Gulf allies initiated a joint campaign to isolate Qatar, which eventually proved completely ineffective. Not even six months later, Qatari Sheikh Tamim bin Hamad al Thani was once again sitting next to the US President, who labelled him a "friend of his" and a helpful force in fighting terrorism. In a densely interwoven development of events, Qatar did in fact manage to find an elegant way out of a situation which once seemed insolvable.
Please sign up and become a premium OilPrice.com member to gain access to read the full article.


Drogheda kids are set to enjoy a unique Easter egg hunt and family fun day to kick off the long weekend at Drogheda Retail Park, on Saturday, March 31.
Led by the Easter Bunny, local children will go on an eggciting adventure, filling their baskets with sweets, treats and surprises.
As well as the Easter Bunny, children will be entertained by magicians, jugglers, face painters and a DJ, with a special appearance by Alice and the Mad Hatter.
The event starts at 12pm, and families are encouraged to get there early to meet the characters and get their face paint ready before the Easter egg hunt at 12.30pm.


text:
Foreign Relations of the United States: Diplomatic Papers, 1942, The Near East and Africa, Volume IV
Memorandum of Conversation, by the Acting Secretary of State
[Washington,] March 23, 1942.
The Minister of Iran called to see me this morning.
The Minister made a very long exposition of the subject matter contained in full detail in Mr. Murray's [Alling's] memorandum of his conversation with the Minister on March 20.67
At the end of the Minister's statement, he asked me what the opinion of this Government might be.
I replied to the Minister that I greatly appreciated the expression of friendship for the Government and people of the United States which he had made in behalf of his Government and told him that his Government and he personally might be assured that this friendship was fully reciprocated. I said it was our desire here to do everything we could to cooperate with the Government of Iran in lending assistance which might be desired, including the services of technicians and experts.
I said that with regard to the specific question he had raised, the Soviet Government had made no communication to the Government of the United States of any character whatsoever with regard to its aspirations and desires concerning new frontiers or new spheres of influence as an outgrowth of the present war.
I stated that the British Government had kept the United States Government informed of the conversations which had been held between the Soviet and British Governments concerning various matters of this character,68 but that this Government had not been informed by the British Government of any discussion between the Soviet and British Governments which affected Iran.
I stated that, for these reasons, it seemed to me that it would not only be inappropriate, but positively prejudicial, for this Government—out of a clear sky insofar as it was concerned—to make any public declarations concerning the independence and integrity of Iran.
I stated that the general position of this Government was fully set forth in the provisions of the Atlantic Charter as signed by the President of the United States and that the principles there enumerated constituted the determined policy which this Government intended to pursue.
The Minister thanked me very effusively and said that he fully agreed that in the light of the circumstances which I had mentioned there would be no appropriate occasion for the United States, at this juncture, to make any public declaration of the kind he had discussed with Mr. Murray. He emphasized the fact that this suggestion on his part had been an individual and informal suggestion and had not been made under instructions of his Government.
I stated at the conclusion of our interview that I would be very glad to keep in touch with the Minister so that if any matters affecting Iran came to my attention, I would have the opportunity of talking them over with him for the information of his Government.
S[umner] W[elles]
Supra.↩
For correspondence on this subject, see vol. iii, pp. 490 ff.↩
The Near East and Africa
General: (Documents 1-32)
Afghanistan: (Documents 33-65)
Egypt: (Documents 66-113)
Iran: (Documents 138-399)
Reservation of American rights regarding certain provisions of Anglo-Soviet-Iranian Treaty of Alliance; unwillingness of the United States to make declaration concerning integrity of Iran (Documents 299-314)
Iraq (Documents 400-418)
Muscat and Oman: (Documents 647-648)
Palestine: (Documents 649-664)
Saudi Arabia: (Documents 665-700)
Syria and Lebanon: (Documents 701-789)


text:
Archive By month July 2019 June 2019 May 2019 April 2019 March 2019 February 2019 December 2018 November 2018 October 2018 August 2018 July 2018 June 2018 May 2018 April 2018 March 2018 February 2018 December 2017 November 2017 October 2017 September 2017 August 2017 July 2017 June 2017 May 2017 April 2017 March 2017 February 2017 January 2017 December 2016 November 2016 October 2016 September 2016 August 2016 July 2016 June 2016 May 2016 April 2016 March 2016 February 2016 January 2016 December 2015 November 2015 October 2015 September 2015 August 2015 July 2015 June 2015 May 2015 April 2015 January 2015 December 2014 November 2014 October 2014 September 2014 August 2014 July 2014 May 2014 December 2013 October 2013 September 2013 May 2013
Category All categories Athena Swan Awards & Appointments Children's Health Clinical Trials Department Gastroenterology General HIV Haematology Immunology Informing Policy Neonatology Neuroimaging Parents & Carers Public Engagement Publication Recruitment Research Research Methods Teaching University Vaccinology Vice Chancellor Other
Solving the riddle of the typhoid toxin
Vaccinology
Salmonella Typhi bacteria can invade the intestines and blood and lead to a disease called typhoid fever – a disease that affects around 11 million people each year globally.
The global value of vaccination
We recently worked with Mediaplanet on the 2019 Health Awareness: Value of Vaccines campaign. The campaign features exclusive content from key thought leaders and industry voices about the critical importance of full immunisation throughout life.
Should vaccines be made compulsory?
Dr Samantha Vanderslott (Oxford Vaccine Group), Dr Eleanor Draeger (sexual health expert and medical writer), and Professor Beate Kampmann (London School of Hygiene and Tropical Medicine) debate compulsory vaccination. Presented by Philippa Thomas on BBC World service.
The key to better childhood vaccines might be in our DNA
Publication Research Vaccinology
PBS features Daniel O'Connor's research on how children's genetic profiles affect their immunity.
Professor Irene Roberts recognised for mentorship role
Awards & Appointments Haematology
Many congratulations to Prof Irene Roberts, recipient of the European Hematology Association (EHA) Education & Mentoring Award 2019.
Paediatrics celebrates International Clinical Trials Day
Sign up to take part in our clinical trials, talk to the research staff, or simply enjoy a Microbe Mugshot Match or a Game of Crohn's (Disease).
How was typhoid eliminated in the past?
Drs Samantha Vanderslott and Claas Kirchhelle introduce their typhoid history research and 'Alice in Typhoidland' public engagement project. This work delves into the history of typhoid in Oxford and highlights why typhoid is still a major global health problem needing both water, sanitation, and hygiene (WASH) interventions alongside vaccines.
IVF and risk of childhood cancers - expert comment
Professor Anindita Roy provides expert comment on research published in JAMA Pediatrics, which found a small association of IVF with overall cancers of early childhood.
A prize-winning poster on personalised medicine
Awards & Appointments
Dr Dominik Aschenbrenner from the Mucosal Immunology Group was awarded the first prize at the Falk Foundation Symposium for his poster titled "IBD: From Pathophysiology to Personalized Medicine".
World-leading neurologist appointed to Professorship at MDUK Oxford Neuromuscular Centre
Acclaimed clinical researcher, Professor Laurent Servais, has been appointed Professor of Paediatric Neuromuscular Diseases at the MDUK Oxford Neuromuscular Centre. The centre is a partnership between Muscular Dystrophy UK (MDUK) and the University of Oxford with the aim of driving research into potential treatments from the lab into the clinic.
Will Blockchain make the healthcare system more efficient?
An undergraduate working with the Healthcare Translation Research Group published an article suggesting that Blockchain could be used to manage electronic health records in a secure, decentralised way.
Rebeccah Slater talks to the BBC about infant pain
Oxford-Harrington Rare Disease Centre to research rare diseases therapies
The University of Oxford and Harrington Discovery Institute at University Hospitals have announced a new affiliation to advance therapies for rare diseases. The joint program combines capabilities to improve treatment options globally for patients with rare diseases.
A new frontier in the fight against rare diseases
In a Medium interview, Professor Matthew Wood, a professor of Neuroscience in the Department of Paediatrics, talks about his work and the advances that a new Rare Diseases Centre could herald for the future of rare disease and genetics.
Blueprint Magazine features paediatric research
Children's Health Clinical Trials Neuroimaging Publication
In the latest issue of the Blueprint, Shaunna Latchman meets Professor of Paediatric Neuroimaging, Rebeccah Slater to discuss the Paediatric Neuroimaging Group and find out why a gentle touch really does goes a long way.
The power of touch
Neuroimaging Publication Research
Work published in Current Biology shows that lightly brushing in an infant can reduce pain-related brain activity evoked by a clinically necessary medical procedure.
Is morphine an effective and safe analgesic for premature babies?
Clinical Trials Neuroimaging Research
The Lancet has published the results of the Procedural Pain in Premature Infants (Poppi) study, ran by the Paediatric Neuroimaging Group and co-ordinated by the National Perinatal Epidemiology Unit (Clinical Trials Unit).
Prestigious fellowship awarded to Paediatrics scholar
Awards & Appointments Neuroimaging Research
Dr Caroline Hartley, a Senior Postdoctoral Research Fellow in the Paediatric Neuroimaging Group, has been awarded the highly competitive Sir Henry Dale Fellowship.
Bliss to fund the study of pain relief in newborns
The Paediatric Neuroimaging research team from the Department of Paediatrics at the University of Oxford will receive a £145,987 grant from Bliss, over three years, to fund a project which seeks to improve the measurement and treatment of pain in premature babies.
"Did you know...?"
From the Town Hall, through pubs, up to shopping centres – throughout October, teams from Paediatrics have been showcasing their work all over Oxford as part of the Ideas Festival.
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© 2019 University of Oxford, Department of Paediatrics, Level 2, Children's Hospital, John Radcliffe, Headington, Oxford, OX3 9DU


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Drivers, expect delays! NDOT to close lanes on Mt. Rose Highway
NDOT announced plans for single-lane closures on a section of the Mt. Rose Highway summit for next week.
Drivers, expect delays! NDOT to close lanes on Mt. Rose Highway NDOT announced plans for single-lane closures on a section of the Mt. Rose Highway summit for next week. Check out this story on rgj.com: https://www.rgj.com/story/news/2019/11/08/ndot-says-drivers-expect-single-lane-closures-mt-rose-highway/2534240001/
Marcella Corona, Reno Gazette Journal Published 2:39 p.m. PT Nov. 8, 2019 | Updated 2:47 p.m. PT Nov. 8, 2019
An image of Mt. Rose Highway near the Mount Rose Ski Tahoe Resort that was taken on Monday, Sept. 16, 2019. (Photo: Andy Barron/RGJ)
Traffic will be reduced to single lanes along Mt. Rose Highway next week as part of a project to improve the roadway, according to the Nevada Department of Transportation.
On Friday, NDOT announced plans for single-lane closures on a section of the Mt. Rose Highway summit.
The closures are scheduled from 7 a.m. to 5 p.m. Nov. 12 to 15, NDOT said in a news release.
Traffic flaggers will indicate alternating directions of travel on the highway just below the ski area.
"Motorists should anticipate minor travel delays," NDOT said in the news release.
The roadway signage is being enhanced to help drivers focus on navigating the mountainous roadway turns.
Two switchback roadway curves were already repaved with a high friction asphalt surface. NDOT also replaced a half-mile roadside concrete barrier rail with a new barrier to keep vehicles from drifting off the highway just below Country Club Drive in Incline Village.
For more information, visit NevadaDot.com, or contact NDOT at 775-888-7000.
Marcella Corona is a breaking news reporter who covers crime and justice in Northern Nevada. Support her work by subscribing to RGJ.com right here.
Read or Share this story: https://www.rgj.com/story/news/2019/11/08/ndot-says-drivers-expect-single-lane-closures-mt-rose-highway/2534240001/


verdict it is still possible to feel some shred of pity for the criminal.
affection, but it is one which invariably appeals to the feminine nature.
vigorous woman who is the first to answer the appeal.
Manor-house friendship had grown into love and the pair were engaged.
along, during which the lovers corresponded continually, but seldom met.
him all night. His answer was reasonable and also affectionate.
bone, so from this one little letter the man stands flagrantly revealed.
strokes in a subtle self-portrait.
Miss Groves had already repented the appointment which she had given him.
its being seen, for my letters are strictly watched and even opened.
acknowledged that there had been one, but refused to give the name.
Manor-house and that no coercion was being used.
appointment with her for next morning.
said this sympathetic and most injudicious master.
'I will do so and get it off my mind,' said Vincent Parker.
time being perfectly calm and collected.
stopped and were standing face to face conversing.
girl's head, until young Parker overtook them.
'Who has been murdering Miss Groves?' asked Reuben Conway.
'I have stabbed her,' said Parker, with the utmost coolness.
'Well, then, you had best help me to carry her home,' said the labourer.
lover, with the body of the dying girl between them.
returned he found Parker holding something to her throat.
'Is she living?' he asked.
dolorous journey they met two farmers, who helped them.
'Who has done this?' asked one of them.
saw the white hair gleaming through the darkness.
'What is amiss?' he cried.
'Who did it?' shrieked the old man.
'Who are you?' he cried.
his pocket--all that was left of their miserable love story.
case. As to the policeman, he had no trouble in looking for his prisoner.
'What have you done with the knife?' asked the policeman.
upon him. They took him into the kitchen and he looked at his victim.
that day with the preformed intention of killing his former sweetheart.
certainly have appealed to the labourer who passed them in the lane.
breadth of England, was tried before Baron Martin at the next assizes.
seemed to be so entirely wanting that he hardly knew right from wrong.
from you, what steps would you take to recover it?' he asked.
consulted, and therefore he recognised the right of no man to judge him.
wicked enough he would be screened from the punishment of his wickedness.
not answerable for his actions should lose his life through his decision.
from the decision of such a case.
decision which satisfied, upon the whole, the conscience of the public.


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Q: DEBUG: During Hook procedure call , it shows vsjitdebugger.exe error My Application contains ole widgets.To handle ole widgets , I use mouse hook procedure to keep track the mouse click events.while closing the application , it provides some flickering and sometimes it shows the following errors

*

*Unable to use the location explorer.exe

*C:\Windows\System32\vsjitdebugger.exe  (Runtime error)

Regards,
karthik

A: The Solution for this problem is as follows:

*

*problem may occur in the function SetWindowsHookEx(),

*you may made threadID as NULL in the function SetWindowsHookEx().
When you replace the NULL as currentthreadID, the runtimeerror is solved.

redpajama_set_name: RedPajamaStackExchange


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中文češtinaNederlandsfrançaisქართული ენაDeutschitaliano日本語한국어portuguêsPyccĸийSrpski, СрпскиEspañolsvenskaTagalogisiZulu
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From Swedenborg's Works
A Brief Exposition of New Church Doctrine Apocalypse Revealed Arcana Coelestia Conjugial Love Divine Love and Wisdom Divine Providence Doctrine of Faith Doctrine of Life Doctrine of the Lord Doctrine of the Sacred Scripture Heaven and Hell Interaction of the Soul and Body The Last Judgement The Last Judgement (Continuation) The New Jerusalem and its Heavenly Doctrine The White Horse True Christian Religion Worlds in Space A Conversation with John Calvin An Ecclesiastical History of the New Church An Invitation to the New Church Apocalypse Explained Arcana Coelestia - Index Canons of the New Church Charity Conversations with Angels Coronis (An Appendix to True Christian Religion) De Domino De Verbo (The Word) Divine Love Divine Wisdom Five Memorable Relations Formula Concordia Index Gad and Asher God the Savior Index 1, to Angelic Wisdom Concerning Marriage Index 2, to Angelic Wisdom Concerning Marriage Index to Apocalypse Revealed Influx Justification Last Judgment (Posthumous) Letters Marriage Miracles and Signs Nine Questions On the Athanasian Creed Precepts of the Decalog Scriptural Confirmations Specimen and Sketch Spiritual Experiences Spiritual Experiences (Interim Diary) Spiritual Experiences-Word Explained Summaries in Exposition of Apocalypse The Consummation of the Age The Inner Meaning of the Prophets and Psalms The White Horse - Appendix True Christian Religion - Additions Swedenborg's Journal of Dreams The Way to a Knowledge of the Soul The Word Explained The Worship and Love of God
Translation: Elliott (1983-1999) Potts (1905-1910) New Century Edition, Cooper (2008, 2013) original (1748-1756) Tafel/Horn (1998) Hemelse Verborgenheden - Genesis, Exodus (2012-2017) Nebeske Tajne Le Boys des Guays traduction Ihunyushwe ngu Z.T. Zungu (2018) Italian (2016) Tradução Nobre (1999) Svenska Översättning (2010) Heger překlad (2017) 中文翻译
(See also other languages)
Arcana Coelestia #8857
Study this Passage
8857. It is similar with love to the Lord. When that love is dominant it is present in every aspect of his life, as when he loves his monarch or loves his parent. While he is in their presence love towards them shines from every part of his face, is heard in every syllable of his speech, and is apparent in every one of his gestures. This is how to understand the command 1 to have the Lord unceasingly before one's eyes and to love Him above all, with all one's soul and all one's heart.
1. Deuteronomy 6:5, 8
Inbound References:
Arcana Coelestia 8865, 8886, 9286, 9394, 9410, 9832
The New Jerusalem and its Heavenly Doctrine 183, 276
References from Swedenborg's drafts, indexes & diaries:
Apocalypse Explained 904
Swedenborg Research Tools
Thanks to the Swedenborg Society for the permission to use this translation.
Translation: The Heavenly City (Woofenden (1993) Chadwick (1990) Tafel (1911) Whitehead (1892) The New Jerusalem and its Heavenly Teachings original (1758) Floyd, Appelgren (2013) Neuen Jerusalem und seiner himmlische Lehre (2014) (pdf) Janssens vertaling (2006) Новый Иерусалим и его Небесное Учение Novi Jerusalim i Njegovo Nebesko Ucenje Le Boys des Guays Traduction (2014) Nuova Gerusalemme e dottrina celeste Tradução Nobre (2013) Appelgren, Manby, Boyesen (2012) Krejza překlad (2003) (2020) 匿名の翻訳 익명 번역
The New Jerusalem and its Heavenly Doctrine #183
183. FROM THE ARCANA COELESTIA.
What Regeneration is, and why it is effected.
At this day little is known concerning regeneration; the reason (n. 3761, 4136, 5398). Man is born into evils of every kind, and thence as to his proprium by birth, he is nothing but evil (n. 210, 215, 731, 874-876, 987, 1047, 2307, 2308, 3518, 3701, 3812, 8480, 8549, 8550, 8552, 10283, 10284, 10286, 10731). Man's hereditary nature is nothing but evil, see the extracts above in this doctrine (n. 83). Man's proprium is nothing but evil, see the same (n. 82). Man of himself, so far as he is under the influence of his hereditary nature and the proprium, is worse than the brute animals (n. 637, 3175). Therefore of himself he continually looks to hell (n. 694, 8480). Therefore, if man should be led by his own proprium, he could not possibly be saved (n. 10731).
Man's natural life is contrary to spiritual life (n. 3913, 3928). The good which he does from himself or from proprium, is not good, because he does it for the sake of self, and the world (n. 8480). Man's proprium must be removed so that the Lord and heaven may be able to be present (n. 1023, 1044). It is actually removed when he is regenerated by the Lord (n. 9334-9336, 9452, 9454, 9938). Therefore he must be created anew, that is, regenerated (n. 8548, 8549,9452, 9937). "Creating" man, in the Word, signifies to regenerate him (n. 16, 88, 10634).
Man is conjoined to the Lord by regeneration (n. 2004, 9338). And consociated with angels in heaven (n. 2474). He does not come into heaven, until he is in a state to be led by the Lord by means of good, which is the case when he is regenerated (n. 8516, 8539, 8722, 9139, 9832, 10367).
The external or natural man rules, and the internal man serves, in the man who is not regenerated (n. 3167, 8743). Thus the state of man's life is inverted from his birth, and must be entirely inverted again in order that he may be saved (n. 6507, 8552, 8553, 9258). The end of regeneration is, that the internal or spiritual man may rule, and the external or natural man serve (n. 911, 913). This is actually effected after man is regenerated (n. 5128, 5651, 8743). For after regeneration the love of self and the world no longer reigns, but love to the Lord and towards the neighbor, thus the Lord and not man (n. 8856, 8857). Hence it is plain that man cannot be saved unless he is regenerated (n. 5280, 8548, 8772, 10156).
Regeneration is a plane to perfect the life of man to eternity (n. 9334). The regenerate man is perfected to eternity (n. 6648, 10048). The quality of the regenerate and the unregenerate man described (n. 977, 986, 10156).
Apocalypse Explained 151, 281, 356, 585
Thanks to the Swedenborg Foundation for their permission to use this translation.
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Abdul Hadi Badi-al-Zamar, a Sufi, set off at dawn to climb a mountain. He left his trust steed, Aqil, tethered with food and water and set out as the sun peeped over the horizon.
He enjoyed the journey, following the single pilgrim path as it mounted past the Tomb of the Saint, and through the grove of beach trees, skirting the Lake of Tranquility, where he sat and ate his simple lunch, drinking from the lake's healing waters. He slept for a bit and then continued up, climbing the steps hewn into the rock-face, and stopping briefly to admire the view from the Great Cave with its wonderful frescoes of geometric designs. After reaching the top of the cliff he scrambled up the rock and stone strewn path till he reached the summit, exactly as the sun set.
He decided to spend the night on the mountain summit, meditating beneath the stars. This he did.
Abdul Hadi rose while it was stll dark, did his ablutions, and started his descent just as the sun peaked over the horizon. Again, during his descent, he stopped at various places, including the Buddhist Stupa, where he prayed briefly, the High Meadow, with its lovely mountain flowers, and once more, the Tomb of the Saint.
He reached the bottom of the mountain just at the moment the sun set.
The Sufi smiled to himself when greeted by one of his disciples. He explained that his journey up and his journey down the mountain had taken exactly the same time. The path was one, and he had never left it.
"Can you prove," he asked his disciple, "that there has to be one place, somewhere between the bottom and the top, where I was at exactly the same time of day, on the way up and the way down?"
His disciple thought for a moment, and then said, "No, it is not possible to prove that."
"Think again," said the Sufi, "it is certainly possible. It can be shown incontravertibly. What you or I cannot be sure of is where. But that it occurred there is no doubt."
The next day the disciple was very excited and said, "Yes. I can prove it."
And he could. Can you?
The proof offered by the disciple will be posted in about a week.
This problem was first posed by Arthur Koestler in his book, The Act of Creation.
For earlier problems posed by Sufi Abdul Hadi click on pictures below.


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National / Social Issues
Japanese municipalities offer services to those worried about dying alone
Seniors take part in a seminar in the city of Chiba on March 6 regarding how they should prepare to conclude their lives. | KYODO
An unmarried Kanagawa Prefecture man in his late 60s recently signed a contract with a funeral home to organize his personal affairs and hold a service for him when he dies.
The man lives in a nursing home, is single and his siblings are too old to task with his posthumous arrangements.
"I'm thinking of preparing for the conclusion of my life as much as I can," said the man from Yamato, who declined to be identified.
The man was accompanied by a Yamato official when he signed the contract in February because the municipal government oversees the funeral support business.
With the baby-boomers reaching their 70s and society rapidly aging, other municipalities are starting to offer similar services.
Many officials say seniors, even those with friends and relatives, are unable or reluctant to rely on them. "I don't want to bother anybody when the time comes," the man said.
Yamato introduced the service in April 2016, focusing on people without relatives or the means to pay for funerals, cremations and other after-life arrangements. Up to ¥206,000 is provided to cover each person's expenses, according to the city.
After the man registered, he was issued a card bearing the name of his funeral operator and the city's contact information. Because he is alone, city workers will also make regular visits to check on him.
For those concerned about how to make such arrangements, regardless of whether they have a regular income or relatives, the Yamato Municipal Government also provides information on judicial or administrative clerks who are available to help.
In January, the Chiba Municipal Government, in association with insurer Aeon Life Co., began holding workshops and consultations for residents.
The city's support center takes inquiries from residents, serves as a guarantor for those who must enter hospitals and nursing homes, prepares trusts for execution via wills, and arranges personal affairs after death.
Explaining the need for the service, a local official said caretakers often say that even though they can care of people while they're alive, they are unable to make other arrangements once they die.
After a jump in cases in which no one claimed remains cremated with public money, the Yokosuka Municipal Government, also in Kanagawa, began helping residents make funeral arrangements in April 2015.
"In many of those cases, relatives refused (to collect the ashes)," said Kazuyuki Kitami, deputy director of the Yokosuka welfare department. "For those who have savings of more than ¥100,000, we can make plans as they wish if they sign a contract prior to death."
Kitami said they field various circumstances and requests, including a widow who asked the city to have her remains placed next to her husband's.
Midori Kotani, a chief researcher at Dai-ichi Life Research Institute who is familiar with the issue, said many seniors are probably interested but afraid to make a decision yet.
"There are probably not so many people applying due to the costs, but just learning about the service offers some reassurance.
"Public welfare services in Japan end once the person dies," she said. "But it is time to consider public assistance for people (in death) as well."
Kanagawa, old age