text:
How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength o
Int J Evid Based Healthc. 2008 Mar;6(1):78-110. doi: 10.1111/j.1744-1609.2007.00098.x.
Association between pacifier use and breast-feeding, sudden infant death syndrome, infection and dental malocclusion.
JBI Libr Syst Rev. 2005;3(6):1-33.
Impact of patient-centered discharge tools: A systematic review
J. Hosp. Med. 2017 February;12(2):77-82
By: Karen Okrainec, MD, MSc , Davina Lau, BSc, Howard B. Abrams, MD, Shoshanna Hahn-Goldberg, PhD, Ronak Brahmbhatt, MBBS, MPH, Tai Huynh, MBA, Kenneth Lam, MD, Chaim M. Bell, MD, PhD
OpenLab, University Health Network
Address for correspondence and reprint requests: Karen Okrainec, MD, MSc, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 8EW-432E, Toronto, Ontario, Canada M5T2S8; Telephone: 416-603-5800 x2141; Fax: 416-603-6495; E-mail: karen.okrainec@uhn.ca
Institute of Health Policy Management & Evaluation, University of Toronto, Institute for Clinical Evaluative Sciences, Department of Medicine, University of Toronto and Mount Sinai Hospital, Toronto, Canada
Patient-centered discharge tools provide an opportunity to engage patients, enhance patient understanding, and improve capacity for self-care and postdischarge outcomes.
To review studies that engaged patients in the design or delivery of discharge instruction tools and that tested their effect among hospitalized patients.
We conducted a search of 12 databases and journals from January 1994 through May 2014, and references of retrieved studies.
English-language studies that tested discharge tools meant to engage patients were selected. Studies that measured outcomes after 3 months or without a control group or period were excluded.
Two independent reviewers assessed the full-text papers and extracted data on features of patient engagement.
Data Synthesis
Thirty articles met inclusion criteria, 28 of which examined educational tools. Of these, 13 articles involved patients in content creation or tool delivery, with only 6 studies involving patients in both. While many of these studies (10 studies) demonstrated an improvement in patient comprehension, few studies found improvement in patient adherence despite their engagement. A few studies demonstrated an improvement in self-efficacy (2 studies) and a reduction in unplanned visits (3 studies).
Improving patient engagement through the use of media, visual aids, or by involving patients when creating or delivering a discharge tool improves comprehension. However, further studies are needed to clarify the effect on patient experience, adherence, and healthcare utilization postdischarge. Better characterization of the level of patient engagement when designing discharge tools is needed given the heterogeneity found in current studies. Journal of Hospital Medicine 2017;12:110-117. © 2017 Society of Hospital Medicine
Patient-centered care, defined by the Institute of Medicine as "health care that establishes a partnership among practitioners, patients, and their families to ensure that decisions respect patients' wants, needs and preferences and that patients have the education and support they need to make decisions and participate in their own care," has been recognized as an important factor in improving care transitions after discharge from the hospital.1 Previous efforts to improve the discharge process for hospitalized patients and reduce avoidable readmissions have focused on improving systems surrounding the patient, such as by increasing the availability of outpatient follow-up or standardizing communication between the inpatient and outpatient care teams.1,2 In fact, successful programs such as Project BOOST and the Care Transitions Interventions™ provide healthcare institutions with a "bundle" of evidence-based transitional care guidelines for discharge: they provide postdischarge transition coaches, assistance with medication self-management, timely follow-up tips, and improved patient records in order to improve postdischarge outcomes.3,4 Successful interventions, however, may not provide more services, but also engage the patient in their own care.5,6 The impact of engaging the patient in his or her own care by providing patient-friendly discharge instructions alone, however, is unknown.
A patient-centered discharge may use tools that were designed with patients, or may involve engaging patients in an interactive process of reviewing discharge instructions and empowering them to manage aspects of their own care after leaving the hospital. This endeavour may lead to more effective use of discharge instructions and reduce the need for additional or more intensive (and costly) interventions. For example, a patient-centered discharge tool could include an educational intervention that uses the "teach-back" method, in which patients are asked to restate in their own words what they thought they heard, or in which staff use additional media or a visual design tool meant to enhance comprehension of discharge instructions.6,7 Visual aids and the use of larger fonts are particularly useful design elements for improving comprehension among non-English speakers and patients with low health literacy, who tend to have poorer recall of instructions.8-10 What may constitute essential design elements to include in a discharge instruction tool, however, is not clear.
Moreover, whether the use of discharge tools with a specific focus on patient engagement may improve postdischarge outcomes is not known. Particularly, the ability of patient-centered discharge tools to improve outcomes beyond comprehension such as self-management, adherence to discharge instructions, a reduction in unplanned visits, and a reduction in mortality has not been studied systematically. The objective of this systematic review was to review the literature on discharge instruction tools with a focus on patient engagement and their impact among hospitalized patients.
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement was followed as a guideline for reporting throughout this review.11
A literature search was undertaken using the following databases from January 1994 or their inception date to May 2014: Medline, Embase, SIGLE, HTA, Bioethics, ASSIA, Psych Lit, CINAHL, Cochrane Library, EconLit, ERIC, and BioMed Central. We also searched relevant design-focused journals such as Design Issues, Journal of Design Research, Information Design Journal, Innovation, Design Studies, and International Journal of Design, as well as reference lists from studies obtained by electronic searching. The following key words and combination of key words were used with the assistance of a medical librarian: patient discharge, patient-centered discharge, patient-centered design, design thinking, user based design, patient education, discharge summary, education. Additional search terms were added when identified from relevant articles (Appendix).
We included all English-language studies with patients admitted to the hospital irrespective of age, sex, or medical condition, which included a control group or time period and which measured patient outcomes within 3 months of discharge. The 3-month period after discharge is often cited as a time when outcomes could reasonably be associated with an intervention at discharge.2
Studies that did not have clear implementation of a patient-centered tool, a control group, or those whose tool was used in the emergency department or as an outpatient were excluded. Studies that included postdischarge tools such as home visits or telephone calls were excluded unless independent effects of the predischarge interventions were measured. Studies with outcomes reported after 3 months were excluded unless outcomes before 3 months were also clearly noted.
All searches were entered into Endnote and duplicates were removed. A 2-stage inclusion process was used. Titles and abstracts of articles were first screened for meeting inclusion and exclusion criteria by 1 reviewer. A second reviewer independently checked a 10% random sample of all the abstracts that met the initial screening criteria. If the agreement to exclude studies was less than 95%, criteria were reviewed before checking the rest of the 90% sample. In the second stage, 2 independent reviewers examined paper copies of the full articles selected in the first stage. Disagreement between reviewers was resolved by discussion or a third reviewer if no agreement could be reached.
Data Analysis and Synthesis
The following information was extracted from the full reference: type of study, population studied, control group or time period, tool used, and outcomes measured. Based on the National Health Care Quality report's priorities and goals on patient and/or family engagement during transitions of care, educational tools were further described based on method of teaching, involvement of the care team, involvement of the patient in the design or delivery of the tool, and/or the use of visual aids.12 All primary outcomes were classified according to 3 categories: improved knowledge/comprehension, patient experience (patient satisfaction, self-management/efficacy such as functional status, both physical and mental), and health outcomes (unscheduled visits or readmissions, adherence with medications, diet, exercise, or follow-up, and mortality).
No quantitative pooling of results or meta-analysis was done given the variability and heterogeneity of studies reviewed. However, following guidelines for Effect Practice and Organisation of Care (EPOC) Risk of Bias criteria,13 studies that had a higher risk of bias such as uncontrolled before-after studies or studies with only 1 intervention or control site (historical controls, eg) were excluded from the final review because of the difficulties in attributing causation. Only primary outcomes were reported in order to minimize type II errors.
Our search revealed a total of 3699 studies after duplicates had been removed (Figure). A total of 714 references were included after initial review by title and abstract and 30 studies after full-text review. Agreement on a 10% random sample of all abstracts and full text was 79% (k=0.58) and 86% (k=0.72), respectively. Discussion was needed for fewer than 100 references, and agreement was subsequently reached for 100%.
There were 22 randomized controlled trials and 8 nonrandomized studies (5 nonrandomized controlled trials and 3 controlled before-after studies). Most of these studies were conducted in the United States (13/30 studies), followed by other European countries (5 studies), and the United Kingdom (4 studies). A large number of studies were conducted among patients with cardiovascular disease or risk factors (10 studies), followed by postsurgical patients such as coronary artery bypass graft surgery or orthopaedic surgery (5 studies). Five of 30 studies were conducted among individuals older than 65 years. Most studies excluded patients who did not speak English or the country's official language; only 3 studies included patients with limited literacy, patients who spoke other languages, or caregivers if the patients could not communicate.
Most studies tested the impact of educational discharge interventions (28 of 30 studies) (Table 1). Quite often, it was a member of the research team who carried out the patient education. Only 3 studies involved multiple members of the care team in designing or reviewing the discharge tool with the patient. Almost half (12 studies) targeted multiple aspects of postdischarge care, including medications and side effects, signs and symptoms to consider, plans for follow-up, dietary restrictions, and/or exercise modifications. Many (19 studies) provided education using one-on-one teaching in association with a discharge tool, accompanied by a written handout (13 studies), audiotape (2 studies), or video (3 studies). While 13 studies had patients involved in creating what content was discussed and 14 studies had patients involved in the delivery of the tool, only 6 studies had patients involved in both design and delivery of the tool. Nine studies also used visual aids such as pictures, larger font, or use of a tool enhanced for patients with language barriers or limited health literacy.
Among all 30 studies included, 16 studies tested the impact of their tool on comprehension postdischarge, with 10 studies demonstrating an improvement among patients who had received the tool (Table 2). Five studies evaluated healthcare utilization outcomes such as readmission, length of stay, or physician visits after discharge and 2 studies found improvements. Twelve studies also studied the impact on adherence with medications, diet, exercise, or follow-up instructions postdischarge. However, only 4 of these 12 studies showed a positive impact. Only 2 studies tested the impact on a patient's ability to self-manage once at home, and both studies reported positive statistical outcomes. Few studies measured patient experience (such as patient satisfaction or improvement in self-efficacy) or mortality postdischarge.
DISCUSSION/CONCLUSION
Our systematic review found 30 studies that engaged patients during the design or the delivery of a discharge instruction tool and that tested the effect of the tool on postdischarge outcomes.6-10,14–38 Our review suggests that there is sufficient evidence that patient-centered discharge tools improve comprehension. However, evidence is currently insufficient to determine if patient-centered tools improve adherence with discharge instructions. Moreover, though limited studies show promising results, more studies are needed to determine if patient engagement improves self-efficacy and healthcare utilization after discharge.
A major limitation of current studies is the variability in the level of patient engagement in tool design or delivery. Patients were involved in the design mostly through targeted development of a discharge management plan and the delivery by encouraging them to ask questions. Few studies involved patients in the design of the tool such that patients were responsible for coming up with content that was of interest to them. The few that did, often with the additional use of video media, demonstrated significant outcomes. Only a minority of studies used an interactive process to assess understanding such as "teach-back" or maximize patient comprehension such as visual aids. Even fewer studies engaged patients in both developing the discharge tool and providing discharge instructions.
Several previous studies have demonstrated that most complications after discharge are the result of ineffective communication, which can be exacerbated by lack of fluency in English or by limited health literacy.2,39-43 As a result, poor understanding of discharge instructions by patients and their caregivers can create an important care gap.44 Therefore, the use of patient-centered tools to engage patients at discharge in their own care is needed. How to engage patients consistently and effectively is perhaps less evident, as demonstrated in this review of the literature in which different levels of patient engagement were found. Many of the tools tested placed attention on patient education, sometimes in the context of bundled care along with home visits or follow-up, all of which can require extensive resources and time. Providing patients with information that the patients themselves state is of value may be the easiest refinement to a discharge educational tool, although this was surprisingly uncommon.6,9,10,17,23,33,37 Only 2 studies were found that engaged patients in the initial stage of design of the discharge tool, by incorporating information of interest to them.23,32 For example, a study testing the impact of a computer-generated written education package on poststroke outcomes designed the information by asking patients to identify which topics they would like to receive information about (along with the amount of information and font size).23 Secondly, although most of the discharge tools reviewed included the use of one-on-one teaching and the use of media such as patient handouts, these tools were often used in such a way that patients were passive recipients. In fact, studies that used additional video media that incorporated personalized content were the most likely to demonstrate positive outcomes.17,34 The next level of patient engagement may therefore be to involve the patient as an interactive partner when delivering the tool in order to empower patients to self-care. For example, 1 study designed a structured education program by first assessing lifestyle risk factors related to hypertension that were modifiable along with preconceived notions through open-ended questions during a one-on-one interview.37 Patients were subsequently educated on any knowledge deficits regarding the management of their lifestyle. Another level of patient engagement may be to use visual aids during discussions, as a well-known complement to verbal instructions.45,46 For example, in a controlled study that randomized a ward of elderly patients with 4 or more prescriptions to predischarge counseling, the counseling session aimed to review reasons for their prescriptions along with corresponding side effects, doses, and dosage times with the help of a medicine reminder card. Other uses of visual aid tools identified in our review included the use of pictograms or illustrations or, at minimum, attention to font size.7,8,16,29,33,35 In the absence of a visual aid, asking the patient to repeat or demonstrate what was just communicated can be used to assess the amount of information retained.18,33
An important result discovered in our review of the literature was also the lack of studies that tested the impact of discharge tools on usability of discharge information once at home. Conducting an evaluation of the benefits to patients after discharge can help objectify vague outcomes like health gains or qualify benefits in patient's views. This might also explain why many studies with documented patient engagement at the time of discharge were able to demonstrate improvements in comprehension but not adherence to instructions. Although patients and caregivers may understand the information, this comprehension does not necessarily mean they will find the information useful or adhere to it once at home. For example, in 1 study, patients discharged with at least 1 medication were randomized to a structured discharge interview during which the treatment plan was reviewed verbally and questions clarified along with a visually enhanced treatment card.26 Although knowledge of medications increased, no effect was found on adherence at 1 week postdischarge. However, use of the treatment card at home was not assessed. Similarly, another study tested the effect of an individualized video of exercises and failed to find a difference in patient adherence at 4 weeks.28 The authors suggested that the lack of benefit may have been because patients were not using the video once at home. This is in contrast to 2 studies that involved patients in their own care by requiring them to request their medication as part of a self-medication tool predischarge.16,30 Patients were engaged in the process such that increasing independence was given to patients based on their demonstration of understanding and adherence to their treatment while still in the hospital, a learning tool that can be applied once at home. Feeling knowledgeable and involved, as others have suggested, may be the intermediary outcomes that led to improved adherence.47 It is also possible that adherence to discharge instructions may vary based on complexity of the information provided, such that instructions focusing solely on medication use may require less patient engagement than discharge instructions that include information on medications, diet, exercise modifications, and follow-up.48
Our review has a few limitations. Previous systematic reviews have demonstrated that bundled discharge interventions that include patient-centered education have a positive effect on outcomes postdischarge.2,5 However, we sought to describe and study the individual and distinct impact of patient engagement in the creation and delivery of discharge tools on outcomes postdischarge. We hoped that this may provide others with key information regarding elements of patient engagement that were particularly useful when designing a new discharge tool. The variability of the studies we identified, however, made it difficult to ascertain what level of patient engagement is required to observe improvements in health outcomes. It is also possible that a higher level of patient engagement may have been used but not described in the studies we reviewed. As only primary outcomes were included, we may have underestimated the effect of patient-centered discharge tools on outcomes that were reported as secondary outcomes. As we were interested in reviewing as many studies of patient-centered discharge tools as possible, we did not assess the quality of the studies and cannot comment on the role of bias in these studies. However, we excluded studies with study designs known to have the highest risk of bias. Lastly, we also cannot comment on whether patient-centered tools may have an effect on outcomes more than 3 months after a hospital discharge. However, several studies included in this review suggest a sustained effect beyond this time period.8,25,32,37
Patient-centered discharge tools in which patients were engaged in the design or the delivery were found to improve comprehension of but not adherence with discharge instructions. The perceived lack of improved adherence may be due to a lack of studies that measured the usefulness and utilization of information for patients once at home. There was also substantial variability in the extent of patient involvement in designing the style and content of information provided to patients at discharge, as well as the extent of patient engagement when receiving discharge instructions. Future studies would benefit from detailing the level of patient engagement needed in designing and delivery of discharge tools. This information may lead to the discovery of barriers and facilitators to utilization of discharge information once at home and lead to a better understanding of the patient's journey from hospital to home and onwards.
C.M.B. and this work were funded by a CIHR Canadian Patient Safety Institute Chair in Patient Safety and Continuity of Care. Funding was provided to cover fees to obtain articles from the Donald J. Matthews Complex Care Fund of the University Health Network in Toronto, Canada. The Toronto Central Local Health Integration Network provided funding for the design and implementation of a patient-oriented discharge summary. None of the funding or supportive agencies were involved in the design or conduct of the present study, analysis, or interpretation of the data, or approval of the manuscript.
1. Hurtado MP, Swift EK, Corrigan JM. Envisioning the National Health Care Quality Report. Washington DC: National Academy of Sciences; 2001. PubMed
2. Mistiaen P, Francke AL, Poot E. Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Serv Res. 2007;7:47. PubMed
3. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828. PubMed
4. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. PubMed
5. Hansen LO, Young RS, Hinami K, et al. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-528. PubMed
6. Osman LM, Calder C, Godden DJ, et al. A randomised trial of self-management planning for adult patients admitted to hospital with acute asthma. Thorax. 2002;57(10):869-874. PubMed
7. Cordasco KM, Asch SM, Bell DS, et al. A low-literacy medication education tool for safety-net hospital patients. Am J Prev Med. 2009;37(6 suppl 1):S209-S216. PubMed
8. Morice AH, Wrench C. The role of the asthma nurse in treatment compliance and self-management following hospital admission. Resp Med. 2001;95(11):851-856. PubMed
9. Haerem JW, Ronning EJ, Leidal R. Home access to hospital discharge information on audiotape reduces sick leave and readmissions in patients with first-time myocardial infarction. Scand Cardiovasc J. 2000;34(2):219-222. PubMed
10. Legrain S, Tubach F, Bonnet-Zamponi D, et al. A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial. J Am Geriatr Soc. 2011;59(11):2017-2028. PubMed
11. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-269. PubMed
12. Partnership NP. National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. Washington, DC: National Quality Forum; 2008.
13. Effective Practice and Organisation of Care (EPOC). EPOC-specific resources for review authors. Oslo, Norway: Norwegian Knowledge Centre for the Health Services; 2013. http://epoc.cochrane.org/epoc-specific-resources-review-authors. Accessed December 21, 2016.
14. Manning DM, O'Meara JG, Williams AR, et al. 3D: a tool for medication discharge education. Qual Saf Health Care. 2007;16(1):71-76. PubMed
15. Perera KY, Ranasinghe P, Adikari AM, et al. Medium of language in discharge summaries: would the use of native language improve patients' knowledge of their illness and medications? J Health Commun. 2012;17(2):141-148. PubMed
16. Lowe CJ, Raynor DK, Courtney EA, et al. Effects of self medication programme on knowledge of drugs and compliance with treatment in elderly patients. BMJ. 1995;310(6989):1229-1231. PubMed
17. Mahler HI, Kulik JA, Tarazi RY. Effects of a videotape information intervention at discharge on diet and exercise compliance after coronary bypass surgery. J Cardiopulm Rehabil. 1999;19(3):170-177. PubMed
18. Al-Rashed SA, Wright DJ, Roebuck N, et al. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54(6):657-664. PubMed
19. Drenth-van Maanen AC, Wilting I, Jansen PA, et al. Effect of a discharge medication intervention on the incidence and nature of medication discrepancies in older adults. J Am Geriatr Soc. 2013;61(3):456-458. PubMed
20. Eshah NF. Predischarge education improves adherence to a healthy lifestyle among Jordanian patients with acute coronary syndrome. Nurs Health Sci. 2013;15(3):273-279. PubMed
21. Gwadry-Sridhar FH, Arnold JM, Zhang Y,et al. Pilot study to determine the impact of a multidisciplinary educational intervention in patients hospitalized with heart failure. Am Heart J. 2005;150(5):982. PubMed
22. Ho SM, Heh SS, Jevitt CM, et al. Effectiveness of a discharge education program in reducing the severity of postpartum depression: a randomized controlled evaluation study. Patient Educ Couns. 2009;77(1):68-71. PubMed
23. Hoffmann T, McKenna K, Worrall L, et al. Randomised trial of a computer-generated tailored written education package for patients following stroke. Age Ageing. 2007;36(3):280-286. PubMed
24. Jenkins HM, Blank V, Miller K, et al. A randomized single-blind evaluation of a discharge teaching book for pediatric patients with burns. J Burn Care Rehabil. 1996;17(1):49-61. PubMed
25. Kommuri NV, Johnson ML, Koelling TM. Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial. Patient Educ Couns. 2012;86(2):233-238. PubMed
26. Louis-Simonet M, Kossovsky MP, Sarasin FP, et al. Effects of a structured patient-centered discharge interview on patients' knowledge about their medications. Am J Med. 2004;117(8):563-568. PubMed
27. Lucas KS. Outcomes evaluation of a pharmacist discharge medication teaching service. Am J Health Syst Pharm. 1998;55(24 suppl 4):S32-S35. PubMed
28. Lysack C, Dama M, Neufeld S, et al. A compliance and satisfaction with home exercise: a comparison of computer-assisted video instruction and routine rehabilitation practice. J Allied Health. 2005;34(2):76-82. PubMed
29. Moore SM. The effects of a discharge information intervention on recovery outcomes following coronary artery bypass surgery. Int J Nurs Stud. 1996;33(2):181-189. PubMed
30. Pereles L, Romonko L, Murzyn T, et al. Evaluation of a self-medication program. J Am Geriatr Soc. 1996;44(2):161-165. PubMed
31. Reynolds MA. Postoperative pain management discharge teaching in a rural population. Pain Manag Nurs. 2009;10(2):76-84. PubMed
32. Sabariego C, Barrera AE, Neubert S, et al. Evaluation of an ICF-based patient education programme for stroke patients: a randomized, single-blinded, controlled, multicentre trial of the effects on self-efficacy, life satisfaction and functioning. Br J Health Psychol. 2013;18(4):707-728. PubMed
33. Shieh SJ, Chen HL, Liu FC, et al. The effectiveness of structured discharge education on maternal confidence, caring knowledge and growth of premature newborns. J Clin Nurs. 2010;19(23-24):3307-3313. PubMed
34. Steinberg TG, Diercks MJ, Millspaugh J. An evaluation of the effectiveness of a videotape for discharge teaching of organ transplant recipients. J Transpl Coord. 1996;6(2):59-63. PubMed
35. Whitby M, McLaws ML, Doidge S, et al. Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis? J Hosp Infect. 2007;66(3):237-242. PubMed
36. Williford SL, Johnson DF. Impact of pharmacist counseling on medication knowledge and compliance. Mil Med. 1995;160(11):561–564. PubMed
37. Zernike W, Henderson A. Evaluating the effectiveness of two teaching strategies for patients diagnosed with hypertension. J Clin Nurs. 1998;7(1):37–44. PubMed
38. Press VG, Arora V, Constantine KL, et al. Forget me not: a randomized trial of the durability of hospital-based education on inhalers for patients with COPD or asthma [abstract]. J Gen Intern Med. 2014;29(1 suppl):S102.
39. Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887–894. PubMed
40. McCarthy DM, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277–282. PubMed
41. Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855–1862. PubMed
42. Cawthon C, Walia S, Osborn CY, et al. Improving care transitions: the patient perspective. J Health Commun. 2012;17(suppl 3):312–324. PubMed
43. Karliner LS, Auerbach A, Nápoles A, et al. Language barriers and understanding of hospital discharge instructions. Med Care. 2012;50(4):283–289. PubMed
44. Enhancing the Continuum of Care. Report of the Avoidable Hospitalization Advisory Panel. http://www.health.gov.on.ca/en/common/ministry/publications/reports/bake.... Published November 2011. Accessed December 22, 2016.
45. Chugh A, Williams MV, Grigsby J, et al. Better transitions: improving comprehension of discharge instructions. Front Health Serv Manage. 2009;25(3):11–32. PubMed
46. Schillinger D, Machtinger EL, Wang F, et al. Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment. J Health Commun. 2006;11(7):651–664. PubMed
47. Epstein RM, Street RL, Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100–103. PubMed
48. Albrecht JS, Gruber-Baldini AL, Hirshon JM, et al. Hospital discharge instructions: comprehension and compliance among older adults. J Gen Intern Med. 2014;29(11):1491–1498. PubMed
Okrainec_Appendix.docx 29.86 KB


You knew this was coming one way or another. You didn't think insurance companies would lose money on Obamacare did you?
Amongst the many hidden provisions in Obamacare, it looks like this legislation will be reimbursing insurance companies for an individual patients costs over $45,000 on what appears to be an annual basis. Of course we don't really mean Obamacare will be paying for it, we mean you and I, the American taxpayers will be footing the bill for high cost enrollees.
But, there's a caveat. With the disastrous signup numbers way below projections and even further below what needs to happen to actually fund the massive ponzi scheme, the entire system could collapse before it really even gets started. If not enough people sign up initially, Obamacare may just never be funded properly and that's when things will get really interesting.
In other words, insurance purchased through Obamacare's government-run exchanges isn't even full-fledged private insurance; rather, it's a sort of private-public hybrid. Private insurance companies pay for costs below $45,000, then taxpayers generously pick up the tab—a tab that their president hasn't ever bothered to tell them he has opened up on their behalf—for four-fifths of the next $200,000-plus worth of costs. In this way, and so many others, Obamacare takes a major step toward the government monopoly over American medicine ("single payer") that liberals drool about in their sleep.
Take this Moron's pencil away! Obama has to be the most imcompetent person on the good Lord's green earth! Why can't people see that he is worthless? He is completely ruining America as it once was!


Blog - Computer Penetration In India – why far behind?
Computer Penetration In India – why far behind?
Throughout the last few years, rural India saw many unprecedented changes. PC penetration is one such welcome expansion which really enhanced the lives and the lifestyle of many rural inhabitants. Truth be told, a progression of bills and acts were passed in order to promote information technology in the provincial regions. These bills combined with the relatively low rates of PCs relevantly encouraged the blast of e-administration in these towns.
In any case, the India's present computer penetration in rural areas is remarkably lesser than its fellow countries. In fact today, India has a much lower rank among the nations with lower PC entrance. Nations like Malaysia, Russia and China have much more prominent PC penetration in country ranges contrasted with India. All in all, why is India falling behind? As per some well known appraisals, numerous people in towns don't buy PCs, notwithstanding when they can bear the cost of it. This is because of the reasonably high rates of PCs. In any case, IT center points and PC organizations are attempting their best to draw the This is because of the reasonably high rates of PCs.provincial clients with some feasible PC bargains.
Indeed, India has computer penetration essentially in light of the high possession costs and the absence of appropriate limitation. Truth be told, the proprietorship cost of a desktop alongside a broadband association, is smidgen higher than what the villagers anticipate. Other than this, scratch pad and other comparative devices are completely past their scope because of the amazingly soak rates these items are accessible in.
How Can Computer Penetration Improve In Rural India?
We can improve by reducing hardware costs up to 40-45% for better customer base in the rural areas. In fact, computer penetration can aptly improve if the IT hubs work for manufacturing hardware in comparatively lower rates.
Government endowments can also help PC infiltration enhance in the rural areas.
The TCA or aggregate proprietor transport cost alongside the cost of a broadband association can be diminished.
Pay tax reductions ought to be given to the people who buy a PC in the rustic ranges.
Buy of PC ought to be advanced among understudies and homes which have a pay not as much as INR 5lakh yearly.
Different backhanded assessments on buying IT equipment can be lessened. The lessening should be possible from 12 to 6 percent which thusly will draw in an extensive number of provincial clients.
Different units like miniaturized scale processors ought to have a lower CVD rate which thus will improve the entrance of PC in provincial India.
Many of the suggestions have been constantly recommended to the Government. Even with a few recommendations the entire figure of IT structure and computer penetration in rural India, can expedite in a single go.


Kristen talks about Breaking Dawn Part2 and coming back to Australia for the premiere/promo.
The HotHits Rupert Sanders directs the upcoming action/drama starring Charlize Theron, and had nothing but positive words to say about Kristen. He revealed "When I met her I was very taken by this rebellious streak to her... she's a very tough girl. If the role demands it she'll throw herself off a cliff."
We also asked the lovely Kristen Stewart to tell us how it was to work with Charlize Theron! "Awesome..." Kristen said. "She's a real game upper. I want to stand on my tip toes around her, I want to impress her..." "You're always taking a bit of a gamble signing onto a movie... (but I knew) I want to work with her... it could be a terrible movie, (but) I want to work with her."


Classroom Library- Where do you even begin?
If you were to look at several primary classrooms you would notice a few things in common between them, one of those things is their classroom libraries.
Why have a classroom library? When students are learning to read they need a lot of practice. In order to give students the practice they need it is important to surround them with books. Another reason? I LOVE children's books and would love my own collection. Yes, my school will have a library that my students can and will use however that takes a lot of time. Time that could be spent reading instead!
How am I starting my classroom library? With the help of my dear friend Craig who happens to have a list named Craigslist. I simply type in 'Children's Books' and check out what comes up. I recently met up with a fellow teacher (in a public place of course) who was selling TONS of books for just $25 for all of them. These 100 books, or maybe more, I figured would be a good start. They aren't in the best condition but 1st graders don't mind and neither do I. Here is a picture of the ones that wouldn't fit into a big box I already packed the rest of the books in.
What do I look for when it comes to books? A variety. I now have a few Halloween, Christmas, and Thanksgiving books to bring out during those holidays. Right now I am just building my collection but I want nonfiction as well as fiction. I want books at a broad range of reading levels for the students who are struggling and for the students who need a challenge.
I believe I will look for and purchase some more books before school starts however as the school year progresses so will my library. I will add new books each month as I buy them through craigslist, goodwill book stores as well as normal goodwills, and through scholastic programs that offer free books. This way it is easy on my pocketbook and my students are constantly being stimulated with new read material.
I am also going to utilize my public library that is close by to check out some books I'll use for read alouds and books to expand on topics we are studying. I'll be keeping an eye on these in the classroom; I wouldn't want my students to ruin these books since I'll be held accountable for them.
I am hoping my school has some sort of magazine subscription because I would love to get a magazine each month and then the next year I'd subscribe to a new magazine. That is something I am also looking into if my school does not provide it.
Anyone have any children's books they want to donate my way? Or have any other helpful tips on expanding a classroom library? I'd love to hear your ideas!
Anyway, I'm really happy that you found a job AND started a blog! I love reading them when I have some time! Good luck with stocking your library!
Also... check out bookstores and their clearance aisles. I'm not sure how cheap but look out for coupons!
You're my very first commenter!! Yay!
Those are for sure places on my list to check out and I'll also be looking for furniture there too for my apartment.
I found ebay also has some great deals and shipping isn't as much as I thought it would be for books.
I've been reading all your blog posts and I love them!
Oh, there's also a discount Scholastics warehouse in Orlando that you can get brand new books for super cheap!
If I think of anywhere else or come across something I'll let you know! Keep the blogs coming, I love reading them.
Hi just came upon your website via Bing after I typed in, "Assemblée générale - BAC2S" or perhaps something similar (can't quite remember exactly).
information from here and I will of course credit you as the reference.


Oil on canvas vintage Romanesque scene painted by Charles Austin Percy(1883-1948) in the early 1900's. The painting as you can observe is large scale measuring 76.5" wide by 47.5" tall with a 1.5" projection. The painting is authentic signed and in need of some light restoration with some minor loss on the canvas and wood frame. Charles Percy Austin was born in Denver, Colorado on March 23, 1883. He studied at the Denver School of Art under William Henry Read (1851-1935). He also ventured to Europe to visit London, France and northern Italy which may be the time frame in which this piece was created. Charles Percy Austin�s work can be found in the Irvine Museum collection and in important private collections. The locations of many Charles Percy Austin�s paintings are unknown.


text:
Capitalism and the Ecological Footprint
by Samir Amin
Samir Amin is director of the Third World Forum in Dakar, Senegal. His recent books include Obsolescent Capitalism (Zed Books), The Liberal Virus (Monthly Review Press, 2004), and The World We Wish to See (Monthly Review Press, 2008). An earlier version of this article appeared in Pambazuka News, July 23, 2009, 443.
1. Our Ecological Footprint by Mathis Wackernagel and William Rees (1996) instigated a major strand in radical social thinking about construction of the future.
The authors not only defined a new concept—that of an ecological footprint—they also developed a metric for it, whose units are defined in terms of "global hectares," comparing the biological capacity of societies/countries (their ability to produce and reproduce the conditions for life on the planet) with their consumption of resources made available to them by this bio-capacity.
The authors' conclusions are worrying. At the global level, the bio-capacity of our planet is 2.1 global hectares (gha) per capita (i.e., 13.2 billion gha per 6.3 billion inhabitants). In contrast, the global average for consumption of resources was already—in the mid-1990s—2.7 gha. This "average" masks a gigantic imbalance, the average for the Triad (Europe, North America, and Japan) having already reached a multiple of the order of four magnitudes of the global average. A good proportion of the bio-capacity of societies in the South is taken up by and to the advantage of these centers.
In other words, the current expansion of capitalism is destroying the planet and humanity. This expansion's logical conclusion is either the actual genocide of the peoples of the South—as "over-population"—or, at the least, their confinement to ever increasing poverty. An eco-fascist strand of thought is being developed that gives legitimacy to this type of "final solution" to the problem.
2. The interest of this work goes beyond its conclusions. For it is a question of a calculation (I use the term "calculation," rather than "discourse," deliberately) put in terms of the use value of the planet's resources, illustrated through their measurement in global hectares (gha), not in dollars.
The proof is therefore given that social use value can be the subject of perfectly rational calculation. This proof is decisive in its import, since socialism is defined in terms of a society founded on use value and not on exchange value. And defenders of capitalism have always held that socialism is an unreal utopia because—according to them—use value is not measurable, unless it is conflated with exchange value (defined in terms of "utility" in vulgar economics).
Recognition of use value (of which the measurement of economic footprints is but one good example) implies that socialism should be "ecological," indeed can only be ecological, as Altvater proclaims ("solar socialism" or "no socialism"). But it also implies that this recognition is impossible in any capitalist system, even a "reformed" one, as we shall see.
3. In his time, Marx not only suspected the existence of this problem, he had already expressed it through his rigorous distinction between use value and exchange value (wealth and value), conflated in vulgar economics. Marx explicitly said that the accumulation of capital destroys the natural bases on which that accumulation is built: man (the alienated, exploited, dominated, and oppressed worker) and the earth (symbol of natural riches at the disposal of humanity). And whatever might be the limitations of this way of putting it, trapped within its own era, Marx's analysis nonetheless remains an illustration of a clear consciousness (beyond intuition) of the problem, which deserves to be recognised.
It is regrettable, therefore, that the ecologists of our time, including Wackernagel and Rees, have not read Marx. This would have allowed them to take their own proposals further, to grasp their revolutionary import, and, of course, to go further than Marx himself on this topic.
4. This deficiency in modern ecology facilitates its capture by the ideology of vulgar economics, which occupies a dominant position in contemporary society. This capture is already under way and, indeed, considerably advanced.
Political ecology (such as that proposed by Alain Lipietz) was located from the beginning within the gamut of the "pro-socialist," political Left. Subsequently, "green" movements (and then political parties) located themselves in the Center Left, through their expressed sympathy with social and international justice, their critique of "waste," and their concern with the fate of workers and "poor" peoples. But, apart from the diversity of these movements, we should note that none of them has established a rigorous relationship between the authentic socialist dimension necessary to rise to the challenge and a recognition, no less necessary, of the ecological dimension. To achieve this relationship, we should not ignore the wealth/value distinction emphasized by Marx.
Capture of ecology by vulgar ideology operates on two levels: on the one hand, by reducing measurement of use value to an "improved" measurement of exchange value, and on the other, by integrating the ecological challenge with the ideology of "consensus." Both these maneuvers undermine the clear realization that ecology and capitalism are, by their nature, in opposition.
5. This capture of ecological measurement by vulgar economics is making huge strides. Thousands of young researchers in the United States, and their imitators in Europe, have been mobilized in this cause.
The "ecological costs" are, in this way of thinking, assimilated to external economies. The vulgar method of measuring cost/benefit in terms of exchange value (itself conflated with market price) is then used to define a "fair price," integrating external economies and diseconomies.
It goes without saying that the work—reduced to mathematical formulas—done in this traditional area of vulgar economics does not say how the "fair price" calculated could become that of the actual current market. It is presumed, therefore, that fiscal and other "incentives" could be sufficient to bring about this convergence. Any proof that such a convergence would really occur is entirely absent.
In fact, as can already be seen, oligopolies have seized hold of ecology to justify the opening up of new fields to their destructive expansion. Francois Houtart provides a conclusive illustration of this in his work on biofuels. Since then, "green capitalism" has been part of the obligatory discourse of men/women in positions of power, on both the Right and the Left, in the Triad, and the CEOs of oligopolies. The ecology in question, of course, conforms to the vision known as "weak sustainability" (the notion that it is possible for the market to substitute for all national resources/forces, none of which is indispensable in defining a sustainable path)—in other words, the complete commodification of the "rights of access to the planet's resources." Joseph Stiglitz, in a report of the UN commission which he chaired, openly embraced this position at the United Nations General Assembly, June 24-26, 2009, proposing "an auction of the world's resources (fishing rights, licences to pollute, etc.)." This is a proposal that quite simply comes down to sustaining the oligopolies in their ambition to mortgage further the future of the peoples of the South.
6. The capture of ecological discourse by the political culture of the consensus (a necessary expression of the conception of capitalism as the end of history) is equally well advanced.
This capture has an easy ride. For it is responding to the alienation and illusion that feed the dominant culture, that of capitalism. An easy ride because this culture is actual, and holds a dominant place in the minds of the majority of human beings, in the South as well as the North.
In contrast, the expression of the demands of the socialist counterculture is fraught with difficulty—because socialist culture is not there in front of our eyes. It is part of a future to be invented, a project of civilization, open to the creativity of the imagination. Slogans (such as "socialization through democracy and not through the market" and "the transfer of the decisive level for decision making from the economic and political levels to that of culture") are not enough, despite their power to pave the way for the historical process of transformation. For what is at stake is a long, "secular" process of societal reconstruction, based on principles other than those of capitalism, in both the North and the South—a process that cannot be supposed to take place "rapidly." But construction of the future, however far away, begins today.
About Samir Amin
View all posts by Samir Amin →
What Needs To Be Done: A Socialist View
The Paradox of Wealth: Capitalism and Ecological Destruction
November 2009 (Volume 61, Number 6) , The Editors
The Paradox of Wealth: Capitalism and Ecological Destruction , John Bellamy Foster and Brett Clark
What Needs To Be Done: A Socialist View , Fred Magdoff and Michael D. Yates
The Resistable Rise and Predictable Fall of the U.S. Supermax , Stephen F. Eisenman
Can Ecological Agriculture Feed Nine Billion People? , Jules Pretty
Ballade of the Poverties , Adrienne Rich
The Real Economy and the Bubble Economy , Ted Trainer and The Editors

redpajama_set_name: RedPajamaCommonCrawl


With our simple, safe domestic and commercial removal service.We can also provide a wide range storage solutions if required.
All Star Removals is a professional, experienced moving company serving all of your relocation needs and house removals. We are based in the North West.
Moving office to minimise disruption can be very stressful.
At All Stars Removals & Storage we can help you to manage & conduct the move.
Our convenient Self Storage Units are the perfect solution for personal and business storage customers.
All Star Removals & Storage are fully insured and conduct a full written inventory before we start the move. Employees are also fully checked and all your belongings are professionally packaged before being loaded onto the lorry.
All Star Removals & Storage understand that moving home can be very stressful. To help you we have a produced a comprehensive guide to ensure everything runs smoothly on the day.
All Star Removals company mission is to provide the highest quality of service at the most reasonable cost. Please read our client feedback. We would welcome the opportunity to earn your trust and deliver you the best service in the industry.


Virginia Woolf was born in London in 1882, the daughter of Sir Leslie Stephen, first editor of The Dictionary of National Biography. From 1915, when she published her first novel, The Voyage Out, Virginia Woolf maintained an astonishing output of fiction, literary criticism, essays and biography. In 1912 she married Leonard Woolf, and in 1917 they founded The Hogarth Press. Having suffered a series of mental breakdowns throughout her life, Virginia Woolf committed suicide on 28 March, 1941.


The powdered latex gloves are off!
A proposed ban in the US could signal the demise of powdered latex gloves.
Gloves are supposed to protect us, right? They're not just fashion items to keep our hands warm when it gets chilly, they're there to shield our pinkies from the perils of abrasion and stringent chemicals. Even butch, professional fighters choose to protect each other's welfare with their padded mitts.
Whatever we do there's a good chance that at some point or other we will entrust the protection of our defenceless digits to a glove designed for the job, and ones made from materials that we trust will be fit for purpose.
Nowhere is this more true than in the clinical environs of the dental practice. For years we have been snapping on those powdered, latex lovelies in the belief that we are protecting both us, and our patients, against the dangers of infection.
Well, if the proposed ban by the US Food and Drug Administration (FDA) is anything to go by, then we have all been operating under a serious misapprehension.
The proposed ban would apply to powdered surgeon's gloves, powdered patient examination gloves and absorbable powder for lubricating a surgeon's glove. However, the FDA has determined that the banning standard would not apply to powdered radiographic protection gloves.
Ansell's statement goes on to outline the risks to both patients and health workers explaining that the powder not only acts as a vehicle for latex antigens, but can also enter the body during surgery.
It is believed that glove powder may trigger an inflammatory response by the immune system, leading to the formation of fibrous bands and post-operative adhesions. These effects have been well documented in the peritoneal cavity but are now being reported in almost every other anatomical site, including the oral region.
Glove powder has also been implicated with decreasing the bonding strength of dental adhesives, by weakening them by getting between the two surfaces.
From the wearer's perspective, prolonged contact with glove powder may have a serious impact on the users' skin condition as well as significantly lowering skin hydration levels, thus producing dryness – which is the first sign of irritation.
Additional concerns are raised regarding inhalation or ingestion of the powder, as it could be responsible for upper respiratory tract symptoms or eye irritation.
So are gloves are supposed to protect us? Well, in this case it would seem not, and for those still using them, it is the advice of the DHAA that you make the switch to powder-free gloves as a matter of urgency.
For detailed information regarding the complications associated with glove powder you can download the Ansell 'Hazards of Powdered Gloves' brochure.


text:
China on Stage symposium / From Classical to Rock-n-Roll: Western Music in China
Campbell Recital Hall
Presented in partnership with Center for East Asian Studies Rhapsody in Red: Western Classical Music in China presented by Sheila Melvin, journalist China is increasingly seen as the last great hope for classical music. But how did classical music get to China and why did it take root? This lecture will explore classical music's introduction to China as a tool -- of religion and politics, of imperialism nationalism, and revolution -- and its eventual absorption into Chinese culture. The Chinese Jazz Age and its Contemporary Repercussions presented by Andrew Jones, Associate Professor, Department of East Asian Languages and Cultures, UC Berkeley What are the roots of modern Chinese popular music and media culture? This lecture will trace contemporary Chinese pop back to its wellsprings in the polyglot culture of the multiply colonized city of Shanghai in the late 1920s and 1930s, examining its links to media technology, the rise of Chinese nationalism, as well as the transpacific migration of Hollywood cinema, gramophone records, and African-American jazz musicians. The panel will be joined by Chinese contemporary dancer Jin Xing, who will share her insights as a successful artist living and working in Shanghai. Professor Jindong Cai, artistic director of the Pan Asian Music Festival, will moderate. ---- Andrew F. Jones teaches modern and vernacular Chinese literature and popular culture. His research interests include music, cinema, and media technology, modern and contemporary fiction, children's literature, and the cultural history of the global 1960s. He is the author of Yellow Music: Media Culture and Colonial Modernity in the Chinese Jazz Age (Duke University Press, 2001), co-editor of a special issue of positions: east asia cultures critique titled "The Afro-Asian Century," and translator of literary fiction by Yu Hua as well as Eileen Chang's Written on Water (Columbia University Press, 2005). He is received his Ph.D. from University of California at Berkeley. Sheila Melvin writes and consults about culture and business in China. She is the author of The Little Red Book of China Business (2007) and the co-author of Rhapsody in Red: How Western Classical Music Became Chinese (2004). Her writing on China has been published in the New York Times, International Herald Tribune, Wall Street Journal, Asian Wall Street Journal, and USA Today. Melvin's China-related business experience includes seven years at The United States-China Business Council. Melvin has an honors M.A. from the Johns Hopkins School of Advanced International Studies and was the recipient of the school's A. Doak Barnett Award for Excellence in China Studies.
lydiac@stanford.edu
http://panasianmusicfestival.stanford.edu


text:
package io.victoralbertos.mockery.internal.built_in_mockery;

import io.victoralbertos.mockery.api.Metadata;
import io.victoralbertos.mockery.api.Mockery;
import io.victoralbertos.mockery.api.built_in_mockery.DTOArgs;
import io.victoralbertos.mockery.api.built_in_mockery.RequestBodyValid;
import io.victoralbertos.mockery.api.built_in_mockery.Valid;
import java.io.IOException;
import java.lang.annotation.Annotation;
import java.lang.reflect.Type;
import okhttp3.MediaType;
import okhttp3.RequestBody;
import okio.Buffer;

public final class RequestBodyValidMockery implements Mockery.Behaviour<RequestBodyValid> {
  private final ValidMockery validMockery;

  public RequestBodyValidMockery() {
    validMockery = new ValidMockery();
  }

  /**
   * Serialize the legal object as content of a {@code RequestBody} deferring to {@link ValidMockery} for object creation.
   * @see ValidMockery
   */
  @Override public Object legal(Metadata<RequestBodyValid> metadata) {
    Object legal = validMockery.legal(validMetadata(metadata));
    RequestBody requestBodyLegal = RequestBody
        .create(MediaType.parse("text/plain"), legal.toString());
    return requestBodyLegal;
  }

  /**
   * Serialize the illegal object as content of a {@code RequestBody} deferring to {@link ValidMockery} for object creation.
   * @see ValidMockery
   */
  @Override public Object illegal(Metadata<RequestBodyValid> metadata) {
    Object illegal = validMockery.illegal(validMetadata(metadata));
    illegal = illegal != null ? illegal.toString() : "";
    RequestBody requestBodyIllegal = RequestBody
        .create(MediaType.parse("text/plain"), illegal.toString());
    return requestBodyIllegal;
  }

  /**
   * Deserialize the content of a {@code RequestBody} as the DTO object and defer to its mockery to perform the validation.
   * @see ValidMockery
   */
  @Override public void validate(Metadata<RequestBodyValid> metadata, Object candidate) throws AssertionError {
    try {
      RequestBody requestBody = (RequestBody) candidate;
      Buffer buffer = new Buffer();
      requestBody.writeTo(buffer);
      String body = buffer.readUtf8();
      validMockery.validate(validMetadata(metadata), body);
    } catch (IOException e) {
      throw new RuntimeException(e);
    }
  }

  /**
   * Support the same type as {@link ValidMockery#supportedTypes(Metadata)}
   */
  @Override public Type[] supportedTypes(Metadata<RequestBodyValid> metadata) {
    Type[] supportedTypes = {RequestBody.class};
    return supportedTypes;
  }

  /**
   * {@inheritDoc}
   */
  @Override public boolean isOptional() {
    return false;
  }

  /**
   * Convert a {@code RequestBodyValid} annotation into a {@code Valid} one.
   */
  private Metadata<Valid> validMetadata(Metadata<RequestBodyValid> metadata) {
    final RequestBodyValid requestBodyValid = metadata.getAnnotation();

    Valid dto = new Valid() {

      @Override public String value() {
        return requestBodyValid.value();
      }

      @Override public String legal() {
        return requestBodyValid.legal();
      }

      @Override public String illegal() {
        return requestBodyValid.illegal();
      }

      @Override public Class<? extends Annotation> annotationType() {
        return DTOArgs.class;
      }

    };

    return new Metadata<>(metadata.getMockingClass(),
        metadata.getMethod(), metadata.getArgs(), dto, metadata.getType());
  }
}

redpajama_set_name: RedPajamaGithub


…what Port25 is to Open Source.
Is it me, or is 'Azure' the worst name you possibly could think of for a Cloud Computing initiative? The word Azure reminds people of a cloudless sky, a clear day. A world without clouds.
If you look up Azure in a dictionary, you get 'cloudless' over and over again. If you look up 'cloudless' in a Thesaurus, you get Azure as the #1 synonym. Perhaps this is reverse engineering the Microsoft thought process.
It reeks of Phillip Morris' nicotine addiction programs or oil companies' alternative fuel advertising. Blatantly disingenuous.
So, what message is Microsoft, the traditional software company, trying to convey with this naming strategy? I think the answer is as clear as day.


text:
Rotten Zambian Political System
Michael Chishala, 12 May, 2017
No Second Term: Why Rupiah Banda's Bid For Presidency is bad for Zambia's Democracy
The Scourge of Freebies
Zambian Political Insanity
Clash of the Titans? ZRA Versus Saviour Chishimba
Mr Saviour Chishimba recently alleged that there was a corrupt tender awarded by ZRA for an electronic Invoice Management System worth K140 million ($14 million). ZRA has denied any wrongdoing and have sued him for the grand sum of ten billion US Dollars! One wonders which dreamer in ZRA came up with this insane figure that is twice the Government budget and equal to the entire foreign debt of Zambia. Is the reputation of ZRA worth that much?
Michael Chishala — 4 May, 2017
The brewing titanic battle between the Zambia Revenue Authority (ZRA) and United Progressive People (UPP) party President Saviour Chishimba is turning out to be a thriller of epic proportions, straight out of a John Grisham novel. We are all eagerly awaiting to see who will blink first between the two. First a quick recap for those of you who have missed the action thus far.
Mr Chishimba recently alleged that there was a corrupt tender awarded by ZRA for an electronic Invoice Management System worth K140 million ($14 million). The reaction from ZRA was swift and emphatic (within 24 hours!). They denied any wrongdoing and suggested Mr Chishimba was bringing their good name into disrepute. They then decided to sue him for the grand sum of ten billion US Dollars! One wonders which dreamer in ZRA came up with this insane figure that is twice the Government budget and equal to the entire foreign debt of Zambia. Is the reputation of ZRA worth that much?
It is worth noting that Mr Chishimba was the one who exposed the Maizegate Scandal involving a corrupt deal in which 100,000 Metric Tons of maize worth $34 million were to be supplied to Malawi. Mr Chishimba presented evidence to the Malawian Parliament, resulting in the investigation and subsequent dismissal of the Agriculture Minister Mr George Chaponda after he was found with more than $200,000 cash at his home during a search by investigators. ZRA would do well to tread carefully.
The "Invoicegate Scandal" took a new twist with an injunction being obtained by ZRA restraining Mr Chishimba or his agents from publishing "malicious falsehood" or anything "bordering on malicious falsehood and damaging to the plaintiff". As much as I am a layman (albeit with a strong interest in legal matters), I am surprised that a judge could accept to hand out such an injunction.
The first obvious question that comes to mind is this: what mechanism exists to determine whether whatever Mr Chishimba says henceforth against ZRA qualifies to be "malicious falsehood"? Suppose a whistle-blower inside ZRA has given him evidence of wrongdoing and he decides to share it with the press, can this information be considered as a "malicious falsehood"? If he keeps publishing things that are demonstrably true, doesn't that make the whole injunction basically pointless and redundant, since it does not prohibit him from commenting about ZRA unless what he says is a "malicious falsehood"? Since what is in contention is the truthfulness (or lack thereof) of the accusations by Mr Chishimba, can the law place a gagging order of this kind without running into absurdities?
The injunction prohibits "utterances bordering on malicious falsehood and damaging to the plaintiff". What does this mean in practice? Suppose Mr Chishimba makes a new statement (unrelated to the Invoicegate scandal) that turns out to be "damaging" to ZRA. Will the law punish him purely because it is "damaging" to ZRA even though it is true? Moreover, it is not a trivial matter to establish what constitutes malice on the part of Mr Chishimba. Can he be rationally accused of malice if he exposes corruption in ZRA?
As Zambians, we cannot help but see the actions of ZRA as very suspicious and a knee jerk reaction that strongly suggests that there is something very fishy going on in the revenue authority that a lot of people within do not want exposed. The swift and extreme reaction by ZRA to sue for a senseless amount equal to twice the entire annual Zambian government budget raises a lot of question marks and lends credence to the theory that it is an effort to silence him by intimidation so that he backs down due to the threat of huge legal fees he will incur defending himself.
Regardless of how this shakes out, I think Mr Chishimba is to be commended for his efforts to bring transparency and accountability to government. For too long, corrupt people have gotten away with shady deals under the table. Corruption has become a normal accepted way of life in Zambia as whistle-blowers like Mr Chishimba are victimized and harassed.
It is hoped that ZRA have got their house in order because they are going down a very slippery slope from which they cannot recover if they are found wanting. Mr Chishimba's lawyers will obviously subpoena crucial documents and ZRA employees in order to mount a good defence.
Is ZRA really prepared for the strong light of the law to shine upon them? Are they prepared to have their employees take the witness stand? Are they prepared to deal with Mr Chishimba's claim that he has audio and video evidence showing corrupt deals within ZRA?
ZRA would do well to remember the lessons from the case where former president Frederick Chiluba sued The Post Newspapers for calling him a thief. When the Zamtrop bank statements were subpoenaed in court, they clearly proved the allegations that Mr Chiluba was a thief. He probably thought he could intimidate them but got the shock of his life. He probably afterwards wished he had just let sleeping dogs lie.
In the current situation, ZRA is in a lose-lose situation. If they don't sue Mr Chishimba, it will be taken by Zambians as an admission of guilt. If they sue and lose the case, there will be plenty of mud on their faces and people will lose jobs and be prosecuted by the Anti-Corruption Commission. I daresay that Mr Chishimba has cleverly manoeuvred them into a corner where he is plotting a check-mate. Given his history thus far, it seems unlikely that he is bluffing.
For now, let us sit back, relax and open a large sack of popcorns as the story in this latest John Grisham novel unfolds.
Next post Rotten Zambian Political System
Previous post Where Did Zambian Bembas Really Come From? The Ugandan Connection


text:
Ecuador boosts oil output as part of deal reached by OPEC - oil minister
OPEC reached an agreement over the weekend with Russia and other oil producers who are not part of the group to raise output from July by around 1 mbpd in response to a recent run-up in crude prices
QUITO: Ecuador will boost oil output above the current level of 520,000 barrels per day (bpd) as part of a deal reached by OPEC, the oil minister said on Monday, with new barrels to come from previously announced plans to hike production at large fields.
The Organization of the Petroleum Exporting Countries reached an agreement over the weekend with Russia and other oil producers who are not part of the group to raise output from July by around 1 million bpd in response to a recent run-up in crude prices.
"We have already started (to increase production), we will easily reach 520,000 bpd, which is our commitment to OPEC," Ecuador's Oil Minister Carlos Perez told reporters. "We will probably exceed that number in the coming weeks."
He did not say how much production would rise. Official figures show output at 518,000 bpd over the weekend. The government is betting on the commercial development of its largest oil field, known as IIT, which state-run Petroamazonas projects will reach 80,000 bpd from a current level of 64,700 bpd.
Perez also said Petroamazonas had granted a $25 million services contract to CCDC, a subsidiary of China's CNPC, to increase production at the Sacha field in the Amazonian province of Orellana.
The contract seeks to boost the field's output by 5,000 bpd from the current 65,700 bpd, he said, without saying the time frame in which this would take place. (Reporting by Alexandra Valencia, writing by Brian Ellsworth; editing by Diane Craft)
Oil output
China National Petroleum Corporation
Most Read in Oil & Gas
India's natural gas imports to rise on lower global prices - Petronet LNG
IndianOil to pump in Rs 2,200 crore investment for various projects in Tamil Nadu
Anant Ambani to wed Radhika Merchant
Trafigura sells out of Russia-backed Indian refiner Nayara Energy
Reliance suspends gas auction after change in marketing rules


One of the founding directors of Vero, Rupert is passionate about the Vero vision to deliver outstanding employment screening services and solutions which mitigate client risk and promote high levels of candidate engagement. With strategic oversight for the business, he is committed to developing collaborative partnerships with clients, operating in a fully transparent and consultative capacity to achieve exceptional levels of service.
You have to do right by people. They deserve the best possible experience we can give them.
One of the founding directors of Vero, Steve brings entrepreneurial flair to the business, using an intuitive understanding of technology and the way people work to ensure our systems remain cutting edge and operational workflow is optimised. Retaining a key role in client implementations, his solution-driven approach is critical to ensuring a complete client partnership is achieved.
One of the founding directors of Vero, Rebecca works closely with the cross-functional Senior Management Team, retaining critical oversight of the business and ensuring operational delivery meets client expectations. Working closely with Human Resources she is committed to ensuring effective talent management within the business and promoting employee engagement.
Certified as a Lead Implementer for the ISO27001 standard, Georgina is Vero's specialist in information security and management. She makes sure every process and procedure is clearly defined. She has an extensive background in employment screening and works closely with IT and Compliance, supporting with internal and external security auditing.
Passionate about client service and with extensive industry experience, Amy has particular focus on service excellence and service delivery. Prince 2 qualified and with responsibility for client implementations, she works closely with Client Services, Sales and Operations to support clients from the point of onboarding and throughout ongoing service delivery.


Green juices are power-packed with nutrition. Green vegetables have the ability to transform sunshine into the food that all creatures consume. True to their nature, greens produce chlorophyll, which oxygenate your body. This enables us to release stored toxins in the body. Your hemoglobin (that has a similar molecular structure as that of your red blood cells) will get elevated, improving the blood circulation as a result and giving your body a boost of energy. A green juice will cleanse your digestive system, lungs, liver (which will rev up, if sluggish — causing you to retain weight) and uterus. So if you are a smoker, this is an excellent supplement to your diet.
Feel incredible energy and focus that lasts all day long and Boost your brain power.


This article shows how major world events are just pebbles in the mosaic of US global power. Syria, Libya, Yemen .. A redrawing of the map … Confrontation in the Ukraine is to fulfil only to separate Russia from Europe and to prevent trade, and thereby get rid of Europe's energy dependence on Russia…. They want Russia into economic depression. More broadly, to prevent Russia from once again becoming a superpower. ,,, It is one reason for low oil prices … Turkey has finally understood it is to be thrown overboard…. May God save the world.
The war propagandists are winning the support of many unsuspecting American citizens. The followingg 90 seconds video may provide a refreshingly different perspective.
If Islam alone were the completed and perfected religion of God — and if its political completeness was the basis for its long-lasting worldly success (which would be proof of its religious superiority) — then why has it been so comprehensively defeated and impotent? What had gone wrong? The history of modern Islam has largely been the story of failed attempts to overcome this cognitive dissonance.
A model of human migration based on mitochondrial DNA with Africa at the top.
The letters are the mitochondrial DNA haplogroups (pure motherly lineages) that can be used to define fine genetic population.
Beijing has launched major cyber strikes against Google, Apple, Microsoft and Yahoo six times over the past two years, with Politburo approval. They aim to establish Beijing's absolute authority over all Internet operations within China.
to protect corporate power against democracy.
Although this article tries to make the people of Donetsk appear gullible and indoctrinated, it does admit that Kiev is waging a vicious war against its own people—something that East Ukrainians will never forget, and probably never forgive.
IS in Iraq and the Levant is expanding to establish militant affiliates in Afghanistan, Algeria, Egypt and Libya.
What causes our climate to change?
The jet stream, which once used to move over North America horizontally, has become wavy, pushing warm air north while drawing cold air from the south.
Unless Washington figures out that its strategy will not work, we must expect stalemate and a much higher level of US-Iranian tensions. The only reason Iran has not accepted the deal, according to the US view, is that Supreme Leader Ali Khamenei is a hardliner who is constraining the more reasonable Iranian negotiating team from making the necessary compromises. But that reflects a profoundly distorted view of US-Iran relations on the nuclear issue.
A group from Russia, China, Ukraine and parts of Europe use a virus known as Carbanak to access bank employee computers and ultimately get inside their networks.The hackers then transfer money from the bank into off-shore accounts, or order the bank's ATMs to dispense cash to a waiting friend.
Greece won't commit to an extension of the lending program which is tied to the same austerity conditions that have devastated its economy. The Eurogroup will not accept an extension of the lending program unless Greece agrees to further austerity conditions.
54% higher than in 1990. Coal burning was responsible for 43%, oil 34%, gas 18%, and cement 5%.
NSA has successfully developed techniques for hiding spyware on hard drives. Once infected it is impossible to alter and cannot be detected. Infected machines have been found in Russia, Afghanistan, China, Syria and Yemen.
Another level of intimidation to the increasingly militarized police state. It is one step closer to a dystopian future where autonomous robots carry out law enforcement. If a human police officer can get away with killing what would this mean for the robot officer? The K5 does not wield weapons but serves as a total surveillance machine for cops or private clients. It has facial recognition and scans 1,500 license plates per minute, captures audio and 360-degree video, tests the air for chemicals, and maps its surroundings with 3D radar and laser. It pretends to distinguish "suspicious activities" from normal activities. Robots have been used for years to detonate or disable bombs, but police robots are increasingly being developed for use against people.


text:
Q: Where is Selective Sync option on latest Dropbox? On Windows, Dropbox used to have "Selective Sync..." settings under [Windows Tray / Dropbox icon / "Gear" icon / Preferences...,
then "Account" tab.
I don't see it any more?  (Windows 10)

A: On Windows 10, it has moved to "Sync" tab - the last tab in "Preferences" dialog.

redpajama_set_name: RedPajamaStackExchange


Home Depot Leesburg Fl was published on September 24, 2018 at 9:30 pm. It is published in the Home category. Home Depot Leesburg Fl is tagged with Home Depot Leesburg Fl, Home, Depot, Leesburg, Fl..
For decorating the Home Depot Leesburg Fl, the very first suggestions are to produce little landscapes. This small yard indicates a natural place which is on the front of the house like a small location with numerous kinds of flowers which can be wonderful and able to summarize a beautiful green spot. For those who have been inspired from the location park, then you can certainly additionally produce a location park without less gorgeous view for the area park.
Some beautiful crops you're able to choose like trees are colorful plants tiny, and grasses that can meet the terrain spot while in the playground in front of your home. The concept that both the Home Depot Leesburg Fl is a park that's not necessarily natural. This implies layout or a house yard model that can employ other tips, helping to make a tiny swimming, which will be not really a large amount of use green crops, but simply to optimize the big event of water and electricity in it.
In addition to the tiny swimming you can even make sebuaha little waterfall or a little feature that is employed with organic aspects, including the utilization of wood as being a water flushed or from the usage of stones, where the water will soon be revealed more obviously aswell.


Taking into consideration the importance of trade and investment as one of the major contributing factors for fostering economic and social development in the region.
Recall the principles enshrined in the 1997 Bangkok Declaration and reemphasize that cooperation within BIMSTEC will be based on respect for the principles of sovereign equality, territorial integrity, political independence, non-interference in internal affairs, peaceful co-existence and mutual benefit.
Agree to intensify our efforts to realize the objectives and purposes of BIMSTEC as embodied in the 1997 Bangkok Declaration, and reiterate our pledge to work collectively towards making BIMSTEC a stronger, more effective and result-oriented organization for achieving a peaceful, prosperous and sustainable Bay of Bengal Region.
Resolve to achieve, leveraging on BIMSTEC's unique position as a bridge linking South and Southeast Asia, an enhanced level of economic and social development in the region, and remain fully committed to consolidate and deepen cooperation among Member States towards transforming our organization into an effective platform to promote peace, prosperity and sustainability.
Deplore terrorist attacks in all parts of the world including in BIMSTEC countries and strongly condemn terrorism in all its forms and manifestations wherever and by whomsoever committed and stress that there can be no justification whatsoever for any act of terrorism. Affirm that the fight against terrorism should target not only terrorists, terror organizations and networks but also identify and hold accountable States and non-State entities that encourage, support or finance terrorism, provide sanctuaries to terrorists and terror groups and falsely extol their virtues. Reiterate our strong commitment to combat terrorism and call upon all countries to devise a comprehensive approach in this regard which should include preventing financing of terrorists and terrorist actions from territories under their control, blocking recruitment and cross-border movement of terrorists, countering radicalization, countering misuse of internet for purposes of terrorism and dismantling terrorist safe havens.
Repose our faith unequivocally in the principles and purposes of the Charter of the United Nations and strive to strengthen the multilateral system by reforming its rules, institutions and instruments to make it relevant to contemporary global challenges and agree to work together to present a collective voice to safeguard our collective interests for a fair, just, rule-based, equitable and transparent world order.
Decide to task the BIMSTEC Secretariat to prepare a preliminary draft of the charter for the organization, building on the 1997 Bangkok Declaration, defining a long-term vision and priorities for cooperation, clearly delineating roles and responsibilities of different layers of institutional structure and decision-making processes, for consideration by the BIMSTEC Permanent Working Committee (BPWC) and other higher bodies with a view to adopting it by the Fifth Summit; and agree to task the BPWC to develop the Rules of Procedure (RoP) for the BIMSTEC Mechanisms.
Decide to establish a BIMSTEC Permanent Working Committee to deal with administrative and financial matters of the Secretariat and the BIMSTEC Centers and Entities, as well as to prepare schedule of meetings, prioritize and rationalize the organization's activities.
Direct the relevant Ministries/national agencies of our respective governments to explore the possibility of establishing a BIMSTEC Development Fund (BDF), at an appropriate time, with voluntary contributions from the Member States, which will be utilized for research and planning of BIMSTEC and financing of projects, programmes and other activities of BIMSTEC Centers and Entities as agreed upon by the Member States.
Agree to enhance the institutional capacity of the BIMSTEC Secretariat, including through financial and human resources, in order to enable it to coordinate, monitor and facilitate implementation of BIMSTEC activities and programmes; and initiate project proposals as agreed by the Member States as well as fulfil any other responsibility entrusted to it in an effective and efficient manner and agree to raise the numbers of Directors to seven, one from each Member State, in a staggered manner.
Acknowledge the importance of enhancing the visibility and stature of BIMSTEC in international fora by, inter alia, forging common positions, as appropriate, on issues of common interest and seeking group recognition in various multilateral organizations, institutions and processes.
Emphasize the need to accelerate progress in the core areas of cooperation and to review, restructure and rationalize the existing areas of BIMSTEC cooperation and streamline the operational modalities for activities, implementation of programmes and projects under BIMSTEC for bringing out tangible results. Welcome Thailand's concept paper on the Reprioritization of BIMSTEC Pillars of Cooperation proposing to streamline to five pillars which will be subjected to further discussion in the BIMSTEC Permanent Working Committee.
Agree to take up on priority basis the legal documents and instruments that are pending for internal approval process for finalization and ratification.
Commend the role of Lead Countries for the progress made in the respective sectors, as annexed to this declaration, and encourage them to accelerate their efforts to make further progress.
Express our appreciation for former Secretary-General Mr. Sumith Nakandala's valuable contribution in advancing the work of BIMSTEC during his tenure and welcome the appointment of Mr. M. Shahidul Islam of Bangladesh as the Secretary General of BIMSTEC.
Convey deep appreciation to Nepal for the able stewardship of BIMSTEC from March 2014 and welcome Sri Lanka as the new Chair of BIMSTEC.
Reiterate the commitment to timely holding of Summit and other meetings of the BIMSTEC mechanisms to intensify the process of regional cooperation.
Agree to make our directives, commitments and statements of our positions on sectoral review expressed at the Annexure as part of this Declaration.
Express our sincere appreciation to the Government of Nepal for the warm hospitality and the excellent arrangements made for the Summit.
Reiterate our commitment to the eradication poverty in the Bay of Bengal Region by 2030 in line with the 2030 Agenda for Sustainable Development and call for effective implementation of the BIMSTEC Poverty Plan of Action and for gearing up efforts of all sectors to contribute to the over-arching goal of poverty alleviation.
Express commitment to nurturing our workforce by taking concrete measures to provide decent job opportunities for them through increased investment in service and productive sectors of national economy.
Reiterate our resolve to establish seamless multi-modal transportation linkages and smooth, synchronized and simplified transit facilities through the development, expansion and modernization of highways, railways, waterways, sea routes, airways in the region and direct our respective authorities to speed up their efforts to conclude the BIMSTEC Coastal Shipping Agreement and the BIMSTEC Motor Vehicle Agreement as early as possible taking into account the special circumstances and needs of the Member States.
Note with satisfaction the preparation of the draft BIMSTEC Master Plan on Transport Connectivity and call for its early adoption and thank the Asian Development Bank for providing support to prepare the Master Plan and task the BIMSTEC Transport Connectivity Working Group (BTCWG) to work out the modalities for its implementation, giving due attention to the special circumstances and needs of the Member States. We agree that the Master Plan would serve as a strategic document that guides actions and promotes synergy among various connectivity frameworks, such as the ASEAN Master Plan on Connectivity 2025 (MPAC 2025), the Ayeyawady - Chao Phraya- Mekong Economic Cooperation Strategy (ACMECS), to achieve enhanced connectivity and sustainable development in our region.
Decide to establish a Working Group to deal with information technology and communications related matters with a view to provide greater access, more affordable and high-speed internet and mobile communications to the peoples of the region. In this regard, we welcome the offer of the Government of India to host a BIMSTEC Ministerial Conclave at the India Mobile Congress 2018 being held in New Delhi from 25-27 October 2018 on the theme "New Digital Horizons: Connect, Create, Innovate", and encourage all Member States to participate in it.
Renew our commitment to an early conclusion of BIMSTEC Free Trade Area (FTA) negotiations, and direct the BIMSTEC Trade and Economic Ministerial Meeting (TEMM) and its subsidiary bodies including the Trade Negotiating Committee (TNC) to expedite finalization of all related Agreements of the BIMSTEC FTA as early as possible; and express our satisfaction on the progress of negotiation on the Agreement on Trade in Goods and the Agreement on Customs Cooperation and also direct our respective Ministries/Agencies to participate regularly in TNC Meetings.
Agree to revitalize the activities of BIMSTEC Business Forum and BIMSTEC Economic Forum to further strengthen Government–Private sector cooperation for the promotion of trade and investment and task the Expert Group on BIMSTEC Visa Matters to continue negotiation for finalization of the modalities for the BIMSTEC Visa Facilitation.
Welcome the offer of India to host a BIMSTEC Startup Conclave in December 2018, and encourage all Member States to participate in it.
Reiterate our position that terrorism continues to pose a serious threat to peace and stability in our region and reaffirm our strong commitment to combat terrorism in all its forms and manifestations and agree to taking appropriate measures in this regard.
Look forward to the signing of the BIMSTEC Convention on Mutual Legal Assistance in Criminal Matters; call upon the Member States for its early ratification and express satisfaction that many Member States have ratified the BIMSTEC Convention on Cooperation in Combating International Terrorism, Transnational Organized Crime and Illicit Drug Trafficking and call upon the remaining Member State to do so.
Express our determination to strengthen cooperation and coordination among the law enforcement, intelligence and security agencies; and decide to hold meetings at the level of BIMSTEC Home Ministers and continue with the BIMSTEC National Security Chiefs meetings as part of promoting cooperation and coordination on counter terrorism and transnational crimes.
Welcome the offer of Thailand to host the Third Meeting of the BIMSTEC National Security Chiefs in March 2019.
Encourage closer cooperation in disaster management through sharing of information, including early warning system, adoption of preventive measures, rehabilitation and capacity building and agree to build on the existing capacities in the region and decide to establish an Inter-governmental Expert Group to develop a plan of action to improve preparedness and coordination for responding to natural disasters in the Bay of Bengal Region.
Express our serious concerns over environmental degradation, adverse impact of climate change and global warming on the fragile Himalayan and mountain eco-systems and their inter-linkages with the Bay of Bengal and Indian Ocean and resolve to strengthen cooperation to protect and preserve the environment to address, inter alia, the adverse impact of climate change on the lives and livelihoods of our peoples; explore the possibility to establish an Inter-governmental Expert Group to develop a plan of action for collective response to climate change for the region; reaffirm our commitments to operationalize the Paris Agreement, in accordance with principle of common but differentiated responsibilities and respective capabilities (CBDR & RC), taking into account different national circumstances and equity.
Recognize the high potentials of energy resources in the region, particularly renewable and clean energy sources, and agree to expedite our efforts to develop a comprehensive plan for energy cooperation by working closely with each other within the region and decide to constitute an intergovernmental group of experts to enhance energy cooperation including in hydro-power and other sources of renewable energy.
Remain committed to providing uninterrupted and affordable power supply for the economic development of our peoples, including through energy trade; welcome the signing of the Memorandum of Understanding on BIMSTEC Grid Interconnection and instruct the relevant agencies to take concrete measures to initiate harmonization of technical, planning and operational standards for removing barriers to grid interconnections and also ensure early establishment of a BIMSTEC Grid and call for an early operationalization of the BIMSTEC Energy Centre in order to strengthen energy cooperation in the region.
Agree to enhance cooperation for development, access and sharing of affordable technologies – including for Micro, Small and Medium Enterprises for promoting sustainable development across sectors and welcome the efforts of the Member States towards the signing of the Memorandum of Association on the Establishment of BIMSTEC Technology Transfer Facility in Sri Lanka.
Decide to deepen cooperation in the agricultural and allied sectors, including crops, livestock and horticulture, farm machinery and harvest management so as to increase productivity and profitability of agricultural produce in a sustainable manner; task the relevant authorities to intensify cooperation to attain food and nutritional security; and preserve and promote knowledge about traditional farming by appropriately linking both traditional and modern farming, and reducing costs, enhancing income and mitigating risks for farming communities, with the objective of facilitating agricultural trade among member countries and making contribution to the poverty alleviation, job creation, and improvement of quality of life of the masses in our nations.
Welcome the offer of Myanmar to host the 1st BIMSTEC Ministerial Meeting on Agriculture by 2019 and the offer of India to host the BIMSTEC Seminar on Climate Smart Farming Systems in 2019.
Stress on continued cooperation in conservation, management and sustainable use of marine resources in the region; agree to deepen cooperation in fisheries to ensure food security and improve livelihoods of people in our region and task the relevant national agencies to explore the possibility of meaningful collaboration to promote sustainable marine fisheries and direct the relevant authorities to explore how the landlocked Member States can benefit from inland fisheries.
Agree to expand cooperation in our efforts to address non-communicable diseases as well as trans-national public health issues that threaten the economic and social progress of the peoples of BIMSTEC region, including HIV and AIDS, malaria, dengue, tuberculosis, viral influenza-including avian and swine influenza and other emerging public health threats; note the progress in traditional medicine cooperation; remain committed to continuing the collaborative activities in this field; encourage active cooperation among concerned agencies including in the area of traditional medicine through exchange of information, sharing of experience, training of personnel and other concrete programmes to prevent and contain them; and express appreciation to Thailand for their efforts for cooperation in traditional medicine.
Resolve to build a deeper understanding and trust among Member States and promote people-to-people contacts at various levels; note with satisfaction the activities of the BIMSTEC Network of Policy Think Tanks (BNPTT) in enhancing public awareness about BIMSTEC and direct the relevant agencies to finalize the terms of reference (ToR) of BNPTT.
Agree to explore possibility of establishing appropriate BIMSTEC forums for parliamentarians, universities, academia, research institutes, cultural organizations and media community to expand the scope of people-to-people contacts.
Emphasize the need to enhance cultural exchange among Member States to further strengthen the historic cultural ties among our peoples; promote mutual respect and tolerance for cultural diversity; underscore the importance of Buddhism as a connecting thread in the region; and remain committed to giving a clear manifestation to this by establishing a Buddhist Circuit.
Agree to hold meetings of BIMSTEC Cultural Ministers and BIMSTEC Cultural Festival at regular intervals; welcome the offer of Bangladesh to hold the 2nd BIMSTEC Ministerial Meeting on Culture and 1st BIMSTEC Cultural Festival; and strongly encourage our respective Cultural Ministers to participate in these two important events.
Agree to take concrete steps to promote intra-BIMSTEC tourism; task the relevant authorities to devise strategies considering the emerging opportunities and building on the past initiatives including the "Plan of Action for Tourism Development and Promotion for the BIMSTEC Region" adopted in Kolkata in 2005 and reinforced by the 2nd BIMSTEC Tourism Ministers Round Table and Workshop in Kathmandu in 2006; agree to take concrete measures to facilitate tourism by ensuring safety and security of tourists, and smooth transport connectivity; reaffirm our commitment to developing and promoting Buddhist Tourist Circuit, Temple Tourist Circuit, ancient cities trail, eco-tourism and medical tourism; and welcome the offer of Nepal to host a BIMSTEC tourism conclave in Nepal in 2020, coinciding with the Visit Nepal Year 2020.
Underscore the necessity of making concrete efforts to ensure the conservation of mountain ecosystems, including their bio-diversity in order to support sustainable development; welcome the concept note on promoting mountain economies in BIMSTEC countries developed by Nepal to promote cooperation in this area; and decide to establish an Inter-governmental Expert Group to develop an action plan.
Emphasize the importance of blue economy and agree to cooperate in this sector for the sustainable development in the region and decide to establish an Inter-governmental Expert Group to develop an action plan on blue economy, keeping in mind the special needs and circumstances of the landlocked Member States.
Note with satisfaction the hosting of International Blue Economy Conference in Bangladesh in 2017 with participation of government representatives from BIMSTEC Member States.