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Reduction of routine use of radiography in patients with ankle fractures leads to lower costs and has no impact on clinical outcome: an economic evaluation
P. van Gerven ORCID: orcid.org/0000-0003-0010-14961,
J. M. van Dongen2,
S. M. Rubinstein2,
M. F. Termaat1,
M. El Moumni3,
W. P. Zuidema4,
P. Krijnen1,
I. B. Schipper1 &
M. W. van Tulder2,5
on behalf of the WARRIOR study group
To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures.
We performed an economic evaluation alongside the multicentre, randomised WARRIOR trial. Participants were randomised to a reduced imaging follow-up protocol (i.e. radiographs at week 6 and 12 follow-up obtained on clinical indication) or usual care (i.e. routine radiography at weeks 6 and 12). The Olerud & Molander Ankle Score (OMAS) was used to assess ankle function and the EQ-5D-3L was used to estimate Quality-Adjusted Life Years (QALYs). Costs and resource use were assessed using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation was used for missing data, and data were analysed using seemingly unrelated regression analysis and bootstrapping.
In total, 246 patients had data available for analysis (reduced imaging = 118; usual care = 128). Fewer radiographs were obtained in the reduced imaging group (median = 4) compared with the usual-care group (median = 5). Functional outcome was comparable in both groups. The difference in QALYs was − 0.008 (95% CI:-0.06 to 0.04) and the difference in OMAS was 0.73 (95% CI:-5.29 to 6.76). Imaging costs were lower in the reduced imaging group (−€48; 95% CI:- €72 to -€25). All other cost categories did not statistically differ between the groups. The probability of the reduced imaging protocol being cost-effectiveness was 0.45 at a wiliness-to-pay of €20,000 per QALY.
Reducing the number of routine follow-up radiographs has a low probability of being cost-effective compared with usual care. Functional outcome, health-related quality of life and societal costs were comparable in both groups, whereas imaging costs were marginally lower in the reduced imaging group. Given this, adherence to a reduced imaging follow-up protocol for those with routine ankle fractures can be followed without sacrificing quality of care, and may result in reduced costs.
The trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 (www.trialregister.nl/trial/4477).
Ankle fractures are common and account for about 9% of all fractures in the UK [1]. The incidence of ankle fractures around the world is reported to lie between 71 and 187 per 100,000 persons per year and has risen over the last decade due to ageing of the population and increased participation in athletic activities [2,3,4,5]. Routine imaging during the follow-up of ankle fractures is associated with relatively high healthcare costs [6, 7]. Healthcare costs are expected to rise in coming decades [8]. This has led to an increased interest in the effectiveness of imaging in clinical decision-making [9,10,11,12]. Despite increased costs, both national and international trauma protocols dictate that routine radiographs should be obtained at regular intervals during the follow-up of patients with an ankle fracture, although there is little scientific evidence to support this position [4, 13, 14]. For both non-operatively and operatively treated patients, it is recommended that four outpatient clinic visits including radiographs, are to be conducted after a follow-up of one, two, six and twelve weeks [13]. The goal of these radiographs are to monitor the position of the fracture fragments, the position of fixation material, the alignment of the joint and the bone-healing process.
In the Netherlands, with a population of over 17 million, approximately €5 million is spent annually on radiography for patients with ankle fractures. This estimate is based on an incidence of 30,000 per annum [15], with three to four follow-up radiographs [16], at a cost of €50 per radiograph [17]. Various studies have questioned the value of routine radiographs obtained at the first outpatient clinic visit and at intermediate-to-late follow-up (i.e. after the initial 3 weeks) of operatively treated ankle fractures [18, 19]. A recent retrospective analysis, involving a cohort of 528 patients with an ankle fracture, demonstrated that as few as 1.2% (n = 11/928) of routine radiographs obtained after 3 weeks of follow-up led to a change in treatment strategy [16]. These results suggest that current imaging protocols for the follow-up of ankle fracture patients might not be cost-effective.
The aim of this study was to evaluate the cost-effectiveness of a protocol with reduced numbers of routine radiographs in the follow-up of ankle fractures, in comparison with the current usual care.
This economic evaluation was conducted alongside a multicentre, randomised controlled trial. The methods of this trial, including its sample size calculation, are described in detail elsewhere [20]. Both a cost-effectiveness and cost-utility analysis were performed from a societal perspective. The time horizon of the economic evaluation was 12 months. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines were followed in preparing this report [21, 22].
Seven hospitals in the Netherlands participated in the study, including three university hospitals and four large teaching hospitals. Patients were enrolled between July 2014 and October 2017.
Inclusion/exclusion criteria
Patients could participate in the study if they provided written informed consent, were over 18 years of age, had a fracture of the ankle (Lauge Hansen classification types Supination Adduction [SA]2, Supination External rotation [SE]2–4, Pronation External rotation [PE] 1–4 or Pronation Abduction [PA] 1–3) [23] and were able to independently complete the Dutch questionnaires. Distortions or isolated Danis-Weber type A fractures [24] were not included. Exclusion criteria were the presence of fractures to multiple extremities and pathologic or open fractures (Gustillo grades 2–3). If patients were deemed unable to comply with follow-up they were also excluded.
Patients were informed about the study both verbally and by means of an information letter. All participants had to provide written informed consent. Participants were randomised by means of computerised allocation, using an online registration and randomisation program (ProMISe; Project Manager Internet Server; https://www.msbi.nl/promise/ProMISe.aspx). Participants were assigned in a 1:1 ratio to either the intervention group or the control group. Randomisation was carried out using a stratified, randomly varying block design (each block size containing 2 to 6 allocations). The tables were internally pre-generated within the secure data management system and stratified by hospital and initial treatment strategy.
Control group – usual care
Patients randomised to the usual care group were monitored at the outpatient clinic and received routine follow-up radiographs at one, two, six and twelve weeks of follow-up. Additional follow-up moments with or without the use of radiographs could be scheduled at any time if deemed necessary by the treating physician.
Intervention group – reduced imaging
In the reduced imaging group, radiographs were routinely obtained after one and two weeks. Radiographs could be obtained later during follow-up if a specific clinical indication was present or obtained at the discretion of the treating physician. Reasons for doing so included an additional trauma to the affected ankle, a pain score of 6 or higher on a 11-point Numerical Rating Scale (NRS), a decrease in Range-Of-Motion (ROM), or neurovascular abnormalities. Motivations to obtain additional radiographs were required to be logged in the medical file. Aside from the modified imaging protocol at follow-up, all aspects of treatment and follow-up were similar for both groups.
Measurements at baseline included potential confounders [25], such as age, sex, medical history, smoking habits, alcohol intake, functional status, health-related quality of life (HR-QOL) and socioeconomic status. Follow-up questionnaires assessing the patients' clinical outcomes as well as their resource use were administered after 6, 12, 26, and 52 weeks and could be completed either online or by post. Recall periods of these questionnaires varied from 6 weeks at 6-week follow-up to 26 weeks at 52-week follow-up to cover the complete duration of follow-up.
Functional status of the affected ankle was evaluated using the Olerud and Molander Ankle Score (OMAS). This is a nine-item questionnaire assessing both pain and disability related to the affected ankle. OMAS scores were calculated for all of the measurement points separately, ranging from 0 to 100 with a score of 100 equalling no pain or disability [26]. HR-QOL was assessed using the Dutch version of the EQ-5D-3L. At baseline, participants were asked to complete the EQ-5D-3L for their health state just prior to their trauma. At all other time points, they were asked to consider their current health status. Utility scores per time point were estimated using the Dutch EQ-5D-3L tariff [27, 28]. Quality-adjusted Life Years (QALYs) per patient were estimated using linear interpolation of the utility scores for the different time points. Since the patients' utility score right after the trauma was not available (i.e. the patients' "true" baseline utility score), we assumed their utility score at baseline to be equal to that of 6 weeks of follow-up.
Cost measures
Resource use questionnaires were used to measure the patients' use of primary and secondary healthcare, medication, informal care, as well as their levels of unpaid productivity losses, absenteeism and presenteeism. Costs of the intervention (i.e. costs for the radiographs) were gathered from electronic patient records. Primary healthcare use included the patients' number of general practitioner consultations, visits to a company medical officer, physiotherapy treatments and visits to other specialised therapists. All of these visits were required to be associated with the ankle fracture. Information on the use of secondary healthcare services was gathered from electronic patient records and included admissions to hospital, nursing home or rehabilitation centre, outpatient clinic visits, all imaging other than plain radiographs (e.g. CT- or MRI-scans of the ankle) and re-operations. These services also included the initial admission right after the trauma occurred, and the primary intervention, if applicable. All healthcare costs were valued according to Dutch standard costs [29] or, if unavailable, tariffs. Medication costs were calculated as costs-per-day for each medication, which was based upon the standard dosage per day and unit prices of the Royal Dutch Society of Pharmacy [30]. Total medication costs were calculated by multiplying this cost per day with the total days of use. If the duration was not specified, we assumed patients used a certain medication during the complete recall period. Unpaid productivity losses (i.e. volunteer work, caregiving or domestic activities patients could not perform due to their trauma) and informal care (i.e. care provided by relatives, friends or volunteers) were valued at €14.13 per hour, a shadow price that is recommended by the Dutch National Health Care Institute [29]. Absenteeism was defined as the number of days of absence due to the ankle fracture. The Friction Cost Approach was used to value absenteeism, which assumes that costs are limited to the time it takes to replace an absent worker (in the Netherlands: 12 weeks) [29]. The participants' number of presenteeism days were estimated by multiplying the number of days worked (i.e. workable days – sickness absence days) by a self-reported score reflecting their productivity level when they were present at work ranging from 0 (equalling no productivity) to 10 (equalling full productivity). Days of absenteeism and presenteeism were valued using gender-specific price weights [29]. The trial's follow-up was 12 months and discounting of costs and effects was, therefore, not necessary. All costs were converted to Euros 2016 with the help of consumer price indices [31].
Analyses were performed in accordance with the intention-to-treat principle. Missing data were multiply imputed using STATA (Version 12 SE, Stata Corp, College station, TX). The imputation model included utility scores, OMAS scores, and all available cost values at baseline, 6, 12, 26 and 52 weeks as well as the baseline variables: fracture classification, BMI, ASA classification, smoking habits, alcohol intake, hospital, age, sex, randomisation result and operative- or non-operative treatment. These baseline variables were added because they were regarded as possible confounders, because they differed between groups at baseline, and/or because they were predictive of the 'missingness' of data. Five complete datasets were generated in order for the loss-of-efficiency to be lower than 5% [32]. Each dataset was analysed separately and estimates were pooled using Rubin's rules. This method takes into account both imputation variability within each dataset, as well as imputation variability between the separate datasets [32]. Seemingly unrelated regression analyses (SUR) were used to estimate total cost (ΔC) and effect differences (ΔE). The advantage of SUR is that ΔC and ΔE are modelled simultaneously so that their possible correlation can be accounted for [33]. For OMAS, the patients' 52-week follow-up scores were used as dependent variable. For total costs and QALYs, the patients' total costs and QALYs experienced during follow-up were used as dependent variable, respectively. OMAS analyses were adjusted for baseline scores and other possible confounders measured at baseline (Table 1). In contrast to the recommendation of Manca et al. [34], we decided not to adjust QALYs for baseline utility scores, as a "true" utility score was lacking in the current study. That is, the baseline utility value in this study described the patients' utility value prior to their fracture, instead of right after their fracture. The incremental cost-effectiveness ratio (ICER) was estimated by dividing the cost difference by the effect difference (ΔC/ΔE). To estimate the uncertainty around the ICER and to estimate 95% confidence intervals (95% CI) surrounding the cost differences, bias-corrected and accelerated bootstrapping was performed with 5000 replications. For all 5000 replications, the cost and effect pairs were plotted on a cost-effectiveness plane to graphically illustrate the uncertainty surrounding the ICER [35]. A summary measure of the joint uncertainty surrounding costs and effects was provided by constructing cost-effectiveness acceptability curves (CEACs). These curves give an indication of the probability that the reduced imaging protocol for ankle fractures is cost-effective for a range of willingness-to-pay values. CEACs were pooled using a combination of Rubin's rules and the incremental net monetary benefit approach. Statistical significance was assumed at p < 0.05.
Table 1 Patient characteristics by treatment allocation
Sensitivity analyses
A total of six sensitivity analyses were planned. In the first sensitivity analysis, only data of participants with complete data were used (SA1). The second sensitivity analysis (SA2) made use of the measured utility score at baseline (prior to the fracture), instead of the value derived from the utility score at 6 weeks. The third sensitivity analysis (SA3) used the Human Capital Approach to calculate productivity losses instead of the Friction Cost Approach. The Human Capital Approach assumes that productivity losses occur during the complete period of absence instead of being limited to the friction period. For the fourth sensitivity analysis (SA4), costs were assessed from a healthcare perspective. A healthcare perspective regards only costs accruing to the formal Dutch healthcare system, meaning that costs of informal care, absenteeism, presenteeism and unpaid productivity losses were disregarded. The fifth (SA5) and sixth sensitivity analysis (SA6) only included patients with either a non-operative or an operative treatment strategy, respectively.
We enrolled 312 participants in the study (Fig. 1). Six were excluded after randomisation, because an exclusion criterion was present that was not identified before randomization (Fig. 1). Of the remaining 306 participants, 156 were randomised to usual care and 150 to reduced imaging. In total, 60 patients, 28 in the usual care group (18%) and 32 in the reduced imaging group (21%) did not return any of the follow-up questionnaires and were lost to follow-up. Thus, 246 participants were included in the analysis (n = 128 usual care and n = 118 reduced imaging). Aside from a higher mean Body-Mass-Index (BMI) in the reduced imaging group, no meaningful differences were observed between groups at baseline (Table 1). Surgery was performed in 60% of participants in the usual care group (n = 77/128) and in 65% of participants in the reduced imaging group (n = 77/118). Out of a total of 1230 (246*5) baseline and follow-up questionnaires, 1096 were returned by the participants (89%).
Flowchart of participants
There was no statistically significant difference in OMAS (0.73; 95% CI:-5.3 to 6.8) and QALYs (− 0.008; 95% CI:-0.04 to 0.03) between groups. An overview of the patients' OMAS and EQ-5D-3L scores per time point can be found in Additional file 1.
Costs and use of resources
As a result of the intervention, patients randomised to the reduced imaging group had fewer radiographs taken of their ankle fracture than patients randomised to usual care, equalling a median number of radiographs of 4 (Interquartile Range [IQR] 3–5) in the reduced imaging group versus a median of 5 (IQR 4–6) in the usual care group. This resulted in a significant reduction in radiograph costs in favour of the reduced imaging group (−€48 per patient, 95% CI:-72 to − 25). All other costs, including total societal costs, were not statistically significantly different between groups (Table 2).
Table 2 Mean cost (in euros) per participant in the intervention and control group and mean cost differences between groups during follow-up
For QALYs, the intervention was dominated by the control, based on a cost difference (ΔC) of €131 and an effect difference (ΔE) of − 0.008 QALY. The ICER for functional outcome was 178, based on the same ΔC of €131 and a ΔE of 0.73 points on the OMAS (Table 3). The CE-plane for QALYs shows that the cost-effect pairs were scattered across all four quadrants of the CE-plane (Fig. 2). The CEAC in Fig. 3 indicates that if decision-makers are willing to pay €20,000 per QALY gained, the probability of reduced imaging being cost-effectiveness compared with usual care was 0.45. This probability reduced with increasing values of willingness to pay to about 0.37 at a willingness to pay of €80,000 per QALY. The CE-plane for the OMAS also shows that the cost-effect pairs were scattered across all four quadrants of the CE-plane (Fig. 4). For OMAS, the CEAC indicates that if decision-makers are not willing to pay anything per point improvement, the probability of reduced imaging being cost-effectiveness compared with usual care was 0.47. This probability increased with increasing values of willingness-to-pay to about 0.59 at a willingness to pay of €5000 per point improvement (Fig. 5).
Table 3 Differences in pooled mean costs and effects (95% Confidence intervals), incremental cost-effectiveness ratios, and the distribution of incremental cost-effect pairs around the quadrants of the cost-effectiveness planes for reduced imaging compared to usual care
Cost-effectiveness plane for QALYs, representing the results from the 5000 bootstrapped replications, and the point estimate. Higher on the Y-axis corresponds to costlier than control, more right on the X axis corresponds to more effective than control
Cost-effectiveness acceptability curve for QALYs, showing the probability of the intervention being cost effective at a certain willingness-to-pay value per QALY
Cost-effectiveness plane for OMAS, representing the results from the 5000 bootstrapped replications, and the point estimate. Higher on the Y-axis corresponds to costlier than control, more right on the X axis corresponds to more effective than control
Cost-effectiveness acceptability curve for OMAS, showing the probability of the intervention being cost effective at a certain willingness-to-pay value per point increase of the OMAS
Six sensitivity analyses were performed. Outcomes of the sensitivity analyses demonstrated many similarities with those of the main analysis (Table 3). Except for SA6, differences in QALYs were in favour of the usual care group. Cost per category for the non-operatively and operatively treated subgroup are reported separately (Additional file 2 and Additional file 3). Except for SA5, OMAS scores were higher in the reduced imaging group than in the usual care group and except for SA4 and SA5, total costs were highest in the reduced imaging group. However, all of these differences in costs and effects were not statistically significant. It is perhaps important to note that the relatively large differences in ICERs between the main analysis and some of the sensitivity analyses were due to small between-group differences in QALYs and OMAS scores.
The reduced imaging follow-up protocol resulted in a significant decrease in the number of radiographs as well as the associated cost compared to usual care. Other cost categories, including total healthcare costs and total societal costs, did not statistically differ between groups. Furthermore, no statistically significant differences were found between groups for QALYs and OMAS. This indicates that functional outcome and HR-QOL were unaffected by reducing the number of radiographs performed at 6 and 12 weeks follow-up. The probability of the reduced imaging protocol being cost-effective compared with usual care was relatively low (0.45) at a willingness-to-pay threshold of €20,000 per QALY. In the Netherlands, this is deemed an acceptable cost-per-QALY for interventions for diseases/disorders with a relatively low disease burden [36]. For OMAS, it is currently unknown how much decision-makers are willing to pay per unit of effect gained, so it is not possible to draw any firm conclusions for this outcome. Sensitivity analyses confirm these findings. Literature on the (cost-)effectiveness of omitting routine extremity radiography is scarce. This is discussed in our retrospective review [37] and has been confirmed by researchers investigating the usefulness of an additional shoulder radiograph [38]. Results from this study however were consistent with results from our study which examined the cost-effectiveness of reduced imaging in distal radius fractures [39]. In that study we also saw no difference in functional outcome, but a significant reduction in cost for radiographic imaging in the reduced-imaging group.
This economic evaluation was performed alongside a pragmatic randomised controlled trial. Therefore, our results are likely to have a high internal validity, while their external validity is improved by the pragmatic nature of the trial. Of course, this study has limitations as do all studies. First, the sample size calculation was based upon a margin of non-inferiority [40] for the OMAS, rather than a meaningful difference in societal costs or QALYs. Wide confidence intervals surrounding the aggregate and disaggregate cost differences suggest that the study was underpowered to detect a meaningful difference in cost between groups. This is common in economic evaluations as powering to detect a meaningful difference in societal costs would have required many more participants. This would have been neither feasible nor ethical. Second, the number of radiographs omitted was lower than anticipated. This was due to a high number of protocol violations in the reduced imaging group. The protocol was adhered (i.e. no routine radiograph obtained at both 6 as well as 12 weeks of follow-up) to in just 59 of 118 participants (50%) in this group. We have reported on this in more detail in an earlier report [41]. Third, self-reported questionnaires were used to query the effect, and some costs. These questionnaires had a maximum recall period of 26 weeks, which might have introduced recall bias. However, as the recall period was similar in both groups we assume that if present, this bias was similar for both groups. Fourth, 79% (195/246) of the participants had at least one missing item on at least one of the questionnaires. The number of participants with complete cost and effect data was 242 at baseline (100%), 227 at week 6 (92%), 216 at week 12 (88%), 206 at week 26 (84%), and 201 at week 52 (82%). Multiple imputation was used to deal with missing data. In an economic evaluation, multiple imputation is considered the gold-standard for dealing with missing data [32]. Moreover, a sensitivity analysis using data of complete cases showed similar results as the main analysis, i.e. no significant differences between groups for costs, OMAS and QALYs. Finally, the patients' EQ-5D-3L health status following the fracture was not assessed, but evaluated prior to the fracture and at the various follow-up measurement points. To deal with this issue, we assumed the patients' 6-week EQ-5D-3L health state to be representative for the complete period between the occurrence of the fracture and 6-week follow-up and used this value for calculating QALYs. We opted for this strategy, instead of using their pre-injury EQ-5D-3L health state, since most patients would have had a cast, or non-weightbearing mobilisation during these 6 weeks. We do not expect this to have biased our outcomes, since a sensitivity analysis using the patients' EQ-5D-3L health state before the occurrence of the fracture showed similar results as the main analysis.
Reducing the number of routine follow-up radiographs (on average one per patient) has a relatively low probability of being cost-effective compared with usual care. However, functional outcome, health-related quality of life and societal costs were comparable in both groups whereas imaging costs were lower in the reduced imaging group. In the light of these findings and the potential for further reduction of the number of routine follow-up radiographs in daily clinical ankle fracture care, we advise a reduced imaging follow-up protocol for patients with ankle fracture.
The datasets analysed in the current study can be made available by the corresponding author upon request.
CEACs:
Cost-effectiveness acceptability curves
CHEERS:
Consolidated Health Economic Evaluation Reporting Standards
HR-QOL:
Health-Related Quality Of Life
ICER:
Incremental cost-effectiveness ratio
IQR:
Inter-Quartile Range
NRS:
Numerical Rating Scale
OMAS:
Olerud&Molander Ankle Score
PA:
Pronation Abduction
Pronation External rotation
Project Manager Internet Server
QALYs:
Quality-Adjusted Life Years
Supination Adduction
SE:
Supination External rotation
SUR:
Seemingly unrelated regression analyses
95% CI:
95% confidence intervals
ΔC:
Cost difference
ΔE:
Effect difference
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Piaggio G, Elbourne DR, Pocock SJ, Evans SJ, Altman DG. Reporting of noninferiority and equivalence randomized trials: extension of the CONSORT 2010 statement. J Bone Joint Surg Am. 2020. https://doi.org/10.2106/JBJS.19.01381.
van Gerven P, Krijnen P, Zuidema WP, El Moumni M, van Tulder MW, et al. Routine radiography following the initial 2-week follow-up of ankle fracture patients does not have added value. The Warrior-TRIAL: a multicenter randomized controlled trial. J Bone Joint Surg. 2020.
This study was performed by the Warrior Study Group. It includes the authors and (in alphabetical order):
L. van Bodegom-Vos PhD, (Leiden University Medical Center [LUMC] Leiden, the Netherlands);
R.S. Breederveld MD, PhD (LUMC);
R.J. Derksen MD, PhD (Zaans Medisch Centrum, Zaandam, the Netherlands);
B. van Dijkman MD (Flevoziekenhuis, Almere, the Netherlands);
J.C. Goslings MD, PhD (Amsterdam University Medical Center [Amsterdam UMC], Amsterdam the Netherlands);
J.H. Hegeman MD, PhD (Ziekenhuis Groep Twente, Almelo, the Netherlands);
J.M. Hoogendoorn MD, PhD (Haaglanden Medical Centre [HMC], Den Haag, the Netherlands);
C. van Kuijk MD, PhD (Amsterdam UMC);
S.A.G. Meylaerts MD, PhD (HMC);
F.R. Rosendaal MD, PhD (LUMC);
N.L. Weil MD (LUMC);
K.W. Wendt MD, PhD (University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands).
This work was supported by ZonMw, The Netherlands Organization for Health Research and Development, grant number 837002403. The funding party required us to use a patient reported outcome measure (PROM) as the primary outcome. Apart from this requirement ZonMw had no involvement in trial design, data collection, interpretation and analysis or the writing of the manuscript.
Department of Traumasurgery, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, the Netherlands
P. van Gerven, M. F. Termaat, P. Krijnen & I. B. Schipper
Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences research institute, Vrije Universiteit, Amsterdam, the Netherlands
J. M. van Dongen, S. M. Rubinstein & M. W. van Tulder
Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
M. El Moumni
Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
W. P. Zuidema
Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
M. W. van Tulder
P. van Gerven
J. M. van Dongen
S. M. Rubinstein
M. F. Termaat
P. Krijnen
I. B. Schipper
L. van Bodegom-Vos
, R. S. Breederveld
, R. J. Derksen
, B. van Dijkman
, J. C. Goslings
, J. H. Hegeman
, J. M. Hoogendoorn
, C. van Kuijk
, S. A. G. Meylaerts
, F. R. Rosendaal
, N. L. Weil
& K. W. Wendt
PvG: Acquisition of data, analysis of data, interpretation of data, drafting of the primary manuscript and revising the manuscript based on co-author's comments. JMvD: Analysis and interpretation of data, revising the manuscript. SMR: Conceptualization and design of the study, revising the manuscript. MFT: Conceptualization and design of the study, revising the manuscript. MEM: Conceptualization and design of the study, revising the manuscript. WPZ: Conceptualization and design of the study, revising the manuscript. PK: Conceptualization and design of the study, interpretation of data and revising the manuscript. IBS: Conceptualization and design of the study, revising the manuscript. MWvT Conceptualization and design of the study, interpretation of data and revising the manuscript. All authors read and approved the final manuscript.
Contributions of the study group:
LvB-V: Conceptualization and design of the study.
RSB: Conceptualization and design of the study.
RJD: Conceptualization and design of the study, Acquisition of data.
BvD: Conceptualization and design of the study, Acquisition of data.
JCG: Conceptualization and design of the study.
JHH: Conceptualization and design of the study, Acquisition of data.
JMH: Conceptualization and design of the study, Acquisition of data.
CvK: Conceptualization and design of the study.
SAGM: Conceptualization and design of the study, Acquisition of data.
FRR: Conceptualization and design of the study.
NLW: Conceptualization and design of the study, Acquisition of data.
KWW: Conceptualization and design of the study.
Correspondence to P. van Gerven.
The study was approved by the Medical Ethics Committee of the Leiden University Medical Centre (Protocol number P14.086). All participants provided written informed consent before randomisation.
Outcome scores per treatment allocation per timepoint.
Mean cost (in euros) per conservatively treated participant in the intervention and control group and mean cost differences between groups during follow-up.
Mean cost (in euros) per operatively treated participant in the intervention and control group and mean cost differences between groups during follow-up.
van Gerven, P., van Dongen, J.M., Rubinstein, S.M. et al. Reduction of routine use of radiography in patients with ankle fractures leads to lower costs and has no impact on clinical outcome: an economic evaluation. BMC Health Serv Res 20, 893 (2020). https://doi.org/10.1186/s12913-020-05725-1
Cost-effectiveness analysis
Randomised controlled trial


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text:
Emily A. Haozous, PhD, RN
Premature death rates rise for some U.S. ethnic groups
UNM researcher finds greater risks for American Indians and Alaska Natives
By Keiko Ohnuma | February 06, 2017
Improvements in diagnosing and treating chronic killers like cancer and heart disease have beaten back death rates for adults under age 65 in this century – but not for all ethnic groups.
A study of U.S. mortality data by researchers at the National Cancer Institute, the UNM College of Nursing and others has found that premature death rates actually rose for whites and American Indians and Alaska Natives between 1999 and 2014, and that these disparities are growing. The increase is due largely to drug overdoses, alcohol-related deaths, and suicide, the researchers concluded, and parallels the rise in heroin and opioid use over the last two decades.
While the surprising increase in premature deaths among white Americans was widely reported last year based on Centers for Disease Control and Prevention data, the researchers also wanted to investigate health disparities among Native Americans. Lead researcher Meredith S. Shiels of the National Cancer Institute called on Emily A. Haozous, PhD, RN, a Native researcher and associate professor in the UNM College of Nursing, to help.
As reported in the Jan. 25 Lancet, the researchers looked more closely at cause-of-death data from the National Center for Health Statistics, coupled with census data for the period 1999-2014. While they expected disparities across demographic groups, they were stunned by how stark it was for Native Americans, Haozous said.
American Indians and Native Alaskans had the highest mortality across all age groups in the period 2011-2014, after the highest increases in mortality for most age groups from the period 1999-2002.
Most other ethnic groups saw premature death rates fall between those two periods, thanks to improvements in prevention and treatment of cancer, heart disease and HIV. But such declines were not seen in the Native American groups, where heart disease deaths actually increased.
Haozous, who is Fort Sill Apache and studies Native health trends, said the reasons are complicated and political, related partly to inadequate funding for the Indian Health Service – which faces a "heartbreaking" prognosis under current plans to scrap the Affordable Care Act. Three-quarters of Native Americans live in urban areas and lack adequate access to care, she said. "These numbers reflect that."
Overall, black Americans showed the greatest improvements in premature death rates, though they still die at one to five times the rate of whites in the same age group. Premature mortality has likewise fallen for Hispanics and Asian-Pacific Islanders across all age groups since 1999, thanks largely to declines in smoking and medical advances in treating chronic diseases.
But for young and middle-aged whites, as well as the Native American groups, any such improvements have been canceled out by the rise in drug overdoses, alcohol-related deaths (liver disease) and suicides. The largest increases were seen in young adults, age 25 to 30, especially women, and in regions such as West Virginia and Kentucky for whites.
"Mental health is a place where the whole population needs to address this problem," Haozous said. "I really hope this study will lead to not only more research, but action."
Increases of 2 to 5 percent per year in death rates, as seen among younger whites and Native Americans, are exceedingly rare in developed countries outside emergencies such as the AIDS epidemic, the researchers noted. In Canada, England and Wales, premature death rates declined steadily over the study period.
U.S. drug overdose deaths have more than doubled since 2000, and the United States now leads the world in per-capita use of prescription opioids.
Categories: Education, College of Nursing, Community, Research
Tags: Premature death, Ethnic disparities
Emily Haozous, PhD, RN

redpajama_set_name: RedPajamaCommonCrawl


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Kiwi lamb supply helps UK farmers – Colin Ley:
A significant drop in New Zealand lamb exports to the United Kingdom this year has been noted by Scottish farm economist Stuart Ashworth as a key factor in a recent improvement in lamb values on the British market.
"NZ data suggests that their lamb kill in the run-up to the key Easter period has been lower than last year and exports to the UK and Europe have been running significantly below last year's levels," Ashworth said during a press briefing in Edinburgh that focused on how Scotland's livestock farmers might fare over the next two years of Brexit negotiations.
While he believed it would be "pretty much business as usual" for the UK's overseas meat trade in general, he agreed British sheep prices, since the turn of the year, had been at their lowest level for four years. . .
Impressive line-up for Fonterra Dairy Woman of the Year 2017:
Three of New Zealand's emerging dairy industry leaders are finalists in the sixth annual Fonterra Dairy Woman of the Year.
They are Claire Nicholson from Bay of Plenty, Jessie Chan-Dorman from Canterbury and Jolene Germann from Southland.
Claire Nicholson (Ngāti Ruanui) is a Director of Paraninihi Ki Waitotara (PKW) and Chief Executive of Sirona Animal Health, Jessie Chan-Dorman is a Fonterra Shareholders Councillor and a Director of the Ashburton Trading Society, and Jolene Germann is an Agribusiness Consultants dairy consultant and Chair of Rural Business Network Southland.
One of them will receive the coveted Fonterra Dairy Woman of the Year title at an awards evening during the annual Dairy Women's Network conference, this year held in Queenstown, 11-12 May. . . .
Poaching reward no April Fools' joke – Grant Shimmin:
A Timaru businessman who last week offered a substantial reward in connection with the alleged poaching of rare white tahr has stressed it was not an April Fool's gag.
Neville Cunningham announced on Friday he was putting up a reward of $25,000 for information leading to a successful prosecution for the poaching of animals on a leased conservation block in the Mackenzie Basin. He asked people with information to contact him directly.
He and business partner Ray Harrington are trying to obtain resource consent for a conservation attraction, where visitors will be able to photograph New Zealand game animals, on the 100-hectare Twizel block. . .
Pieces of Clydesdale history go under auction hammer in Pirongia – Cailtin Morrby:
It will be an emotional moment for Nick and Jill van der Sande when the auction hammer falls on their original DB Clydesdale wagon.
A selection of heavy and light horse wagons, carriages and gigs will be up for auction at Pirongia Clydesdales at 10.30am on Saturday.
The van der Sande family has owned the Waikato attraction since 1999 and are ready to take a step back. . .
Dozens of Wisconsin farmers lose their milk contracts – Anna-Lisa Laca:
Imagine walking to the mailbox on a Monday only to find a note from your processor that in one month they will no longer be picking up your milk. That's what happened to several Grasslands producers in Southern Wisconsin this week.
Grasslands handles the majority of cream sold in Wisconsin. The generic, unsigned letter producers received cited issues selling product to Canada as the reason for their decision to cut ties with some of their producer suppliers, but some producers aren't buying it. For the approximately 75 producers reportedly being dropped, distance from the milk plant appears to be a factor in determining to kill their contracts.
At press time, Grasslands had not responded to a request for comments. . .
Primary sector exports continue to grow:
Primary Industries Minister Nathan Guy is welcoming new figures forecasting that primary sector exports will reach $37.5 billion for the year ending June 2017, up $0.8 billion from the previous December forecast.
"This is the first time the Ministry for Primary Industries has produced a quarterly update of its Situation Outlook for Primary Industries (SOPI) which will give us a more accurate picture during the year," says Mr Guy.
"Next year overall primary sector exports are expected to grow by 9.7% to $41 billion. It shows we have a strong and diversified primary sector with sectors like forestry and horticulture continuing to do well. It's also pleasing to see dairy on the rebound after a tough few seasons. . .
A Man for All Seasons:
Allan Fong, the Pukekohoe market gardener and face of The Fresh Grower, who's introduced New Zealanders to an exciting menu of versatile and flavourful vegetables, has been recognised as an outstanding leader and innovator winning a prestigious Australasian agribusiness award for all-round excellence.
"Our seasonal selections reinvent familiar veges but with a fresh take and grown to fit the current generation's values, lifestyles and tastes for natural, convenient, whole foods that are safe and delicious to eat," says Allan, who runs The Fresh Grower with brother Colin. "We take what are niche or exotic products like baby cos and fancy lettuces or slender broccoli stems and make them readily accessible, mainstream lines that add variety and versatility to every day meals." . .
If at first you don't succeed, keep trying until you're really screwed.
Dairy farm with options placed on the market for sale:
An easy-to-manage dairy farm near the Waikato township of Pipiroa has been placed on the market for sale.
The 59 hectare flat and fertile property is made up of 14 individual land titles of varying sizes. The farm milks 144 fresian and fresian-cross cows – producing 52,101 kilograms of milk solids last season with a contract to Open Country Dairy – and is located at 1460 State highway 25, Pipiroa beside the banks of the Piako River.
The property's 47 paddocks are separated with a mix of one and two-wire electric fencing – with a loop race ensuring ease of both stock and farm machinery movement across the land. The farm water source is from a quality council-supplied water line. Bought-in feed has been up to 150 bales of silage over the past two summers to supplement the chicory grown on-site. . .
Beef + Lamb New Zealand resolutions pass:
Farmers have supported the three resolutions made at the Beef + Lamb New Zealand Annual Meeting on 30 March 2017.
They related to changes to the Beef + Lamb New Zealand Constitution, changing the directors' fees pool and appointing an auditor.
The official results from Electionz.com who conducted the vote on behalf of Beef + Lamb New Zealand are:- . .
Vodafone, Spark and 2degrees submit joint proposal to enhance broadband and mobile services for rural communities:
Vodafone, Spark and 2degrees today announced a joint proposal to improve rural broadband and mobile infrastructure. The three telecommunications providers have made a submission to the Government for the delivery of high speed broadband and mobile infrastructure using the Rural Broadband Initiative Extension (RBI2) and Mobile Black Spot Fund.
If successful, the bid would see Vodafone, Spark and 2degrees invest hundreds of millions of dollars over the life of the project, including a capital contribution of $75m to establish the infrastructure. The investment package also includes the contribution of spectrum, ongoing operating expenditure and other resources required to deliver and run this significant infrastructure deployment programme. This more than matches the Government's own contribution of $150m, via the Telecommunications Development Levy (TDL). . .
1 Comment	| business, Farming, food, rural	| Tagged: 2degrees, Allan Fong, Beef + Lamb NZ (B+LNZ), Claire Nicholson, Colin Fong, essie Chan-Dorman, Fonterra Dairy Woman of the Year, Grant Shimmin, Grasslands, Jill van der Sande, Jolene Germann, Mobile Black Spot Fund, Nathan Guy, Neville Cunningham, Nick van der Sande, Pirongia Clydesdales, Ray Harrington, Rural Broadband Initiative Extension (RBI2), Spark, Stuart Ashworth, The Fresh Grower, Vodafone	| Permalink
100 years 100 horses unites community:
The tale behind this Saturday's 20km trek by 100 horses and riders to honour their Anzac war dead has galvanised rural communities around Waikari, north Canterbury, even after the worst drought for 60 years.
On Anzac Day, a spectacular remembrance called '100 Years, 100 Horses', assisted by a Fonterra Grass Roots Fund donation, will see 100 riders in formation – many of them dressed in replica gear from World War I. They will pay tribute, not just to the fallen, but to the community spirit behind the Canterbury Mounted Rifles.
Fonterra's Grass Roots Fund was touched by the story of the Rifles, part of the New Zealand Mounted Rifle Brigade which left Lyttelton in 1914 for the conflict in Turkey with just under 2000 men and over 2000 horses. The north Canterbury townships of the Hurunui district – Waikari, Hurunui, Mason Flats, Peaks and Hawarden – provided 187 of the riders, 42 of whom did not return. . .
Landowners ease path to Tinui Cross, NZ's first Anzac memorial – Gerard Hutching:
Farmers and landowners in the Tinui district of the Wairarapa have been "superb" over the creation of a walkway across their land to the historic Tinui Anzac Cross.
The first Anzac memorial built in New Zealand, the cross was built in 1916 on top of Mount Maunsell, or Tinui Taipo as it is known locally.
It has long been a tradition for locals to walk the three kilometres from the Tinui cemetery to the cross on Anzac Day, but in recent years numbers have grown.
Chairman of the Tinui Parish Anzac Trust, Alan Emerson, said the Trust had wanted to establish informal access to the cross for a number of years, and a route through Tinui Forest Park and a neighbouring farm belonging to Mike and Lesley Hodgins proved most suitable. . . .
Dealing weeds a crushing blow – Time Cronshaw:
Frustrated by weeds infiltrating his crops Aussie farmer Ray Harrington borrowed coal mining technology to come up with an invention turning heads internationally, writes Tim Cronshaw.
Crushing was the final C option that farmer-inventor Ray Harrington turned to for eliminating persistent weeds on his Western Australia farm.
"I knew we would have to do something different to stave off the impending (herbicide) resistance and knew what was coming. That is why I decided to build in my mind what I dubbed as as the Big C project. We knew the chaff (coming from the header) when we harvested crops contained 98 per cent of the weed seeds and I had to catch the chaff, cart it, cook it, crush it or cremate it and that was the project in my head." . . .
Bees show taste for toxic pesticides – study:
A New Zealand bee scientist says new international research that shows bees may be getting hooked on some types of pesticides, only paints part of a wider picture.
A study published in the science journal Nature this week shows bees prefer food laced with neonicotinoids in lab tests undertaken at Newcastle University.
Neonicotinoids are long-lasting insecticides which are primarily used to coat the seeds of plants, making them toxic to all insects when they grow.
There is international debate on whether bees are affected by them. . .
Horticulture production exceeds $7 billion:
Plant & Food Research is a New Zealand-based science company providing research and development that adds value to fruit, vegetable, crop and food products.
New Zealand's horticultural production has exceeded $7 billion for the first time, according to the latest edition of the industry statistics publication Fresh Facts. . .
Leave a Comment »	| Anzac Day, business, Farming, food, rural	| Tagged: Alan Emerson, Canterbury Mounted Rifles, Fonterra Grass Roots Fund, Mount Maunsell, Ray Harrington, Tim Cronshaw, Tinui Parish Anzac Trust, Tinui Taipo	| Permalink


A Letter To My Fiancé!
You might dismiss me for being old fashioned. Oh! Well so be it! There is something super romantic about being like an old gran knitting warm jumpers, making bread pudding and? Writing! That's right! Writing long-ish letters just to ask how someone may be doing and that all was well at her's. Well you might think in this age of machines who actually has the time and patience to sit and write love stories or even relate something like that? Perhaps, not many of us.
Well I do, I think it is just so romantic. This whole idea of sitting and taking time out and make that little extra effort to make the most heartfelt feelings take the shape of very beautiful little pearls of words may be sentences that touch your heart and soul.
Quite honestly, I am a little nervous excited. Anxious about everything. Every little thing feels so different and so good, it is just surreal. Change that is going to take place is gonna be massive. Everything is gonna be all new. I have no clue just as yet good or bad. I hope all good just worried how things might turn up for me. Things that I may or may not be expecting. The funny feeling is only increasing with every passing day.
So, I thought maybe now is the time to get all my curiosities satisfied. I want to convey all my thoughts and gather as clear a picture as I possibly can.
1- Career and home! How are we managing that?
Currently, both of us have too much on our respective plates and Iam sure work will only get more and more exhaustive. You reckon we will be able to manage alright? Juggling between the two. I love you with the bottom of my heart but my career comes first. Iam once bitten twice shy so I just want to be sure my new family does not have any reservation about it.
2- Finances- We two are one!
I want us to function as a unit. We both earn but spend as one. We are family now and not separate from each other. I understand how you love me and how you will look for silliest of reasons from keeping me to spend. But hey! Remember that is not cute. I want you to know we two are one.
I have some horrendous confession to make my love. I love you heartedly and would love to be able to dish out something that I can lovingly cook for you. Tell you what though, Iam terrible I know not how to cook. Little bit of juggling will be needed. Iam still learning. Until then please bear with me lovely we might have to do with takeaways and may be will try my hand at roasts or nice somethings at the weekend when i have time to explore kitchen and recipes.
4- Faith- I hope it never leaves us!
I know in the future there will be times when we will have arguments or when there could be misunderstandings, but I do wish and pray that the faith we have in each other never leaves us. I might even get too difficult to deal with and you may have completely different opinions about me then, but I want you to know I love you and I will try my bestest. There could circumstances that might create barriers between us. I just hope that we never stop believing in each other and in the love that we have for one another.
Wonder what the future holds for us. How easy or how difficult times our relationship will have to witness. I just hope we swivel through such times beautifully and sail through the toughest. No room for pretension at all honey. I never will I promise and I expect the same from you too. I hope that both of us will always try to keep everything real, just as it is. Be it the positive things or negative most upseting bits. Being together and facing the reality as one will be better than living with the things that aren't real at all. Sham doesn't work. Does it?
Pretty much it. These were certain things I wanted to tell you the moment you took my hand in your's promising to spend life together with me. I have such soaring dreams for us, bright hopes and wishes that come true for us.
I hope we never forget the way destiny worked to have us in each other's arms. I hope the love that we have now, never fades away. Like the present, I hope that I never stop writing for you. I wish to continue writing more and more for you each day and all of it dedicated to you my love. Like the present, I hope you continue surprising me with mouth watering delicacies every now and again. How I love to stargaze with you, would love to do that more often and read our favorite books on every Sunday afternoon, together. I hope we go for long walks and stop for tea at the same stall near the beach. I wish we explore every part of the world and visit our favorite places over and over again. I wish we have the best of days spent together and life continues like this forever. I want to grow old spending time with you just as Iam now.
I hope we continue going on dates even when we have grey hair. As the number of years pass, I hope that our love only grows and shines brighter than ever. No, I don't hope for no arguments, but I do hope that those only add fizz to the love that we already have. Unlike others, I hope that we do not allow stupid things to ruin this special something that we have.
Maybe not like a fairytale, but certainly not far off. I love you.
I hope to conquer the world with our love.
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Agrotis liouvillei is een vlinder uit de familie van de uilen (Noctuidae). De wetenschappelijke naam van de soort is voor het eerst geldig gepubliceerd in 1932 door Le Cerf.

liouvillei

redpajama_set_name: RedPajamaWikipedia


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Removal of Aqueous Thiocyanate Anions by Titanium Dioxide Nanoparticles
Mehran Zargaran 1, 2
Behrooz Zargar 3
Saadat Rastegar Zadeh 3
Rashin Andayesh 1, 2
1 Department of Chemistry, Science and Research Branch, Islamic Azad University, Ahvaz, Iran
2 Department of Chemistry, Islamic Azad University of Ahvaz, Ahvaz, Iran
3 Depatment of Chemistry, Faculty of science, Shahid Chamran University, Ahvaz, Iran
Dissolved Thiocyanate in drinking water is a source of global health concern. The purpose of the present study was to remove aqueous Thiocyanate anions by using the titanium dioxide nanoparticles (TiO2 NPs). Titanium dioxide is inexpensive and non-toxic, making it an attractive choice for drinking water purification. Thiocyanate was adsorbed by the surface of nanoparticles into Fe-SCN complex and a filter was used for removing the nanoparticles. The effect of different parameters such as pH, buffer, time of stirring, the number of nanoparticles, concentration of the aqueous iron, and concentration of the electrolyte and its optimal amounts were investigated. Removal of the aqueous SCN- showed the best performance at the pH of 9, 0.5 mL of buffer, stirring for 15 min, and 0.5 g of TiO2. It was analyzed by means of spectrophotometry at ƛ=456.8 nm. Langmuir adsorption isotherm and Freundlich adsorption isotherm explained the best correlation between the Thiocyanate adsorption and equilibrium data. Langmuir adsorption isotherm showed more adaptability and the its sorption capacity was 11.6 mg/g-1 for nanoparticles. This method was tested for removing Thiocyanate from some real samples including tape water, Karoon River water, and water from petrochemical wastewater. Majority of the TiO2 NPs revealed an acceptable sorption capacity and reuse-ability in Thiocyanate anions removal in water solution.
Thiocyanate
Titanium Dioxide Nanoparticles
Fe-SCN complex
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Revise Date: 24 January 2020
Accept Date: 05 February 2020
Zargaran, M., Zargar, B., Rastegar Zadeh, S., & Andayesh, R. (2020). Removal of Aqueous Thiocyanate Anions by Titanium Dioxide Nanoparticles. Advanced Journal of Chemistry-Section A, 3(Special Issue), 551-568. doi: 10.22034/ajca.2020.102701
Mehran Zargaran; Behrooz Zargar; Saadat Rastegar Zadeh; Rashin Andayesh. "Removal of Aqueous Thiocyanate Anions by Titanium Dioxide Nanoparticles". Advanced Journal of Chemistry-Section A, 3, Special Issue, 2020, 551-568. doi: 10.22034/ajca.2020.102701
Zargaran, M., Zargar, B., Rastegar Zadeh, S., Andayesh, R. (2020). 'Removal of Aqueous Thiocyanate Anions by Titanium Dioxide Nanoparticles', Advanced Journal of Chemistry-Section A, 3(Special Issue), pp. 551-568. doi: 10.22034/ajca.2020.102701
Zargaran, M., Zargar, B., Rastegar Zadeh, S., Andayesh, R. Removal of Aqueous Thiocyanate Anions by Titanium Dioxide Nanoparticles. Advanced Journal of Chemistry-Section A, 2020; 3(Special Issue): 551-568. doi: 10.22034/ajca.2020.102701


text:
		<canvas id="pieVote"/>

				<?php if(@$proposal["status"] == "tovote" && $auth){ ?>
					 <?php echo Yii::t("cooperation", "VOTE NOW"); ?>
				<?php }else if(@$proposal["status"] != "tovote"){ ?>
					 <?php echo Yii::t("cooperation", "RESULTS"); ?>
				<?php }else if(!$auth){ ?>
					 <?php echo Yii::t("cooperation", "You must be member or contributor to vote"); ?>
				<?php } ?>

 	<?php
 		$voteRes = Proposal::getAllVoteRes($proposal);
 		$totalVotant = Proposal::getTotalVoters($proposal);
 		foreach ($voteRes as $key => $value) {
 			$identities = "";
 			if(@$proposal["voteAnonymous"] && @$proposal["voteAnonymous"] == "false"){
	 			$nbVotant=0;
	 			if(@$proposal["votes"][$key])
	 			foreach ($proposal["votes"][$key] as $idVotant) { $nbVotant++;
		 			if($nbVotant<50){
			 			$votant = Element::getByTypeAndId("citoyens", $idVotant);
			 			$identities .= $identities!="" ? ", " : "";
			 			$identities .= $votant["username"];
			 		}else if($nbVotant==50){
			 			$identities .= "...";
			 		}
		 		}
		 	}else{ $identities = Yii::t("cooperation", "votes are anonymous"); }

		 	$tooltipsVoteCantChange = "";
		 	if($hasVote && @$proposal["voteCanChange"] == "false")
		 		$tooltipsVoteCantChange = Yii::t("cooperation", "You can not change your vote");
 	?>

				<?php if($key == $hasVote){ ?>

					<i class="fa fa-user-circle pull-right tooltips" style="margin-top:8px;"
						data-original-title="<?php echo Yii::t("cooperation", "You did vote"); ?> <?php echo Yii::t("cooperation", $hasVote); ?>"
						data-placement="right">
				<?php } ?>

				<?php if(@$proposal["status"] == "tovote" && $auth && (!$hasVote || @$proposal["voteCanChange"] == "true")){ ?>
					<button class="btn btn-send-vote btn-link btn-sm bg-<?php echo $value["bg-color"]; ?> tooltips"
							data-original-title="cliquer pour voter" data-placement="right"
							data-vote-value="<?php echo $value["voteValue"]; ?>"><?php echo Yii::t("cooperation", $key); ?>
					</button>
				<?php }else{ ?>
					<label class="col-lg-12 col-md-12 col-sm-12 badge padding-10 bg-<?php echo $value["bg-color"]; ?> tooltips"
						   data-original-title="<?php echo $tooltipsVoteCantChange; ?>" data-placement="right">
						<?php echo Yii::t("cooperation", $key); ?>

				<?php } ?>

			<div class="col-lg-2 col-md-2 col-sm-2 text-center pull-left margin-top-5 tooltips"
						data-original-title="<?php echo $value["votant"]; ?> <?php echo Yii::t("cooperation", "voters"); ?>" data-placement="right">
				<?php echo $value["percent"]; ?>%

			<div class="col-lg-4 col-md-4 col-sm-4 text-center pull-left margin-top-5 hidden-sm hidden-xs tooltips"
				 data-original-title="<?php echo $identities; ?>" data-placement="top">
				<?php echo $value["votant"]; ?> <?php echo Yii::t("cooperation", "voter"); ?>(s)

	<?php } ?>

		<?php if(@$proposal["status"] != "amendable" && $auth){ ?>
			<?php if($hasVote!=false){ ?>

<?php echo Yii::t("cooperation", "You did vote"); ?>
					<span class="letter-<?php echo Cooperation::getColorVoted($hasVote); ?>">
						<?php echo Yii::t("cooperation", $hasVote); ?>

			<?php }else{ ?>

<?php echo Yii::t("cooperation", "You did not vote"); ?>

			<?php } ?>

		<?php } ?>

				 <?php echo Yii::t("cooperation", "Changing vote"); ?> :
				<?php if(@$proposal["voteCanChange"] == "true"){ ?>
					<?php echo Yii::t("cooperation", "Allowed"); ?>
				<?php }else{ ?>
					<?php echo Yii::t("cooperation", "Not allowed"); ?>
				<?php } ?>

				 Vote anonyme :
				<?php if(!isset($proposal["voteAnonymous"]) || @$proposal["voteAnonymous"] == "true"){ ?>
					<?php echo Yii::t("common", "Yes"); ?>
				<?php }else{ ?>
					<?php echo Yii::t("common", "No"); ?>
				<?php } ?>

				 <?php echo Yii::t("cooperation", "Rule of majority"); ?> :
				<?php echo @$proposal["majority"]; ?>%

				<?php if(@$voteRes["up"] && @$voteRes["up"]["percent"] && $voteRes["up"]["percent"] > @$proposal["majority"] ){ ?>
					 <?php echo Yii::t("cooperation", "Proposal"); ?>
					 <?php if($proposal["status"] == "tovote"){ ?><?php echo Yii::t("cooperation", "temporaly"); ?> <?php } ?>
					 <?php echo Yii::t("cooperation", "validated"); ?>
				<?php }else{ ?>
					 <?php echo Yii::t("cooperation", "Proposal"); ?>
					 <?php if($proposal["status"] == "tovote"){ ?><?php echo Yii::t("cooperation", "temporaly"); ?> <?php } ?>
					 <?php echo Yii::t("cooperation", "refused"); ?>
				<?php } ?>

redpajama_set_name: RedPajamaGithub


So I'm pretty excited to introduce you to the online store Prairie Charms.
Recently I was approached on Twitter asking if I'd like to participate in the 'Project Blogger'. Project Blogger is an initiative where I (and all the other bloggers) receive 50% off of anything on their website.
Immediately I felt in love with everything on their website and after realising that they donate a cut of the profit to the Great Ormand Street Children's Hospital Charity, I couldn't wait to get involved!
After waiting one week, what definitely is not a long time for a package that came all the way from the UK right here to Switzerland, I received my order today in a very shiny gold bag. After opening that really glamorous package, I found my bracelet wrapped in pink tissue paper.
I was browsing the site and I found a really cute bracelet that I just had to get it - The Sadia Bracelet with a gold feather.
This bracelet fits perfectly around my wrist and I absolutely love these white gemstone beads. It fits just right in my jewellery box. The whole ordering process was very simple and all things on their website are kind of girly, floral and quirky - there's definitely something for you too! I will definitely be buying some more jewellery from this company!
That's very pretty. I'll have to check out the website :) Thanks for sharing!


text:
New Nenagh MDC Cathaoirleach Cllr Bugler puts tourism as top priority
Fine Gael's Cllr Phyll Bugler has been elected as the new Cathaoirleach for Nenagh Municipal District Council.
The Ballina-based councillor was elected unopposed at the MDC's annual general meeting last Thursday, replacing party colleague Cllr Ger Darcy.
She was proposed by Fianna Fail's Cllr John Carroll and seconded by Labour's Cllr Fiona Bonfield.
However, Sinn Fein's Cllr Seamus Morris, while welcoming her appointment, said the manner of her election had shown "disrespect to other councillors and especially two big-hitters from Lower Ormond", a reference to Cllr Joe Hannigan and Cllr Michael O'Meara.
A believer in the d'Hondt method, Cllr Morris said the pact system on the council was "old, failed politics" that had been rejected by the country.
"I will work with Cllr Bugler, but it is rubbing the noses of four other councillors," he said.
Meanwhile, the new Cathaoirleach has set tourism as one of her priorites for the coming year.
"I want to promote tourism," she said, saying the Butler Trail and the Lough Derg Canoe Trail can bring dividends to the MDC aera.
She would like to see a Garden Route along the lake and promised to work with Waterways Ireland to promote water features in all the villages on its shores.
"We have to use all the assets we have to revitalise our towns and villages," she said.
Cllr Bugler will also work with Nenagh Chamber of Commerce as well as local committees to develop local festivals.
Roads funding will also be a priority as well as the taking in charge of estates, which she said would be "huge on my list".
"Every area has problems, but we do have problems with lights. These people bought their houses in good faith but now have no lights in the winter," she said.
Cllr Bugler agreed to a call from Cllr Hughie McGrath to meet Nenagh Chamber of Commerce as her first initiative.
She pledged to be a Cathaoirleach for the whole Nenagh municipal area, and, calling for new initiatives from her colleagues, she promised that "no idea is off the wall".


text:
John Carpenter's Ghosts of Mars (2001)
directed by John Carpenter
featuring Ice Cube, Natasha Henstridge, Jason Statham, Pam Grier
Writer and director John Carpenter returns to the mixture of science fiction and horror that made The Thing (1982) a success. Natasha Henstridge stars as Lt. Melanie Ballard of the Martian Police Force, a member of a law enforcement team two centuries in the future, dispatched to the remote colony of Shining Canyon. There, the most notorious criminal on Mars, James "Desolation" Williams (Ice Cube), awaits transport to a more secure jail. Besides Ballard, the other cops include the rookie Bashira (Clea Duvall), hotshot and fast talker Jericho (Jason Statham), tough veteran and squad leader Helena (Pam Grier), and reliable soldier Descanso (Liam Waite). Once Ballard and her companions arrive in Shining Canyon, however, they discover that it's a literal ghost town. It seems that an archaeologist team led by Professor Whitlock (Joanna Cassidy) has uncovered an ancient relic at a nearby dig site, unleashing the vengeful spirits of the planet's long-ago warrior inhabitants, which have now possessed the bodies of the human invaders and set about trying to destroy them. After her team is decimated by the Martian specters, Ballard is forced to turn for help to the one person she can't really trust: Williams. Ghosts of Mars screenwriter Larry Sulkis broke into the film business as producer of the satirical commercials in Carpenter's They Live (1988). Karl Williams, Rovi Read Less
Writer and director John Carpenter returns to the mixture of science fiction and horror that made The Thing (1982) a success. Natasha Henstridge stars as Lt. Melanie Ballard of the Martian Police Force, a member of a law enforcement team two centuries in the future, dispatched to the remote colony of Shining Canyon. There, the most notorious criminal on Mars, James "Desolation" Williams (Ice Cube), awaits transport to a more secure jail. Besides Ballard, the other cops include the rookie Bashira (Clea Duvall), hotshot and ... Read More
Science Fiction > Sci-Fi Horror
Science Fiction > Sci-Fi Action
Horror > Sci-Fi Horror
Action > Sci-Fi Action
Action > Escape Film
Blu-Ray, New
2019, Mill Creek Entertainment
CONSHOHOCKEN, PA, USA
Studio: Mill Creek Entertainment
Jason Statham, Natasha Henstridge, Ice Cube. 2019 Run time: 98. BRAND NEW Amazing low price.
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huntingdon valley, PA, USA
Jason Statham, Natasha Henstridge, Ice Cube. New. 2019 Run time: 98. Buy with confidence-Satisfaction Guaranteed! Delivery Confirmation included for all orders in the US.
DVD, New
2001, Sony Pictures Home Entertainment
M and N Media
ACWORTH, GA, USA
Release: Special Edition
Studio: Sony Pictures Home Entertainment
New. 043396062504 Please allow 4-14 business days for Standard shipping, within the US. Thank you for supporting our small, family-owned business!
1899, Mill Creek Ent
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New. B00JPQ1II8 Please allow 4-14 business days for Standard shipping, within the US. Thank you for supporting our small, family-owned business!


We have all reviewed usage data to enable us to make budgetary decisions among the numerous apps our schools' use to enhance, supplement or deliver mainstream curriculum. These decisions are all too often driven by anecdotal information whether we are diving into each tool's usage data, soliciting feedback or walking the halls. How do we align these tools with the learners that need them? How do we realize the actual impact of the many great digital resources we use everyday? Let's mash up our usage data with student performance data and see jump start the personalizing of our learner's experience in our schools.
Milford used CatchOn, tracks usage of apps.


text:
Vermont Receives D- Ranking on State Corruption
By Rebecca Walker
In a recent investigation conducted by the Center for Public Integrity and Global Integrity, Vermont was ranked at a "D-" on the scale of state integrity. This earned the Green Mountain State a spot at 39th place among all fifty states.
Although disheartening, this less than satisfactory grade was not unique to Vermont. Alaska ranked first in this integrity investigation, but it still only earned a C on the test. The goal of the 2015 version of this State Integrity Investigation was to take into account the transparency, accountability and ethics of the laws in the individual states to determine an overall ranking.
The State Integrity Investigation identified certain flaws that were common among many states, providing some explanation for the low rankings. First, The Center for Public Integrity and Global Integrity confirmed that many part-time legislators and officials have fallen into the tempting trap of lobbyists and the self-interest that it entails.
In addition, the State Integrity Investigation proves that often, the bodies responsible for monitoring the ethics laws are not given enough funding and are unable or unwilling to perform their proper tasks.
Another element of the test that caused states to receive poor rankings was the lack of open data measures, which were considered necessary in this world of digitally available data.
Vermont has proven to be no exception to these fatal flaws. Its low ranking can be attributed to two main aspects of the state government: its shortage of ethics safeguards and the lack of other institutions involved in maintaining government ethics.
The means of monitoring ethics have typically been informal and inadequate, according to this standard. However, ethics enforcement was not the only thing bringing Vermont down on this nationwide test. The state also scored extremely low on the portion of the test that ranked legislative accountability.
This low ranking is due to the fact the part-time citizen legislators are not forced by law to disclose their assets. In addition, they have full rights to go directly into work in the private sector as soon as they have left public office, which could be considered a conflict of interest, thus lowering their score.
Given Vermont's unfavorable ranking, there is clearly room for change and improvement. Jim Condos, Vermont Secretary of State, has offered the beginnings of a solution for this problem.
"At the very least, we need clear ethical standards for everyone in state and local government, as well as in the Legislature," Condos told the Burlington Free Press.
"[We need] standards for conflicts of interest, financial disclosure, nepotism, and outside employment among other things," Condos continued.
Condos is not the only one seeking to take action to improve Vermont's transparency and ethics. Organizations throughout Vermont are showing interest in taking action against corruption.
One group, Vermont Acts, is working to encourage the implementation of anti-corruption legislation to improve the state's standards. This group is also organizing petition signing and demanding that issues such as the prevention of political bribery and the creation of an independent ethics commission be discussed at upcoming town meetings across Vermont. They hope that these solutions will remain on the political agenda in the future until visible until the state government makes visible change. With its flaws exposed, there is hope that Vermont will begin increasing transparency, accountability, and ethics, not just for improving in the ranking, but for improving the state government as a whole.
Tags: corruption
One Response to "Vermont Receives D- Ranking on State Corruption"
Mary Gerdt on November 20th, 2015 6:43 pm
Sad that such poor grades may go unnoticed. "A" for voter, constituent apathy. There is no agency or entity in Vermont who helps taxpayers with unscrupulous, careless, or greedy collection tactics. Each town collects funds differently, sends to state. the state has no accountability. Each taxpayer is forced to lawyer up and protest or pay and give up.
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text:
Dementia Training Australia (DTA)
Aged and Community Care Services Australia
Australian Council of Social Service
Australian Fronto-Temporal Dementia Association
Australian Commission on Safety and Quality in Health Care
Bendigo Health - Regional Dementia Management Strategy Pathway
beyondblue
Carers Australia
Continence Foundation of Australia
COTA National Seniors
Creutzfeldt-Jacob Disease (CJD) Support Group Network
Dementia Behaviour Management Advisory Service (DBMAS)
Dementia Collaborative Research Centres
Down Syndrome Australia
Kate Swaffer
Mental Health Council of Australia
National Aged Care Data Clearinghouse
National Aged Care Alliance
National Ageing Research Institute (NARI)
National Health Services Directory
National Health and Medical Research Council (NHMRC) National Institute for Dementia Research (NNIDR)
Palliative Care Australia
Parkinson's Australia
Severe Behaviour Response Team
Veterans' MATES
Cognitive Decline Partnership Centre (CDPC)
Dementia Training Australia (DTA) is a consortium funded by the Australian Government to provide nationwide education on the support and care of people living with dementia. DTA offers a range of courses and resources including e-learning, workshops, webinars and nationally accredited vocational training. The vocational training is delivered by Dementia Australia to 6,500 people every year through the Dementia Essentials courses.
The consortium is made up of Dementia Australia and five universities – the University of Wollongong, La Trobe University, Queensland University of Technology, Wicking Dementia Research and Education Centre (University of Tasmania) and the University of Western Australia. Its work is guided by a 'salutogenic' approach: a focus on factors that support health and wellbeing, and opportunities for a person with dementia to live as full a life as possible.
For more information on DTA courses, services and resources, visit dta.com.au.


text:
The Thirteenth Special Session begins tomorrow in the Administrative Center of the Government of the Republic of Srpska
The Thirteenth Special session of the National Assembly was scheduled for tomorrow, May 20, 2020, at 10 a.m. in the Conference Hall of the Administrative Center of the Government of the Republic of Srpska, which satisfied the epidemiological conditions caused by the corona virus.
Proposed Agenda for the 13th Special Session:
1. Decision on abolition of the state of emergency for the territory of the Republic of Srpska;
2. Confirmation of acts adopted by the President of the Republic during the
state of emergency and decision-making on the cessation of the validity of regulations with legal force
The Notification for Expert Discussion on the Draft Law on the protection of the right for the trial within a reasonable period
President Čubrilovic talked with the Deputy High Representative to BiH: Preparations for the session in the second half of July are underway
MPs adopted the new Rules of Procedure of the National Assembly
Presidnet Čubrilović congratulated Vidovdan to the Third regiment – the Patron Saint of the Army of the Republic of Srpska
The continuation of the Tenth Regular Session of the National Assembly
Čubrilović: Corridor of Life - historical and one of the crucial actions of the Army of the Republic of Srpska
The Committee on Constitutional Affairs determined the answers to the Constitutional Court of the Republic of Srpska in two cases
Vice President Of the Parliament Zeljka Stojicic participated in an expert discussion on the topic "How after the corona" in Banja Luka
The Tenth Regular Session of the National Assembly of the Republic of Srpska has been scheduled for Tuesday, 16 June, 2020 at 10.00
Collegium for scheduling the 14th Special Session on Friday at 11 am
Trg jasenovačkih žrtava 1
78 000 Banja Luka
Secretariat General
Telephone: +387 51 338-104
Fax: +387 51 301-087
About National Assembly
Symbols of RS
Activities of the President
Audio and video archive


Estrella World Street Food in National Geographic Traveller Food.
Estrella World Street Food in National Geographic Traveller Food, out with the September 2018 issue of National Geographic Traveller (UK).
Estrella World Street Food In Every easyJet Plane Worlwide!
We are thrilled to announce that you can read about Estrella in easyJet Traveller, the flagship inflight magazine for easyJet, which reaches up to 7.2 million passengers a month.
Estrella in Blue Magazine of AEGEAN Airlines!
New life in the Old Athens Triangle. Blue Magazine writes about Estrella Athens and #jezebel!
Estrella At The National Geographic Traveller Magazine, For The Third Time!
Bougatsan is featured at the worldwide food trends to try right now, according to The National Geographic Traveller Magazine!
New International Review From The Times.
Estrella World Street Food is featured at The Times London (UK)!
New Miles+Bonus Partnership With Aegean Airlines!


Up 'til now I have resisted the many many urges that come to me to write about my present employment. But they have really outdone themselves now.
I'll start with this. I have worked here for going on two years, they still think my name is Rebecca and that it is okay to call me Becky. It is NOT okay to call me Becky. Not ever. I feel almost like I am more of an automaton than an employee. I'm not asking for special treatment, but would it be to much to ask that they acknowledge that my first name is REBEKAH? I have written about this before but it is still really irking me.
But here is what imspired me to write this post. They are now restricting our lunches. They want only two of us to go to lunch in any given hour between 11:00 AM and 2:00 PM. I see the logic behind that, sort of. We don't deal with customers, we work in the back office, so we legitimately have NO CONTACT with anyone, so what does it matter if three people are out to lunch at the same time? No one needs to talk to them at that specific minute. But still...I see why it could potentially be a problem. Here is the kicker though...they want SEVEN people to go to lunch TWO at a time in THREE hours.
You figure that math out, because I missed the lesson where they taught us that 7÷3=2.
I am so with you on getting people's names right. I have a different first name and it gets irritating when I'm called by the wrong name. People just make assumptions.
Good lord. I love it when management comes up with bright ideas. I hope someone points it out to them!
I can completely empathize with you on the name thing. My name is Kandi, and I HATE it when people call me Candace as though that was my given name. It's not.
Pisses me off something fierce.