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Development of a novel diagnostic system for a telepsychiatric application: a pilot validation study
Savita Malhotra1,
Subho Chakrabarti1,
Ruchita Shah1,
Aarzoo Gupta1,
Anurati Mehta1,
B Nithya1,
Vineet Kumar1 &
Minali Sharma1
A net-based, decision support system for diagnostic assessment and management of psychiatric disorders, developed as part of a telepsychiatry service, which aims to deliver mental health care to underserved population of remote areas in India is described. This paper presents the development and preliminary results of diagnostic validation of the application, intended for use among adult patients. The bilingual (English and Hindi) diagnostic tool consists of a core diagnostic section comprising a screening sub-module and criteria-based diagnostic sub-modules for 18 adult psychiatric disorders, and additional sections covering background information. The diagnostic tool of the application was examined among 100 consecutive consenting adult outpatients, by comparing it with detailed semi-structured clinical assessments led by a consultant psychiatrist, on accuracy of diagnoses generated, and examining the feasibility of its use.
The screening sub-module had high sensitivity and high specificity, low positive predictive values, but high negative predictive values for most disorders. For the diagnostic sub-modules, there was moderate (kappa = 0.4-0.6), to substantial agreement (kappa > 0.6) between diagnoses generated by the tool and consultants' diagnoses, for all the disorders except dysthymia. Sensitivity was high barring a few disorders. Specificity was high for all the disorders, positive predictive values were acceptable to high for most disorders, and negative predictive values were consistently high. Completion rate was 100%; average time taken was five minutes for screening alone, and 30 minutes for complete assessment with screening and criteria-based evaluation. A majority of the patients, their relatives, and interviewers were satisfied with the interview.
The preliminary results indicated that despite some limitations, the new diagnostic system was reasonably comprehensive, time-efficient and feasible, with an acceptable level of diagnostic accuracy. Hence, it appeared to be suitable for use as a telepsychiatric application.
Mental disorders are highly prevalent and equally disabling in India as in the rest of the world [1, 2], and as in other low-income countries, most people suffering from mental disorders continue to receive inadequate treatment [3]. Existing discrepancies between resources and need, urban and rural services, and primary, secondary and tertiary care, lead to what has been referred to as the 'mental health gap' [4]. Efforts are already underway in India to reduce the 'mental health gap' under the aegis of the National Mental Health Programme [5] by strengthening existing resources, developing new ones and enhancing manpower [4, 6]. However, these measures are highly resource intensive, and a long gestation period is expected before they begin to take effect. Telepsychiatry, the use of information and communication technologies to provide or support clinical psychiatric care from a distance, has been proposed as an alternative strategy [7]. Telepsychiatric programmes, which are being increasingly used in developed nations usually follow different approaches such as direct patient management though video-conferencing, consultation models, or collaborative-care models [8, 9]. However, in developing countries like India, such models are difficult to implement, because of resource and manpower constraints. Instead, a newer approach involving development of software packages with codified medical knowledge and logical decision support systems to aid assessment, diagnosis and management of psychiatric disorders could be a logical alternative [10]. With the broader aims of codifying medical knowledge, and providing an internet-based decision support system for diagnosis and treatment of psychiatric disorders, a pilot telepsychiatric project is underway at the department of psychiatry of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. The department is the nodal centre of this service, with three peripheral sites located in the adjoining hill states of north-India. Right from its onset, this telepsychiatric project has followed a different model of training and enabling non-specialist (i.e., general physicians and para-professionals) personnel at remote sites to diagnose and treat mental illnesses on their own, with minimal consultation, supervision, or direct care from the nodal centre. To suit the needs of what has been construed by the authors as 'tele-enabling' model, in contrast to the existing 'tele-consultation' models, a computerised diagnostic and treatment application had to be constructed. For this purpose, a logically linked computerised decision support system for diagnosis and management of common psychiatric disorders in adults, and in children and adolescents, has been developed as a part of this project. This internet-based application is envisaged to enable non-specialists accessing it at remote areas to independently provide care. This requires 8 to 10 hours of training over two weeks, conducted through video-conferencing by the nodal centre. The software application has two separate decision support systems one for adults, and one for children and adolescents. In each case, the diagnostic system is logically linked to the pharmacological and psychological intervention modules taking into account the diagnosis, age, and medical illnesses. All the components of the decision system have been developed based on expert knowledge and guidelines, clinical experience and expertise; and utilize mainly ICD-10 [11] criteria.
For the diagnostic part of the application, the requirement was for a brief, but a comprehensive interview, which would generate reliable diagnoses and be simple to use. Two diagnostic interviews fulfilled these requirements; the well-validated Mini-International Neuropsychiatric Interview (MINI) [12], and a comparatively newer computerized clinical assessment tool, the Global Mental Health Assessment Tool – Primary Care Version (GMHAT-PC) [13]. Both the MINI [12] and the GMHAT-PC [13, 14] take about 15 to16 minutes for each assessment, while the time taken by other structured interviews ranges from 45 to 180 minutes [12]. However, because of copyright issues, none of these brief interviews could be used. Moreover, both instruments did not include many common disorders such as delirium, dementia, adjustment, somatoform and dissociative disorders, neurasthenia or sexual dysfunctions [12, 13]. Therefore, it was decided to develop an entirely new and indigenous diagnostic tool, in keeping with the aims of the telepsychiatry project described earlier.
This paper describes the development of a new diagnostic system for this net-based application. Apart from development, this initial pilot study also focuses on the accuracy of diagnoses generated by the tool, in comparison to more detailed semi-structured clinical assessments by teams led by consultant psychiatrists. Additionally, preliminary data on feasibility of use of this new diagnostic tool is also presented.
Basic approach and format of the diagnostic tool
The new net-based diagnostic tool was designed to consist of a comprehensive psychiatric clinical interview, albeit with a more focused and systematic approach. A balance between an objective criteria-based diagnostic exercise and conducting the interview in a conversational style was considered crucial, with the aim of replicating the routine clinical interview situation, where there is a greater need (as opposed to research settings) to establish a therapeutic relationship with the patient right from the onset of assessment. Moreover, the tool was primarily intended for use by non-specialists (i.e., general physicians and para-professionals) in remote- care settings. In keeping with these objectives, a structured format in simple language, easily understood by both patients and interviewers was adopted. It was decided that the diagnostic tool should cover both common and severe mental disorders. To meet the dual objectives of a comprehensive screening and a focused evaluation, a scheme of initial screening of patients for all disorders included in the tool, followed by a detailed assessment for specific disorders was incorporated. The interview was also segregated into 'core' and 'additional' sections to reduce the time required for the entire diagnostic interview to about half an hour. Diagnoses were based primarily on ICD 10 criteria, both from the Clinical Diagnostic Guidelines [11] and the Diagnostic Criteria for Research [15]. In certain parts (e.g. the diagnosis of delirium or dementia), DSM IV [16] criteria were used.
The content and structure of the diagnostic tool
The diagnostic tool assesses for 18 disorders in adults, namely, delirium, dementia, mania (current and past), depression (current and past), dysthymia, psychosis, obsessive compulsive disorder, generalized anxiety disorder, panic disorder, phobias, reaction to severe stress and adjustment disorder, somatoform disorder, dissociative disorder, neurasthenia, sexual dysfunctions, alcohol dependence, substance dependence and mental retardation. It mainly assesses for current symptoms, except for symptoms of mood disorders, where both current and past symptoms are elicited. To avoid multiple diagnoses, it includes a diagnostic hierarchy by giving precedence to diagnostic categories appearing first in the ICD10 manuals.The diagnostic exercise follows a stepwise approach to reach the final descriptive clinical diagnosis (see Figure 1). Firstly, the identification details, socio-demographic profile, presenting complaints and precipitating events are elicited and recorded. This is followed by the 'core' diagnostic assessment, which includes initial screening for all disorders, followed by detailed criteria-based questions for specific disorders endorsed positive on screening. The screening sub-module contains a total of 18 questions pertaining to the 18 disorders, and acts as the first gateway to the entire diagnostic exercise. Depending upon the positive responses on screening, the detailed diagnostic sub-modules open in an order based on an inbuilt hierarchy. In each diagnostic sub-module, there is a second-level enquiry about the primary or typical symptoms of that disorder, which proceeds with items pertaining to the other criteria only if the specified threshold is met at the second-level enquiry. Alternatively, it skips the remaining part of that sub-module and moves to the next sub-module as indicated in the first screening. This 'core' diagnostic assessment is sufficient to generate a psychiatric diagnosis, but can be further supplemented by 'additional' sections on past, family, personal, developmental, medical and treatment history details, and physical and mental status examinations, whenever required. In addition, separate scales have been developed to assess symptom severity (on a five-point scale) and socio-occupational functioning (on a visual analogue scale) at the end of diagnostic work-up.The diagnostic algorithm for the screening and diagnostic sub-modules consists of three main components, namely the question item with its serial number; the 'rater's rule' for the rater to apply; and the 'decision rule' for computer automation (see Figure 2). Each question item is based on the official classificatory systems, but is more descriptive, uses culturally relevant idioms and examples, and is simple to comprehend. For every question item in the screening and diagnostic sub-modules, a 'rater's rule' has been framed in a 'yes/no' format. The rater's rule specifies how the interviewer should rate an item as present or absent, based on the intent of the question, the duration and persistence of symptoms, and the distress or dysfunction caused by the symptoms. Thus, it incorporates a threshold for symptoms. For example, in the sub-module for mania, the response to the question about 'feeling high or unusually happy' is considered positive only if the said behaviour 'lasts for a period of at least 4 days', as mentioned in the 'rater's rule'. There is also a provision for recording information, which is considered significant by the interviewer, but is not captured in the categorical 'yes/no' format. The third component, the 'decision rule' is an automated rule that governs the flow of the diagnostic algorithm, as it defines how this 'yes' or 'no' response will influence the diagnostic decision tree. The 'decision rules' have been built based on the diagnostic thresholds set by standardized classification systems, as well as socio-cultural norms, duration of symptoms, possibility of self-limiting symptoms, and dysfunction caused by symptoms. The 'decision rules' also incorporate hierarchical rules for skipping certain modules if a specific diagnosis is made, even though those modules are indicated by the screening (for example, if a diagnosis of schizophrenia is made, the module for anxiety disorders would not open, even if indicated by screening).
Flow of the diagnostic tool. The diagnostic exercise follows a stepwise approach to reach the final descriptive clinical diagnosis. First, the identification details, socio-demographic profile, presenting complaints and precipitating events are elicited and recorded (Sections A and B in the figure). This is followed by the 'core' diagnostic assessment (Section C in the figure), which includes initial screening for all disorders, followed by detailed criteria-based questions for specific disorders endorsed positive on screening. This 'core' diagnostic assessment is sufficient to generate a psychiatric diagnosis, but can be further supplemented by 'additional' sections on past, family, personal, developmental, medical and treatment history details (Section D), and physical and mental status examinations (Section E), whenever required. In addition, separate scales have been developed to assess symptom severity (on a five-point scale) and socio-occupational functioning (on a visual analogue scale) (Section F). At the end of the diagnpostic work up, a descriptive clinical diagnosis is generated (Section G).
Sample of the software requirement specifications to build the core diagnostic support system. The core diagnostic support system contains diagnostic algorithms for the screening and diagnostic sub-modules. These algorithms consist of three main components, namely the question item with its serial number; the 'rater's rule' for the rater to apply; and the 'decision rule' for computer automation. Each question item is based on the official classificatory systems, but is more descriptive, uses culturally relevant idioms and examples, and is simple to comprehend. For every question item in the screening and diagnostic sub-modules, a 'rater's rule' has been framed in a 'yes/no' format. The rater's rule specifies how the interviewer should rate an item as present or absent, based on the intent of the question, the duration and persistence of symptoms, and the distress or dysfunction caused by the symptoms. Thus, it incorporates a threshold for symptoms. The third component, the 'decision rule' is an automated rule that governs the flow of the diagnostic algorithm, as it defines how this 'yes' or 'no' response will influence the diagnostic decision tree. The 'decision rules' have been built based on the diagnostic thresholds set by standardized classification systems, as well as socio-cultural norms, duration of symptoms, possibility of self-limiting symptoms, and dysfunction caused by symptoms.
Examining the diagnostic accuracy and feasibility of use of the diagnostic tool
The diagnostic accuracy and feasibility of the tool was examined for the English, as well as local language (Hindi) versions of the diagnostic tool as applicable to patients, at the department of psychiatry of PGIMER, the nodal centre, after receiving approval from the 'Institution Ethics Committee' of Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. For this purpose, consecutive outpatients aged more than 18 years, who gave written informed consent, were assessed using the new diagnostic tool. Interviews with the diagnostic tool were for the most part conducted by four psychologists who had Master's level training in psychology, but had limited experience in diagnosis and assessment of patients. They were all trained by psychiatrists in the use of the diagnostic tool. Patients were randomly allocated to undertake the tool-based assessment followed by consultant's evaluation, or vice versa. Clinical assessments were undertaken in the department by team of a trainee psychiatrist and a consultant psychiatrist. These detailed semi-structured assessments also used ICD10 diagnostic criteria and generated ICD10 diagnoses. The interviewers using the new diagnostic tool were blind to the consultant's diagnosis, and the consultant psychiatrist was blind to the diagnostic tool based assessment. Demographic data, ratings on screening and diagnostic modules, diagnoses generated by the tool and the consultants' diagnoses were all recorded. Additionally, details regarding the completion rate, the total time taken, and feedback on comprehensibility of language, style of questioning and satisfaction, were also obtained from interviewers, the patients and the relatives accompanying them. The required sample size for kappa values of 0.4 to 0.6, at a power of 80% and alpha of 0.05, was estimated to be 100.
Statistical analysis was carried out using the Statistical Package for Social Sciences-version fifteen [17]. Apart from descriptive analyses, paired t-tests were conducted to compare the mean number of diagnosis generated by the two interviews. Analyses were carried out both for the broad ICD 10 diagnostic categories, as well as some individual categories belonging to mood and neurotic disorders. Sensitivity, specificity, positive and negative predictive values were computed for the screening and the diagnostic sub-modules of the tool, compared to the consultant's diagnosis. Additionally, kappa coefficients were computed to assess agreement between the diagnoses generated by the diagnostic sub-modules and the consultant's diagnosis.
Over a period of 6 months a total of 107 persons were included in the study; seven of these had to be excluded, because a clear diagnosis could not be made after the consultant's evaluation. About half of these patients (n = 54) were assessed on the diagnostic tool first, while the remaining patients underwent consultants' evaluation prior to assessment with the tool.
Demographic profile of participants
Table 1 depicts the demographic profile of the 100 patients included in the study.
Table 1 Demographic details of participants (N = 100)
Patients were middle-aged, with more men than women constituting the study sample. They were mostly educated, married, either employed or engaged in household work, and mainly came from urban or semi-urban areas. This corresponded to the usual profile of attendees at this centre.
Diagnostic profile of participants
The mean number of total diagnoses made by the diagnostic sub-modules of the tool was 1.38 (SD 0.82), and that made by the consultant's evaluation was 1.23 (SD 0.48). No significant difference was found between the mean numbers of diagnoses between the two methods of assessment. Organic disorders were diagnosed in 2% of the patients, alcohol use disorder in 4%, substance use disorders in 6%, psychoses in 18%, mood disorders (bipolar disorder, major depression, dysthymia) in 47%, neurotic, stress related and somatoform disorders in 40%, disorders of sexual functioning in 1%, and mental retardation in 5% by the diagnostic tool. No diagnosis could be reached by the tool in four patients, and consultants' diagnoses for these patients were somatoform disorder, anxiety disorder, organic mood disorder and psychosis respectively. The frequencies of diagnoses in each category made by the diagnostic tool and by the consultant's evaluation are included in Table 2.
Table 2 Frequency of diagnoses and agreement between diagnoses made by diagnostic sub-module and the clinical interview
Agreement between the diagnostic tool and consultants' diagnoses
a. Screening sub-module of the diagnostic tool
Table 3 depicts the sensitivity, specificity, positive predictive value and negative predictive values of the screening sub-module of the diagnostic tool, compared to the diagnoses obtained following the consultant's evaluation.
Table 3 Sensitivity, specificity, positive and negative predictive values of screening sub-module of the diagnostic tool
The results show that the sensitivity of screening part of the tool was high for most disorders except organic brain disorders (60%) and sexual dysfunctions (50%). This was because of the small number of patients in these categories, and the high false negative rates obtained in both these categories. The specificity of screening was also high for most of the disorders, apart from the broad category of mood disorders (48%) and the category of neurotic and stress-related disorders (28%), where it was mainly compromised by low specificity of the diagnoses of generalized anxiety, panic, phobic and stress-related disorders. In all these categories, low specificity appeared to result from the relatively low rates of true negative cases. Positive predictive values were low for almost all disorders, except mood disorder and mental retardation. This was a reflection of the high rates of false positive diagnoses in most categories. On the other hand, negative predictive values were consistently high because of the high rates of true negative cases in most categories.
b. Diagnostic sub-modules of the diagnostic tool
Table 2 depicts the Cohen's kappa values, sensitivity, specificity, and positive and negative predictive values of the diagnostic sub-modules of the tool, compared to consultants' diagnoses.
Cohen' kappa values revealed substantial (>0.6) to near perfect agreement for alcohol dependence, psychosis, mood disorders (broad category), bipolar disorder, hypomania/mania (current), unipolar and bipolar depression (current), neurotic, stress related and somatoform disorders, obsessive compulsive disorder, sexual dysfunction and mental retardation. There moderate agreement (0.4 - 0.6) for organic disorders, drug dependence, anxiety and stress-related disorders, and somatoform and dissociative disorders. Low agreement was seen for dysthymia (0.14) alone. Sensitivity of diagnoses was high, apart from dysthymia (20%), organic disorders (40%), generalized anxiety, panic, phobic, and stress-related disorders (46%), sexual dysfunctions (50%) dissociative disorders (52%) and somatoform disorders (54%). Low sensitivities were primarily due to the high rates of false negative cases. Unlike the screening section of the tool, specificity was high for all the disorders, and positive predictive values were acceptable to high for most disorders, except dysthymia (0.16) and dissociative disorders (0.47). Thus, the numbers of false positive diagnoses were reduced after applying the diagnostic sub-modules. Similar to the screening sub-module, negative predictive values were consistently, high because of the high rates of true negative cases.
c. Discordance analysis
The number of discordant cases in each diagnostic category is shown in Table 4. The maximum number of discordant cases was seen in mood disorders, and neurotic, stress -related and somatoform disorders. Most of discordance between tool-based and clinical diagnoses was accounted for by the two broad categories of unipolar and bipolar depression (current), and anxiety (generalized anxiety disorder, panic disorder, phobias) and stress-related disorders. Eight discordant cases in the category of current depression were diagnosed by consultants as having dysthymia or a neurotic disorder. Eleven out of 15 discordant cases in the category of anxiety (generalized anxiety disorder, panic disorder, phobias) and stress related disorders were diagnosed by consultants as having another neurotic and stress-related disorder or depression.
Table 4 Frequency of concordant and discordant cases in each diagnostic category
Duration of assessment using the new diagnostic tool
Details regarding the duration of assessment by the new tool are shown in Table 5. The time taken for assessment by the 'core' diagnostic tool was about 30 minutes, and that for screening alone was about five minutes.
Table 5 Results of the feasibility analysis of the diagnostic tool
Feasibility of use of the new diagnostic tool
Results regarding feasibility of use are also are depicted in Table 5.
All the participants completed the entire interview. A majority of the patients, their relatives and the persons conducting the assessment were satisfied with the interview, especially with the language used and the style of questioning, as well the extent to which the presenting complaints were addressed by the interview.
Assessing and detecting psychiatric disorders in general health care settings, particularly in developing countries like India, is a highly challenging task [18]. Several strategies including training of general health workers or physicians have been proposed [18], and tried in the National Mental Health Programme [5], but these strategies have numerous problems such as inadequate training, short-lived gains of the limited training received, lack of motivation of personnel, and lack of support by psychiatrists. It is, therefore, necessary to look for additional alternatives, which do not rely on presence of psychiatrist for every patient, and yet can deliver specialized care in the most effective manner. The net-based tool for diagnosing and treating psychiatric disorders in adults developed as part of this project is envisaged to fulfil many of these needs. The advantages of the tool are that: it is based on standardized classificatory systems; it is structured, fully automated, with an in-built logical support system for diagnosis management: it has facilities for real-time and post-interview monitoring and support, whenever required. These features not only enhance the performance of the tool, but also empower the interviewer to carry out the process of diagnosis satisfactorily.
The primary focus of the current paper was to describe the development of the tool, and present the preliminary findings regarding the performance of the tool as a screening and a diagnostic instrument, which would justify its use as a part of the telepsychiatric application. Existing validated interviews such as the MINI could not be used, mainly because of issues regarding copyright. Therefore, an entirely new diagnostic tool had to be constructed. Being a pilot and proof-of-concept study of this new diagnostic tool, certain limitations were inherent in its design. Firstly, though the sample size was adequate based on targeted kappa values, a much larger sample would eventually be required to test the diagnostic accuracy of the entire tool. The numbers involved for many diagnostic categories were small. Therefore, the agreement between diagnoses generated by the tool and consultants' diagnoses were tested for the broad categories in case of neurotic disorders, and not individual disorders. Secondly, the comparison was carried out with detailed semi-structured assessments made by a team headed by a consultant psychiatrist. Ideally, another structured interview could have been used for comparison, as it has been noted that reliability of open-form clinical interviews is comparatively low [19], though it can be improved by using diagnostic criteria [20], as is the case in our clinical setting. Other studies have also relied on consultants' diagnoses in the absence of a structured interview comparison, or even otherwise [21, 22]. Finally, at this initial stage only a pre-computerised version of the diagnostic tool could be tested. The aim was again to gather as much data and experience with what was an entirely new diagnostic interview, before going in for online activation and testing. The results of this study need to be viewed in the light of these limitations.
Screening instruments for psychiatric disorders should include commonly encountered disorders and have high sensitivity for detection of these disorders, owing to their disabling consequences [23]. The screening sub-module of the diagnostic tool fulfilled both these criteria, as it included a broad range of commonly prevalent disorders and, with certain exceptions, had a high sensitivity for detecting these disorders. Sensitivity was low for organic disorders, because some of these were labelled as 'functional' psychiatric disorders, a fallacy that has been commonly noted earlier [24]. Low sensitivity in case of sexual dysfunctions was due to the inability to detect one patient, presumably because of the sensitive nature of the subject [25]. The specificity of screening was high for most disorders as well, except for the broad category of mood disorders and neurotic and stress-related disorders, where it was mainly compromised by low specificity of the diagnoses of generalized anxiety, panic, phobic and stress-related disorders. Low specificity of screening instruments for the milder psychiatric disorders, particularly anxiety disorders, is common with other screening tools as well [26]. Positive predictive values were also low for most disorders, which indicate a high rate of false positive diagnoses. This is another problem that has been noted for psychiatric screening tools [27, 28]. However, a substantial number of patients with false positive results meet diagnostic criteria for other mental disorders, and the burden of follow-up assessments for patients with positive screens is usually not too high. Hence, it has been suggested that erring on the side of sensitivity is preferable for instruments screening for psychiatric disorders [29]. Finally, the consistently high negative predictive values indicated that the screening module was correctly identifying all those without a psychiatric disorder who would not require any further psychiatric intervention.
Although the mean number of diagnoses generated by the diagnostic sub-modules of the tool was somewhat higher than the clinical evaluation, this difference was not significant. This finding was unlike that seen with structured interviews; for example, the Composite International Diagnostic Interview-Auto (CIDI-Auto) generates a mean number of 2.53 diagnoses per patient [30]. While this may be useful in research interviews, it might present problems for routine clinical evaluation. In this regard, the inbuilt hierarchies and exclusion rules of the diagnostic tool reduced the chances of multiple diagnoses, thereby simplifying the entire process for the interviewer.
The kappa values indicated moderate (0.4-0.6) to high (>0.6) agreement between the two assessments for all disorders, except dysthymia. Moreover, sensitivity of the detailed diagnostic sub-modules was high apart from dysthymia, organic disorders, generalized anxiety, panic, phobic and stress-related disorders, sexual dysfunctions, and dissociative and somatoform disorders. Unlike the screening module, specificity was high for all the disorders and positive predictive values were acceptable to high for most disorders, except dysthymia and dissociative disorders, while negative predictive values continued to remain high for all disorders. Discordance analysis revealed that for common mental disorders including depression, dysthymia, and anxiety and stress-related disorders, a large number of cases were classified interchangeably, which might explain the comparatively low level of agreement seen with these disorders. Overall, considering the kappa values, sensitivity and the proportion of discordant diagnoses, the diagnostic tool performed relatively poorly for the minor or common mental disorders. Similarly, with other diagnostic interviews such as the NIMH-Diagnostic Interview Schedule (DIS), the CIDI, or the MINI, agreement for dysthymia, anxiety disorders and somatoform disorders has usually been found to be lower when compared to clinical diagnosis, as clinicians regarded other diagnoses as dominant, and did not diagnose anxiety disorders separately though they agreed on the presence of symptoms [12, 22, 31]. Nevertheless, these results suggested that refinement of diagnostic criteria were needed to improve this aspect of the diagnostic tool.
Finally, the feasibility analysis demonstrated that the instrument was easy to administer and was rated highly both by the interviewer and the interviewee. In the new tool a lot of emphasis has been placed on flexibility of interviewing and establishing a therapeutic relationship with the patient, without compromising on the objectivity of assessment. The feasibility analysis suggested that these features of the tool helped it recreate the clinical situation to a large extent. All this was achieved in a time of about 30 minutes, which was about a-third of that required for detailed clinical evaluations. Only the MINI [12] and the GMHAT/PC [14] take less time. Moreover, the time taken for using the screening sub-module was about five minutes, which was in keeping with the suggestion that screening time should not be more than about five minutes if an instrument is to be widely adopted [12].
Therefore, despite some methodological limitations and concerns about certain parts of the new diagnostic tool, the findings of this preliminary study suggested that it could prove suitable for use as a part of an online telepsychiatric application. Efforts are already underway to further enhance the accuracy of the online version of the diagnostic tool, to test its validity at the primary and secondary care levels with larger samples, and to validate it against other structured interviews such as the MINI.
The development of a fully structured and automated diagnostic system for adult psychiatric disorders is described. Preliminary results suggested that despite some limitations, diagnoses generated by the tool had an acceptable level of accuracy, and the tool appeared to be feasible to use. Therefore, it seemed to be suitable for use as a part of an online telepsychiatric application meant for diagnosis and management of adult psychiatric disorders.
ICD 10:
International Classification of Diseases – Tenth Revision
DSM IV:
Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition
SCID:
Structured Clinical Interview for DSM IV disorders
Mini-International Neuropsychiatric Interview
CIDI:
Composite International Diagnostic Interview
GMHAT-PC:
Global Mental Health Assessment Tool – Primary Care Version
DIS:
The NIMH-Diagnostic Interview Schedule.
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Leon AC, Portera L, Olfson M, Kathol R, Farber L, Lowell KN, Sheehan DV: Diagnostic Errors of Primary Care Screens for Depression and Panic Disorder. The Int J Psychiatr Med. 1999, 29 (1): 1-11.
Peters L, Andrews G: Procedural validity of the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in the anxiety disorders. Psychol Med. 1995, 25 (6): 1269-1280.
Wittchen HU: Reliability and Validity Studies Of The WHO Composite International Diagnostic Interview (CIDI): A Critical Review. J Psychiatr Res. 1994, 28 (I): 57-84.
The authors gratefully acknowledge the financial support received from Department of Science & Technology, Government of India, New Delhi, India' to carry out the project 'Development and Implementation of a Model Telepsychiatry Application for Delivering Mental Healthcare in Remote Areas (using a medical knowledge-based decision support system)'.
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
Savita Malhotra
, Subho Chakrabarti
, Ruchita Shah
, Aarzoo Gupta
, Anurati Mehta
, B Nithya
, Vineet Kumar
& Minali Sharma
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Correspondence to Savita Malhotra.
We have applied for patent relating to the content of the manuscript.
SM conceptualised, planned and carried out the development of the diagnostic tool, planned the study design, participated in data analysis and interpretation, and manuscript preparation. SC planned and carried out the development of the diagnostic tool, planned the study design, undertook monitoring, participated in data analysis and interpretation, and drafted the manuscript. RS participated in content designing, designing and co-ordination of the study, monitoring, data generation, data analysis and interpretation, and drafting of the manuscript. Aarzoo and AM participated in content designing, data collection, data analysis and interpretation and manuscript preparation. BN participated in content designing. VK participated in content designing, data analysis and interpretation, and drafting of the manuscript. MS participated in data collection, analysis and interpretation. All authors have read and approved the final manuscript.
Malhotra, S., Chakrabarti, S., Shah, R. et al. Development of a novel diagnostic system for a telepsychiatric application: a pilot validation study. BMC Res Notes 7, 508 (2014) doi:10.1186/1756-0500-7-508
Telepsychiatry application
Adult psychiatric disorders
Diagnostic accuracy


Point View Resort is the perfect place to relax and enjoy the beauty of the Ozarks. Tucked away on a quiet arm of the lake, each of our cabins has easy access to the lake and amenities. Whether you want to go boating, fish off the docks, play in the water, or just relax, it's all just steps away.
Located on the southeast end of Lake of the Ozarks, Point View Resort in Camdenton, MO is a cozy getaway from all the stresses of everyday life.
No matter your boating needs, we can make it happen. Bringing your own boat? Our three separate docks provide our guests with private boat slips and we can launch boats up to 22 feet at the resort. Have a bigger boat? We can help arrange local launching. Looking to rent a small fishing boat? We have 16-ft Jon Boats with 15HP and 25HP motors for daily rental. We make it easy for fishermen to find their own little hook nook in the many surrounding coves, where excessive boat traffic won't scare your catch away.
Looking for something faster? The calmer pace of the Little Niangua is perfect for tubing and wakeboarding. We work with local boat rental companies to have your ideal boat waiting for you when you arrive. The area is great for fishing, watersports, and exploring the lake by water. Everything you need is within your reach.
The lake water that surrounds the resort is clean and refreshing, as our location is upstream from the main channel. With much lighter boat traffic than more populated parts of the lake, it's easy to jump in and enjoy the water from the swimming dock. Or for the more adventurous kids (and kids at heart) you can play on the huge water trampoline. You can enjoy our two manicured sand beaches to play in the shallow water, or swim out a little farther to play in the deep water perfect for floats and other water toys.
Nothing is as relaxing as spending time outside and the lake, and we give you plenty of ways to enjoy it. Plenty of lounge chairs around the resort allow you to take in the peaceful beauty of the lake. Two small playgrounds give smaller kids some time to play away from the water.
Our new fire-pit gives you a place to gather with friends and share your fish tales. Or spend some alone time on the deck of your cabin. It's your vacation – spend it as you like.
Located on the southeast end of Lake of the Ozarks, Point View Resort in Camdenton, MO is a cozy getaway from all the stresses of everyday life. We are in a premium location for fishing, with an abundance of crappie, black bass, catfish and many other species.
Fishing from our well-maintained fishing docks will delight novice casters and challenge experienced fishermen. Our Crappie beds are maintained each year to keep the docks as stocked as possible. By boat, easily explore the surrounding coves and find your own haven on the water. The indoor, heated fishing dock (with fully maintained crappie beds) makes every day the perfect day to fish the lake!
Checkout our Fishing Habitat page for more information about our crappie beds from FishHiding.
If you want to explore the world outside our resorts at the Lake of the Ozarks, restaurants and shopping centers are just a short drive away. Explore the wonders of the Ozarks and see the amazing underground formations at the nearby Bridal Cave. Miniature golf, bumper cars and batting cages are fun family activities to enjoy if you are looking for a break from the sun and water, and they are just a quick drive from your cabin.
The Lake of the Ozarks is widely known for its boating, fishing and water-related activities, but there are so many other fun activities to enjoy during your visit at Point View Resort. There are 16 golf courses in the area that offer various levels of difficulty and beautiful views of the surrounding area. Ha Ha Tonka, a state park located nearby, has 3,600 acres of beautiful landscapes, caves and hiking trails, along with the remains of a European-style castle. Horseback riding, bird watching and hunting for turkey and deer in-season provide more adventure for you and the family.
Come experience our beautiful resort and begin to build your own memories and traditions. We are dedicated to making Point View Resort your home away from home, and will strive to make your stay with us relaxing and stress free.
© 2018 Point View Resort.


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Watch Apple's Carpool Karaoke teasers ahead of series premiere
Romain Dillet	@romaindillet / 2 years
Carpool Karaoke is growing up and becoming so much more than just segments on James Corden's Late Late Show. Apple has commissioned 16 standalone episodes, and the show is about to premiere on August 8. The company shared three different teasers this week to promote the show.
On The Late Late Show, Carpool Karaoke segments usually feature James Corden along with a music artist. The standalone series is going to be a bit different as James Corden won't appear on every show, and there will be basketball players, actresses and other famous people.
Here's a trailer showing many of the guests on the show. You can spot James Corden and LeBron James, Alicia Keys and John Legend, three of the judges on Planet of the Apps (Jessica Alba, Gwyneth Paltrow and will.i.am), Shaquille O'Neal and John Cena, etc.
And if you're a fan of The Fresh Prince of Bel-Air, another teaser shows Will Smith and James Corden singing the main theme song as they head over to a heliport. They then end up singing "I Believe I Can Fly" in a helicopter:
Finally, another montage of the various episodes was shared on The Late Late Show's official YouTube channel:
Apple originally planned to release Carpool Karaoke in March 2017. The show was delayed at the last minute. But now it looks like Carpool Karaoke is ready for prime time. If you're an Apple Music subscriber, you'll be able to watch a new episode every Tuesday in the Apple Music app.

redpajama_set_name: RedPajamaCommonCrawl


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26 Best and Worst Food Trends of 2016
A year in review of what people have been pinning, sharing, and eating—for better or for worse...
By Olivia Tarantino December 11, 2016
The past 365 days have been loaded with ups and downs. On one hand, Michael Phelps cemented his Olympic legacy with another round of gold medals, and on the other hand, we lost the company of one of the world's greatest athletes: Muhammad Ali. Just like in sports, there are also winners and losers in the food world. And that's especially the case when it comes to food trends. We've selected a collection of some of the most popular food trends of the last year and sorted them into the best and worst. Want another way to stroll down memory lane? Check out these 42 Best and Worst Health News Stories of 2016.
First… The Worst
Freakshakes
Photo courtesy of @freshmen15
Nothing is more fitting than the fact that this photo was uploaded to Instagram by a user known as "freshman 15." Regardless, it's not just freshmen who could gain weight after consuming too many of these monstrosities. Although we know cheat meals are a helpful part of a weight loss journey, one of our tips is to create a calorie buffer in order to minimize the damage of a cheat meal. The only issue in this case? You wouldn't be able to eat all day if you were looking to finish this freakshake. Keep those cheat meals to reasonable portions.
Six Spaniards came together to create this odd wine. A blend of red and white grapes from vineyards just outside of Madrid, the wine gets its blue hue from indigo, a natural dye extracted from a flower called a woad. In addition to grapes and yeast (what turns the grapes into alcohol), the winemakers also added an unspecified, non-caloric sweetener to the mix to give the drink a little extra flavor. The bottle is making its rounds through Europe before hopping across the pond into the US, but we're not all too excited about getting our hands on it.
Reviving '90s Foods
Crystal pepsi
It's not just the reprise of shows like Full House and Gilmore Girls that came back from the '90s this year. It was also products like Crystal Pepsi. We wish we could welcome it with open arms, but this soda is just plain dirty. It has the sugar equivalent of three Snickers bars and was just a play for nostalgia. Luckily, it was only sold for eight weeks this summer. Before you crack open another can, don't miss this shocking list of the 70 Most Popular Sodas—Ranked by How Toxic They Are!
Ramen Burger
Why? Why has ramen followed us from our college microwaves to our grown-up lives? Yes, it's cheap and quick, but we'd rather not eat a burger sandwiched between two blocks of deep-fried ramen that's just loaded with saturated fatty oils.
This year, the low-carb craze got a little cloudy. Made from eggs, cream cheese, cream of tartar, and sometimes a sweetener, cloud bread is a high protein, low-carb alternative to bread. While we understand the important role protein plays in helping you lose weight, bread is still one of the top sources of fiber in the American diet, so don't shy away from it. Instead, just make sure you're picking up a waistline-friendly brand like Dave's Killer Bread.
Spicy Yogurt
We had high hopes for this interesting duo (which has been explored by brands like Noosa and Chobani), especially since it was a combination of probiotic-rich yogurt and metabolism-boosting spices. However, Noosa's offerings are way too high in sugar for our liking—an astonishing 31 grams are packed into each 8-ounce container!
Rainbow Everything
Experts speculate the reason why we love rainbow foods so much is because we evolved to find out that many different colors are associated with many different vital nutrients. Unfortunately, that's usually never the case with these sweets—which range from fairy bread and cheesecakes to donuts and bagels—as they're likely dyed with artificial, coal-derived colors that have been linked to learning and concentration disorders (like ADHD) in children.
Rosé Gummie Bears
We said it once and we'll say it again: having a glass of wine can offer some health benefits. Having that glass of wine in sugary gummy bear form won't.
Aqua-what-now? Aquafaba is the liquid that canned chickpeas are soaked in. This year, we found out it's a great egg white alternative and has since appeared in vegan mayos and vegan mousses. If you're an omnivore, we wouldn't recommend dumping your egg carton just yet—egg whites are higher in protein and nutrients than aquafaba.
Everything in moderation. That adage also applies to fruit and fruit sugar. While there are countless benefits of eating fruit, "we still want to be mindful of how much fruit we're eating because it does contain sugar," explains Isabel Smith, MS, RD, CDN, founder of Isabel Smith Nutrition. The sugar in fruit can still have a blood-sugar-spiking effect if eaten in excess, and Smith recommends keeping it to a serving at a time—and generous smoothie bowls often exceed this suggestion. Smoothie bowls can be large whacks of carbs and sugar, so if you aren't adding any protein or fats to help slow digestion, you could be doing some serious damage to your insulin response.
Now… The Best
Sprouted Foods
These activated foods sprung onto the food scene promising to help those with sensitivities to high-fiber foods. Thanks to sprouting—a process where seeds are activated, their enzymes are turned on, and their hard-to-digest fibers are broken down—those who haven't been able to eat beans, nuts, or bread finally got the chance to.
Souping
2015 was the year of bone broth, and 2016 was the year of the soup cleanse. It was a tastier, warmer, and much more filling alternative to juicing thanks to the presence of satiating fiber. Want to continue the trend at home? Check out these soup recipes!
Sweet Potato Toast
This short-lived trend still earned an "Eat This!" seal of approval. It consisted of slicing a sweet potato to ¼-inch thickness, tossing it into your toaster, and then topping it with traditional toast toppers. Why'd we love this particular idea so much? It's simple: sweet potatoes are nutritional powerhouses. They're full of A and B vitamins and loads of anti-inflammatory antioxidants.
Cauliflower Pizza & Cauliflower Rice
We were all about living that low-carb lifestyle this year, and cauliflower was the veggie that took center stage. Whether it was shredded and sauteed to make a veggie fried rice or tossed with an egg for a perfect pizza crust, we just couldn't get enough of it.
Turmeric & Golden Milk
Take a step back, ginger. It's time for your golden cousin to get some time in the sun. Turmeric took over the health food scene thanks to it's anti-inflammatory, anti-cancer abilities and bright hue. It was used in countless turmeric recipes, but one of our favorites was a golden milk latte: a rich, smooth drink made with milk, turmeric, and other warming spices like ginger and black pepper. Want to try it out? Get the recipe from Heavenlynn Healthy .
Nitro Coffee
Last year cold brew, this year nitro cold brew. It's been around the independent coffee shop scene for a while now, but this year Starbucks got in on the nitro trend. For the uninitiated, the Nitro Cold Brew is coffee infused with nitrogen for a smooth, creamy texture. Because it tastes creamy without the cream, opting for this pick over a plain coffee can help you cut calories by being a little more light-handed with your heavy cream.
We were still happy to see that pulses, like chickpeas, took a front-row seat in our dishes this year. That was in part because The United Nations dubbed 2016 the International Year of Pulses. We ate more beans and got lean!
Pasta Made a Comeback
We were initially confused by this one, seeing as we eat pasta on the reg, but according to a Google Food Trends report, people have been searching for "rigatoni" and "linguine" more and more over the past couple years. And after that Italian study came out with the finding that a high pasta intake was not associated with an increased body mass index (BMI), people became more accepting of the oft-frowned-upon carb.
Spiralized Veggies
Spiralized veggies maintained their popularity throughout 2016. They made it on our list of 36 Easy Ways to Cut 50+ Calories because they not only save you hundreds of calories a week (because we all know how much you eat pasta), but they also make it easy to get in an extra serving of veggies while phasing out refined carbs.
Poké (pronounced poh-keh) originated in Hawaii in the late 1970s but recently made its way over to the mainland. It's a chopped raw fish salad, similar to ceviche but with bigger chunks of fish, that's been dressed with Asian flavors like sesame oil and soy sauce. Because it's made with pieces of fresh, sushi-grade fish teeming with anti-inflammatory omega-3 fatty acids, we give this food trend two thumbs up.
Fat is Back in Fashion
Just when you thought ponchos and choker necklaces were no longer cool, fashion brought them back in vogue. It was the same this year with fats. Once spurned for their high concentration of saturated fats, butter and coconut oil made their way back into the limelight thanks to saturated fat being absolved of its involvement in raising cholesterol and causing heart disease. While we still recommend you eat fats in moderation—they have nearly two times the amount of calories that the same volume of carbs or protein does—they can be a part of a healthy diet thanks to their ability to turn off fat genes (ironic, right?) and keep you fuller for longer.
Despite studies connecting consumption of whole milk with lower weights and risk of diabetes, cows were still crowded off the shelves by almonds, soybeans, and even peas. Why the move? Whether it's because you're vegan, sensitive to dairy, trying to lose weight, or jumping on the trend, more and more Americans are shying away from dairy products and embracing plant-based alternatives. Still roaming the dairy aisle in udder confusion? Here's our guide to the Best and Worst Milks and Milk Alternatives.
Anything In A Muffin Tin
Bite-sized foods took over the food scene this year, and it was all thanks to a kitchen gadget you likely already have: a muffin tin. This glorious gadget helped dieters with the one thing many of us struggle with on a daily basis—portion control. From egg muffins to baked oatmeal, muffin-sized meals made us feel like we were finally in charge of our food and not the other way around.
Peanuts went out of fashion faster than denim leggings. They were replaced with a myriad of pulverized spreads made from almonds to cashews. You don't see us complaining—ounce for ounce, almonds are one of the most nutritious nuts thanks to being high in magnesium, vitamin E, and protein. If you're still not sure which to pick up, check out our guide—The 16 Best Nut Butters for Weight Loss.
Courtesy of Beyond Meat
Grass-fed beef has been one of the top trends of the past few years, but now it's not just cattle who are in search of greener pastures. Whether it was because we're more environmentally conscious (as eating more meat is a burden on the earth's resources) or we've learned more about the cardioprotective benefits of a plant-based lifestyle, consumers jumped on the vegan food bandwagon this year and sought out more plant-based meat alternatives. One of the most notable this year was the release of the veggie burger that bleeds from company Beyond Meat.
Probiotic-Infused & Fermented Foods
You weren't solely limited to Greek yogurt to get your daily dose of probiotics this past year. That's because fermented foods—from sauerkraut and kimchi to dark chocolate and kefir—rose to prominence. Why their rise? Research has shown that replenishing your good gut bugs with probiotics can ward off inflammation and weight gain, so we've given this trend our stamp of approval! As you continue to reap the most benefits from these fermented foods, we recommend you stick to the natural sources of the stuff and steer clear of the enhanced products. Many of the foods with added probiotics are also full of sugar—just like these 10 Probiotic Foods You Should Never Eat.
Olivia Tarantino
Olivia Tarantino is a senior editor of Eat This, Not That!, specializing in nutrition, health, and food product coverage. Read more
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Groceries News


Air Max Trainers 2013 Buy stylish shoes with high quality.
The goal of extending work on relative polynomial time Air Max Trainers 2013 computability from computations relative to sets of natural numbers to computations relative to arbitrary functions of natural numbers is discussed. The principal techniques used to prove that the honest subrecursive classes are a lattice are then used to construct a minimal pair of polynomial degrees with subexponential complexity; that is two sets computable by Turing machines in subexponential time but not in polynomial time are Nike Air Max Tn Trainers constructed such that any set computable from both in polynomial time can be computed directly in polynomial time. We present a collection of simple but powerful techniques for enhancing the efficiency of tableau-based model generators such as Satchmo. The central ideas are to compile a clausal first order theory into a procedural Prolog program and to avoid redundant work of a naı̈ve implementation. We have compared various combinations of our techniques among each other and with theorem provers based on various calculi, using the Nike Air Force Uk Sale TPTP problem library as a benchmark. Our implementation has turned out to be the most efficient for range-restricted problems and for a class of problems we call nonnesting.


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SPIRITS 'Discontent' LP / RED EDITION
Vinyl Colour: red
Label: STATE OF MIND Records
"Discontent," the debut LP by Boston hardcore quintet Spirits (ex members of Test Of Time, No Harm Done, Beartrap, Offsides, Daytrader and more), is an unrelenting 24-minute listening experience. Musically, it is a natural evolutionary step forward following the band's self-titled 7" EP and it marks the first fully cohesive release on which Spirits has carved out a niche for their own melting-pot style of punk and hardcore with dashes of outside genres also thrown in for taste. An eloquent push in lyrical themes, ranging from deeply personal and introspective notations to observations on the current social and political climate pair effortlessly with the often urgent playing style of the instrumentation to create a truly unique release.


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Saudi Cleric Proposes Muslim-Christian-Jewish Peace Delegation to Jerusalem
The head of the Muslim World League has proposed a Muslim-Christian-Jewish interfaith delegation to visit the holy city of Jerusalem and promote peace by finding common ground between all the Abrahamic religions.
Mohammed bin Salman Chides Donald Trump For His Careless Remarks
Trump Working on "Deal of the Century" – Israel-Palestine Peace Process
Dr Mohammed bin Abdul Karim al-Issa, who is an ally of Crown Prince of Saudi Arabia – Mohammed bin Salman (MBS), told Fox News in an interview: "We should send a peace convoy that is representative of all three Abrahamic religions. They should be Muslim, Christian and Jews and they should visit all holy sites. "They should meet everyone and find common ground, and they should provide fertile ground to find solutions for peace."
This initiative is highly significant given the fact that Saudi Arabia has no formal diplomatic relations with Israel, and that much of the Arab world does not recognize Israel as a country.
Dr Muhammad bin Abdul Karim al-Issa, Secretary-General of the Muslim World League
The former Saudi justice minister added that the interfaith delegation should be "independent of politics" and "should have no political agenda. They will be more influential without a political agenda because they are independent." Such a visit "is not from Saudi Arabia and it should not represent Saudi Arabia. It comes from the Muslim world, the Christian world and the Jewish world. It has no relevance to any country whatsoever," al-Issa said.
The Muslim World League (MWL) is a non-government organization of Sunni scholars, based in Mecca, Saudi Arabia. Al-Issa has in the past spoken out strongly against Holocaust denial — prevalent in the Arab world — calling the Nazi extermination program "among the worst human atrocities ever."
Israel and Saudi Arabia have no diplomatic relations, but authorities from Tel-Aviv have frequently hinted at secret relations with Riyadh as both countries share a common fear of Iran's aggression. The rumours of covert relations have been denied by Saudi Arabian officials. However, a Saudi general visited Jerusalem in 2016 and met Israeli lawmakers, and also met with Israeli officials on several occasions in public also.
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China Is Milking India Of Millions Of Dollars In Exchange For Hydrological Data On Brahmaputra River


The Benchmade patented AXIS assist mechanism ensures the Benchmade Mini Barrage (585-2) is both a quick flick away from deployment and can lock open - and closed - securely. The lightweight G10 handle is a perfect blend of ergonomics and style and textured to provide a firm grip. The grippiness is enhanced with finger indents which position the hand perfectly.


Everybody likes to have carpet in their homes. It's comfortable on your feet and warm to step on in the winter. Sometimes keeping your carpets clean is a hassle and who knows what kind of stuff your carpets are holding. This is why it is important to clean your carpets which will in turn decrease allergies and sicknesses in your home.
Carpets are constantly being walked upon so it's not unusual that carpets contain things like soil, allergens, bacteria, pollens, and chemicals. Hearing that just makes you want to shampoo your carpets. No one wants their carpets to be dirty especially when you have babies or toddlers crawling or rolling around on the floors. You can either get professional carpet cleaning or you can clean it yourself.
There are tons of businesses that will provide carpet cleaning in Joondalup, Western Australia for your home. WHAT MESS? CLEANING SERVICES is a big name business that will clean your carpets.
Always vacuum your carpets, if you have animals vacuuming everyday will help. Vacuum high traffic areas as much as possible, the longer the dirt sit on the carpet the harder to get the stain out. Before vacuuming throw down baking soda, this will be your best friend. Not only does baking soda clean but it also lifts up and traps smells and neutralizes the carpets. Let the baking soda sit on the carpets for as long as you can the longer the better.
Always make sure that your beater bar is free of any debris and that the vacuum keeps suction. Biggest mistake that a lot of people make is when there is a spill on the rug, do not scrub it into the carpet blot it. With these small carpet cleaning tips in Joondalup, Western Australia that you can use in your daily routine, you can maintain a clean and fresh smelling carpet. For all your carpet cleaning needs in Joondalup, Western Australia call WHAT MESS? CLEANING SERVICES .


In massage therapy training, therapists have the option to choose classes focused on the power of scents and how they connect to relaxation, mental health, and emotional memory.
While people may be drawn to certain scents for their health properties (lavender comes to mind), there are others they might connect with through association. To this day, I still remember the intoxicating scent of my dad's air conditioning unit and how it smelled like dust and ice cold water. Whether or not you're someone who primarily experiences the world through your senses, you might find that infusing your environment with aromas can be very therapeutic to your overall health.
In the field of massage, aromatherapy is a useful piece in a therapist's toolkit because of how environment can influence this emotional center of the body. If a woman is carrying emotional trauma in her gut or tension in her shoulders or exhaustion in her sympathetic nervous system, both physical touch (massage therapy) and strategic scents (aromatherapy) can be powerfully beneficial to a client's healing journey. This is why people in fields such as massage therapy and essential oil distribution can form such complementary professional partnerships — they're addressing different yet equally necessary client needs. This is why I enjoyed inviting Melanie over to my home for an essential oil presentation one evening.
Run essential oils through your hair when you get out of the shower, for a natural perfume.
Leave an open bag of scented Epsom salts on your bed stand. Let either a fan or air from an open window circulate to help refresh your bedroom even more.
Put lemon slices in your garbage disposal to keep your kitchen sink smelling fresh.
Visit places outside the scope of your normal environment (pine trees in the forest, eucalyptus near the ocean, rose gardens, ethnic restaurants with spices you don't normally use).
Whether it's rose or clove or wild orange, I encourage you to find scents that awaken or calm you and see how they might positively impact your journey toward wholeness.
Bailey Gillespie is a writing instructor at William Jessup University and a freelance academic editor. She lives near Sacramento, California and loves connecting with people over health, creativity, and faith. Recently, her writing has appeared on Real Hope Rising, The Rabbit Room, and The Deeply, Co. Read more at baileygillespie.com or follow her on Facebook, Instagram, Twitter, and Goodreads.


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Wandy Peralta Makes Yankees History By Closing Out ALDS
Ex-Yankees Starter Expected to Sign Contract Worth More Than $56 Million in Free Agency
The market for Jameson Taillon is heating up in free agency, according to this MLB insider.
Max Goodman
Jameson Taillon
Jameson Taillon isn't the biggest name on the open market when it comes to starting pitchers this offseason. That doesn't mean the right-hander won't have some lucrative multi-year offers coming his way over the next few weeks.
According to Mark Feinsand of MLB.com, Taillon is expected to sign a contract worth more than the four-year, $56-million deal that fellow right-hander Jon Gray signed with the Rangers last year.
The insider added that the market for Taillon is "gaining steam" after the veteran right-hander "impressed" teams in his free-agent Zoom meetings.
Taillon is coming off one of the best seasons of his six-year career, his second campaign with the Yankees. The 31-year-old posted a 3.91 ERA over 32 starts, striking out 151 batters in 177.1 innings pitched. He won't pitch in the same tier as other free agents like Justin Verlander, Jacob deGrom and Carlos Rodón, but Taillon has shown over the last two years that he's durable and consistent in his role, holding it down in the middle or bottom of the starting rotation. If Taillon can limit the home run ball—he allowed a career-high 26 home runs in 2022—he'll be even better going forward. .
When the Yankees were eliminated from postseason contention, Taillon mentioned that he would "love" to re-sign and continue pitching in pinstripes in 2023 and beyond. It isn't hard to find a spot for Taillon in New York's staff either. The right-hander can settle back in as New York's No. 5 starter behind Gerrit Cole, Nestor Cortes, Luis Severino and Frankie Montas.
New York may shoot higher than Taillon, though, trying to sign one of those aforementioned aces. Japanese star Kodai Senga is on the Yankees' radar as well.
Wherever Taillon ends up, a contract exceeding $56 million would be a remarkable achievement. Taillon has faced unprecedented adversity in his career to this point, previously diagnosed with testicular cancer while undergoing Tommy John surgery twice.
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Follow Max Goodman on Twitter (@MaxTGoodman), be sure to bookmark Inside The Pinstripes and check back daily for news, analysis and more.
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Does it work with older Raspberry Pi models and are GPIO pins - particularly UART TX RX available?
This simply uses the HDMI port and USB port. It does not use the GPIO pins.
Does this screen work using an Xbox one?
Whilst the screen should display the Xbox One output ok (please note, the resolution is only 480p, so you may need to change the settings on the Xbox - http://support.xbox.com/en-GB/xbox-one/console/tv-resolutions) It's unlikely the touch functionality will work due to driver compatibility.


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The RAND Blog
>A Coronavirus Election? Look to the Bottom of the Ticket
Previous Blog PostFamily Matters: More of the Same in TogoNext Blog PostWake-Up Call for Russia
A Coronavirus Election? Look to the Bottom of the Ticket
(The Washington Post)
Voters wait in line to cast their ballot in the Democratic primary at a polling station in Houston, Texas, March 3, 2020
Photo by Callaghan O'Hare/Reuters
by Patrick S. Roberts
How the president responds to a disease outbreak is important, but it is only one aspect of multifaceted efforts at every level of government. Does a county have a system for prioritizing who receives virus tests and for delivering the results quickly? Will public transit be sanitized? Answering questions such as these is the real work of disease management—and it is not done by the White House.
For all the speculation about whether coronavirus will doom President Trump's reelection, voters motivated by the outbreak would do well to focus further down the ballot, on the state and local races that will determine who bears the lion's share of responsibility for the response. As the coronavirus spreads in communities, it will be mayors, county judges, and school superintendents—not federal officials—who make the tough calls about whether to declare a state of emergency or shutter public schools and other institutions.
Sometimes, those calls will even be at odds with what the White House recommends. During the 2014 Ebola crisis, for example, the governor of New Jersey, Chris Christie (R), put a health worker returning from West Africa under quarantine. Christie clashed with President Barack Obama and Centers for Disease Control and Prevention officials, who thought the lockdown would be ineffective and discourage other health workers from going to Africa to assist with the crisis. But it was Christie, not Obama, who had the jurisdiction to decide.
Today in Maryland, it is Gov. Larry Hogan (R)—not Trump—who is working with county officials to track down contacts with the three people in the state who have tested positive for COVID-19. Hogan was easily reelected in 2018 in part because Marylanders appreciated his efficient governance across party lines. The coming weeks will tell whether voters' confidence was well placed.
Having knowledgeable, competent state and local officials often matters more in how a community fares during a disaster than who occupies the Oval Office.
To the degree that the federal government does have jurisdiction in battling the coronavirus, it relies on state and local leaders to carry out its response measures. For the first time in more than 50 years, the CDC issued a federal quarantine, applied to a planeload of Americans evacuated from Wuhan, China. But federal quarantines are enforced by state officials. And once passengers disembark a plane, they are subject to the jurisdiction of the 2,800 state, local, and tribal health departments across the country who are responsible for setting quarantine rules and providing the staffing to trace viral exposure.
Having knowledgeable, competent state and local officials often matters more in how a community fares during a disaster than who occupies the Oval Office. Consider Hurricane Katrina in 2005. The federal government was heavily criticized for the inadequate response to the devastation along the Gulf Coast, but it was New Orleans Mayor Ray Nagin (D) who delayed issuing an evacuation order, let hundreds of buses available to carry New Orleans residents to safety sit idle, and saw a 15 percent desertion rate among the city's police force after the storm. And it was Louisiana Gov. Kathleen Blanco (D) who delayed the federal government's assistance by not submitting a timely formal request for help.
Katrina exposed what happens when state and local officials fail to lead and prove incapable of coordinating with one another and with federal authorities. Alarmingly, with the coronavirus, we're already seeing states, localities, and the federal government butting heads. In the Seattle area, there are signs that the virus spread undetected and caught health officials flat-footed. State and local officials are trying to ramp up testing and erect temporary housing for homeless people who may be ill while at the same time blaming the CDC for being slow to test. Pressure is mounting to permit state and local labs to run their own testing.
In Texas, Gov. Greg Abbott (R) criticized the CDC for releasing a woman from quarantine in San Antonio after she tested "weakly positive" for the virus on the third of three tests. San Antonio city officials sued the CDC and asked for more testing before people quarantined at Lackland Air Force Base are released. The mayor banned people released from Lackland from entering the city until they have undergone further testing.
Our system of government is not designed for efficiency or unilateral decisionmaking. Response to disasters—whether a hurricane or a disease—is still primarily a state and local responsibility; the federal government intervenes at the request of a state. If voters head to the polls with the coronavirus in mind, they should remember that who sits in state and local offices, and how they engage with federal authorities, may be the most important decision they have to make.
Patrick S. Roberts is a political scientist with a focus on public management and the policy process at the nonprofit, nonpartisan RAND Corporation. He is the author of "Disasters and the American State."
This commentary originally appeared on The Washington Post on March 8, 2020. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.
Patrick S. Roberts
@RamblingRoberts
Senior Political Scientist
Emergency Services and Response
Public Safety Legislation
Coronavirus Outbreak Intensifies: Q&A with RAND Experts
From SARS to 2019-Coronavirus (nCoV)
Jennifer Bouey @BoueyHuang
Global Health and Security
Kathryn E. Bouskill @kebouskill, Elta Smith


text:
Bronx Mistrial Probed After Juror Katheryne Diop Falls for Murder Convict
Sarah Fruchtnicht
The Bronx District Attorney's office has launched an investigation into the hung jury trial of since-convicted murderer, Devon Thomas, after it appears a juror fell in love with him.
Katheryne Diop, 21, has visited Thomas, 28, at Rikers Island over 30 times, The Post reported. In 2008, Diop voted him not guilty in the shooting death of a 24-year-old aspiring basketball player, Abdoul Toure. Eventually the trial ended in a hung jury in June 2012.
On April 15, a second jury found Thomas guilty of first-degree manslaughter and possession of a handgun. He was sentenced to 25 years in prison by Judge James Kindler.
"She visits him [in jail] more often than his own family … He's a very charismatic guy," a source told The Post.
Diop admitted to often visiting Thomas, but claims she truly felt that he was not guilty.
"I'm not the reason for the hung jury or the mistrial. I had no relationship with Devon before or during the trial. That's impossible. I could get in trouble for that," she said.
His mother, Aissata Diane, claims Diop fell for Thomas in court and attempted to get other jurors to acquit him.
"He tried to start a relationship with her during the first trial for his own benefit," Diane said. "She was hoping he could get off and [she could] start a relationship with him after he got out of jail."
Diop appeared in court at his second trial. Thomas blew Diop a kiss after the guilty verdict was heard.
When Diane saw Diop in court supporting Thomas she lashed out at her. "She messed everything up in the first trial. That girl should be in jail!" Diane said. "She put us through a whole new trial. It was devastating to us. We had to relive it all over again. It was like [our son] dying again."
Toure was shot dead on Halloween in 2008 during a neighborhood fight in the Highbridge section of the Bronx. He was a native of the Ivory Coast who came to the U.S. six years earlier. He was known by many in America as Terrance Taylor. At 6-foot-5, he had hoped to play basketball in America.
His sister, 23-year-old Anita Eke, said she cleaned his blood from the street after someone "shot him in the head."
"He was downstairs. He was just standing with friends," Eke told the New York Daily News on Nov. 1, 2008.
Thomas did not grant The Post an interview from prison. His attorney, Kyle Watters, said, "I can't get involved in my clients' social life. I'm just trying to get them out of jail."
Sources: NY Post, Gothamist, NY Daily News
BronxKatheryne Diop


text:
Subtropical Horticulture Research: Miami, FL
ARS Home » Southeast Area » Miami, Florida » Subtropical Horticulture Research » Research » Publications at this Location » Publication #390114
Friends of Chapman Field
Community Day 2017 at Chapman Field
Research Project: Mitigation of Invasive Pest Threats to U.S. Subtropical Agriculture
Location: Subtropical Horticulture Research
Title: Nitric oxide fumigation for control of ham mite, Tyrophagus putrescentiae (Sarcoptiformes: Acaridae)
Yang, Xiangbing
Liu, Yong Biao
SINGH, RIPPY - Former ARS Employee
PHILLIPS, THOMAS - Kansas State University
Submitted to: Journal of Economic Entomology
Citation: Yang, X., Liu, Y., Singh, R., Phillips, T.W. 2022. Nitric oxide fumigation for control of ham mite, Tyrophagus putrescentiae (Sarcoptiformes: Acaridae). Journal of Economic Entomology. 115(2):501-507. https://doi.org/10.1093/jee/toac014.
DOI: https://doi.org/10.1093/jee/toac014
Interpretive Summary: The ham mite, Tyrophagus putrescentiae (Schrank), is a common pest on stored products including cheese, dried fruits, and meats. Management of this mite historically has relied on fumigation with methyl bromide, an ozone-depleting chemical that is now strictly regulated. Recently, nitric oxide (NO) fumigation has been demonstrated to be a safe, effective alternative for control of postharvest insects and mites. Therefore, scientists from ARS and Kansas State University collaborated to evaluate efficacy of NO fumigation against different stages of the ham mite on both lab diet and ham meat. The results showed that NO fumigation was effective against all mite stages under laboratory conditions at 25°C. In general, the eggs were the most tolerant stage to NO fumigation. On lab diet, 100% mortality of eggs was observed after 48, 24, 16, and 8 h treatments at 0.5, 1.0, 1.5, and 2.0% NO concentration, respectively. Immature and adult mites were less tolerant to NO fumigation, requiring significantly less time to achieve 100% control at the same doses. Additional tests conducted on ham meat showed similar results, confirming the efficacy of NO against ham mite. This study identifies NO fumigation as an effective, more environmentally friendly alternative to methyl bromide treatments for control of mite pests in cured-ham.
Technical Abstract: The ham mite, Tyrophagus putrescentiae (Schrank), is a common pest infesting stored products such as cultured cheese, dried fruits and meats, including aged hams. Nitric oxide (NO) fumigation is a recently discovered treatment that is effective for control of postharvest insects and mites. In this study, we report the efficacy of NO fumigation at various concentrations and treatment times under laboratory conditions against different stages of T. putrescentiae on both dietary media and ham meat. Our results showed that NO fumigation was effective against all stages of T. putrescentiae with 100% control achieved at all tested concentrations at 25°C. In general, the T. putrescentiae egg was the most tolerant stage to NO fumigation. On dietary media, 48, 24, 16, and 8 h treatments were needed to achieve 100% mortality at 0.5, 1.0, 1.5, and 2.0% NO concentrations, respectively. Tyrophagus putrescentiae mobile immatures and adult stages were less tolerant to NO fumigation, with 100% mortality achieved after 16, 8, 8, and 4 h treatments at 0.5, 1.0, 1.5 and 2.0% NO concentrations, respectively. Also, the median lethal concentration (LC50) of NO on T. putrescentiae eggs was determined to be 0.86, 0.68, and 0.32% for 8, 16, and 24 h treatments. In addition, a confirmatory test conducted on ham meat showed similar efficacy. Complete control of T. putrescentiae eggs was achieved after 48 and 24 h treatments at 0.5, and 1.0% NO concentrations, respectively, and 100% control of larvae and adults was observed after 16 and 8 h at 0.5 and 1.0% NO concentrations, respectively. Our results demonstrated that NO fumigation is effective against T. putrescentiae and can be a potential alternative treatment to methyl bromide for cured-ham pest control.


This summer I came to Tuscarora to enjoy a final summer before entering the "Real World". Come December I will be finishing graduate school and be faced with the prospect of finding a normal 9-5 job, thus I decided that instead of looking for a summer internship I wanted to spend my summer somewhere exciting and adventurous, so I came to work at Tuscarora Outfitters on the Gunflint Trail. Here I expected to work hard but also to spend my time off exploring the wilderness of Northern Minnesota and the BWCA.
Two weeks ago another staffer, Andrew Yates, and I went on our first overnight BWCA trip of the summer. Neither Andrew nor I had seen much of the area around Tuscarora so we decided the goal of our trips was to "Make Tracks" and see as much of the surrounding area as we could during our day off. I would have to say that we were completely successful in our goal as in 23 short hours (12 of which we were making camp) we covered 22 portages (totaling over 1,300 rods), 21 total miles and over 20 different lakes!
We set out at 3:00 pm after work on Monday (May 31st) from Round Lake and headed to Tuscarora Lake, where we had originally planned to camp for the night. On our way we got to do the legendary Tuscarora Portage, which depending on which map you consult is anywhere from 360-425 rods (anyway you look at it, that is long and over a mile). A personal point of pride is that I carried our aluminum canoe over the entire portage! When we got on Tuscarora it was still early and we had favorable winds so we decided to keep going instead of making an early camp. The result was we were able to make it to Crooked Lake and find a suitable campsite by around 6:00 pm. In camp we enjoyed the delights of expired dehydrated foods (which we get for free from Tuscarora Outfitters as they cannot sell it to clients), a campfire, a beautiful sunset, and starry night (complete with loon calls and beaver tail slaps).
Tuesday morning (June 1st) we got up at sunrise, packed up camp, and were canoeing again by about 6:00 am. As there had been decent winds the day before we decided we wanted to get out early in order to get to Little Saganaga before any major winds camp up (Little Sag is a big lake, despite its name, and unfavorable winds would have made canoeing it very difficult). When we arrived at Little Sag the wind was just getting going for the day, but lucky for us it was mostly at our back. As the wind increased we decided that we would take a chain of smaller lakes back to Tuscarora Outfitters in the afternoon as opposed to going into other big lakes such as Gabimichigambi and Peter Lake. The result of this decision was a lot of portages! Despite our aluminum canoe though we only had one big pack and a small backpack so there was no double portaging for us.
Our final stop on our trip was on Bat Lake, where we stopped for a quick lunch at midday, before we finishing the last leg of our journey that afternoon.
Overall it was a great first trip! We managed to see a big portion of the BWCA that is right in our backyard. It is great having seen all these lakes as many of them are ones that our clients here at Tuscarora are constantly going on trips to, thus now when they ask us questions ahead of time or tell us about their trip afterwards we will be more knowledgeable about the area. Finally it is good to know that it still only mid-June and that there will be many more trips yet to come as a part of this summer adventure in the BWCA.


London, England—Tech giant Facebook Inc. is expanding its presence in London's West End, adding 60,000 square feet of space to its existing 87,000-square-foot offices in British Land Co.'s Regent's Place campus. Facebook will now occupy the building's fifth floor, floors nine through 16, as well as a ground floor events space.
Located at 338 Euston Road between Baker St. and Euston stations in central London, British Land's Regent's Place mixed-use campus incorporates 112,000 square feet of Class A office space across 17 floors. According to Property Mall, the building is home to 45 companies from various industries, as well as The Triton Building – a 26-story tower featuring 94 apartment units.
Facebook recently revealed plans to expand its offices in Menlo Park, California, with a 985,719-square-foot addition designed by Frank Gehry.


Whether you are a complete novice, keen but inexperienced, or simply fancy the challenge of bowling regularly in our fun league, LA Bowl can help to build your confidence or advise you on the league which is most appropriate to your needs.
And remember, during league or league practice play, our regular bowlers enjoy substantial discounts against our normal tariff.
Currently our league runs on a Monday night from 7pm and takes the form of doubles.


There is a reality even prior to heaven and earth; Indeed, it has no form, much less a name; Eyes fail to see it; it has no voice for ears to detect. To call it Mind or Buddha violates its nature, For it then becomes like a visionary flower in the air. It is not Mind, nor Buddha; Absolutely quiet and yet illuminating in a mysterious way, It allows itself to be perceived only by the clear-eyed.
It is Dharma, truly beyond form and sound; It is Tao, having nothing to do with words. Wishing to entice the blind, The Buddha has playfully let words escape his golden mouth; Heaven and earth are ever since filled with entangling briars. O my good worthy friends gathered here, If you desire to listen to the thunderous voice of the Dharma, Exhaust your words, empty your thoughts, For then you may come to recognize this one essence.
Basho was able to enjoy the moment with friends, each just as they were. With humor and it seems to me, affection, he was able to observe the moon, himself, and companions, with no gilding needed. Nothing I have said should be taken to mean any of us has to be more than he or she is, quite the contrary. Forgetting the self leaves only this body, this mind, this… no more, no less. I include the haiku in our introductory talk because I've been struck more and more in recent years as to how deeply self-doubt and shame run through so many of us growing up in the United States. For the practice of Zen, let me say two things succinctly: You are not alone in your doubts. At one time or another I suspect most people in the room have taken a turn thinking he or she is the worst Zen student ever. Secondly, when it is your turn, you can smile to yourself for the uncomfortable folly of it all, and bring your attention back to the breath without need to further comment or resolve. No need to worry about the truth of the feeling – there is a lot of competition. As you sit, there is no need to extinguish the thoughts that arise, abandon them instead, place your attention on the counting of your breath. It is the returning to the breath that is important, not so much the concentration. Even if you never get to 5! Don't worry about it, just return as soon as you notice you're mind has wandered. I even had months when my mind was constantly distracted for reasons I could not fathom. Persisting through it, sitting anyway, only after dull and seemingly fruitless months, could I tell something was happening all that time. Only then could I see it was like practicing a tennis serve. Your body learns with each serve even if we can't see what's going on. I will stop here today. Please, ask any questions you have about things I've said today, the practice, or anything else.
 Case 32 of the Gateless Barrier, translation by Robert Aitken.


As Wrap starts to unveil itself a number of people have queried how we are building the Wrap element. Brett Rogers worked closely with the design team and builder to simplify what is quite a complex element. Pictures tell the story best, if you look at the rotating images above you will see how simple it became.
On the facade photo you will notice on the west face (RHS) the slab edge beam at each level projects beyond the front of the building this aligns with the vertical precast spine (LHS) that is rear fixed to the front slab edge, this spine dissects the left and right hand side of the north elevation. The space in between is where the prefabricated Wrap element is inserted. This is a rectangular steel hollow section pre-painted is a highly durable gloss white, it has fixing points at each end one connecting to the slab edge the other to the spine. Access panels at the rear hide the fixing connection. Each piece is simply lifted by the crane into position, a bit like a meccano set.
Both the spine and edge beam get painted white, and with the pre finished element placed between it forms the Wrap. Thats how we made Wrap… Wrap. Simple really!


Huntingdon, PA – J.C. Blair Memorial Hospital, along with other national, state and community organizations, are leading a massive effort to highlight the importance of advance healthcare decision-making—an effort that has culminated in the formal designation of April 16 as National Healthcare Decisions Day (NHDD). As a participating organization, J.C. Blair is providing information and tools for the public to talk about their wishes with family, friends and healthcare providers, and execute written advance directives (healthcare power of attorney and living will) in accordance with Pennsylvania state laws. These resources are available at www.jcblair.org and www.nationalhealthcaredecisionsday.org.
Specifically, on Thursday, April 18, from 7:30 to 9:00 a.m., J.C. Blair's Director of Palliative Care Dr. Margaret Hallahan is hosting a continental breakfast and panel discussion with Attorney Ray Ghaner and Pastor Gene Tucker to provide different perspectives on the importance of advance healthcare planning and decision making at the J.C. Blair Education Center at 860 Bryan Street on the hospital campus. Free information about advance care planning and advance directive forms will be provided. RSVPs are appreciated by calling the hospital's community relations office at (814) 643-8548.
In addition, Dr. Hallahan and J.C. Blair Case Manager Diane Yutzy will be sharing advance healthcare planning information and advance directive forms at the Senior Expo hosted by State Representative Rich Irvin on Wednesday, April 24, from 10 am to 2 pm at the Smithfield Fire Hall.


The March/April 2019 Newsletter is up!
The 2019 Membership Lists are current as of April 18, 2019.
Board Minutes for the March 2019 meeting have been posted.
Minutes for the March 2019 meeting have been posted.
Board Meetings have been placed on the calendar. All members are welcome to attend. Just RSVP Lynn.
The proposed 2019 budget has been posted along with the final 2018 statement.