text:
Newsletter/Journal 3
Upcoming Meeting/Conference 1
United States Meeting/Conference 1
Education and Training 155
Simulators 27
Missed Care 4
Fatigue and Sleep Deprivation 10
Medical Complications
Patient Falls 112
Emergency Nursing 6
Ways You Can Help Your Family Prevent Medical Errors!
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Twenty Tips to Help Prevent Medical Errors in Children.
Patient Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; September 2002. AHRQ Publication No. 02-P034.
This consumer fact sheet advises parents on how to help their children avoid medical errors pertaining to medicine, hospital stays, surgeries, and other medical needs.
20 Tips to Help Prevent Medical Errors.
Patient Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0089.
This fact sheet for patients provides recommendations to help them prevent medical errors when taking medications, during a hospital stay, and prior to having surgery.
Web Resource > Database/Directory
Spotlight Archive.
Rockville, MD. Food and Drug Administration.
This website provides information to consumers about health-related issues of current interest to the general public.
The incidence and severity of adverse events affecting patients after discharge from the hospital. Get Citation
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:161-167.
This article explains a prospective study at an academic hospital studying adverse events in 400 consecutive patients after discharge from a medical service. The authors describe the incidence, severity, and preventability of reported events along with specific examples captured during the study. They discuss strategies to improve patient safety by emphasizing the vulnerability of the discharge transition from hospital to home. The study identifies an important target for future interventions by suggesting improvement in the coordination and follow-up of care immediately after hospital discharge.
National Center for Patient Safety Falls Toolkit 2004.
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.
Preventing complications of central venous catheterization. Get Citation
McGee DC, Gould MK. N Engl J Med. 2003;348:1123-1133.
Safety of patients isolated for infection control. Get Citation
Stelfox HT, Bates DW, Redelmeier DA. JAMA. 2003;290:1899-1905.
This study discovered that patients isolated for colonization or infection with methicillin-resistant Staphylococcus aureus suffered more preventable adverse events, less satisfaction with care, and less documentation for their care, but no difference in mortality compared to a control group. Examples of the reported differences in care quality included absence of accurately recorded vital signs, missing daily physician progress notes, and less delivery of disease-specific standards for heart failure management. While safety precautions and isolation of selected patients certainly reduce the transmission of communicable infections, a potential patient safety issue results from the care these patients receive once isolated—an unintended adverse consequence.
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. Get Citation
Zhan C, Miller MR. JAMA. 2003;290:1868-1874.
Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.
Preventing Infections in the Hospital—What You As a Patient Can Do.
Chicago, IL: National Patient Safety Foundation.
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines practical tips to minimize risk.
Preventable deaths: who, how often, and why? Get Citation
Dubois RW, Brooke RH. Ann Intern Med. 1988;109:582-589.
One of the first studies to examine the link between quality of care and hospital deaths, this article discusses a novel methodology for investigating the prevalence of preventable deaths. The study involved four phases, starting with a sampling method in which 182 deaths from 12 hospitals were identified for chart review. Clinical experts then prepared discharge summaries, including an opinion on whether a death was preventable, while investigators collected demographic and illness severity information. The final phase called for developing a screening tool to identify patients at admission who were at high risk for dying from preventable causes. Based on their described process, the authors reported that 14% to 27% of deaths might have been prevented. The findings are focused on diagnoses of myocardial infarction, cerebrovascular accident, and pneumonia. The authors suggest that a few conditions accounted for most hospital deaths and that systematic reviews of deaths may serve as catalysts for improved performance.
Audiovisual > Course Material/Curriculum
Keeping Each Patient Safe.
McKeesport, PA: University of Pittsburgh Schools of the Health Sciences.
A collection of three educational modules that address key areas of concern in patient safety. These include protecting patients from hospital-acquired infection, minimizing falls and confusion, and emphasizing the value of providers calling for help early when needed. The organization was recognized for this work with the John Eisenberg award in 2004.
The hazards of hospitalization. Get Citation
Schimmel EM. Ann Intern Med. 1964;60:100-109.
This article examines a prospective study of more than 1000 patients admitted to a university medical service. The author studied the type and frequency of hospital complications during a given hospitalization and found that nearly 20% of patients experienced a medical complication. Such patients endured longer hospitalizations while suffering from a variety of complications, including developing acquired infections and reactions to diagnostic procedures, therapeutic drugs, or transfusions. The author thoroughly describes the episodes, which range in severity from minor to fatal. This was one of the first studies to document the frequency of iatrogenic injury in hospital care.
Incidence and types of preventable adverse events in elderly patients: population based review of medical records. Get Citation
Thomas EJ, Brennan TA. BMJ. 2000;320:741-744.
This retrospective study reviewed 15,000 medical records following hospital discharge to determine the rate and characteristics of preventable adverse events. Using a random sample of records, the study design required a physician and a nurse to review charts and identify 18 criteria associated with an adverse event. These events were subsequently reviewed by two study investigators to judge preventability. Results indicated a significant number of adverse events in both elderly (>65) and nonelderly patient populations. A detailed table in the paper presents the number and types of events recorded. The authors conclude that elderly patients experience higher rates of falls, preventable adverse drug events, and events related to procedures; these findings suggest potential areas for safety interventions.
Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.
Most evidence reports are placed on shelves and gather dust. This one, which reviewed the state of the evidence behind nearly 80 different safety practices (including computerized order entry, use of pharmacists on rounds, methods to prevent falls and nosocomial infections, and interventions to create a culture of safety), became quite influential, in part because it was the first effort to subject safety practices to the same scrutiny as other clinical practices in terms of their evidence of effectiveness. Nearly 100,000 copies of the report have been obtained from the Agency for Healthcare Research and Quality, and its now-famous list of the top 11 practices became the focus of many a new patient safety program at hospitals around the nation. The report served as one of the intellectual underpinnings of subsequent rankings of practices such as those by the National Quality Forum and the Leapfrog Group. It also engendered a spirited debate between those who advocated a practical approach to the adoption of safety practices and those promoting a more evidence-based approach. Readers are cautioned that evidence reports have limited shelf-lives, and it is worth reviewing recent literature before adopting even the most highly rated practices in this report.
Iatrogenic illness on a general medical service at a university hospital. Get Citation
Steel K, Gertman PM, Crescenzi C, Anderson J. N Engl J Med. 1981;304:638-642.
This study describes adverse events discovered in 815 consecutive admissions to a medical service. Results report an overall 36% rate of iatrogenesis, the frequency and type of events, and the associated factors with each event. Exposure to drugs represented a particularly important factor in determining which patients experienced complications. The authors conclude that, while benefits of hospitalization will continue to exist, mechanisms to study its hazards also must receive emphasis to minimize the occurrence of adverse events.
Identification of in-hospital complications from claims data. Is it valid? Get Citation
Lawthers AG, McCarthy EP, Davis RB, Peterson LE, Palmer RH, Iezzoni LI. Med Care. 2000;38:785-795.
In order to validate a computerized screening method, this study determined whether ICD-9 codes used to identify complications are coded accurately and if the screening method appropriately distinguished a preexisting condition from one that developed during hospitalization. Investigators compared coding from Medicare claims with those independently reviewed for more than 1200 medical records in two states. Discussion includes full presentation of the findings for each diagnosis code as well as the estimated predictive values of the computer screening method in correctly identifying hospital complications. While the authors suggest that their method has validity for capturing most surgical complications, the screening tool fails to adequately identify enough events. They propose the addition of a timing indicator to Medicare claims to improve detection of hospital complications and validate this important quality measurement tool.
Electronic alerts to prevent venous thromboembolism among hospitalized patients. Get Citation
Kucher N, Koo S, Quiroz R, et al. N Engl J Med. 2005;352:969-977.
With reported underutilization of deep-vein thrombosis (DVT) prophylaxis, this study examined the impact of a computer alert program to increase use and reduce the incidence of DVT. Investigators linked a software program to an existing patient database to identify patients at risk who were not receiving prophylaxis. The provider involved then received an alert and was given a number of appropriate options. Results demonstrated increased use of both mechanical and pharmacologic prophylaxis, as well as decreased incidence of DVT and pulmonary emboli. The authors conclude that use of electronic alerts in institutions with available information technology can lead to improved care.
Validation of a discharge summary term search method to detect adverse events. Get Citation
Forster AJ, Andrade J, van Walraven C. J Am Med Inform Assoc. 2005;12:200-206.
Identifying adverse events by chart review, as in the Harvard Medical Practice Study and other major epidemiologic studies in patient safety, is a time- and labor-intensive process. Most institutions could not afford to make such investments of resources to identify adverse events except in the setting of a funded research study. To address this issue, the authors applied a commercially available search engine to scan for scanning discharge summaries to identify adverse events. Using a set of cases with known adverse events, the investigators developed rules based on combinations of terms associated with adverse events. The sensitivity of this approach using the particular combinations of terms examined by the authors was only 23%, but the specificity was 92%. Thus, this approach may provide an efficient means of flagging cases for internal review. In other words, while this natural language processing approach misses cases, the cases it does identify have a high probability of representing true adverse events. Running this search on a regular basis would yield cases likely to reflect quality or safety problems without requiring the same investment of resources as would screening for cases through manual chart review.


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Home Local Utah News Future Ute Gymnast MyKayla Skinner Named U.S. Olympic First Alternate
Local Utah News
Future Ute Gymnast MyKayla Skinner Named U.S. Olympic First Alternate
Gephardt Daily Staff
Future Ute gymnast MyKayla Skinner has been named one of three alternates for the 2016 Olympic Games in Rio de Janeiro. Photo Courtesy: Wikipedia
SAN JOSE, Calif., July 11, 2016 (Gepardt Daily) — Future Ute gymnast MyKayla Skinner has been named one of three alternates for the 2016 Olympic Games in Rio de Janeiro.
Skinner placed fourth in the all-around at the U.S. Olympic Trials, but only the all-around champion automatically qualified for the five-person USA Olympic Team, with the balance of the team and the three alternates chosen by the Olympic selection committee. In addition to her fourth-place all-around finish, Skinner was second on vault and fifth on beam and floor.
As the U.S. team's first replacement athlete, Skinner, 19, will train and travel with the team to Rio, according to a statement from the University of Utah.
"I'm so proud," Skinner told KPNX-12 News, from her home state of Arizona. "I just wanted to go out there and go four-for-four and rock night two, and that's what I did.
"Being an alternate is still the same. It's being on the team. I'm still working just as hard as the other girls, and it'll be a great experience being an alternate."
Skinner will train with the team in Texas next week the team before heading to Rio for the Olympic Games.
Skinner, who won the all-around at the 2016 Glasgow World Cup, signed with Utah in November 2014, but deferred enrolling for a year to pursue a berth in the Olympics. She plans to report to school in late August.
Team USA will send one of its most decorated and competitive women's gymnastics teams ever to next month's Rio 2016 Olympic Games as it attempts to defend its Olympic team gold medal for the first time in history.
Chosen after two intense nights of competition at the U.S. Olympic Team Trials, the team is led by three-time all-around world champion Simone Biles, who is already the most decorated U.S. gymnast and will look to cement her place in history at her Olympic debut in Rio.
Gabby Douglas and Aly Raisman return to the Olympic team after winning both team and individual golds at the London Olympic Games four years ago. They become the first U.S. women's gymnasts to make two Olympic teams since Dominique Dawes and Amy Chow did so from 1996 to 2000.
Joining them is first-year-senior standout Laurie Hernandez, who finished second to Biles at Olympic Trials and becomes the first Puerto Rican woman to make a U.S. Olympic Gymnastics Team, and uneven bars specialist Madison Kocian, who last year won the world title in uneven bars in a four-way tie.
The other two replacement athletes are Ashton Locklear and Ragan Smith.
Future Ute gymnast MyKayla Skinner has been named one of three alternates for the 2016 Olympic Games in Rio de Janeiro. Photo Courtesy: YouTube
2016 Olympic Games in Rio de Janeiro
Gabby Douglas
MyKayla Skinner
US Olympic Trials
USA Olympic Team
Utah gymnastics signee MyKayla Skinner
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https://gephardtdaily.com/
U.S. Olympians featuring Utah's MyKayla Skinner, Grace McCallum, Simone Biles coming to WVC
Former U of U gymnast Mykala Skinner wins Olympic silver in Toyko Olympics days after nearly heading home; thanks supporters in video
3 Utah gymnasts heading to Tokyo Olympics
Amber Alert cancelled after 7-year-old girl found safe
Pelosi desk-sitter Richard Barnett found guilty on 8 counts in Jan. 6 attack
Nickelback tour includes July 6 Utah stop at USANA
Car-semi collision kills man in Uintah County
Gov. Spencer Cox announces intent to sue social media companies for practices harmful to juveniles
Former BYU linebacker Fred Warner grabs souvenir as 49ers bounce Cowboys from NFL playoffs
Teen uses SafeUT app to report kidnapping at Airbnb in Salt Lake City
Update: Layton police find missing 16-year-old girl
Damar Hamlin in attendance for Buffalo's playoff game against Cincinnati
Man arrested for allegedly pulling knife on SLCPD officer after fleeing earlier incident

redpajama_set_name: RedPajamaCommonCrawl


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Are you researching an expat health insurance for Ivory Coast (Côte d'Ivoire)? It is important to inform yourself on the local healthcare system first.
Whether you are moving to Ivory Coast or you are already living there as an expat, read our guide to the Ivorian healthcare system, your different options of medical insurance for Ivory Coast and an overview of the average cost of local healthcare.
The standard of healthcare and health insurance in Ivory Coast is generally considered as sub-par, so health insurance including repatriation is strongly advised if you are visiting or moving to the West African country.
Be warned that the social protection system in Ivory Coast does not offer health insurance, but instead covers only occupational accidents and illnesses. Care in public health facilities incurs a cost (this was introduced in 1994 due to the inability of the state to meet public health needs on its own). For private health facilities, admission is subject to prior insurance payments. For these reasons, it is strongly recommended to have a private health insurance in Ivory Coast.
The healthcare system in Ivory Coast has been negatively affected by socio-political disturbances in the country since December 1999 and the post-election crisis of 2010-2011. Although the country recovered well, basic services have still not been completely re-established and structural problems remain. The country's Ministry of Health and the fight against AIDS summarised in a report on national health policy that its funding is inadequate and the population's geographical and financial accessibility to quality basic healthcare is limited.
Rural areas in particular suffer from a shortage of hospitals and medical staff. Large cities have more of a medical infrastructure, both private and public, and it is generally recommended to go to Abidjan for treatment. Some private hospitals, such as the Sainte Anne-Marie International Polyclinic or the Hôtel Dieu offer good quality care. However, as a general rule, medical facilities in Abidjan remain below the quality standards of Western medical centres.
In the case of certain specialist health problems, it may even be necessary to seek treatment in another country due to local healthcare facilities not necessarily having all the necessary medical technology. It is therefore essential to have international health insurance which includes evacuation/repatriation so that the costs incurred in the event of evacuation as well as the medical care delivered outside the country are not at your expense.
An international health insurance will cover you not only in Ivory Coast but also in your country of nationality. Often the area of cover is worldwide without the USA, but in order to reduce the premium, you could also opt for an insurance policy that is only covering Africa. However as already indicated above, it is important that your insurance policy includes repatriation/evacuation assistance in order to be evacuated to the nearest medical centre that can offer adequate care or to be repatriated to your home country.
Expat Assure helps you decide the most appropriate expat health insurance for Ivory Coast depending on your situation and needs. Don't hesitate to contact us for your personalised health insurance comparison.
If you would like wider financial protection in the event of stopping work due to an accident or disabling illness, Expat Assure can also advise you on expat life insurance for Ivory Coast and income protection. To find out more, please, read our page on income protection and life insurance for expatriates.
What is the best health insurance for expats in Ivory Coast ?
The best health insurance in Ivory Coast for another expat might not be the best for you as everyone has different needs and criteria.
In order to find which one is the it is important to consider several aspects such as your medical history, your age, your specific needs in terms of medical cover, your situation in Ivory Coast, alongside other parameters.
Expat Assure helps you to find the international medical insurance for Ivory Coast that best suits your profile and needs. Contact us today to request your free an non-obligatory health insurance comparison.
How much does healthcare cost in Ivory Coast?
A single room in a hospital: around 50,000 CFA francs (£68/$87). Please note, this does not include doctor's fees, nursing costs, treatment or procedures. A hospital bill without insurance can easily amount to several thousand pounds.
What is the cost of private health insurance in Ivory Coast?
Such as with any type of health insurance, the price of medical insurance for expats in Ivory Coast varies greatly depending on the age, medical history, family composition of the applicant and other factors.
If you would like to have a precise estimation of the cost of international health insurance for Ivory Coast, which applies to your specific situation and needs, we can prepare for you a personalised comparison of different international health insurance plans. Contact us today for your free health insurance comparison.
A yellow fever vaccination certificate is required for all travellers entering the country. It is also recommended that your immunisation schedule is up to date. Vaccinations against hepatitis B, rabies, meningococcal meningitis and typhoid can be advised depending on the nature of your stay.
Ivory Coast is classified as Zone 3 for the risk of malaria, so there is a high risk in all areas throughout the year. Before departure you should seek advice from a doctor or tropical diseases vaccination centre about suitable antimalarial tablets.
Ivory Coast is one of the most highly affected countries in West Africa by the AIDS virus. Basic precautions for protection against the AIDS virus must be taken.


Forest Guardian Quest Part One has just been uploaded/added! This one includes general information about the main quest, and it shows how to get the purple jewel. The rest of the guides will mostly just consist of how to get the other jewels, though some might have extra tips.
I have another video ready to edit. Hopefully that one will be up by tomorrow.
I am very interested in the Forest Guardian quest videos in the future. It could help a ton when I'm stuck on a particular one.
The videos will hopefully all be out in time for the update on the 16th.
Part two is out. This is a guide to the red jewel, which is found at the Weepingroot.
Two pillars/videos down, four to go. Three days left until the 16th.
Just posted part three. At this point, I've made guides for the purple, red, and pink jewels. Three pillars down, three to go. Halfway there.
I'm almost there with the other pillars. I'm just missing all the insects and all the rare stuff except for a cardinal. Other than that, I have the rest of the items. I've been spending all my time after school putting these videos together. If I keep this up, I should be able to finish by Friday.
Part four is out. Guides for the purple, red, pink, and now orange jewels have been made. Only two pillars left! I'll have to do them tomorrow if I am going to get them out by Friday.
If you haven't noticed, I've made the color of the title/text screens the color of the jewel found in each video. So, text screens were purple in the purple jewel guide.
Edit: I'm redoing the editing on this video. There was a typo in it (I put Praire instead of Prairie), and there's something weird going on with the mirror scene. The re-edited version will be out sometime later today.
Edit 2: Video has been re-edited and re-uploaded. I had to start from scratch with the editing because my computer didn't save the other one before it was rendered. The video that is in the original post is the re-edited version. Fixed the typo and fixed the other problem.
Looking forward to the update and future videos. Keep it up, Spot!
Thanks! I accidentally stayed up all night doing the most recent video. Oops.
Oh no. Make sure to get a good night's sleep tonight!
In my defense, by the time I got done with it all, it was 6:30am and I was supposed to be up at 7. No point in going to sleep for 30 minutes.
Part five has just been uploaded. The last one will be out sometime tonight as well.
Part 6 just finished uploading. That was the last part! Guides for each pillar/jewel have been made. It's only been a few hours since the update was launched, so I'd say that I did pretty good with getting all the guides out in time. Couldn't have done it without playing 20+ hours of Cattails combined over the last 2-3 days, but it's always worth it.
Not sure when the next tutorial will be out, but I should probably train the kittens for real this time. That option won on the poll, but I decided to do all the Forest Guardian guides first since a lot of people will be wanting to finish it so they can make their own colonies.
Great job, Spot. Must be dead and tired, eh?
I am enjoying the update. The only thing is I keep running out of mews and its getting on my nerves.
Thank! This definitely caused my gameplay hours to skyrocket again, just like the Romance guide. I had 205 hours before doing the quest guides and now I have 225. I should probably comment in the videos that some of the items can now be purchased. They couldn't be when I made the videos.
Hmm. A guide about how to get mews quickly would probably be a good idea.
Also, the music piece I used in the blue jewel guide is literally titled "Cattails". I felt like I just had to use it once I saw that, so I did.
I think the mews guide would be VERY handy. I would love helping by giving methods if you chose so.


A phl file extension is related to the Amazon Kindle e-book reader. A phl file contains data to view popular highlights in e-books.
What is phl file? How to open phl files?
The phl file extension is associated with the Amazon Kindle, an e-book reading device and same named e-book reading software for various platforms.
The phl file stores popular part of texts in an e-book highlighted by Kindle users.
The .phl file is simple text with XML schema.
The *.phl file is viewable in Amazon Kindle.
and possible program actions that can be done with the file: like open phl file, edit phl file, convert phl file, view phl file, play phl file etc. (if exist software for corresponding action in File-Extensions.org's database).
Click on the tab below to simply browse between the application actions, to quickly get a list of recommended software, which is able to perform the specified software action, such as opening, editing or converting phl files.
Programs supporting the exension phl on the main platforms Windows, Mac, Linux or mobile. Click on the link to get more information about listed programs for view phl file action.
Programs supporting the exension phl on the main platforms Windows, Mac, Linux or mobile. Click on the link to get more information about listed programs for settings phl file action.


text:
Q: One-Hot-Encode only integers, slices( `:`), ellipsis( `...`), numpy.newaxis(`None`) and integer or boolean arrays ar valid indicies problem I'm trying to solve below problem through one-hot-encode, but error occured, too.
I'm trying to make image classification(catching rectangle), and when I try to let it one-hot-encode, the error occured.
Before change into one_hot_label,
the labels like:
 'circle' 'circle' 'circle' 'circle' 'circle' 'circle' 'circle' 'circle'
 'pentagon' 'pentagon' 'pentagon' 'pentagon' 'pentagon' 'rectangle' ....
 'triangle' 'triangle' 'triangle' 'triangle' 'triangle' 'triangle']

I made T into[[0, 0, 0, 0, 0], ... , [0, 0, 0, 0, 0]] because I have 5 kinds of figure.
But on row[X[idx]] = 1,I got an error:
only integers, slices (:), ellipsis (...), numpy.newaxis (None) and integer or boolean arrays are valid indices
def _change_one_hot_label(X):
    T = np.zeros((X.size, 5))
    for idx, row in enumerate(T):
        if(X[idx] == 'rectangle'):
            row[X[idx]] = 1

    return T

I don't know what should I do to solve this problem...
Please help me. Thanks.
=====================================================================
TRYING TO SOLVE WITH ABOVE WAY. (ONE-HOT-ENCODE)
=====================================================================
I'm studying deep-learning.
I got an error: 'ufunc 'multiply' did not contain a loop with signature matching types (dtype(' dtype('

I tried to solve it myself, but I need help.
I'm loading my image dataset with
data_list = glob('dataset\\training\\*\\*.jpg')

def load_label(data_list):
    labels = []
    for path in data_list:
        labels.append(get_label_from_path(path))
    return np.array(labels)

x_batch example: [[0.00392157 0.00392157 0.00392157 ... 0.00392157 0.00392157 0.00392157]
 ...
 [0.00392157 0.00392157 0.00392157 ... 0.00392157 0.00392157 0.00392157]]

t_batch example: ['circle' 'circle' ... 'circle' 'circle']
train_size = 3 # x_train.shape[0]
batch_size = 22
for i in range(242): # iters_num = 242
   batch_mask = np.random.choice(train_size, batch_size)
   print( t_train, batch_mask )
   x_batch = x_train[batch_mask]
   t_batch = t_label[batch_mask]
   grad = network.gradient(x_batch, t_batch) # error start position

When I try to get gradient, it flows self.loss(x_batch, t_batch) # each parameter is x, t ->
def loss(self, x, t):
        y = self.predict(x)
        return self.lastLayer.forward(y, t)

def forward(self, x, t):
        self.t = t
        self.y = softmax(x)
        self.loss = cross_entropy_error(self.y, self.t)
        return self.loss

def cross_entropy_error(y, t):
    if y.ndim == 1:
        t = t.reshape(1, t.size)
        y = y.reshape(1, y.size)

    batch_size = y.shape[0]

    return -np.sum(t * np.log(y+1e-7)) / batch_size

And the latest line, return -np.sum(t*np.log(y+1e-7)) / batch_size,
I got an error: UFuncTypeError: ufunc 'multiply' did not contain a loop with signature matching types (dtype('<U32'), dtype('<U32')) -> dtype('<U32')
I tried to change labels into a int for examples: 'circle' = 0, 'rectangle' = 1, but then my deep learning do not learn about it.
I don't know what I'm missing..
Can somebody help me please.

A: To solve the one hot encoding problem you can use the following function.
import numpy as np

label2idx = dict(rectangle=0, circle=1, pentagon=2, ..)

def _change_one_hot_label(X):
    T = np.zeros((len(X), 5)).astype('int32')
    for i in range(T.shape[0]):
        label = X[i]
        T[i, label2idx[label]] = 1

    return T

_change_one_hot_label(['circle', 'rectangle', 'rectangle'])

For the other question, as you are saying the variable t is a string array containing ['circle', 'rect' ..] and you cannot multiply strings and numbers.
First, you should apply the one hot encoding function to t.
def cross_entropy_error(y, t):
    # It is nota good practice, but you can place this instruction here
    # Maybe, if you have a 'batch preprocessor function' you should place it there
    t = _change_one_hot_label(t)

    if y.ndim == 1:
        t = t.reshape(1, t.size)
        y = y.reshape(1, y.size)

    batch_size = y.shape[0]
    return -np.sum(t * np.log(y+1e-7)) / batch_size

redpajama_set_name: RedPajamaStackExchange


The future is now. Facebook is keen to get users watching their favourite shows in its new Oculus Go headset. Starting with Facebook Watch shows first (Netflix will surely soon follow), this is an interesting attempt by the social media company to try and get consumers buying into VR as well as demonstrating the intrinsic value of Oculus beyond VR roller coasters and the like.


Promoted after saving Rice during the bogus "Niger Uranium" scam.
The fall guy for the bogus "Niger Uranium" scam.
Stephen J. Hadley was US National Security Advisor. During George W. Bush's first term he served as Deputy National Security Advisor.
In an article on war profiteers, Global Research writes that "Perhaps the most notable example is that of [Raytheon director] Stephen Hadley... [who] wrote an editorial in The Washington Post with the headline, "To stop Iran, Obama must enforce red lines with Assad." Nowhere in those appearances was it disclosed, according to the report, that Hadley is a director with Raytheon, a weapons manufacturer that produces the Tomahawk cruise missiles the US almost certainly would have used had it intervened in Syria. Hadley earns an annual salary of $128,5000 from Raytheon and owns 11,477 shares of Raytheon stock. His holdings were worth $891,189 as of August 23."
In December 2015 Hadley was chairman of the Board of Directors of the spooky United States Institute of Peace which has been consistent in its efforts to undercount the dead of the Iraq War.
↑ Biography of Stephen Hadley, Assistant to the President For National Security Affairs, National Security Council,accessed 8 June 2008.
↑ RightWeb: Individual profiles: Stephen J. Hadley, accessed 8 June 2008.
This page was last edited on 24 July 2016, at 15:06.


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text:
Sharrouf's teenage daughter gives birth
7:40am Jun 26, 2019
The teenage daughter of notorious Australian terrorist Khaled Sharrouf has given birth just days after being rescued from a refugee camp in Syria.
Zaynab Sharrouf, 18, gave birth to her third child on Monday night local time, The Australian reports.
Zaynab is among a group of children of two dead Islamic State fighters who are on their way to Australia from the refugee camp.
A file photo of Zaynab Sharrouf, right, with her sisters. (Nine)
The group includes Zaynab's three children, her sister Hoda, 16, and brother Humzeh, aged eight.
The others are three children aged between six and 12, who are the orphans of ISIS fighter Yasin Rizvic and his wife, Fauzia Khamal Bacha.
The children are in a "safe location" outside of Syria before making the journey to Australia where they are likely to be settled in Victoria or NSW.
Confirming their return this week, Prime Minister Scott Morrison said the government had carefully considered their cases and would consider others.
Khaled Sharrouf, right, was killed in an air strike in September 2017, along with his two older sons, Abdullah, 12, and Zarqawi, 11. (Nine)
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The rise and fall of the Islamic State caliphate
"They can't be held responsible for the crimes of their parents," he told reporters in Perth.
"That you would take a child and put them in a conflict zone like this is despicable and I find it disgusting."
The Sharrouf children were in April reunited with their Sydney grandmother, Karen Nettleton, in northern Syria's al-Hawl camp, where those fleeing the last ISIS enclave at Baghouz ended up.
The children's grandmother Karen Nettleton has been lobbying for their release. (Nine)
It's believed Mrs Nettleton, who had not seen her grandchildren since 2014, had been negotiating with officials to bring them back to Australia.
Sharrouf was killed in an air strike in September 2017. His two older sons - Abdullah, 12, and Zarqawi, 11 - are also believed to have died in the strike.
The children's mother, Mrs Nettleton's daughter Tara, died of medical complications in 2015.
Property News: 7 tips to keep your indoor plants alive while you're on holiday - domain.com.au


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text:
Q: Evaluate the limit of following I need help in evaluating the limit of this expression.
$$\lim_{x\to0}\dfrac{\sqrt{x+4}-2}x$$

A: This is nothing other than the derivative of $\sqrt{x}$ evaluated at 4:
Define $f(x) = \sqrt{x}$.  Note that $f'(x) = \dfrac{1}{2\sqrt{x}}$.
Then $$\lim_{x \to 0} \dfrac{\sqrt{x+4}-2}{x} = \lim_{x \to 0} \dfrac{\sqrt{4+x}-\sqrt4}{x} = \lim_{x \to 0} \dfrac{f(4+x)-f(4)}{x} = f'(4) = \dfrac{1}{2\sqrt{4}} = \dfrac{1}{4},$$
where the third equality is justified by the definition of the derivative.

A: $$\lim_{x\to0}\dfrac{\sqrt{x+4}-2}{x}
=\lim_{x\to0}\dfrac{(\sqrt{x+4}-2)(\sqrt{x+4}+2)}{x(\sqrt{x+4}+2)}
=\lim_{x\to0}\dfrac{x+4-4}{x(\sqrt{x+4}+2)}
=\lim_{x\to0}\dfrac{x}{x(\sqrt{x+4}+2)}
=\lim_{x\to0}\dfrac{1}{\sqrt{x+4}+2}
=\dfrac{1}{\sqrt4+2}
=\dfrac{1}{2+2}
=\dfrac{1}{4}$$

A: it is
$\frac{\sqrt{x+4}-2}{x}=\frac{1}{\sqrt{x+4}+2}$
thus the searched limit is $\frac{1}{4}$.
Sonnhard.


text:
Frankie Randall- First To Defeat Chavez- Died Wednesday
Melina Pizano- Matchroom Boxing USA
With the days dwindling down on 2020 comes the sad news that the fighter who holds the distinction of being the first to ever defeat Hall of Famer Julio Cesar Chavez has passed away.
Frankie Randall died in a Tennessee nursing home from complications from dementia, drug and alcohol abuse on Wednesday. He was 59.
Known as "The Surgeon," Randall's career began as an outstanding, multi-time Golden Glove amateur champion from Tennessee. But, he was denied a chance to represent the United States in the Olympics, when the U.S. boycotted the 1980 Moscow games.
Undaunted, Randall turned professional the next year and rattled off 23 straight pro wins rocketing up the rankings in the Super Lightweight division. He suffered his first pro loss to fellow, future World Champ, Edwin Rosario a 10-round decision in 1985.
However, Randall with his slick boxing style and fast combinations put himself in position for another potential World title chance, by eventually winning 17 fights in a row. That got him a shot in January, 1994 in Las Vegas for the WBC Super Lightweight Championship against Chavez.
The Mexican superstar had an astounding 89 – 0 – 1 record, when Randall out fought him over the course of a 12 round split-decision win.
It was not without controversy, as referee Richard Steele correctly deducted points from Chavez in two different rounds for low blows. Randall also scored an 11th round knock down that Chavez and his camp claimed was a slip. However, that knockdown turned out to be the difference in the fight by one point on one judge's card, to have Randall's hand raised in victory.
Randall became an even more massive favorite son in East Tennessee after the Chavez win. That's where, he had followed in the footsteps of former Knoxville native and early 80s, WBA World Champ "Big John" Tate.
Just four months after the upset, Randall and Chavez had another controversial rematch that Randall was actually winning until an accidental butt cut Chavez and the fight was stopped for a technical decision in the eighth round.
There was also an obscure rule from the WBC that Randall had to be penalized for the accidental butt stopping the fight and the judges were then to score the 8th round. And because of that deduction, one judge's card flipped in favor of Chavez to win on an 8 round technical split decision and regain his title.
Randall captured the WBA version of the 130 lb. title in his next fight and defended it twice before losing it.
Unfortunately, for Randall those two losses signaled a downward spiral, where he not only repeatedly lost but was being knocked out or stopped over and over, again. At one point in the late 90s and early 2000s, Randall lost seven fights in a row most by KO. He suffered KO or stoppage in four defeats in his final five fights before before finally retiring in July of 2005.
He finished with a 58-18-1 record.
Those KO losses coupled with his known drug and alcohol abuse later in his career and post boxing life contributed to his mental problems.
Randall's son had given an interview with Ring TV earlier this year saying that his father was in dire mental and physical situation in the Tennessee facility that said in part,
"It has been hard to watch my father become a shell of what he used to be. It almost seems like he is stuck in time. I feel like he will wake up and be his normal self again, but that is not the case – this is a new fight. People will remember Frankie Randall the boxer, but it's my dad, my hero, just sitting there, slowing down. It's been a challenge, and the challenge has become my fight."
The same fighting spirit that made Frankie Randall a three time World Champ.
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Let's be honest: A sales activity tracker sounds like micromanagement.
Used a certain way, it can be. Tracking sales activities for the sake of monitoring every rep every moment of every day is definitely micromanagement.
But sales activity management gives a new meaning to sales activity tracking. Instead of using it to control sales behaviors, sales activity management uses tracking to guide selling and coaching.
The new sales activity tracker – often referred to as a sales scorecard – helps motivate selling activities that lead to closing business.
Which sales activities are worth tracking?
With activity-based selling, you can identify the key sales activities you should be tracking.
Let's say you run a field sales team, and you've defined the key steps of your sales process as new opportunities, face-to-face meetings, VP-level conversations and wins. These are your activity metrics. Use conversion rates between each step of the process to calculate how much of each activity you need to achieve quota. Then take it a step further to divide the total number of activities among your sales team, and assign individual metric goals.
Now you've got strong goals in place. Time to start tracking.
Activity goals for the entire quarter or year can be intimidating. But a sales activity tracker breaks down that data by week or month, making them much more achievable. In a sales activity management system, the tracker automatically logs activities so reps stay up-to-date on progress to goals.
Modern sales leaders are embracing this type of sales activity tracker. Here are six compelling reasons why.
1. A sales activity tracker creates transparency around key sales metrics.
From top to bottom and across all teams, alignment is critical. When sales leaders report on close ratio or MRR, but the executive team focuses on total contract value, the entire company suffers from misalignment. How can anyone understand how the company performs if no one speaks the same language?
A sales activity tracker keeps individual and team goals at the forefront. This keeps everyone aligned around the most important initiatives and helps demonstrate how daily activities roll up to large company goals.
2. A sales activity tracker helps onboard new hires faster.
Even the most talented sales reps need time to understand your company's specific sales process. According to CSO Insights, more than 40 percent of sales teams report a ramp-up time of more than 10 months. That's almost a year before sales reps become fully productive.
When equipped with a sales activity tracker, new reps understand exactly what activities they need to do now to hit their quota in three months. They aren't left to find a path to success through trial-and-error. The sales activity tracker guides them to the next appropriate selling steps, decreasing their overall ramp time. Paycor cut their sales onboarding time down from six months to three using the LevelEleven sales activity management system.
3. A sales activity tracker cuts through day-to-day noise with visibility into what matters.
Salespeople are busy. They get lost in the day-to-day noise of responding to emails, crafting perfect pitches and handling support requests. Reps want to close deals just as much as you do, but sometimes they experience difficulty prioritizing tasks. That's why sales leadership must create focus for reps around the activities that lead to closing business.
With a sales activity tracker, the most important day-to-day tasks for each sales role stay top of mind. They understand that those 3-4 activities almost always take precedence above other tasks. This enables reps to efficiently prioritize their time.
4. A sales activity tracker improves decision-making for each salesperson on where they spend time.
Many salespeople get laser-focused on activities at the bottom of the funnel. It makes sense. They want to close deals and bring in revenue for the company. But that often leads to little time for top-of-the-funnel activities like prospecting and qualifying leads.
In addition to driving focus around the right selling activities, the sales activity tracker informs reps exactly how much of each activity they need throughout the funnel. It alerts reps when they fall behind pace to goal and tells them what to do to get back on track.
5. A sales activity tracker enables real-time course correction.
Reports and dashboards tell you what has already happened after the month, quarter or year is over. Sure, you might be able to use that information to guide future actions. But wouldn't it be nice to have this data before it was too late to do anything about it?
A real-time sales activity tracker does just that. The system tracks and reports data in real time, so your sales leaders know exactly when performance falls out of line and what they need to do about it. If the entire team falls behind on a metric, rally them around it with a quick contest or spiff. When an individual sales rep doesn't hit their activity goals, dig into the data to see where they struggle and might need coaching.
6. A sales activity tracker brings in more revenue.
When you know what activities lead to closing more business, you simply need them to happen more often. That's exactly what a sales activity tracker will do for you. Focusing rep efforts on those key activities makes them happen more often, which results in more revenue.
With a sales activity management system, Jackson SVP of national sales development Doug Mantelli saw more year-over-year activity with less salespeople. He explained to a panel at Dreamforce, sharing how sales activity levels for the entire organization increased 30 percent.
Want to learn how you could benefit from a sales activity tracker? Use our sales activity management calculator to find out!


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CKD and CKD-related mineral and bone disorders (CKD-MBDs) are associated with high cardiovascular and mortality risks. In randomized clinical trials (RCTs), no single drug intervention has been shown to reduce the high mortality risk in dialysis patients, but several robust secondary analyses point toward important potential beneficial effects of controlling CKD-MBD–related factors and secondary hyperparathyroidism. The advent of cinacalcet, which has a unique mode of action at the calcium-sensing receptor, represented an important step forward in controlling CKD-MBD. In addition, new RCTs have conclusively shown that cinacalcet improves achievement of target levels for all of the metabolic abnormalities associated with CKD-MBD and may also attenuate the progression of vascular and valvular calcifications in dialysis patients. However, a final conclusion on the effect of cinacalcet on hard outcomes remains elusive. Tolerance of cinacalcet is limited by frequent secondary side effects such as nausea, vomiting, hypocalcemia and oversuppression of parathyroid hormone, which may cause some management difficulties, especially for those lacking experience with the drug. Against this background, this review aims to summarize the results of studies on cinacalcet, up to and including the publication of the recent ADVANCE and EVOLVE RCTs, as well as recent post hoc analyses, and to offer practical guidance on how to improve the clinical management of the most frequent adverse events associated with cinacalcet, based on both currently available information and personal experience. In addition, attention is drawn to less common secondary effects of cinacalcet treatment and advisable precautions.
CKD is currently accepted as an independent cardiovascular (CV) and mortality risk factor (1). Multiple CKD-related derangements may account for the extremely high mortality observed in these patients (1) and, among these disturbances, CKD-related mineral and bone disorders (CKD-MBDs) seem to play an important role (1–3). Classic biochemical alterations of calcium (Ca), phosphate (P), Ca × P product, parathyroid hormone (PTH), and other bone-related biomarkers have been increasingly associated, although not uniformly, with prediction of bone disease and also with CV events and survival (2–5). On the other hand, it has been suggested that patients with CKD stages 3–5D, with known vascular or valvular calcifications, should be considered at the highest CV risk; therefore, it seems reasonable to use this information to guide the management of CKD-MBD (3,6–8). Nevertheless, the evidence from randomized clinical trials (RCTs) in dialysis patients is limited and contradictory results have been obtained on whether treatment of laboratory abnormalities or attenuation of the progression of calcifications actually affects mortality (3,9–14).
Drug interventions in RCTs aiming to correct anemia or dyslipidemia have not been proven to increase survival in this population, and controversial or only nominally significant secondary end points have been described with P binders such as sevelamer or lanthanum (9,15). A recent meta-analysis promoted debate on this issue, overriding the negative results of previous meta-analyses (15,16). Significant and robust but questionable associations with improved survival have been described with both vitamin D derivatives and calcimimetics in retrospective cohort studies in dialysis patients (17–21).
Against this background, this review aims to summarize the results of studies on cinacalcet in the context of the complex CKD-MBD up until the publication of the recent ADVANCE (A Randomized Study to Evaluate the Effects of Cinacalcet Plus Low-Dose Vitamin D on Vascular Calcification in Subjects with CKD Receiving Haemodialysis) and EVOLVE (Evaluation of Cinacalcet Therapy to Lower CV Events) trials and to offer practical guidance on potential ways to improve the clinical management of most frequent secondary effects associated with cinacalcet, based on both the currently available information as well as our own personal experience.
Although there may be debate over whether CKD-MBD is really a syndrome (22), CKD-MBD has been defined as a trinity of laboratory and bone abnormalities and vascular (or other soft tissue) calcification, all of which are linked to hard outcomes such as fractures, CV morbidity, and mortality (3,23). This concept has been accepted by various national and international societies striving to improve outcomes (3,6,7).
In CKD, the failing kidneys disrupt the complex pathophysiologic regulation of Ca, P, vitamin D metabolism, fibroblast growth factor 23 (FGF23), and other as-yet-unidentified molecules, leading to secondary hyperparathyroidism (SHPT) (24). From the early CKD stages, FGF23 production is increased in response to several stimuli, including P retention and klotho reduction. The hyperphosphaturic effects of PTH and FGF23 are compromised by reduced PTH receptor and klotho expression, at least partially explaining the presence of resistance to PTH and FGF23 in CKD (24). Chronic overstimulation of PTH causes a progressive polyclonal parathyroid gland hyperplasia, which may later transform into a benign, tumor-like monoclonal growth (24).
The excessive production of PTH increases bone resorption and leads to classic osteitis fibrosa (25). However, in other situations, the initial increase in PTH and bone remodeling may be excessively slowed by a multitude of factors leading to low bone turnover or adynamic bone disease (ABD) (5). Both high and low bone turnover bone diseases are associated with a high risk of skeletal fractures and poor clinical outcomes (3,25).
The increase in circulating Ca × P product, as well as the active transformation of vascular smooth muscle cells into osteoblast-like cells, favors the development of CV calcification, arterial stiffness, and CV diseases (3,8,22). Thus, the old well known relationship between kidney disease and bone ("renal osteodystrophy") is now extended to a new bone–vascular axis (23,26), and bone has even been recently considered as a new endocrine organ at the heart of CKD-MBD (27).
Traditional therapies for SHPT have entailed correction of hypocalcemia and excessive synthesis and secretion of PTH by administration of Ca salts and vitamin D derivatives, as well as prevention of hyperphosphatemia by means of Ca- or aluminum-containing P binders or, only recently, nonmetal-containing P binders (24). However, these therapies are limited by the occurrence of hyperphosphatemia and hypercalcemia, by a lack of specificity, and by limited long-term efficacy. On the other hand, surgical parathyroidectomy is not exempt from important, sometimes neglected, risks, as recently reported (5,28). Fortunately, with the advent of calcimimetics, enormous progress has been made in extending the armamentarium against SHPT, although we acknowledge that there is insufficient high-grade evidence on whether any treatment or a combination thereof should be preferred to control SHPT in dialysis patients (29,30).
Cloning of the calcium-sensing receptor (CaR) led to the discovery of several compounds capable of modulating its function in different organ tissues (31,32). Type I calcimimetics mimic the effects of extracellular calcium (eCa2+) and type II calcimimetics act as allosteric activators of the CaR, changing its structural conformation and stereoselectively increasing sensitivity to eCa2+. Cinacalcet hydrochloride (AMG-073) belongs to the second generation and is the only approved calcimimetic. By increasing the sensitivity of the CaR to eCa2+, cinacalcet shifts the Ca-PTH concentration-response curves to the left and reduces the "set point" for Ca-regulated PTH secretion (31–33). Cinacalcet decreases the secretion of PTH in a dose-dependent manner and diminishes serum Ca concentration by mechanisms that are discussed below. Consequently, cinacalcet is currently indicated for the treatment of SHPT in dialysis patients and is shown to reduce hypercalcemia in patients with parathyroid carcinoma and in selected cases of primary hyperparathyroidism (34,35). AMG-416 is currently in development and represents a novel, third-generation intravenous long-acting selective peptide agonist of the CaR (36,37).
Cinacalcet is not indicated in patients with CKD who are not on dialysis. Investigational studies have shown that cinacalcet increases the risk for hypocalcemia, which may be attributable in part to lower baseline Ca levels, the presence of residual renal function, and the use of an inappropriate high dose of cinacalcet for often mild SHPT (34,35,38,39). In these patients, increased levels of P associated with decreased P urinary excretion have also been described (38,39). Preliminary studies have shown that cinacalcet has been successfully used to control hypercalcemia in patients with CKD and autonomous hyperparathyroidism (40,41).
In renal transplant patients, several reports and a recent RCT showed that cinacalcet effectively corrected the hypercalcemia and hypophosphatemia associated with persistent hyperparathyroidism (42,43), although no beneficial effect was observed in the percent change in bone mineral density (43).
Phase 1 and phase 2 studies in dialysis patients with SHPT demonstrated the efficacy of cinacalcet in reducing circulating levels of laboratory abnormalities such as PTH, Ca, P, and the Ca × P product. The combined results of RCTs and phase 4 studies confirmed these results (11,13,21,44–58) (Table1), among other benefits, including a substantial reduction of the elevated bone formation rate/tissue area, generally improving bone disease (57,58). Importantly, two recent prospective RCTs evaluated both the efficacy of cinacalcet in preventing the progression of CV calcifications (ADVANCE) (11), and its effect on clinical outcomes, including all-cause mortality and CV events (EVOLVE) (13).
First, the ADVANCE trial suggested that cinacalcet plus low doses of vitamin D may attenuate the progression of coronary, aortic, and valvular calcification compared with flexible vitamin D therapy (11). Although significant changes in the volume of coronary artery calcifications were described, the predefined primary end point of the study (Agatston score or surface of coronary artery calcification) did not strictly reach statistical significance (Table 1). In a recent post hoc analysis, treatment with cinacalcet was found to have statistically significant beneficial effects among participants who adhered to the prespecified protocol (12).
Second, the EVOLVE RCT did not reach its clinical primary composite end point after an unadjusted intention-to-treat (ITT)–based analysis (Table1) (13). These results were supported by a recent meta-analysis, mainly driven by this negative EVOLVE primary result, which included other heterogeneous studies with different designs (59). Thus, a recent European Renal Association–European Dialysis and Transplant Association position statement did not recommend the routine use of calcimimetic therapy to improve survival in patients with CKD stage 5D and biochemical evidence of SHPT (30). Nonetheless, we believe that it is important to emphasize that prespecified secondary ITT analysis adjusting for baseline covariates revealed a nominally significant improvement in the cinacalcet group (Table 1) (13). The effect of cinacalcet was more pronounced among older patients (13) and was significant in post hoc analysis (hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.60 to 0.81; P=0.01) (60). This finding is probably attributable to differences in underlying CV risk leading to a higher frequency of events in patients aged ≥65 years, an effect that has also been shown in other RCTs with other CKD-MBD–related drugs (9,15), or differential application of cointerventions that reduce PTH (60). Lag-censoring and other sensitivity analyses, including an inverse probability of censoring weighted analysis, were performed in the EVOLVE study to account for biases that may have been introduced due to drop-outs (individuals who discontinued the study drug before an end point or the end of the study but were statistically analyzed as having received cinacalcet throughout). These prespecified companion analyses suggested a nominal beneficial effect of cinacalcet on the primary composite end point (13), but their interpretation is too controversial beyond allowing generation of new hypotheses (30). Accepting the limitations of post hoc analysis, patients randomized to cinacalcet experienced fewer nonatherosclerotic CV events (including sudden death and heart failure) (HR, 0.84; 95% CI, 0.74 to 0.96; P=0.01) (61). Finally, nominally significant decreases in incidence of the need for parathyroidectomy, episodes of calciphylaxis, and clinically reported fractures were also observed in the cinacalcet-treated group in the EVOLVE study, among other positive secondary and post hoc analyses (13,62).
Several important factors could have seriously hindered the interpretation of the primary end point of the EVOLVE study (63,64), especially the excessive rate of drop-ins (19.8% of patients [annual rate 7.4%] randomized to standard of care plus placebo finally received commercially available cinacalcet but were analyzed as having received placebo throughout the study according to the ITT principle) and drop-outs (62% of patients [annual rate 27.3%]). These problems render the EVOLVE study an inconclusive trial (re-estimated statistical power of only 54%); thus, cinacalcet has not formally been proven to improve all-cause or CV mortality in dialysis patients (30), but neither has a positive effect been formally ruled out.
Previous meta-analyses have confirmed that calcimimetic treatment effectively improves significant biochemical parameters of SHPT and enables more patients to achieve common targets (65,66). Other studies and meta-analyses have confirmed that cinacalcet has a significant beneficial effect in preventing parathyroidectomy and hypercalcemia (13,49,59,65–69), but these studies also found that cinacalcet increases nausea, vomiting, and hypocalcemia, with relative risks of 2.02 (95% CI, 1.45 to 2.81), 1.97 (95% CI, 1.73 to 2.24), and 6.98 (95% CI, 5.10 to 9.53), respectively (59). Therefore, these are the problems that nephrologists encounter more frequently with the clinical use of cinacalcet, together with PTH oversuppression (5).
For all of the reasons mentioned above, cinacalcet may not be warranted in all dialysis patients and it cannot be recommended to improve survival (30), but it remains an important and potent prescription for controlling moderate to severe SHPT according to guidelines (3,6,7). Cinacalcet unquestionably improves the achievement of target levels for all metabolic abnormalities associated with CKD-MBD (Table 1). Thus, some national and international guidelines, including the Kidney Disease Outcomes Quality Initiative (KDOQI) US commentary on the 2009 Kidney Disease Improving Global Outcomes (KDIGO) guideline, suggest that the primary choice of an antiparathyroid treatment may be based on basal levels of Ca and P (3,6,7,70). Consequently, in patients with SHPT and nonpharmacological hypercalcemia (tertiary hyperparathyroidism) or in those prone to hypercalcemia, calcimimetics are currently often used as first-line treatment. Calcimimetics may also allow safer concomitant use of active forms of vitamin D (68), also covering their attributed pleiotropic effects. Similar reasoning may be followed in patients with SHPT and hyperphosphatemia, as discussed below (71).
Although a final conclusion on the effect of cinacalcet on hard relevant outcomes remains elusive (30,71), the use of cinacalcet may be fully justified at least as a component of a multitargeted intervention in dialysis patients with SHPT, including P binders and vitamin D (71). Furthermore, in experimental conditions, the possibility of a crossed positive, bidirectional and additive interaction between calcimimetics and vitamin D derivatives has been described (72,73). Such an interaction is probably mediated by the heterologous upregulation of the parathyroid vitamin D and Ca receptors (72,73). An ITT analysis is mandatory to establish the universal applicability of results observed in the studied population; however, from the perspective of the individual patient, it may be much more important to know whether cinacalcet can be taken without side effects and whether the benefits that it offers in terms of increased survival and other important clinical outcomes justify the associated risks (64). Therefore, practical guidance regarding potential improvements in management of the most frequent secondary effects is definitely needed.
Gastrointestinal adverse events (mostly nausea and vomiting but also diarrhea, among others) are the secondary effects most frequently associated with cinacalcet. The vast majority of episodes of nausea and vomiting are mild to moderate in severity and transient in nature (34,35,46,47,74). Although such episodes are not usually a cause of treatment withdrawal and a dose reduction often proves sufficient, it is also the case that discontinuation of therapy as a result of undesirable effects is mainly attributable to nausea (1% placebo; 5% cinacalcet) and vomiting (<1% placebo; 4% cinacalcet). These gastrointestinal adverse events add to the common digestive secondary effects of other agents given for the control of CKD-MBD, such as P binders (3,9). In the Summary of Product Characteristics (SmPC) (34), the reported incidence of nausea is 31% in cinacalcet-treated patients versus 19% in placebo-treated patients, and the comparable rates for vomiting are 27% versus 15%, respectively (34).
The mechanisms by which cinacalcet induces nausea and vomiting are still not well identified. It has been suggested that cinacalcet may stimulate the CaR present in the hypothalamus and other brain regions controlling vomiting (75). It also seems that nausea and vomiting may be a consequence of a direct effect of cinacalcet on the gastrointestinal CaR; however, gastrointestinal and pancreatic enzymes do not appear to be uniformly modified by cinacalcet (76,77).
It cannot be forgotten that the availability of cinacalcet increases by approximately 50%–80% with food; consequently, it is recommended that cinacalcet be administered with food or shortly after a meal (34,35,74). With a view to reducing nausea and vomiting (74), in the study to investigate cinacalcet treatment in hemodialysis patients with secondary hyperparathyroidism (SENSOR) study, we investigated the effect of administration of cinacalcet with the first main meal after dialysis and found that this improved its efficacy and tolerance. In our study, the rate of treatment discontinuation due to nausea and vomiting was low (2.5% of patients overall), and only a 1% withdrawal rate was reported in the postdialysis meal group. For unclear reasons, the incidence of gastrointestinal adverse events in the SENSOR study also appeared to be lower when cinacalcet was administered in the evening; this was possibly related to distinct geographic dietary habits, chronobiology, or a potential timing effect rather than a food effect (74).
Although nausea and vomiting may appear after an initial 30-mg single dose, there is a clear dose dependence in the frequency of these symptoms. The mean dose in the SENSOR study was 67 mg/d in the postdialysis meal group, which is lower than the doses in phase 3 trials although patients had more severe disease (mean PTH 840±766 pg/ml). In the EVOLVE study, the median daily dose was 55 mg for a median PTH of 695 pg/ml for the same targets. It is necessary to remember that 180 mg/d is the maximum dose recommended in the SmPC (34,35). Taken together, these findings suggest that an earlier intervention with cinacalcet may allow lower doses and decrease the potential for secondary effects.
If only mild/moderate nausea and vomiting are present, cinacalcet should not be immediately withdrawn because symptoms may diminish with time. Obviously, when symptoms appear after increasing previous doses, a similar approach can be utilized and, if symptoms do not abate, reduction to the previous tolerated dose is often sufficient. Rapid escalations of cinacalcet doses should also be avoided, and intermediate doses (e.g., 15 mg/d, 30–60 mg/60–90 mg every other day) have also been successfully used for clinical control in both primary hyperparathyroidism and SHPT (33,40), although this practice is not specified in the SmPC (34,35). It is often forgotten that in primary hyperparathyroidism, cinacalcet is indicated twice a day (34,35,41).
Antiemetic drugs, mainly metoclopramide, have long been used but many antiemetic gastroprokinetic drugs, including domperidone, cisapride, or ondansetron can affect the electrocardiographic QT interval (http://www.QTdrugs.org or http://www.sads.org.uk/drugs_to_avoid.htm). In November 2014, metoclopramide was added to the combined list of drugs that can affect the QT interval. Although cinacalcet is not on this list, hypocalcemia can prolong the QT interval (see below).
A summary of the measures that may be taken to control nausea and vomiting is presented in Table 2.
As a consequence of its unique mode of action, cinacalcet may cause hypocalcemia instead of the hypercalcemia associated with vitamin D derivatives (3,17,24,29,68). The decreases in serum Ca levels mainly occur during the first 2 weeks of treatment and are significantly greater among patients with relatively higher baseline or pretreatment PTH values. By contrast, demographic factors do not materially influence the Ca-lowering effect of cinacalcet. The use of concurrent therapies such as Ca-containing medications, vitamin D sterols, and dialysate Ca content may modify the effect of cinacalcet in decreasing serum Ca levels (78).
The mechanism responsible for these reductions in serum Ca levels is not fully understood, but alterations in the exchange of Ca between the extracellular fluid and a miscible pool of Ca in bone are probably responsible (31,79), especially in the absence of substantial residual kidney function. Ca levels will thus be affected significantly when plasma PTH levels are lowered abruptly by enhanced activation of the CaR and the secondary decrease of bone turnover by cinacalcet (58). Two other potential mechanisms may favor calcimimetic-induced hypocalcemia: (1) stimulation of the CaR in the thyroid C cells and the secretion of calcitonin and (2) inhibition of the intestinal Ca transporter protein TRPV6 (80,81).
Consequently, when using cinacalcet, it is recommended to pay attention to the rare appearance of symptomatic hypocalcemia (including paresthesias, numbness, tingling, myalgias, or cramping) and to monitor serum Ca levels frequently, especially soon after the initiation of treatment and whenever a dose increase is prescribed. According to the SmPC, serum Ca levels should be monitored within 1 week after initiation or dose adjustment of cinacalcet (34,35). Once the maintenance dose has been established, serum Ca is usually measured monthly. Initiation of cinacalcet is contraindicated when the corrected serum Ca is below the lower limit of the normal range (usually 8.4 mg/dl). However, during the maintenance phase, lower levels do not necessarily imply a need for modification of the cinacalcet dose. In fact, hypocalcemia, defined as a corrected Ca <8.4 mg/dl at two consecutive determinations, has been reported in up to 45% of patients, but it was almost always asymptomatic and caused treatment withdrawal in <1% of patients (51,74). In patients with CKD who were receiving dialysis and were administered cinacalcet, 4% of serum Ca values were undesirably lower than 7.5 mg/dl (34). Approximately 30% of patients have at least one serum Ca value <7.5 mg/dl (35). In patients with CKD receiving dialysis who were administered cinacalcet, 29% of those in the 6-month registration trials and 21% and 33% of those (within the first 6 months and overall, respectively) in the EVOLVE clinical trial had at least one serum Ca value <7.5 mg/dl (13). A continuous risk analysis showed a 10% increase in HR for mortality for a noncorrected serum Ca as low as <6.37 mg/dl but also for serum Ca >9.66 mg/dl (82).
Manifestations of severe hypocalcemia may include muscle spasms, tetany, and seizures. These life-threatening events and fatal outcomes have been reported in adult and pediatric patients treated with cinacalcet, and this information is currently included in the new package insert (35). Cinacalcet is not indicated for use in children and adolescents, because of a lack of data on safety and efficacy. A fatal outcome was reported in a pediatric clinical trial patient with severe hypocalcemia, and caution is advised in patients with other risk factors for QT prolongation (see below) (35). Other uncommon drug interactions (mostly with infrequently used drugs) should also be taken into account when using cinacalcet (Table 3).
It should be noted that although symptomatic hypocalcemia is extremely rare, caution is recommended to avoid severe hypocalcemia (i.e., <7.5 mg/dl); in those at risk, the administration of cinacalcet should therefore be withheld until serum Ca levels reach 8 mg/dl. Despite their inclusion in the SmPC (Table 4) (35), we do not recommend the use of "prophylactic" Ca-based P binders or an increment in the Ca content in the dialysate because these options are untested and in fact may be harmful, given that undesirable Ca deposition cannot be excluded.
It is important to consider that in order to properly evaluate PTH levels, PTH should be measured at least 12 hours after dosing with cinacalcet because a rapid nadir for PTH concentration occurs approximately 3 hours after dosing (34,35,83). PTH should be measured 1–4 weeks after initiation or dose adjustment of cinacalcet and every 1–3 months during maintenance (34,35). Treatment with cinacalcet apparently does not alter the relationship between intact and bioactive PTH (34,35), although this issue may need to be revisited in light of the recent description of a lower ratio of whole/intact PTH in cinacalcet users versus nonusers with comparable levels of serum Ca (84).
Studies have found that approximately 19% of patients may show levels of intact PTH below the classic 150 pg/ml target (53,85), and cases of ABD have been confirmed after cinacalcet treatment and chronic low PTH levels (57,58). Low as well as high PTH levels have been associated with decreased survival in dialysis patients; consequently, both "extremes of risk" should be avoided. Thus, current KDIGO guidelines recommend maintaining intact PTH levels at 2–9 times the upper limit of normality for a particular PTH assay, although any tendency within these limits should also be taken into account (3). It must be emphasized that a significant proportion of patients with such intermediate PTH levels present quite different rates of bone remodeling, ranging from adynamic to normal to high turnover bone disease (25). Therefore, the clinical use of PTH (PTH monitoring and goals) is controversial (86,87). Nevertheless, because maintenance of appropriate PTH levels remains one of the main goals in contemporary nephrology practice, it probably should be monitored not only on a regular basis but also more frequently, at least until more specific new biomarkers and/or drugs with different targets demonstrate clinical superiority over current standard nephrology protocols (4,30).
It is also important to emphasize that classic US KDOQI limits between 150 and 300 pg/ml have been associated with improved survival in at least two different populations (88,89). Therefore, some authors and guidelines continue to recommend these "old" targets, or even lower ones (90), although a correction of PTH values for the kit utilized is currently advised in order to take into account the great variability in PTH assays (i.e., approximately 2–5 times the upper limit of normality for a particular PTH assay) (6,7,91–93). Consequently, the KDIGO target range for serum PTH in dialysis patients may be considered too broad, and a narrower range is still preferred by some (6,7,92,93). Recent changes in therapeutic approaches leading to increasing PTH levels have been documented in a recent analysis of the Dialysis Outcomes and Practice Patterns Study (DOPPS), where it was also shown that compared with PTH of 150–300 pg/ml, in adjusted models, all-cause mortality risk was higher for PTH of 301–450 pg/ml (HR, 1.09; 95% CI, 1.01 to 1.18) and >600 pg/ml (HR, 1.23; CI, 1.12 to 1.34) (94). In any case, general agreement seems to exist that oversuppression of PTH levels to below 2 times the upper limit of normality should be avoided, owing to the fear of inducing ABD and its potential detrimental consequences (5). Very low PTH (<50 pg/ml) was also associated with mortality in the recent DOPPS publication (94).
When PTH decreases below target levels, it is generally suggested that Ca-based P binders should be avoided and the doses of vitamin D and/or calcimimetics should be reduced (3,5–7). Treatment-induced low PTH is reversible and does not seem to represent an acute problem. The dose of Ca-based P binders can be decreased or substituted with non–Ca-based P binders in other to maintain control of serum P levels (5). The preferential adjustment of vitamin D doses should be considered when low PTH levels are associated with hypercalcemia and/or increased serum P. Some authors also prefer this approach if there is evidence of vascular/valvular calcification, in accordance with the results of the ADVANCE study (8,11). In fact, in the presence of low PTH levels or if active forms of vitamin D are withdrawn for any reason, supplementation with native vitamin D to correct vitamin D deficiency may be considered (5–7,17).
On the other hand, we consider reducing cinacalcet only if both Ca and PTH levels are low (see the section on hypocalcemia), and we do not abruptly discontinue cinacalcet unless symptomatic or significant hypocalcemia develops. Once PTH increases above the desired target, restarting cinacalcet at the next lowest dose is the usual approach, taking into account the other components of CKD-MBD (3).
Finally, it is also important to emphasize that cinacalcet therapy should not be discontinued when PTH target levels are reached (in the fear that a continuously decreasing PTH could lead to low PTH) because PTH levels will rebound after treatment withdrawal. There are obvious parallels with other conditions such as dyslipidemia, hypertension, and anemia, in which there would be no question that abrupt cessation of treatment when targets have been reached would be inappropriate. However, some fine adjustment may ultimately be required, and it has been suggested that cinacalcet doses may be decreased after long-term treatment in some circumstances perhaps due to regression of the parathyroid hyperplasia and/or apoptosis induction (95,96).
Cinacalcet is not on the combined list of all drugs that can affect the electrocardiographic QT interval or the list of drugs to be avoided by patients with congenital long QT syndrome. Decreases in serum Ca concentration can prolong the QT interval, potentially resulting in ventricular arrhythmia, several cases of which have been reported in patients treated with cinacalcet during the postmarketing period (35); this information has been included in the most recent SmPC, although frequencies cannot be estimated from available data (34). Thus, although a QT evaluation is not mandatory, QT evaluation is advised in high-risk patients (e.g., those with a familial history, bradycardia, recent cardiac ablation, hypokalemia, hypomagnesemia, etc.).
Cinacalcet has also been associated with decreasing levels of P in dialysis patients, although this is not a uniform finding and is probably linked to the severity of SHPT (55,56,77,97). In a recent study, the P-lowering potential of cinacalcet was secondarily evaluated using data from a pan-European study (55,97). PTH was a key predictor of serum P reduction and regression analysis confirmed a significant 3% overall decrease in serum P for every 10% reduction in PTH. The authors concluded that serum P reduction appeared to result mainly from PTH reduction, rather than from changes in vitamin D or P binders (97). This subgroup probably represents those patients with the highest bone-derived P load. Decreasing levels of FGF23 have also been described with cinacalcet and AMG-416 (36,98). This possible mechanism for a beneficial effect of cinacalcet on vascular calcification and CV outcomes awaits further investigation, as well as other off-target effects of cinacalcet that cannot be just neglected (74).
Other common undesirable reported effects of cinacalcet include asthenia, anorexia, dizziness, headache, dyspepsia, constipation, diarrhea, abdominal pain, upper respiratory infection, dyspnea, cough, and hyperkalemia. Although most of these effects could not be directly attributable to cinacalcet treatment, the contribution of cinacalcet could not be excluded based on best-evidence assessment of causality (35).
Seizures (convulsions) were found to occur in 1.4% of cinacalcet-treated patients versus 0.7% of placebo-treated patients (35). Although the basis for the reported difference in seizure rate is not clear, it is known that the threshold for seizures is lowered by significant reductions in serum Ca. In the EVOLVE study a nonsignificant trend toward an increase in the crude incidence of seizures was observed in the cinacalcet-treated group (2.5% versus 1.6%) (13). In any case, cinacalcet must be used with caution in patients with seizures, and hypocalcemia should be avoided in these cases. Other nervous system disorders such as tingling, numbness, and paresthesias, which are frequent in dialysis patients, were observed to be significantly higher in the cinacalcet-treated group in the EVOLVE study (36.7% versus 30.5%; P<0.01) (13).
Testosterone levels are often below the normal range in patients with ESRD. In a clinical study, free testosterone levels decreased in cinacalcet-treated patients (34,35), but the clinical significance is unknown.
Clinical trial data showed that hypotension occurred in 7% of cinacalcet-treated patients versus 12% of placebo-treated patients, and heart failure occurred in 2% of patients receiving cinacalcet or placebo (35). In postmarketing safety surveillance, isolated, idiosyncratic cases of hypotension and/or worsening heart failure have been reported in patients with impaired cardiac function, but a causal relationship with cinacalcet could not be established. On the other hand, the HR of heart failure in the EVOLVE study was nominally significantly lower in the cinacalcet-treated group (0.72; 95% CI, 0.58 to 0.89; P=0.003) (13).
In the postmarketing experience, allergic reactions including rash, urticaria, angioedema, and leukocytoclastic vasculitis have been described (34,35). Cinacalcet should be used with caution in patients with moderate to severe hepatic impairment, because of the potential for 2- to 4-fold higher plasma levels of cinacalcet. No change in starting dose is necessary. Finally, patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption should not take cinacalcet, in accordance with the SmPC (35).
In summary, CKD-MBD is associated with a high risk of mortality. No single drug intervention has been shown to decrease this risk and improve survival in dialysis patients in any RCT, but several robust secondary analyses point toward potential important beneficial effects of controlling SHPT with cinacalcet in addition to standard therapy, whenever it is tolerated. An improvement in the management of common cinacalcet-related secondary effects such as nausea and vomiting, hypocalcemia, and PTH oversuppression is absolutely plausible, while new drugs and studies on hard outcomes become available.
J.B. has received speaking honoraria from AbbVie, Amgen, Genzyme, and Shire; fees as a consultant for AbbVie, Amgen, Vifor, and Genzyme/Sanofi; and a research grant from AbbVie. P.U. reports personal fees and grants from Amgen, AbbVie, Genzyme-Sanofi, Hemotech, and Fresenius. M.C. reports lecture honoraria from AbbVie, Shire, Amgen Genzyme, and Roche and research grants from AbbVie and Shire.
J.B. belongs to the Spanish National Network of Kidney Research RedinRen (RD12/0021/0033), the Spanish National Biobank network RD09/0076/00064, and to the Catalan Nephrology Research Group Agency for Management of University and Research Grants 2014 SGR-1441, and collaborates with the Spanish Fundación Iñigo Alvarez de Toledo.


Homelessness has become a silent epidemic in America. Today, more families find themselves without an adequate place to live or sustenance to sustain them. Nevertheless, America is still considered by many as the richest country in the world. This is not acceptable.
We Feed the Homeless Philly is of the opinion that history will judge us by the character of our actions. Therefore, we are unable and unwilling to ignore the plight of the human condition and pledge to take those steps necessary to enrich the livelihood of America's homeless by providing nutritious sustenance. Moreover, we shall respond to this emergent situation with due diligence, and in such a way that America's homeless are treated with the utmost dignity and respect. Lastly, we remain prayerful that our deeds are recognized for what they are, a sincere attempt to make positive contributions to the greater societal good.
We Feed the Homeless Philly is a non-profit grassroots organization focusing and servicing the food insecure and homeless population in the Philadelphia and surrounding area. As change agents, our work includes: volunteering, mentoring, and educating to empower our community.
If you would like to donate to We Feed the Homeless Philly, please use the donate button below. It is with your help that we are able to continue our mission. Thanks for all that you do!
It's that time of the year again...you can make We Feed the Homeless Philly the recipient of your Combined Federal Campaign Donation. We are on the donator's list of the Combined Federal Campaign also known as CFC. If you are a Federal Employee or know someone who is, donations can now be made through the annual CFC Campaign in the Philadelphia and surrounding areas. The CFC# is 28824.


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#EstamosAqui: The Pride & Pain of This Year's Parade
By Nancy A. Ruffin
Puerto Rican flags waved proudly along Fifth Avenue this past Sunday, June 10, 2018 at the 61st National Puerto Rican Day Parade. Despite the devastation that Puerto Rico has endured this past year, for many attendees (including myself) it was important to come together in solidarity and strength as a community. The parade which has traditionally been a celebration of our people, our culture, and our contributions to this country had a different purpose this year. Many of the floats and attendees used their voices and platforms to shed light on the ongoing recovery, rebuilding, and renewal efforts in Puerto Rico.
It's been nine months since Hurricane Maria wreaked havoc on the island destroying everything in its path. The island's infrastructure, already shaky after years of neglect, was devastated. Almost a year later, there are almost 7, 000 homes and businesses still without power and thousands of displaced families trying to recover and rebuild what Maria destroyed. For many of us in the diaspora, when Hurricane Maria hit, we did all we could to help our people on the island. Whether it was through fundraising, collecting food, water, and medical supplies, or merely sharing information about survivors and connecting them with loved ones we all did what we could. Which was why it was important that our participation in this year's parade reflected the ongoing plight of our people.
As the Capicu float turned onto Fifth Avenue it was extremely difficult to make our way down the parade route without thinking about what so many of our people have lost; their homes, their belongings, their loved ones, and for some their mental health. For the survivors trying to rebuild, the psychological impact of losing everything isn't something that is at the forefront of discussions when talking about the Hurricane Maria aftermath. In fact, in an article in The National Geographic Magazine, psychologist Domingo Marqués, said "The storm takes away the foundations of society. Everything you thought gave you certainty is gone. You see people anxious, depressed, scared." Marqués estimates that 30 to 50 percent of the population is experiencing post-traumatic stress disorder, depression, or anxiety. No one knows what the lasting effects of the hurricane will have on the mental health of survivors.
Moreover, a recent Harvard study estimated that 4,645 Puertorriqueños lost their lives as a result of the Hurricane. When you consider the loss of everything you've worked your entire life for, coupled with the loss of loved ones the psychological effects can be devastating. And while the number of deaths being reported in the Harvard study are being challenged and may not be an accurate calculation of the total lives lost, neither is the 64 that the U. S. Government has cited as being the official death count. Whatever that number is, the fact remains that 1 too many people lost their lives due to the disregard and slow to action response of this country's administration. Our chant of four thousand, six hundred, forty-five (Estamos Aqui) was our way of honoring those who perished because of the negligence of this administration.
Power is in our people. Working together is love for our community , island and people. #estamosaqui be strong be proud be a leader
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We used our voices to spread awareness and to remind people we are here, we have always been here, and we will continue to be here even if this administration refuses to acknowledge us. The most difficult part of the day for me was talking with the displaced families and hearing first-hand what they experienced. From stories of drinking unclean water, to not knowing how they were going to feed themselves and their children, the stories were heart wrenching. They were also heartwarming because despite losing everything they haven't lost hope. They came to New York with nothing more than the clothes on their backs, not looking for a handout, but looking for a hand up and thanks to grassroots organizations like New York Disaster Interfaith Services (NYDIS) and WHY NOT CARE they received it. Whether it's helping them find housing, helping the children get enrolled in school, or helping them find employment these organizations are working directly with our people and helping them piece their lives back together. To help support the evacuees and the continued relief efforts you can donate to http://www.nydis.org
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