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Determinants of patient and health system delay among Italian and foreign-born patients with pulmonary tuberculosis: a multicentre cross-sectional study
Annalisa Quattrocchi1,
Martina Barchitta1,2,
Carmelo G A Nobile3,
Rosa Prato4,
Giovanni Sotgiu5,
Alessandra Casuccio6,
Francesco Vitale6,
Antonella Agodi1,2
on behalf of the CCM 2013 TB network
1 Department of Medical and Surgical Sciences and Advanced Technologies 'GF Ingrassia', University of Catania, Catania, Italy
2 LaPoSS, Laboratory of Policies and Social Services, University of Catania, Catania, Italy
3 Department of Health Sciences, University of Catanzaro 'Magna Græcia', Catanzaro, Italy
4 Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
5 Department of Biomedical Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
6 Department of Sciences for Health Promotion and Mother-Child Care 'G. D'Alessandro', University of Palermo, Palermo, Italy
Correspondence to Prof. Antonella Agodi; agodia{at}unict.it
Objectives The aim of this cross-sectional study was to identify key factors associated with patient delay (PD), health system delay (HSD) and total delay (TOTD) in patients with tuberculosis (TB) to inform control programmes.
Setting The study was conducted in four Italian regions in 2014–2016. Data were obtained using a questionnaire including: sociodemographic and lifestyle data, TB comorbidities, patient knowledge and attitudes towards TB, stigma, access to TB care and health-seeking behaviours.
Participants Patients' inclusion criteria were being diagnosed as a new smear positive pulmonary TB case and living in one of the participating Italian regions. Overall, 344 patients from 30 healthcare centres were invited to participate and 253 patients were included in the analysis (26.5% non-response rate); 63.6% were males and 55.7% were non-Italian born.
Outcome measures Risk factors for PD, HSD and TOTD in patients with TB were assessed by multivariable analysis. Adjusted ORs (aOR) and 95% CIs were calculated.
Results Median PD, HSD and TOTD were 30, 11 and 45 days, respectively. Factors associated with longer PD were: stigma (aOR 2.30; 95% CI 1.06 to 4.98), chest pain (aOR 2.67; 95% CI 1.24 to 6.49), weight loss (aOR 4.66; 95% CI 2.16 to 10.05), paying for transportation (aOR 2.66; 95% CI 1.24 to 5.74) and distance to the health centre (aOR 2.46; 95% CI 1.05 to 5.74) (the latter three were also associated with TOTD). Shorter HSD was associated with foreign-born and female status (aOR 0.50; 95% CI 0.27 to 0.91; aOR 0.28; 95% CI 0.15 to 0.53, respectively), dizziness (aOR 0.18, 95% CI 0.04 to 0.78) and seeking care at hospital (aOR 0.35; 95% CI 0.18 to 0.66). Prior unspecific treatment was associated with longer HSD (aOR 2.25; 95% CI 1.19 to 4.25) and TOTD (aOR 2.55; 95% CI 1.18 to 5.82). Haemoptysis (aOR 0.12; 95% CI 0.03 to 0.43) and repeated visits with the same provider (aOR 0.29; 95% CI 0.11 to 0.76) showed shorter TOTD.
Conclusions This study identifies several determinants of delays associated with patient's behaviours and healthcare qualities. Tackling TB effectively requires addressing key risk factors that make individuals more vulnerable by the means of public health policy, cooperation and advocacy to ensure that all patients have easy access to care and receive high-quality healthcare.
public health policy
quality in health care
tuberculosis patients
This is the first multiregional cross-sectional study, in Italy, investigating the association of key factors with patient delay, health system delay and total delay in patients with pulmonary tuberculosis.
Data were collected by healthcare providers and cultural mediators, using a multilingual standardised questionnaire.
The prospective collection of data and the adjustment for confounding factors with logistic regression analysis are among the strengths of the present study.
A selection bias should be considered, especially for foreign-born patients who may have experienced difficulties during the interview, resulting in refusal or in missing data.
Self-reported dates for onset of symptoms and healthcare seeking may have been affected by recall bias.
Early diagnosis and prompt treatment of tuberculosis (TB) disease represent key components of any effective national TB control programme.1 2 If adequately implemented and scaled-up, they can contribute to the reduction of Mycobacterium tuberculosis transmission and TB elimination by 2050.3
However, delays in diagnosis and treatment of TB frequently occur.4 Long delays lead to a more advanced disease that may result in poor response to therapies, undesirable clinical sequelae and higher mortality risk.5 In addition, delay contributes to M. tuberculosis transmission within the community.6 7 It has been shown that an untreated smear-positive patient can infect, on average, 10 healthy contacts annually.8 Finally, TB diagnosis delay is associated with higher direct and indirect costs.9
Delay may occur at patient or at health system level. Factors contributing to patient delay (PD) can be: sociodemographic, physical, financial, health literacy, religious-cultural and stigma.10 Health system delay (HSD)-related factors can be: poor TB knowledge among healthcare providers, lack of effective diagnostic tools, number and types of providers encountered before TB diagnosis, patient satisfaction with TB services and waiting time.10 11 Thus, understanding and identifying the causes of delay in diagnosis and treatment initiation are critical to strengthen TB control programmes. Particularly, the importance of social variables as drivers of epidemics and disease risk has been long recognised. Incorporating the perspectives and methods of social epidemiology into studies of infectious disease arises many opportunities to control the disease.12
However, in Europe, and especially in Italy, few studies have focused on social determinants and TB delays.
The aim of the present study was to identify the duration and the key factors related to PD, HSD and total delay (TOTD) in pulmonary patients with TB, in four Italian Southern regions, with a focus on social determinants.
The present cross-sectional study was conducted in four Italian regions (Calabria, Apulia, Sardinia and Sicily) from October 2014 to July 2016, and was approved and financed by the Italian Ministry of Health.
Patients' inclusion criteria were being diagnosed as a new smear-positive pulmonary TB case (with or without extrapulmonary TB) and living in one of the above-mentioned Italian regions. Foreign-born patients were enrolled regardless of their legal migrant status (eg, refugees, asylum seekers and illegal migrants). Negative smear, relapse, retreatment cases and those with only extrapulmonary TB were excluded.
The participants were fully informed of the purpose of the study and signed a written informed consent. All data collected were treated confidentially and analysed in aggregated and anonymous form.
The present study was conducted without patient and public involvement. Results of the research will be available on request to any study participant to disseminate key study findings providing feedback on the research outcome towards which they have contributed.
Sample size calculation and sampling procedure
A sample size of 261 was estimated by using single population proportion estimation formula with an assumption of 95% CI, 6% margin of error and 50.4% proportion of PD (>30 days).13
Furthermore, considering 20% of non-response rate, the final sample size was 321. All patients meeting the inclusion criteria, attending the healthcare facility during the study period, were prospectively invited to participate in the study.
Data collection and definitions
Data were collected by healthcare workers of each participating centre, during a face-to-face interview at the time when patients were diagnosed and/or initiated treatment. A standardised questionnaire available in Italian, English and French was used, and if possible, a cultural and linguistic mediator assisted the interview with the task to facilitate communication and understanding, both on linguistic and cultural level. Operators with adequate background of the health topic, within the specific cultures/languages, supported and assisted patients and healthcare professionals during clinical examinations.
The questionnaire contained several domains: i) sociodemographic and lifestyle data; ii) integration index (II) in Italy (only for foreign-born patients), computed as described in a previous study14; iii) TB comorbidities; iv) patient knowledge of TB-associated symptoms and attitudes towards TB; v) TB-related stigma, measured according to the WHO questionnaire15; vi) access to TB diagnosis and treatment and health-seeking behaviours; vii) dates of: onset of symptoms, first contact with healthcare service, TB diagnosis confirmation and treatment initiation; viii) satisfaction with care, assessed by adopting and modifying the United States Agency for International Development (USAID) questionnaire.16
PD was defined as the time interval between the onset of symptoms and patient's first contact with any type of healthcare service (including hospital and primary healthcare).15 16 HSD was defined as the time interval between the first consultation with a healthcare provider and the initiation of treatment.15 16 This can be subdivided into: diagnostic delay (DD) as the time interval between the presentation to a healthcare provider and the date of diagnosis and treatment delay (TD) as the time interval between TB diagnosis and initiation of anti-TB treatment. Thus, TOTD was defined as the time interval from onset of symptoms until treatment initiation.16 17
Statistical analyses were performed using the SPSS software (IBM SPSS Statistics for Windows, V.22.0).
The response rate and descriptive statistics were used to characterise the sample using frequencies, means, medians and IQRs. Valid percentage was reported when data were missing (pairwise deletion method). Furthermore, the magnitude (proportion) of missing data was quantified and is reported in online supplementary table S1.
Poverty was defined in relation to housing circumstances as living in community centres, first aid centres or prisons. Education level was dichotomised into two categories (high and low), using a cut-off of 8 school years.
Variables related to stigma and satisfaction with care were recorded on a 5-point Likert scale.15 16 Scores were converted as mean percentage score, calculated as follows: (sum of score obtained/maximum score that could be obtained)×100.
For TB cases born abroad, the II was calculated based on the score sum of 11 selected variables from the study questionnaire and then standardised to range from 0 to 10.14
Longer delays (outcome) were defined according to previous Italian studies. Particularly, long PD was defined as >30 days, while long HSD and TOTD were defined as >the median value observed in the study population, for HSD and TOTD, respectively.13 18
Prevalence estimates of longer delay, using cut-off values reported from other studies, are reported in online supplementary table S2.
Median values were also used as cut-off points to dichotomise quantitative variables (eg, age and stigma). The two-tailed Χ2 test was used for the statistical comparison of categorical variables, whereas quantitative variables were compared using Student's t-test, as the sample was big enough. The Levene's test was performed to verify the homogeneity of variance across groups.
The characteristics of patients with longer delays (all forms) were compared with those of patients without (comparators) and the crude ORs and the corresponding 95% CIs were computed.
All variables with p<0.1 on univariate analysis were included in the multivariable logistic regression analysis, using a backward-stepwise selection procedure. The analysis was only run on cases which have a complete set of data. The breakpoint for variable removal was set at p=0.10. The adjusted ORs (aOR) with the respective 95% CIs were reported. A p value <0.05 was considered to be statistically significant.
A total of 344 patients from 30 healthcare centres were invited to participate. Overall, 91 (26.5%) refused the interview, and 253 patients were included in the analysis. Patients who refused the interview were older than patients who agreed (mean age: 46.0 and. 40.7 years, respectively; p=0.023). However, no statistical differences resulted for country of birth and gender. Completion rate for all questions included in the analysis was ≥80%. Missing data ranged from 0.4% to 21.7% (online supplementary table S1).
Overall, 55.3% of patients were temporary or permanently living in Sicily, 22.1% in Calabria, 17.4% in Apulia and 5.2% in Sardinia.
Table 1 shows the main characteristics of the study population and comparisons by origin and gender. Mean age was 40.7 years (median 38; IQR 27–53) and 63.6% were males. One hundred forty-one (55.7%) patients were born abroad and they were younger than Italians (mean age 34.3 and 48.7 years, respectively; p<0.001).
Patients' characteristics by origin and gender
Stratifying by country of origin, 47.9% of patients came from European countries, and mostly from Romania (82.1%), 28.6% from the African countries, 11.4% from Eastern Mediterranean countries, 9.3% from South-East Asia, 2.1% from Western Pacific countries and 0.7% from American countries. Foreign-born patients reported higher degree of poverty and literacy: they lived in nursing homes or did not have permanent residency (47.8%), 64.7% were unemployed or occasional workers and 79.4% were illiterate or had <8 years of educational activities (p<0.05).
About one-third suffered of chronic diseases (ie, HIV/AIDS, diabetes, chronic obstructive pulmonary disease, disability, renal failure and cardiovascular disease), particularly those born in Italy (39.1%). Current smokers and alcohol users were 27.2% and 6.9%, respectively. Higher percentages of smokers and alcohol users were found among male patients (32.5% and 10.1%). However, no significant differences were observed between Italian and foreign-born patients (table 1).
Patient knowledge and symptoms recognition
Foreign-born patients reported lack of knowledge on the disease more often compared with Italian-born (see online supplementary table S3). Foreign-born patients were less aware that TB is an infectious disease and is transmitted by airborne bacteria. They did not know the symptoms most frequently associated with the disease, how TB is diagnosed and cured and that multidrug-resistant TB may require a longer treatment time to achieve a cure (p<0.05).
Only 3.6% of patients with TB reported no symptoms, while 49% of patients reported three or more symptoms. Overall, 65.6% had cough for >3 weeks. Sputum with blood was reported by only 13.4% of patients. The main reason for not seeking care was that they perceived the TB symptoms to be mild (58.9%).
Foreign-born patients reported more frequently the following symptoms: cough, sputum with blood, weakness, weight loss and chest pain, compared with Italian-born patients. Furthermore, women reported tiredness/weakness, weight loss, chest pain and night sweating less frequently compared with men. Being irregular migrant was the only reason for delayed seeking care in women, while in men other motivations were reported (see online supplementary table S3).
Attitude towards TB and stigma
A higher percentage of men (38.6%) and foreign-born patients (44.9%) did not inform their families and friends on the disease, compared with women (12.2%) and Italian-borns (9.1%) (p<0.001). Detailed results are reported in online supplementary table S4.
A moderate level of stigma was found (mean: 59.5%; median and IQR: 58.7%, 22.7%–94.7%) in all patients. Overall, 53.9% of foreign-born patients reported TB-related stigma above the median value, compared with 41.4% of Italian borns (p=0.049) (table 1).
Healthcare-seeking behaviour and access to TB care centres
General practitioners (GP) were consulted, as first choice, by 30% of patients, mostly Italians (46.8%). On the contrary, foreign-born cases were shown to seek more frequently the hospital care (70.3%). Around 41% of cases were visited by more than one healthcare provider, and this was mainly reported by the Italian group (53.2% vs 31.7%; p=0.001). Overall, 59% of the cases received unspecific treatment (mainly antibiotics) before TB diagnosis; this occurred more frequently among cases born in Italy (75.7% vs 51.6%; p=0.005).
Risk analysis of delay
Median PD, HSD and TOTD were 30, 11 and 45 days, respectively (table 1). On univariate analysis, factors associated with long PD (>30 days) were: TB-related stigma, paying for transportation, distance to the healthcare centre, presence of unintentional weight loss, fatigue, chest pain and suffering of chronic diseases. In the final model of the multivariable analysis, stigma (aOR 2.30, 95% CI 1.06 to 4.98), paying for transportation (aOR 2.66, 95% CI 1.24 to 5.74), distance to the healthcare centre (aOR 2.30, 95% CI 1.06 to 4.98), weight loss (aOR 4.66, 95% CI 2.16 to 10.05) and chest pain (aOR 2.67, 95% CI 1.24 to 6.49) remained associated with PD (table 2).
Risk analysis for patient delay (univariate and logistic regression analysis)
Prior unspecific treatment, patients referring to a GP at the first visit, and those visited by multiple providers in different facilities were more likely to report long HSD (>11 days), while female gender, non-Italian origin, seeking care at hospital level, presence of cough for >3 weeks and dizziness were associated with shorter HSD. On multivariable analysis, being foreign-born (aOR 0.50, 95% CI 0.27 to 0.91), female gender (aOR 0.28, 95% CI 0.15 to 0.53), seeking care at hospital (aOR 0.35, 95% CI 0.18 to 0.66) and presence of dizziness (aOR 0.18, 95% CI 0.04 to 0.78) remained associated with shorter HSD. Prior unspecific treatment was associated with longer HSD (aOR 2.25, 95% CI 1.19 to 4.25) (table 3).
Risk analysis for health system delay (univariate and logistic regression analysis)
Factors associated with long DD (>7 days) were the same as those associated with HSD, and in addition, having cough for >3 weeks was significantly associated with shorter DD (online supplementary table S5). No variables were associated with long TD (>2 days).
Finally, good knowledge of TB, paying for transportation, distance to reach the health centre, prior unspecific treatment and weight loss were associated with long TOTD (>45 days), while patients reporting cough and hemophthisis and those who had repeated visits with the same provider showed shorter TOTD. In the logistic regression analysis, paying for transportation (aOR 2.10, 95% CI 1.01 to 4.35), distance to the healthcare centre (aOR 3.09, 95% CI 1.38 to 6.90), prior unspecific treatment (aOR 2.55, 95% CI 1.18 to 5.82), weight loss (aOR 3.55, 95% CI 1.56 to 8.09), repeated visits with the same provider (aOR 0.29, 95% CI 0.11 to 0.76) and haemoptysis (aOR 0.12, 95% CI 0.03 to 0.43) were independently associated with TOTD (table 4).
Risk analysis for total delay (univariate and logistic regression analysis)
Reducing the time interval between symptoms recognition and TB treatment can decrease mycobacterial transmission, morbidity and mortality. Although there is no general consensus on what may constitute an acceptable interval between onset of symptoms and initiation of TB treatment,19 it has been suggested that overall TB delay could be used as a key indicator of programme performance.4
The TB notification rate in the general Italian population has been stable in the last years.20 However, most of the cases occur in vulnerable groups, who do not recognise the symptoms or have poor access to healthcare services. The two most affected groups are the elderly and foreign-borns. The latter group accounts for about 50% of all TB cases in Italy (data until 2008).21
In our study, 55.7% patients were foreign-born, and they were younger than Italians. Younger age among foreign-born patients has also been reported in other studies.13 22 Although the TB notification rate is decreasing in Europe, the reduction in individuals of foreign origin is still slower than in native residents. This represents one of the main challenges for TB elimination, especially in those European countries where individuals of foreign-born origin represent a large proportion of TB cases.23
In our study, the median values of PD (30 days) and HSD (11 days;7 days of DD and 2 days of TD, respectively) are similar to those reported by other studies conducted in Italy and in other European countries with a low TB incidence. Particularly, a recent Italian study reported median PD and HSD values of 31 and 15 days, respectively.13 European studies reported median PDs of 14 days (France),24 28 days (Norway)25 and 29 days (UK).19 Considering HSD (and its two components), studies reported median values of 15 days (Croatia),26 25 days (for DD in France),24 30 days (UK)19 and 33 days (Norway).25 However, in our study, median TOTD (45 days) was lower than values reported elsewhere, which ranged between 62 days (UK)19 and 63 days (Norway).25
Online supplementary table S2 shows median values reported by other studies,13 19 24–26 and the prevalence of delay that would have been detected in our study, by using them.
It is worth noting that some studies evaluated both forms of TB (pulmonary and extrapulmonary), and tools for data collection and definitions of delays were widely heterogeneous among studies, thus comparisons should be made with caution.
Nevertheless, median values detected in our study are encouraging. Indeed, for PD a median value of 30 days has been considered an acceptable value by many authors,18 27 although others have suggested values <3 weeks.28
Regarding HSD, our median value is below the accepted value, which is considered to be 15 days.27 Low values of HSD and TOTD might probably due to a higher level of awareness of TB among involved healthcare professionals in Italy, in recent years. Similarly to our results, other studies have found that PD was longer than HSD,13 29 while others have found the opposite,24 25 or no differences.19 It is likely that patients who contact the health system later could have more severe symptoms facilitating TB suspicion and prompt diagnosis,13 thus the higher the PD, the lower the HSD, and vice versa.4 25
In our study, longer PD was associated with high degree of stigma, paying for transportation, distance to healthcare facility, presence of unintentional weight loss and chest pain. Aside from stigma and chest pain, all others were also detected as risk factors for TOTD. Our results are consistent with findings of the WHO Eastern Mediterranean Region study, where stigma, economic factors and time to reach the health facility were among the main determinants for delayed access to healthcare system.15
TB-related stigma represents a cultural aspect which drives individuals to hide their condition from others, and refusing seeking care,30 but evidence shows that stigma barriers may be avoided through interventions addressed improving TB-related health literacy.10
The reason why chest pain and weight loss were associated with long PD is not clear since these symptoms, together with persistent cough, are considered key TB signs. Other studies retrieved similar results. Chest pain was found positively associated with longer PD (>90 days) in a Brazilian study,31 and with TOTD (>60 days) in Ethiopia.27 Similarly, weight loss was associated with longer PD, both in Brazil (>30 days)31 and in Italy (>15 days),13 with PD (>27 days) and TOTD (>50 days) in Uzbekistan,32 and with HSD (>18 days) in another Brazilian study.33 These results could be explained by the assumption that patients consider these as transient symptoms from a general illness, hence, maybe, initiating self-treatment lasting until deterioration and manifestation of other specific symptoms. Furthermore, timely referral to healthcare facilities for disabling symptoms may be challenging due to financial constraints, poor health literacy and stigma. In addition, a long delay until diagnosis favours disease progression and therefore symptom appearance. Also, non-specific symptoms could lead to longer suspicion delays by the clinician.
Especially for foreign-born patients, language barriers, poor knowledge of symptoms, fear of immigration authorities and long wait for appointment have been associated with delay in seeking care,34 35 raising concerns about the equity of access to care among patients with TB. Thus, understanding immigrants' views of TB and the obstacles that they face when accessing the health system, taking into consideration the social, economic and legislative context of the new country where they live, has an important role and should be considered in TB control programmes.
The association of HSD with birth place might be due to the low TB rate in Italy, thus TB would be less suspected and investigated in the Italian-born population, or by contrast, being a migrant may point physicians to a prompt TB diagnosis.13 This finding is consistent with other studies.13 19
Female gender was associated with shorter HSD, in contrast with other studies.4 In general, female patients are reported to encounter greater barriers (financial, physical and health literacy) for appropriate medical care and treatment. Further investigations on possible confounders should be considered.
In line with others,4 30 36 37 a first healthcare contact in hospital, was strongly associated with shorter HSD, while referring to GP was a risk factor for longer HSD. A combination of several factors may explain this result: lack of TB suspicion among primary care providers in low-endemic countries; seeking assistance in hospital for patients at higher risk of TB (eg, migrants from endemic countries) and/or with more severe TB disease who are thus investigated faster; availability and easier access to diagnostic tests and specialists within the hospital.24
Furthermore, repeated visits, especially with different healthcare workers in different health facilities, has been retrieved as predictor of HSD in other studies15 17 38–40; however, we did not find this association in the final model. It has been reported that generally, patients see different healthcare providers in case of poor clinical suspicions of signs and symptoms, failure to request for proper investigations, refer patients to specialised TB centre for further investigations41 or when they receive inappropriate treatment that can modify the clinical picture of the disease.40
The association of HSD and TOTD with previous unspecific treatment is in agreement with other results.13 24 This is of a particular concern in the current global epidemiological scenario where antimicrobial resistance is rapidly developing and spreading and a more prudent use of antimicrobials is urgently needed by, for instance, limiting the use of empirical antibiotics in patients with respiratory symptoms.24 Training GP for the early identification of signs and symptoms and prompt referral of suspected cases to TB diagnosis and treatment health centres is essential.
Finally, other factors associated with shorter TOTD were presenting sputum with blood and having visits by the same provider. Sputum with blood is usually recognised as a late sign of TB, thus patients with severe symptoms are immediately suspected for TB. Intuitively, having visits with the same provider might reduce repetition of examinations and misdiagnosis.
Our study has some limitations, some of them specific to the cross-sectional study design. A selection bias should be considered. In fact, the cultural mediator was not often available in hospitals, thus, foreign-born patients recently arrived in Italy, may have experienced difficulties during the interview, resulting in refusal or in missing data. In any case, no difference has been detected for country of birth among responders and non-responders and the completion rate for the questions included in the analyses was at least 80%.
Missing data are a challenge which could affect the quality of the evidence, limit power and reduce generalisability, causing a distortion from the truth.42 43 There is no general consensus from the literature regarding an acceptable percentage of missing data in a data set for valid statistical inferences, yet. Cut-off values have been proposed ranging from 5% to 20%.44 45 In our study, we retrieved a certain amount of missing data, up to 21%, and observations with missing data have been excluded in the multivariable analysis, hence reducing the final sample size. In addition, the pattern of missingness was not explored. Thus, missing data may represent potential bias in our findings. The questionnaire used for data collection could have been a plausible cause for missing data in our study, because of the length of the survey, and the unavailability of translation in languages other than English and French. Thus, to prevent missing data in further studies, the data collection tool should be designed and adapted to the needs of the target population, piloted and monitored during the study.
Also, the low education level of the overall population may have contributed to an information bias. However, since a higher frequency of low educational level was shown in foreign-born patients than in those born in Italy, a differential misclassification could be supposed and thus the direction of the bias is unpredictable. Furthermore, as the onset date of symptoms was self-reported it may have been affected by recall bias that could have occurred heterogeneously in the whole sample. Another limitation is that data on HIV status and other risk factors (eg, alcohol and drug use and detention status) were not available for the majority of patients.
In the present study, several aspects have been investigating as key factors contributing to PD and HSD in patients with TB. However, further studies addressing other components of delays6 30 46 may be necessary to understand all factors that are closely associated with delay in the diagnosis and treatment of TB. Furthermore, in our regression model we did not take into account for the potential collinearity of explanatory variables, which could explain complex relationship involving several risk factors at the same time, for example, the use of unspecific antibiotics and multiple visits with healthcare providers.
A possible approach to combine the relevant variables into summary scores or indexes and to assess the relationship of these with the outcome of interest should be explored.
Nevertheless, this is the first multiregional cross-sectional study, conducted in Italy, which investigated the association of several factors with PD, HSD and TOTD in patients with pulmonary TB. It provides new evidence which can be addressed through tailored actions, in order to reduce the burden of TB in Italy. Furthermore, the prospective collection of data in four Italian regions, using a multilingual standardised questionnaire and the adjustment for confounding factors with logistic regression analysis are among the strengths of the present study.
In conclusion, this study detected several modifiable factors associated with longer delay in patients with TB, both attributable to patients and health system service. Interventions designed to empower the general population and stakeholders, by increasing knowledge and awareness and screening of active TB in migrants on arrival are key actions to reduce PD and HSD and achieve TB control.47 Strategies should mainly target alleviating stigma around TB, improving TB-related health literacy and access to care among the general population, education of GP, earlier referral of TB suspects to the hospital, where appropriate investigations for final diagnosis are readily available, and limiting the use of unspecific treatment in patients with respiratory symptoms.
To the memory of Professor Caterina Mammina, University of Palermo, First Coordinator of the project. The Authors are grateful to all dedicated staff of the participating hospitals: Silvana Adinolfi, Alessandra Bergamasco, Giulia Bertoli, Gaetano Brindicci, Daniela Castronuovo, Pierpaolo Ciavarella, Vanessa Cozza, Consuelo Geraci, Anna Giannelli, Nicola Grandi,Giuliana Guadagnino, Maria Elena Locatelli, Viviana Marras, Carmen Martino,Alice Medaglia, Maria Cristina Monni, Alessio Pampaloni, Simona Piacenti, Piero Pirina, Rachele Russo, Teresa Scarabaggio, Fabio Sultani, Iulia Adelina Turiac.
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. Patients' and health system's delays in the diagnosis and treatment of new pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: a cross-sectional study. BMC Infect Dis 2016;16:673.doi:10.1186/s12879-016-1995-z
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. The impact of migration on tuberculosis epidemiology and control in high-income countries: a review. BMC Med 2016;14:48.doi:10.1186/s12916-016-0595-5
Contributors AA, CGAN, RP and GS conceived, designed and supervised the study and coordinated regional data collection. AC and FV coordinated the project. MB and AQ designed the questionnaire and managed data collection at the central level. AQ performed the statistical analysis and wrote the first draft of the manuscript. AA, MB and AQ interpreted the results and wrote the advanced version of the manuscript. All Authors critically reviewed the manuscript and approved the final version.
Funding The project entitled 'Valutazione dei determinanti di ritardo nell'accesso ai servizi sanitari, nella diagnosi e nel trattamento della tubercolosi polmonare (PTB) in popolazioni vulnerabili. Valutazione dell'impatto sull'epidemiologia locale e sulla prevalenza di resistenza/multiresistenza ai farmaci antitubercolari'—'Assessment of determinants of delay in healthcare access for the diagnosis and treatment of PTB in vulnerable populations. Assessment of the impact on the local epidemiology and on the prevalence of antituberculosis drug resistance/multiresistance' was approved and financially supported by the Italian Ministry of Health (Centro nazionale per la prevenzione e il Controllo delle Malattie, CCM 2013).
Patient consent Obtained.
Ethics approval All procedures followed were in accordance with the Declaration of Helsinki 1975, as revised in 2008.
Data sharing statement No additional data available.
Collaborators CCM 2013 TB network: Alessandro Bisbano; Celestino Bonura; Bruno Cacopardo; Maria Giovanna Cappelli; Antonio Cascio; Francesco Cesario; Paola Di Carlo; Anna Di Taranto; Francesca Fortunato; Antonina Franco; Anna Grimaldi; Carmelo Iacobello; Maria Clara La Rosa; Valentina Mascaro; Andrea Maugeri; Arturo Montineri; Salvatore Nisticò; Cecilia Occhino; Grazia Pantò; Maria Polimeni; Vincenzo Portelli; Graziano Provenzano; Pasquale Quartararo; Francesco Quintieri; Salvatore Requirez; Francesca Savalli; Consiglia Venitucci; Maria Teresa Zorzetto; Rossella Zucco.

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: how to manage different python versions on a computer I recently moved my os from debian7 to archlinux. On debian 7, the default python version is python2.7 but on archlinux the default is python3.4.
I once wrote a spider program using beautifulsoup4 on my debian7 but now I want to run this program on archlinux.
I use sudo pacman -S python-pipto install pip and then use sudo pip install beautifulsoup4. But this time this package goes into /usr/lib/python3.4/site-packages/.
I know I can download bs4 to my spider's directory and run it with python2, but I just want to know how do you install packages using pipsince you have 2 python version installed. And btw if I change the default python link to python2*, will it break my system?

A: Try python2-pip and pip2 or pip2.7.
In arch linux all of the python 3 packages have no version number and all the python 2 packages have a 2.  The commands are the same way.
To select what version a script uses use the version number in the hashbang.
#! /usr/bin/env python2

or
#! /usr/bin/env python3

I'm not sure if debian has a python2 link but they can easily be created on systems where /usr/bin/python is python2.7.
sudo ln -s /usr/bin/python /usr/bin/python{2,2.7}

A: "on archlinux the default is python3.4" - wow, this is ambitious.
The archlinux wiki on Python provides a lot of tips.  You should install python2-pip to make sure that pip is installed for the right version.

A: Archlinux usually provides packages prefixed with python- for Python 3.x and python2- for Python 2.x. You can also use virtualenv to manage local Python environments, which means you can have a Python2 project and a Python3 project without conflicts between them.

redpajama_set_name: RedPajamaStackExchange


text:
Books > Buddhist > Buddha > Buddha Zen Tao Tantra: The Spiritual Path
Buddha Zen Tao Tantra: The Spiritual Path
About the Book BUDDHA 'Buddha is a scientist of the inner world-a scientist of religion. That is a rare combination. To be religious is simple, to be a scientist is simple-but to synthesize these two polarities is incredible."
ZEN Only once in the whole history of human consciousness has a thing like Zen come into being. It is very rare."
TAO With Tao you have to go it alone, you have to De alone-Tao says that if you impose a discipline on yourself, you will be a slave. The discipline has to arise out of your awareness, then you will be a master."
TANTRA This is the Tantra message: don't live a repressed Iife, otherwise you live not at all. Live a life of expression, creativity, joy. Live the way existence wanted you to live; the natural way."
About the Author Osho (1931-1990) is a contemporary mystic whose teachings have inspired millions of people from all walks of life. His works, which have been published in more than 40 languages, are transcribed from extemporaneous talks given over a period of 35 years. They cover everything from the individual search for happiness to the most pressing social, political, and spiritual concerns of our time. The Sunday Times of London has named Osho as one of the "1000 Makers of the 20th Century." His books are best-sellers in many languages and many countries.
Introduction There has always been a fascination in Western countries with the mysteries of the East-and in recent decades that interest has extended to the spiritual realm. As people begin to define themselves as "spiritual" rather than "religious"-dropping out of organized religions in search of a more open and individual approach to the sacred-the Eastern wisdom traditions have held a special appeal. Unlike the religions that were born in the Middle East-Judaism, Christianity, and Islam-most Eastern approaches to spirituality place little or no emphasis on a supreme being as a source of divine guidance and dispenser of blessings. Rather, the emphasis is to develop one's own inner sense of the sacred-or, in the words of Buddha, to "be a light unto yourself."
This volume explores four major streams of Eastern wisdom as seen through the understanding of a contemporary mystic, Osho. In the course of his own search, Osho has deeply explored both the differences and the common concerns of East and West, psychology and philosophy, the religions of prayer, and the paths of meditation.
The depth and breadth of that understanding is apparent in these pages. Originally published separately as books on Buddha, Zen, Tantra, and Tao, this combined volume offers the reader a window into a broad spectrum of new possibilities, from the relaxed acceptance of Tao and Tantra to the disciplined awareness of Buddha and Zen. Each has something to offer the Western reader with an open mind and a taste for the challenge of breaking old patterns and exploring new possibilities.
Osho says: The Western mind can succeed as far as science is concerned, but it cannot succeed in religious consciousness. Whenever a religious mind is born, even in the West, it is Eastern. In Eckhart, in Boehme, the very quality of the mind is Eastern. And whenever a scientific mind is born in the East, it is bound to be Western.
East and West are not geographical. West means the Aristotelian, and East means the non-Aristotelian. West means equilibrium, and East means no equilibrium. West means the rational and East means the irrational. Tertullian was one of the most Eastern minds in the West. He said, "I believe in God because it is impossible to believe. I believe in God because it is absurd." This is the basic Eastern attitude: because it is absurd. No one can say this in the West. In the West they say that you should believe something only when it is rational; otherwise it is just a superstition.
Eckhart, too, is an Eastern mind. He says, "If you believe in the possible, it is of no consequence. If you believe in the argument, it is not religious. This approach belongs to science. Only if you believe in the absurd does something come to you that is beyond the mind." This concept is not Western. It belongs to the East.
Confucius, on the other hand, is a Western mind. People in the West can understand Confucius, but they find it difficult understand Lao Tzu. Lao Tzu says, "You are a fool if you are only rational. To be rational, reasonable, is not enough. The irrational must have its own corner to exist. Only if a person is both rational and irrational is he reasonable."
A totally rational person can never be reasonable. Reason has its own dark corner of irrationality. A child is born in a dark womb. A flower is born in the dark, in the underground roots. The dark must not be denied; it is the base. It is the most significant, the most life-giving thing.
The Western mind has something to contribute to the world-it is science, not spirituality. The Eastern mind can contribute spirituality, but not technology or science. Science and spirituality are complementary. If we can realize both their differences and their complementariness, then a better world culture can be born out of it.
Book's Contents and Sample Pages
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Some farmers are facing a crisis this harvest season because trains aren't keeping up with transport demand.
FARGO, N.D.—Deregulation has been a popular theme in U.S. politics for decades, but a Surface Transportation Board hearing here last week on railcar shortages and service delays provided an example of how dependent rural America still is on a federal regulatory agency to push the railroads to provide vital services.
The BNSF Railway Company and the Canadian Pacific Railway Company move commodities from the northern tier of states stretching from Minnesota through the Dakotas and Montana to the ports in Washington state and to processing facilities elsewhere. But if the carriers do not provide cars to ship wheat, corn, soybeans, and other commodities this fall, farmers and agribusiness risk losing billions of dollars and the U.S. reputation as a reliable supplier of agricultural products will be tarnished, a wide range of witnesses testified at Thursday's hearing.
If rail carriers don't provide cars to ship wheat, corn, soybeans, and other crops this fall, farmers risk losing billions of dollars.
The problems began last winter when BNSF (formerly the Burlington Northern Santa Fe) and Canadian Pacific fell way behind schedule in providing railcars to ship the 2013 crop and there were fears that the rails would not provide fertilizer before spring planting. The railroad executives have blamed last winter's severe weather and congestion at rail yards in Minneapolis-St. Paul and Chicago, but the farm leaders say the railroads are favoring the growing energy industry in the Bakken area of western North Dakota or at least have made more promises of service than they can deliver.
On April 15, the STB ordered the two railroads to report within three days their plans to ensure the delivery of fertilizer and to provide weekly status reports on those deliveries. On June 20, amid continuing complaints about negative effects from backlogged grain-car orders and delayed shipments of loaded grain cars, the STB gave the railroads one week to submit plans to resolve their service problems and ordered them to provide weekly reports on the outstanding grain-car orders and the average number of days late for all outstanding orders until each carrier resolves its backlog.
The reports showed that the fertilizer did arrive when it was needed and that there has been some progress in reducing the backlogs of grain-car orders, but with analysts predicting a huge crop this year, the STB decided to hold the field hearing. The board required rail executives to testify and to stay through the day to listen to the agriculture industry and public officials explain the economic impact of elevators running out of storage capacity, risks of stored grain spoiling, and penalties incurred by farmers and other shippers for products that are not delivered on time.
The STB's actions occurred amid considerable pressure from Sens. Heidi Heitkamp, D-N.D., John Hoeven, R-N.D., and John Thune, R-S.D., and Rep. Kevin Cramer, R-N.D., who have been impressing on the railroad officials the gravity of the situation. The role has been an odd one for the legislators because they have not proposed legislation. Heitkamp explained in an interview on the sidelines of the hearing that "legislation wouldn't happen fast enough" and that the only place to which the ag community could turn is the STB, the agency that was established in 1995 when the old Interstate Commerce Commission was terminated. The ICC's heavy regulatory hand didn't work but there is still a role for government to help "captive shippers"—people and companies with few or no transportation alternatives—when they have complaints, Heitkamp said.
North Dakotans have already lost almost $67 million due to rail delays, and could lose another $95.4 million.
STB Chairman Daniel Elliott, a former transportation union lawyer appointed by President Obama, had obviously gotten the message.
"Ag in the Upper Plains is in dire straits," Elliott said in an opening statement.
He and the other commissioners—Deb Miller, a Democrat and former Kansas transportation secretary, and Ann Begeman, a former Republican congressional aide who noted she came from a farm background in South Dakota—proved to be aggressive questioners, especially of Canadian Pacific, which lawmakers and the STB have previously criticized for being particularly lax in making plans to improve service.
Heitkamp, a lawyer and former North Dakota attorney general, said she has been discussing Elliott's powers with him and that she believes that "some things can be tweaked" at the STB to force the railroads to improve.
Is Sweet Green the Ultimate Millennial Brand?
Jerry Hagstrom is a columnist for National Journal. He writes and publishes The Hagstrom Report, a daily email newsletter on agriculture and for DTN, an Omaha-based agricultural news service, Agweek, which is published in Grand Forks, N.D., and for the Capital Press, a West Coast agricultural newspaper.


text:
The Silliest Thing We Can Imagine
May 1, 2019 March 6, 2018
Elon Musk decided to test his revolutionary Falcon Heavy rocket with the "silliest thing we can imagine". Usually test payloads for new rockets are made of boring hunks of steel and concrete, but if Elon's past actions are any indication –see his Boring Company branded flamethrower— normal just wouldn't do. So Musk tweeted out this 'silly' idea: "Payload will be my midnight cherry Tesla Roadster playing Space Oddity".
The destination for his Tesla Roadster: Mars orbit. The FAA approved the payload on February 2nd – their payload authorization showing 'Tesla Roadster'; a decidedly-odd cargo for a spacecraft which will usually carry practical cargo like satellites.
Launching something revolutionary into space requires a serious commitment to revolutionary thinking on Earth. As a key element of his success, Musk has been known to bring a unique perspective, management style, and brand of communication to every project he embarks on. A previously unpublished company-wide email, released just recently, gives insight into Musk's unique leadership philosophy:
Subject: Communication Within Tesla
There are two schools of thought about how information should flow within companies. By far the most common way is chain of command, which means that you always flow communication through your manager. The problem with this approach is that, while it serves to enhance the power of the manager, it fails to serve the company…
Instead of a problem getting solved quickly, where a person in one dept talks to a person in another dept and makes the right thing happen, people are forced to talk to their manager…
Anyone at Tesla can and should email/talk to anyone else according to what they think is the fastest way to solve a problem for the benefit of the whole company.
Musk's beliefs on communication, however, don't just apply to electric sports cars with a 'ludicrous mode', or to roadsters heading to Mars with a mannequin in the driver's seat. In taking a progressive stance on how information should flow within a team, Musk also gives us a point a view that can be applied to the TMF.
An inefficient and stifling hierarchy is a common problem among TMF teams. Distracted by an ever-growing array of new tools and technologies, TMF leaders neglecting the most essential component of the TMF: their TMF team. Because of this single-minded focus on new features and technology, TMF stakeholders continue to experience a widening gap between TMF expectations and reality and the continued erosion of their decision-making abilities. Slowly, but surely, TMF stakeholders are becoming disenfranchised from their own TMF.
So, inspired by Musk's philosophy, now is the time to reevaluate the strength of the human network supporting your TMF. Is your team inspired to speak up if there is a problem? Will your team speak out if more clarification is needed, or is your team constantly second-guessing and waiting for your approval? Is the leadership of your TMF focused on big-picture success or mired in micromanagement? The answers to these questions are of critical importance to the success of your TMF.
If you are a TMF leader, take a moment to evaluate where your enthusiasm is invested. A revolutionary TMF leader will be as excited about their team as they are about new technology. Investment in the knowledge and decision-making of the TMF team will have a greater impact than any single piece of software or technology, and is usually a whole lot cheaper too.
But, even, with Elon Musk, every new idea brings with it the risk of failure. SpaceX claimed, in April 2011, that the Falcon Heavy would be ready for launch in 2013. It took five extra years to overcome the unexpected engineering challenges, with several notable explosions in-between. Even with the successful launch of the Falcon Heavy, and although the two boosters landed in astounding harmony, the center core smashed into the ocean at three hundred miles per hour. Even the Tesla Roadster overshot Mars orbit and is heading towards the asteroid belt.
From these very public failures, it is clear that even the greatest of accomplishments don't necessarily mean perfection. In light of this reality, we fully recognize that revolutionizing the human network of the TMF is challenging. Still, despite the obstacles, the potential benefits of a reimagined TMF are critical to the future of drug development. Because of the importance of the mission, there is simply no reason to settle for anything less than unusual excellence. If the Falcon Heavy launch proves anything, it proves this: behind every once-impossible triumph is someone who dared to dream the silliest things imaginable.
Fear, Indecision, And The Memo To File
Is Your TMF Ready For GDPR? Part One: Know Your Roles


Ogiek is a Nilo-Saharan, Satellite-Core, Core, Eastern Sudanic, Southern, Nilotic, Southern, Kalenjin language spoken by a community of Hunters and Gatherers living in the region of the Eastern Escarpement of the Mau Forest in Kenya. In the framework of a still very poorly described linguistic family, this work represents a first, non exhaustive and tentative descriptive grammatical sketch of the dialect spoken by the circa 15.000 Ogiek belonging to the 7 clans of the Morisionig family. The book contains also a short vocabulary of the language, where 646 Ogiek entries are recorded. The vocabulary is completed by a corresponding English-Ogiek wordlist.


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Jailed Woman Charged with Food Stamp Fraud
(Deming) – A Deming woman who has been jailed for nearly two months has now been charged with fraud and conspiracy.
Luna County Sheriff's Captain Kelly Gannaway said 38-year-old Elizabeth Eidinger, who was incarcerated in October for felony possession of over a pound of mercury and concealing her identity, is now being accused of attempting to sell her food stamps for cash while she has been in jail.
Gannaway said the investigation into the food stamp fraud is continuing, and other charges may be filed.
Eidinger was arrested in October at the scene of a homicide at 5335 Columbus Road.
That was the location where deputies, who were called by an out-of-state spouse to check on her husband, found a decomposing body.
Officials with the Office of the Medical Investigator in Albuquerque determined the man, who has yet to be positively identified, died from a stab wound to the throat.
Eidinger claimed to be the property owner where both the body and the mercury were discovered.


All will become apparent some time after midnight when my latest Case Notes Blog post goes live.
Sounds like a great idea - no bah humbug from me. Looking forward to reading them (alas, I'm yet to create a website as I find the writing gets in the way - it's on my list of things to do).
Well, you don't have to have a website Ray - just something to link back to if people enjoy the story and want to know more about the writer.
Only real requirement is a story online somewhere.
Could be worse Bob. At least you didn't get socks.
After that, if I don't hear from any more TTA contributors, we'll field stories from a couple of message board irregulars.
And after that we'll use anyone else, and at the moment I have five more people who come under that heading.
I am not doing any quality control here - within the criteria set out, I will simply link to stories in the order people mail the links to me, so you need to get in quick.
It would be nice to hear from a few more TTA contributors.
Remember, I'm not replying to anyone. You need to watch this space to find out if/when your story will be linked to.
You know, I should have thought to say that when I sent my email, too So blonde, even if my hair's more of a mucky brown these days.
I like this idea. Looking forward to it!
If I'd written anything new in the last, er, 9 months, I'd even throw myself in for consideration (perhaps as a sort of coal-flavoured stocking filler).
Shaun, doesn't have to be a recent story. If you have anything with whiskers, but it's still hanging about online, then let me know.
No more TTA contributors have been in contact, but I have three message board irregulars and seven other people in the kitty, so we're good up to the 14th at the moment.
Did you get my email saying that my first choice was no longer online, Pete? My second-choice story is finishing off its pie and bovril before it wobbles onto the pitch, but it is ready and willing.


When Wonderful Pistachios shot this commercial, it wrongly assumed that "Gangnam Style" was about to become a historic piece of pop culture and not a one-hit wonder whose appeal wouldn't outlast the New Year. There's little effort here to even remix the song or make it especially relevant to nut lovers. Too lazy, too late.


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Photo Courtesy of Anthony Pham
Ali Elmalky and Annie Qiao
June 6, 2018|248 Views
Teacher: Katie Wi
Subject(s): Modern World History and Honors American History
What made you decide to accept a job here at Portola?
"I accepted a job at Portola because it's hands down the best school around! There's really no other school quite like PHS. It is such a unique campus in that every single aspect of the school is structured with learners in mind. From the "bell" schedule to the set up from the learning spaces, everything about the school is set up to help foster a welcoming learning environment. The teachers and students are so supportive of each other, and the culture at Portola is something I definitely wanted to be a part of."
Teacher: Anthony Pham
Subject(s): Physics in the Universe and AP Physics 1
What are some fun/interesting facts about you that you would want students at PHS to know?
"I love building and designing stuff. My favorite recreational activity at the moment is doing escape rooms with my friends. I also hike, ice skate, kayak, boulder and play video games (I own a Switch, PS4 and a PC). I also play Fortnite on PC. I've also been on Ellen's 12 days of Christmas."
Teacher: Caroline Aldemir
Subject(s): Spanish 2 and Spanish 3
Why did you decide to teach Spanish?
"I actually began my career as an English teacher but wanted to teach Spanish because I always loved Spanish class and found it so fun, engaging and critical to learn a second language. It's fun to teach a class that allows you to help your students develop a crucially important life skill and also to learn all about the world around us."
Teacher: Jen Ochsner
Subject(s): Enhanced Math 3, Math 2 and Math 3
Why did you decide to become a teacher?
"I have always enjoyed working with students and helping them discover a passion for learning. There is no greater joy for a teacher than watching a student 'get it' for the first time and start to see math in a new light!"
Teacher: John Olivares
Why did you decide to teach Physics?
"Physics is where we can unlock the secrets of the universe. Everything obeys the laws of physics. If it exists, it can be described with physics."
Teacher: Desmond Hamilton
Subject(s): Literary and Language Arts
"My experience with caring and dedicated educators made me keenly aware of the power of education and caring educators to dramatically influence a person's life. I think high school is an important stage in a learner's development, and it should be a time when meaningful ideas and great thinkers are presented to young people for review and analysis."
Ali Elmalky, Staff Writer
Ali Elmalky is a staff writer for the Portola Pilot. This is his second year on the team, and he's looking forward to participating in its production...
Annie Qiao is your 2019-20 Arts & Entertainment Editor for her fourth year at the Pilot! As a passionate admirer of the arts, she hopes to bring a...


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Fascinating Facts about Rowan and Martin's Laugh-In
Long before Saturday Night Live became the number one sketch comedy series that has kept the night owls laughing up to now, there was once Rowan and Martin's Laugh-In. Hosted by comedians Dan Rowan and Dick Martin, it became one of the most popular and the "hippest" classic TV shows during that time that ran from 1968 to 1973. And like Saturday Night Live, Rowan and Martin's Laugh-In was broadcast on NBC.
Of course, many would remember future president Richard Nixon's guesting as well as the legendary "sock it to me" catchphrase. But there's a lot more to know about Rowan and Martin's Laugh-In that may make you to look at the series a bit more differently!
1. A daytime spin-off series?
If you are a really knowledgeable fan of Rowan and Martin's Laugh-In, then you might have also seen its spin-off daytime show Letters to Laugh-In, which was a short-lived 1969 game show. It was hosted by Gary Owens, who was the announcer for Laugh-In.
2. Topps Rowan and Martin's Laugh-In trading cards.
The popularity of Rowan and Martin's Laugh-In resulted to numerous merchandises, which include trading cards manufactured from the company Topps, which was known for its TV tie-ins. This time around, however, designers came up with clever interactive designs which allowed card players do certain things such pulling the cards' pop-ups to reveal a joke's punchline.
3. Laugh-In magazine
Another merchandise tie-in was the humor publication entitled Laugh-In Magazine, which was published from October 1968 through October 1969. Since it rolled out only 12 issues, Laugh-In Magazine is now considered a rare collectors' item.
4. The Beatles were huge fans of the show.
Of course, even superstars become fans themselves of something or someone else. In this case, the world-famous Fab Four were huge fans of Rowan and Martin's Laugh-In. The boys were even re-enacting Laugh-In's scenes, sketches and catchphrases in-between studio rehearsals. That climaxed when Ringo Starr guested on the show sometime in 1970; his appearance there lasted no more than 30 seconds.
5. Laugh-In comic strip.
Cartoonist and illustrator Roy Doty (1922-2015) created a syndicated newspaper comic strip, simply titled Laugh-In, which ran from 1968 to 1972. He was also known for his other works such as Judy Blume's children's novels Tales of a Fourth Grade Nothing and its sequel Superfudge.
6. 1977 reboot.
Four years after the original Rowan and Martin's Laugh-In ended, NBC revived the series only for a brief time in 1977. Simply titled Laugh-In, it presented an all-new cast which included a fledgling comedian named Robin Williams (who would shoot to overnight fame a year later with his breakout role in the sitcom Mork & Mindy).
7. The show actually inspired an ice cream flavor!
The late actor Flip Wilson, who was one of the show's regulars, first popularized the catchphrase "Here comes the judge." It quickly trended among baby boomers. More than that, it even inspired a chewy and chocolate-y Baskin-Robbins concoction, named "Here Comes the Fudge." The ice cream chain produced this flavor for many decades.
8. "Here comes the judge" also inspired a specially-made vehicle.
"Here comes the judge" inspired not only a Baskin-Robbins ice cream flavor, but also muscle cars. The catchphrase became trending during that time, that General Motors launched a special "The Judge" Pontiac GTO model in 1969. Further taking advantage of the catchphrase's popularity, GM injected promotional phrases such as "All rise for the Judge" and "The Judge can be bought."
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Interesting Facts about "The Wonder Years"
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Nephlim were physical entities, and of another world. Bible says the end times will be"As it was in the days of Noah." It also describes a great falling away from god. Aliens from another planet would do that. It also describes a great deception. Be ready people.
My friend, we are well in the middle of the great deception. Everything we are told by government and media is utter lies. Everything we have been force fed from birth is b.s. Our history is not what we have been conditioned to believe. Our whole existence is as the Matrix. 100% indoctrination.
Hello. As you can all see from many different media reports, disclosure appears to be inching ever closer. Well, you will see it all burst into the public view immediately following the Democratic convention this summer; it is a sanctioned and coordinated information release, and is, apparently, being orchestrated with our "allies" - and I do use this term loosely.
I am in the final stages of an aggressive illness and will not see out the summer; however, I was deeply involved in the EBE program as military officer for more than 33 years. Some one has broken ranks over the past few years, and some rather detailed reports of our program (mostly the initial development of the Nupreen A field Transmuters used in Operation TEN HIGH and the most delicate interplay that happened in and around the California towns of Indio and Upland) had been posting on to a small bigfoot hobbyist board until the researcher was incarcerated.
Unfortunately for the program manager, several others were involved in this research and there were simply too many loose threads. In any case, you will see a startling release of information and an equally startling confirmation of what many have held as speculation. This will be done in concert with the Vatican and release of a Canonical by the Holy Zee.
I wish you all the very best of luck and envy your days ahead - you do indeed live in heady times! If you smoke, please quit today.
Thanks for the information, Joe. Sorry to hear about your plight. I always knew that these beings were from another dimension, not another planet. The physics of their actions didn't quite add up to the laws we live by. I don't smoke, never have. glad of that. I pray you find peace.
Joe Shey: I don't kno what it is but I am tempted to consider your post authentic. I am a researcher for a new novel on disclosure Joe and really need detail about ET to make the fiction engaging. I'm in to the project deep enough to believe that there is a nexus between ET and the Luciferian Occult. I am specifically interested in ET involvement in 911. Do you know the term "twilight language"?
If you haven't already you me be interested in the material by L.A. Marzulli. He has done extensive research on the UFO, alien, alien hybrid, bigfoof, demonic connection. I think you might like his position.
I have had a positive interface with "extraterrestrials" since I was a small child and still enjoy this relationship today. They are not just out there but have been an integral part of the colonization of this planet for probably over a billion years. There are myriads of advanced space civilizations that run circles around us... and whether humans like it or not this planet is only one small part of a huge intergalactic order. There is so much going on out there and here I am in constant amazement.... earth is way out of control with the balance that exists in this universe and this situation will be corrected sooner than later. think positive folks... we are now being observed directly by many different worlds... Have a good day to you all!


KEES FRIJTERS has positions Director (COMPANY DIRECTOR), Director (COMPANY DIRECTOR) in companies ROSCOLAB LIMITED, GEKKO LIGHTING LIMITED. At current position Director (COMPANY DIRECTOR) of company ROSCOLAB LIMITED is 21 years, Director (COMPANY DIRECTOR) of company GEKKO LIGHTING LIMITED is 5 years.
KEES FRIJTERS has been employed at ROSCOLAB LIMITED since 1998.01.05 currently as a Director (COMPANY DIRECTOR).
KEES FRIJTERS has been employed at GEKKO LIGHTING LIMITED since 2014.03.10 currently as a Director (COMPANY DIRECTOR).
KEES FRIJTERS Score for KEES FRIJTERS is 5 stars.


In 1804, Walter Scott moved his family into a new home near Selkirk, situated in a secluded spot above the banks of the River Tweed: Ashiestiel. He had only moved to the area a few years beforehand, initially only due to one of the stipulations of his role as Sheriff Depute of Selkirkshire.
Yet the decision to head for the Borders turned out to be an inspired move for the then-aspiring writer, for it was in these years that he wrote the works which first made him famous.
Today, Ashiestiel – which has been variously spelled as Ashestiel, Ashiesteel and even Echesteile in the past – is looking for a new owner to enjoy this beautiful spot. The property went on the market last year as part of a wider 863-acre estate with a price tag of £5.5 million. Now, however, it is available at £1.25m in a more manageable 10 acres of land which takes in lawns, hills and picturesque mature woodland. That woodland has a story to tell, too: several of the trees on site have plaques to commemorate the visit of Queen Elizabeth II and Princess Alexandra during their Royal Tour in the 1960s.
Scott lived in the house from 1804 to 1812, which he described as amongst the happiest of his life, and during which he produced the three narrative poems which brought him instant fame and smashed all publishing records for poetry: 1805's The Lay of the Last Minstrel; and the even more successful follow-ups Marmion, and The Lady of the Lake. When Scott's lease at Ashiestiel expired, he moved to a farm not far away where he built Abbotsford, the home where his career as a historical novelist took off.
Ashiestiel House as it stands today is a grand Grade A listed country house located in the heart of the beautiful Scottish countryside. It originated in the 17th century as a peel tower, which has since been extended and enlarged before being completed in the 19th century with the addition of the East Wing.
Completely refurbished by the current owners, the interior is of an exceptionally high standard, featuring well-proportioned and stylish rooms throughout the property.
Complete re-wiring and re-plumbing has been completed, including the instillation of underfloor heating in the lower ground floor. The property boasts four reception rooms, nine bedrooms and a stunning family kitchen, which includes an electric aga and walk-in pantry, leading out through French doors onto a terrace overlooking the river.
The attention to detail throughout the property is superb, with double cornices and pillared marble mantelpiece in the grand drawing room. Outside, there are a range of traditional stone outbuildings, including a drying/boot room, garage and two stables.
The Gardeners Cottage is situated to the rear of the property, which is ideal for overspill accommodation for family and friends, featuring an open plan dining, kitchen and sitting room, and bedroom with en-suite shower room.
Finally, for those who want more room, there is the opportunity to offer for the additional land and dwellings, which include an equestrian complex and paddocks, East Lodge – a single storey, two-bedroom home – and West Lodge, a three-bedroom house.
Ashiestiel is on the market with Savills with an asking price of offers exceeding £1.25 million – see more pictures and details.


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redpajama_set_name: RedPajamaGithub


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By Jessica Galang Technology June 12, 2017
Impression Ventures closes $30 million Fund II to boost Canada's "massive" FinTech talent
Impression Ventures has raised $10 million for its Fund II, bringing its total funding to over $30 million.
Limited Partners in the fund include US and European institutions and family offices, and about two dozen current and former senior executives from Canadian banks and financial institutions. The Toronto-based firm also announced that it's establishing a Montreal presence with the addition of Maor Amar as managing partner. Amar is a former BMO managing director, and UBS Investment Bank managing director.
Geoff Belsher, CIBC's former co-head of Wholesale Banking, and James Estey, former CEO of UBS Canada, have joined Impression Ventures as advisors.
"My view has always been that we have massive disproportion talent in financial services in this country," said Lassonde, who launched Impression Ventures targeting early-stage FinTechs in 2013.
"We think extremely high barriers to entry also make extremely profitable businesses down the road."
"Tech was inevitably — and we've seen it in the UK — starting to really disrupt financial services. Disrupt is a loaded word because there's a lot of talk around, do FinTechs enable financial companies? Do they disrupt financial companies? Do they displace financial companies? The reality is they do all three of those things."
Fund II, which closed $20 million in August 2016 with FairVentures, will focus on late seed to early Series A companies, and do rounds between $3 million to $6 million.
Companies currently in Impression Ventures' portfolio include Wealthsimple, Zoocasa, and Sensibill. Moving forward, the firm is especially looking out for startups in the wealth management space, as well as companies that leverage blockchain and AI. As for which FinTech vertical has the most potential, Lassonde points to insurance tech as one to watch.
"It's probably the most complex landscape to navigate of all the FinTech sectors, but that's exactly the type of thing that interests us," said Lassonde. "Where there's large barriers to entry, where there's large incumbents that are hard to move, out of the way, we think those extremely high barriers to entry also make extremely profitable businesses down the road."
Lassonde noted that Impression Ventures' concentrated approach is meant to free up the firm to be as hands-on as possible with startups; it calls for having no more than 10 startups in its portfolio at a time. He gives a personal example of stepping in as a CMO of one portfolio company until they could find the right talent to fill the gap.
Lassonde also points to the expertise of himself and the team; Lassonde exited two startups during his decade in the Valley, and Amar has spent 20 years in the financial services industry.
"We're somewhat different than most funds in Canada, though not unique in this respect. High-performing VCs in the Valley tend to be very focused," said Lassonde. "That's a very deliberate and concentrated fund thesis around spending a disproportionate amount of time with startups…where there's a talent gap, we're not afraid to provide hands-on support."
Lassonde knows he's tapping into a hot market — Toronto is currently ranked North America's 4th financial centre and 10th worldwide, while financial services is now 20 percent of Canada's GDP. "If we're going to build a focused team, where are we as a nation — where we can build a proportion of billion-dollar businesses? That's where that GDP pie in my mind became obvious," said Lassonde.
FinTechfunding
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With 5M Monthly Users, biNu Adds Cloud Storage Service for Feature Phones
Today biNu, a startup that gives smartphone-like functionality to feature phones, announced the launch of its new cloud storage service, MyMedia, and a new…


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Limpets are hardy survivors on the rocky shore and are commonly seen clinging tightly to rocks at low tide. Limpets have a soft body underneath the hat-shaped shell and they graze algae by scraping it with their radula - a tongue-like structure covered in teeth. Limpets always return to the same spot on the rocks and eventually wear a groove in the rocks that fits their shell exactly.


Jurgen Klopp has looked to continue his spending spree at Liverpool but has seen a £33 million bid to Sporting Lisbon for Joao Mario rejected.
The Portuguese midfielder, who was part of the winning Euro 2016 squad, has appeared as a target for Klopp as he prepares for the new Premier League season.
Sadio Mane and Georginio Wijnaldum have arrived at Anfield this summer for a combined total of £55 million ($72 million) but Klopp has looked to make Mario another big-money signing, according to the player's father.
Klopp is currently in California on Liverpool's pre-season tour ahead of the new season.
Why Is Mamadou Sakho's Liverpool Future in Doubt?


You've made an investment in your landscape and created your own slice of paradise. But what happens when insects or weeds attack your once flawless front yard? We suggest Plant Health Care. The Plant Health Care Division is our version of chicken soup for your landscape. This group of experts makes house calls and comes equipped with the knowledge and experience to keep your trees, turf, shrubs and plants healthy and thriving. Besides, you didn't come to your mountain home to spend time worrying about aphids. We'll do that for you!
The members of this highly specialized group are considered the doctors of the company. They've been selected for their intimate knowledge of every aspect of landscaping from construction and maintenance to plant pathology and entomology. The team is led by a horticulturist, ISA Certified Arborist and Colorado Qualified Supervisor with over 25 years in the landscaping industry. Together, they've amassed extensive experience in solving problems with Rocky Mountain landscapes while earning the respect of both clients and industry peers.
The PHC Division is directly responsible for both routine operations such as lawn, tree and flower fertilizer applications and providing diagnostics to landscape health problems. Based upon the established principles of Integrated Pest Management (IPM) our technicians view the release of pesticides as a last resort option. They seek to provide environmentally conscious solutions in a world increasingly sensitive to the use of pesticides. In fact, the vast majority of our Plant Health Care consultations are not resolved through pesticides. With families, homes and landscapes of our own this is something we understand and take very seriously.
Rocky Mountain Custom Landscapes is fully licensed and accredited with the Colorado Department of Agriculture. Our technicians spend a considerable amount of time in classes throughout the season to remain current with the latest research and techniques. We are committed to continuing education, remaining a leader in the industry, and protecting the environment through the use of advanced, less toxic pesticides.
Call us today to discuss your plant health care needs or submit a request. Don't go it alone!


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Entertainment Bollywood 26 Jul 2017 Action fever catches ...
Action fever catches on! Here is a list of B'town hotties debuting in this genre
Published Jul 26, 2017, 5:47 pm IST
Updated Jul 26, 2017, 5:47 pm IST
Sushant Singh Rajput, Ranbir Kapoor and fresher Harshvardhan Kapoor have never attempted action before. This year will prove to be a game changer for them.
Mumbai: Action movies have been an integral part of Hindi Cinema since the 90's era and to embrace the legacy we have our young generation stepping into this territory that has been immortalized by acting doyens like Amitabh Bachchan, Sunny Deol and Suniel Shetty, to name a few.
The 'macho-men' in the showbiz are now geared up to make their action acting debut, thanks to a whole new bunch of action films that are set to hit the theatres very soon. While the films are being made, let's take a look on 4 such actors who are going to break all records by their action-debut in Bollywood.
1. Sushant Singh Rajput
Sushant Singh Rajput has cemented his position in Bollywood with movies like, 'Kai Po Che' and 'M.S Dhoni The Untold Story'. Having been appraised by the movie fraternity and the mass audience he has successful put his name under the top hero list of Bollywood. After such an excellent start he is now aiming to make his action-debut with the forthcoming film, 'Raw'.
2. Ranbir Kapoor
The remarkable actor of our generation has made his mark in the Indian film industry with his variant performances in all kind of genres. From 'Rockstar', 'Barfi', 'Tamasha' and now 'Jagga Jasoos', Ranbir has given cult performances on screen. But now he is back on screen with his action-debut, 'Dragon'.
3. Angad Bedi
Angad Bedi debuted in Bollywood with Shoojit Sircar's courtroom drama 'Pink'. He has also been seen in Gauri Shinde's directorial drama, 'Dear Zindagi'. After two sensational box office hits, he is back on the screen with his action-debut opposite the superstar, Salman Khan. YRF's upcoming sequel 'Tiger Zinda hai' has been in pipeline and set to hits the theatres soon. The actor is prepping up for with professional trainers for the actions sequences in the movie.
4. Harshvardhan Kapoor
Harshvardhan Kapoor has begun filming director Vikramaditya Motwane's 'Bhavesh Joshi' and the actor says it is a hardcore action film. Bhavesh Joshi is the second movie of Harshvardhan, after his debut film 'Mirzya'. The movie's first schedule is believed to be over, which was more performance based and the makers will to start with its second schedule that is strictly action. Currently, Harshvardhan is training for his action sequence for the movie.
5. Emraan Hashmi
Emraan Hashmi has been around in the film industry for quite a long time and has proved his versatility by rendering multiple blockbusters. The actor has earned the image of a 'serial kisser' across the globe for kissing his female co-stars in almost all of his films.
Now the actor is all geared up to break the monotony from being serial kisser to an all time action star with his next magnum opus film 'Baadshaho'. The film has ensemble cast comprising action stars Ajay Devgn and Vidyut Jamwal. The movie is touted to be full fledged action movie and all the stars including Emraan who will be seen performing high octane action scenes for the very first time throughout the film. We have loved Emraan being a romantic hero before and it would treat to his fans to see him in action avatar in his next.
Tags: emraan hashmi, sushant singh rajput, angad bedi, ranbir kapoor, harshvardhan kapoor, action genre, action movies in bollywood
SRK says, 'a soldier asks what he can do for his country'
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'Brahmastra Part One: Shiva' earns Rs 75 crore in worldwide collection on day one