There are moments that you struggle in an unhealthy relationship. Find out and understand how you can avoid and get out of it.
At one time or another we have all experiences a realization that a relationship we are in is just not healthy for us anymore. It could be with a mate, a friend, our body, or even food; however, the root of this feeling is the same across the board.
We think to ourselves, "This just doesn't serve me anymore." At one point, the relationship provided some level of happiness, but now the cons far outweigh the pros.
This is where the crossroad lies. The choice we face is simple: do we continue down this path because it is familiar and comfortable, OR do we take the road less traveled, removing ourselves from an unhealthy environment so that we can live a happier life?
Before you answer, let's take a look at the process of moving on, which so often is filled with fear and holds us back.
Just the single realization that you need to make a change is a HUGE part of the process, and can provide some relief. You can't change what you aren't aware you need to change, right?
So, once you can look at the situation objectively as a 3rd person, and say, "Hmm this is not a healthy situation," you have already started to shift.
The process is actually more mental than physical. Yes, we need to take action to make positive changes in our life, but the bigger hurdle is getting our mind to agree to stick to the plan.
We must know, with certainty, that this is the right thing for us. Remember – the body is the servant of the mind, not the other way around.
You can "do" all kinds of things, but the reality is, if your thoughts and your feelings are not 100% in alignment with what you are doing, you are going to end up right back in the same spot.
Step 2: Deciding what you DO want.
So you have decided that this is what you DON'T want. Now you have to decide what it is that you DO want.
This sounds silly, but if you are going to remove something from your life, you MUST be clear about what you want to replace it with. This new void is going to get filled with something, much like a hole you dig in your backyard.
In a short amount of time, nature will fill it back up. 9 times out of 10, if you don't take the time to consciously choose what to replace it with, you risk ending up with another relationship that doesn't serve you any more than the first.
This parallels the smoker that gives up smoking, but ends up overeating to compensate because they didn't stop and make a conscious decision of what positive action they would take when the urge kicks up.
Take some alone time and really put thought into this. Write a clear description.
I have a journal and I write everything from my sleeping dreams to my intentions to brilliant words of wisdom that I come across. When you commit this stuff to paper, it gains a life of its own, and is actually the first step in the creation process.
It becomes real and powerful. I tie this back to the whole idea of getting clear in your mind what it is that you want.
Step 3: Remove yourself from the current situation.
This is the big gnarly monster that stands in the doorway between the life we want and the life we are currently living. How many times do we allow this fear of the unknown to keep us stuck in a mediocre life?
We are afraid of what we would have to face, change or possibly even fail at to get to where we want to be. It's ok to be afraid and to feel fear.
However, the difference between the people who are living a life of happiness and those that aren't, is that the happy people step up, face the monster, feel the fear, and make a decision to pass through that doorway, no matter what!
The reality is, all real change will bring up fear, doubt and anxiety; but, that is also where growth, success, and new results await us!
Happy people are the ones who know the secret: that whenever you want to change something for the better, you always have to go through something uncomfortable, but on the other side lies bliss.
I don't know about you, but I am willing to trade some discomfort for a life of bliss. And I have… and still do, on many occasions.
I could list multiple examples from boyfriends and friends, to how I have felt about myself or my living environment, to the future of my career and my business.
I have had to take this step with courage and wisdom when I knew my current circumstances were not in alignment with my vision. I absolutely had to move on.
I had to do what I knew was right for me and the attainment of my goals. Don't expect other people to understand. They may not support you. In fact, even the most well meaning people could very well discourage you and attempt to squelch your hopes for a better life. Often times you will represent the courage they themselves do not have, so keep this in perspective.
My certainty, that the benefit of "moving on" was far greater and more powerful than the fear holding me back, was what gave me the strength to charge forward!
How do I remove myself in order to move on?
Well, I think that the answer is fairly obvious, but one that we sometimes choose to block from our sight. In the case of a mate or friends, we simply stop hanging around the people who are unhealthy for us.
If it is our mate that is unhealthy for us, we sit down and have a serious and honest discussion about our needs, values and goals. If their values and needs are not in alignment with yours, or if this has been an on-going issue, then it is time to tell them how you feel.
This conversation is one that can be a challenge for sure. If it is a long-term relationship with living arrangements, children, finances, and so forth involved, then obviously it is more of a transition than a conversation. The crucial point is that you begin the process.
If the unhealthy relationship is with yourself, with food, or with an addiction, then this step would involve removing the triggers from your environment.
Begin a journal that documents how you feel and what is going on when an urge hits. Notice it and observe the emotion with a judgment free awareness.
When you journal enough of these triggers, you will notice a pattern that will then empower you to find a more positive outlet. You'll begin to have a heightened awareness of any emotions just as they begin to surface, and that is a defining moment!
You now have the conscious decision to move forward in faith, or to step back into fear, doubt, and/or anxiety.
This is not easy, but it IS attainable. I have found that surrendering is one of the most helpful and powerful gifts you can give to yourself.
So you are frustrated because you just left a relationship and you still have feelings for him or her? Surrender to it! Who says you need to hate them just because you aren't with them anymore?
The temptation to dig in the freezer for some Haagen Dazs is overwhelming? Surrender to the feeling (without going near the freezer!). After all, that is not who you are, that is who you were. You are in the process of making new decisions and creating new results!
Give yourself permission to feel what you feel. It is the easiest and fastest way to get the emotion to actually move through you and dissipate. What you resist will persist.
Allow yourself to be uncomfortable and acknowledge the steps you are taking, because this is part of the process and reason to celebrate. Your new life is rushing towards you at this very moment! Congratulations!
Step 4: Filling the void.
So you have made it this far, you are clear on what you want, you are beginning to heal any wounds, and you are stepping forward in faith. Now what?
It's time to start filling your life with new, healthy alternatives. Refer back to the description you wrote above of what it is that you do want.
What steps can you take now to begin putting that in place? Are there certain places you can start going in order to meet other people who want this as well?
Groups you can join? This step is all about filling your environment with things that will help to reinforce this new vision that you have for yourself.
You must do the things that you would do if this vision were already your reality right now! Go to those places. Meet those people. Act in that way. Think in that way.
You must not only reinforce in your mind that this is what you have chosen, but you also to keep the doors open to allow it to flow into your life.
Step 5: Taking some time to grieve.
Ok, even if there IS cause to celebrate, it's natural to feel a little sad when we make this kind of a BIG change. Our mind tends to revert to the good times in our memory and want it back. We want to "fix" our own pain and discomfort.
We start to rationalize (ration lies to the mind) that "oh, it wasn't so bad…maybe I'm expecting too much…". Sadness is a natural human emotion.
We have it for a reason and we shouldn't stifle it. As mentioned above, it's important to feel it, so we can move through it. If we try to block it out, chances are it will return to wreck even more damage in later days and uglier ways.
Choose a specific amount of time to just allow yourself to grieve. Tune into the emotions for a short period of time so that you can burn through them.
This is also a great time for some self-examination. What can you learn from this relationship, so that in the future, you make healthier choices?
Let go of regret, guilt, shame. This is not a time to judge yourself. I learned a long time ago that every single experience in our lives is there to teach us something.
So look at the situation objectively, from the 3rd person again, and write out five or ten reasons why this relationship has made you a stronger, better, and a savvier individual.
What kind of lessons are you able to carry forward that you can actually thank the other person, or situation, for? Even in the most painful experiences, when we are willing, we can find blessings.
This is why forgiveness is such a powerful practice. Once you can forgive yourself and release judgment, then you can find the beauty in the murk, so to speak.
Then, and only then, can you face the situation and say "thank you "for-giving" me that experience". That is true power!
Note: This step may not be applicable for every circumstance, but if you need to take time to heal, make sure to take that time.
At this point, if you are truly following the steps listed above, you are going to be seeing a dramatic shift in not only how you feel, but also what you are experiencing in your life. Most likely, you will feel light years different and better.
If not, then go back and review Steps 1-5 and ask yourself if you are REALLY giving this everything you've got.
Now is the time to reflect on your new experiences and to be grateful for them. If you want to make a list of all the things you are grateful for in your life now, all the better.
The stronger the message you can send to your mind that you are loving this new life, the stronger you will make those connections, and the more you will bring similar experiences into your life.
Now that you understand what is involved with moving on, you can make a conscious decision on whether or not you need to remove yourself from an unhealthy relationship.
Avoidance can work for a little while, but sooner or later, unhappiness hits us up side the head like a ton of bricks. This is your life and you are in charge. It's time to start directing the show, isn't it?


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Morgan Properties Buys Pittsburgh Apartments for $29M
Meet the Fifields the MHN Excellence Winners in 'Executive of the Year'
See a slideshow of the Steve and Randy Fifield, one of the multifamily industry's power couples.
MHN Awards
Chicago—The winners in the MHN 2015 Excellence Awards Executive of the Year Category, Steve and Randy Fifield of Fifield Cos. and Century West Partners (CWP) are recognized as leaders in their fields in both Chicago and Los Angeles, as well as one of the multifamily industry's most powerful couples. In his role as president & CEO of Fifield Cos., and as co-founder of CWP, Steve is responsible for the financial feasibility and construction of all new projects. Randy, vice chairman of Fifield Cos., leverages her 25 years of design and build experience to oversee the architecture, design, interiors, asset management and marketing of all Fifield projects in Chicago, as well as those from Century West Partners.
Combined, the Fifields' real estate companies currently have 3,000 apartment units representing $1.5 billion in development in both the Chicago and Los Angeles areas and have built more than 5,000 high-rise residential units in Chicago, Los Angeles, Southeast Florida, Las Vegas and Waikiki.
See the full list of MHN 2015 Excellence Award winners here.
For more than 15 years, Randy and Steve have led Fifield Cos. to become one of Chicago's largest developers and built some of the city's most iconic apartment developments; pioneered the expansion of urban neighborhoods with transit-oriented infill developments in both Chicago and Southern California; and helped usher in the new era of luxury rentals that both regions are still experiencing today. The Fifields have redefined what luxury apartment living can be, setting a new standard that dozens of development firms have now followed.
Fifield Cos.' most recent development is E2, a 356-unit luxury rental project in downtown Evanston, Ill. E2 marks Evanston's first uber-luxury apartment development. Since opening in spring 2015, E2 has created a new gateway to dynamic downtown Evanston and filled a much-needed demand in the North Shore market.
The Fifield's $850 million K Station development with 2,145 units across five apartment towers stands as one of Chicago's biggest apartment success stories. The 496-unit K2, the development's final tower, was built for $127 million and sold in November 2014 for $214 million, earning over a 30 percent IRA.
CWP is currently developing eight projects comprising more than 2,000 luxury apartment units in and around Los Angeles. One of CWP's most influential projects was AVANT—a three-building, 440-unit project in Los Angeles.
Innovation is at the heart of each Fifield project—always on the cutting edge of apartment finishes and amenities, developing the first project in Chicago with USB wall outlets and the first to include wireless-enabled wall speakers.
As leaders and mentors in the industry, the Fifields are committed to promoting professional advancement for both Fifield employees and other real estate professionals. Additionally, Fifield Cos. aggressively recruits women for senior roles within the company. Today, 40 percent of their senior executives are women.
Century West Partners
Randy Fifield
Apartment Jobs Snapshot for Q4 2019
Atlas Homewares Opens Door to New Design Options
Harbor Group Buys $1.8B Multifamily Portfolio
Senior Housing 2020: Gearing Up for the Silver Tsunami

redpajama_set_name: RedPajamaCommonCrawl


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Cognizant Technology tops estimates
Cognizant Technology Solutions (Nasdaq: CTSH) beat analysts' targets for its fourth quarter on Tuesday. Net income and revenues both rose more than 70 percent compared to a year ago.
Shares in the maker of e-business software applications closed Monday's session down $0.50 to $46.50. The company also hurdled analyst targets for its third quarter. Cognizant provides applications maintenance and services for large corporations.
Teaneck, N.J.-based Cognizant reported earnings of $5.4 million, or 27 cents per diluted share, in the quarter, on revenues of $41.1 million. The results were two cents better than the 25 cents a share analysts' consensus estimate from First Call.
Fourth-quarter earnings and revenues both rose compared to the $3.1 million, or 15 cents per share, profit seen on revenues of $24.1 million in the fourth quarter of 1999.
The company said that e-business revenues grew to 36 percent of total revenues while application management revenues increased 70 percent.
Cognizant CFO Gordon Coburn attributed the strong earnings performance to expanded operating margins. He also said that the company generated $13 million in cash from operations in the quarter.
For the full fiscal year 2000, the company saw a 57 percent increase in net income year-over-year, reporting a profit of $17.7 million, or 87 cents per diluted share, as compared to $11.2 million, or 58 cents per diluted share in 1999. Full year earnings came out ahead of consensus estimates calling for a profit of 86 cents a share.
Revenue for the year jumped 54 percent over the year-ago period to $137.0 million, from $88.9 million in the prior year. Excluding Y2K-related gains, revenue for the year increased 82 percent.


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Fuel Soccer Talk: De Bruyne is "mesmerizing;" What's next for St. Louis?; Stadium renderings in Nashville
Is Kevin De Bruyne the best soccer player in the world?
Full disclosure…I'm a City fan.
But is there any doubt that Kevin De Bruyne is one of the best players in the world. Maybe even THE best!
He is simply brilliant with the ball. There are players who 99 percent of the time just make the safe pass. There is a Man City who either makes the safe pass or gives the ball away – but I will leave his identity to myself. De Bruyne either makes the safe pass or the brilliant pass, threading the needle or hooking/placing the ball to a perfect spot for a teammate to run onto. He's one of those players you can't take your eyes off.
De Bruyne now has 50 Premier League assists in just 122 appearances.
But don't take my word for it.
From Gary Neville: "He mesmerizes me, De Bruyne. He mesmerizes me watching him. He is the type of player I just think is so good, he's world class like you wouldn't believe. His positions are always good but I alluded in commentary about, I used the names David Beckham and Steven Gerrard, because they're the two best crossers of the ball that I've seen from this right-hand side in the Premier League. He matches them in terms of the quality that he delivers and that is high praise."
What's next in St. Louis after MLS expansion announcement?
ST. LOUIS – St. Louis has its MLS franchise in hand, but the next item on the club's priority list may be just as challenging.
For Jim Kavanaugh and the rest of the ownership group, almost everything depends on the stadium.
"The next priority, at a high level, is to finalize the land and the specific design of the stadium," Kavanaugh said at Tuesday's formal announcement, which will make the city home to the league's 28th team in 2022.
The stadium, designed to accommodate up to 25,000 fans, will sit on the western edge of downtown. It will serve as the terminus of a sports corridor anchored in the east by Busch Stadium, the nest of the MLB's St. Louis Cardinals, and Enterprise Center, home of the 2019 Stanley Cup champion St. Louis Blues.
"We have to get the stadium process moving as fast as we possibly can," Kavanaugh said. "That's really what's going to drive everything to our projected season opener in 2022."
The architectural stadium partners, Snow Kreilich Architects and St. Louis-based HOK, unveiled stadium renderings in April. The rectangular design surrounds a field 40 feet below street level. A translucent canopy will cover the seats. A mixed-use area of retail stores, restaurants and gathering spaces are planned adjacent to the stadium. The stadium will be financed overwhelmingly by private funds.
Nashville SC release new stadium renderings
Everyone loves a good stadium rendering. Thankfully, Nashville SC are here to satisfy our collective fix with a new look at what will be the largest soccer-specific stadium in the US when it's built, with an expected capacity of 30,000.
Nashville CEO Ian Ayre gave an update on the progress of the stadium and revealed the new renderings at a meeting with the Metro Sports Authority on Thursday.
Nashville SC are set to begin their MLS expansion season in 2020, with the new stadium currently projected to open in 2022. Until then, the club will share their home games with the NFL's Tennessee Titans at Nissan Stadium. During his presentation on Thursday, Ayre said Nashville is on track to hit that 2022 target for opening the new venue, adding that the design and development phase is currently underway and will hopefully be completed by October of this year.
Email me at tajacoby@comcast.net
Fuel Soccer: Could Lloyd play in the NFL?; Paige Monaghan honored; VAR gives Tottenham a hand in draw with City
Fuel Soccer Talk: Special U.S. Open Cup Finals Preview


Several factors complicate the diagnosis of Asperger syndrome (AS), an autism spectrum disorder (ASD). Like other ASD forms, Asperger syndrome is characterized by impairment in social interaction accompanied by restricted and repetitive interests and behavior; it differs from the other ASDs by having no general delay in language or cognitive development. Problems in diagnosis include disagreement among diagnostic criteria, controversy over the distinction between AS and other ASD forms or even whether AS exists as a separate syndrome, and over- and under-diagnosis for non-technical reasons. As with other ASD forms, early diagnosis is important, and differential diagnosis must consider several other conditions.


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Avians never failed to fascinate the human kind. Desire to feel the freedom; independency and the beauty of the earth from a distance… all could possibly be among the reasons for that fascination. Similar feelings were experienced when a flock of Flamingos were encountered near the marsh near Sitra Causeway (near to Ford Showroom) one morning while returning from an early morning shoot in the Eastern Coast.
Flamingos are so sensitive. They sense you approaching them from as far as 50 meters or more and start to respond. A series of photographs were taken from the moment they realise your appoach till they are flying in formation.
Seen here is the moment of recognition of danger…
The flock begings to move away and one of them assumes the leadership position… prearranged and agreed. Excellent display of camaraderie… No full-body scan… no seat belts… no in-flight movies to suffer… no need to have to endure the complimentary meals. Just fly.
Due to the weight these poor birds has to endure during the flights (yes, there bones are hollow) taking-off is a sight not to be missed. Think an A380 or a B52.Flamingos run several steps, starts flapping their wings before they become airborne… When landing, the procedure is reversed: the bird touches down and then runs several paces.
Moments just after being airborne, the phase of reorientation occurs. Blindly follow the leader of the flock seems to be the doctrine. But whom does the leader follow….?
Flock is still in a disorganised array… as we watch further, the formation is more identifiable.
And finally they are in full formation, shown partially… resembling an arrow, or whatever. A flamingo flies with its head and neck stretched out in front and its legs trailing behind. Flight speed of a flock of flamingos can reach 50 to 60 kph (31-37 mph). Flamingos have been known to fly 500 to 600 km (311-373 mi.) each night between habitats. The majority of lakes where flamingos live have extremely high concentrations of salt. The only source of fresh water for some of these birds comes from boiling geysers. They are capable of drinking water at temperatures that approach the boiling point.
Birds fly; well, most of them. But the way some of them fly is worth watching… For the same reason why people instinctively look up the sky when they hear a jet engine…


Tired of memorizing public transportation schedules? Don't want to go through the hassles of travelling in Taxis? Then why would you worry when you can rent a car in Dubai Creek with one of the leading car rental company in UAE – TripJohn. Enjoy the beauty and infrastructural developments around Dubai Creek in a stylish and a luxurious car. TripJohn gives you the freedom to choose whatever car you want and drive wherever you want.
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So leave your transportation worries and rent a car in Dubai Creek with us and focus on your journey around Dubai Creek. Trusted by numerous customers, you can safely rely on our car rental in Dubai Creek. Book your favourite car now.


text:
Q: Is there any way I can use my Wii U to play movies I have on my computer? Is there any way I can use my Wii U to play movies I have on my computer? So if I have purchased a movie through iTunes for example?

A: You can setup a Plex server on your home PC. Plex server essentially hosts your videos and other media for use from the home, and supports many platforms such as the iPhone/Android, Chromecast, Smart TVs, other PCs, and major consoles.
There isn't a Wii-U app directly to support it, however you can use the Wii-U's built in web-browser with ease.
The basics for setting up a server is beyond a hand-written tutorial for this website, especially as the software changes over time. A quick Google search will need you plenty of high-quality tutorials for your device in question.

redpajama_set_name: RedPajamaStackExchange


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[ASC-media] Australian "OPAL" provides hope for HIV treatment
Elaine Mulcahy emulcahy at unimelb.edu.au
Mon Feb 28 12:03:50 EST 2005
Previous message: [ASC-media] Media Release: "CSIRO Communications in Turmoil": Fresh Facts
AVAILABLE FOR IMMEDIATE RELEASE
News Desk / News Editors
Australian "OPAL" provides hope for HIV treatment
Australian researchers have made a major discovery in the fight against
AIDS, with the development of a novel, simple and safe technique for
boosting the body's immune response to deadly viruses like HIV, which is
even effective against drug resistant forms of the disease.
Associate Professor Stephen Kent from the University of Melbourne's
Department of Microbiology and Immunology says the findings hold great
promise for the treatment of HIV, other chronic viral infections, and
drug resistant infections, which are becoming a major problem.
"We have invented a simple new technology to boost the ability of the
immune system to fight chronic infections such as AIDS and Hepatitis C.
This involves using a patient's own blood treated with small overlapping
proteins of the virus (called peptides)," Associate Professor Kent says.
The research will be published today in the Journal of Virology.
**Images of Associate Professor Kent and his research team are
The researchers call the therapy Overlapping Peptide Pulsed Autologous
Cells (OPAL). They have been awarded National Health and Medical
Research Council (NHMRC) funding of almost $500,000 to refine the
technique so that it can be studied in humans.
"The ability to induce and expand the immune response across most or all
parts of the virus is highly advantageous. Our results, which
consistently demonstrated sharply enhanced immunity in vaccinated
animals, suggest that this therapy could also work in humans."
The researchers initially set out to develop a technique for measuring
the effectiveness of a HIV vaccine. They first extracted blood from
previously vaccinated animals and then coated the cells with HIV peptide
markers (a technique which only takes an hour to complete).
In a normal situation, when HIV or any virus infects a cell, it leaves
behind tell-tale markers or peptides on the cell surfaces which tell the
immune system that the cell is infected. In this study, the researchers
did not infect the animals with HIV, but rather created the illusion to
the body that these cells were infected because they had the tell-tale
markers (peptides) on their surface.
When they injected this peptide-coated blood back into the vaccinated
animals they found that it triggered a huge immune response.
"When we analysed HIV-specific immunity in the weeks following the
assays (peptide-coating), a marked enhancement of virus-specific
immunity was induced," Associate Professor Kent says.
"The technique was also effective for boosting the immune response to
Hepatitis C peptides and we believe that it could be refined for many
different viral infections and cancers. We have also shown it can be
used to induce immune responses against drug resistant forms of HIV. The
OPAL technique is simpler than current cell-based vaccine techniques
which usually require isolation of rare specialised cells from blood."
Associate Professor Kent led a dedicated team of scientists, Ms Socheata
Chea, Dr Jane Dale and Dr Rob De Rose at the University of Melbourne's
Department of Microbiology and Immunology, and collaborated with
colleague Dr Ian Ramshaw at the Australian National University's John
Curtin School of Medical Research.
Associate Professor Kent says there is an urgent need to develop simple
methods to induce or enhance HIV-specific immunity to prevent or control
the disease. "Our research is a major step forward in this regard."
The researchers will now embark on a series of experiments to refine the
technique to make it even more practical and generate even bigger
responses. Associate Professor Kent's group plans to begin human testing
of the OPAL therapy in the next one to two years.
Media Officer, University of Melbourne
Elaine Mulcahy
Email : emulcahy at unimelb.edu.au
Stephen Kent
Mobile : 0438 290994
Email : skent at unimelb.edu.au
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Editor's Note: It's one thing to eat yuca, but it's another thing to prepare it! If you'd like to add yuca to your side dish recipe repertoire, then you'll want to take a look at this guide on How To Peel And Cook Yuca. You'll only need two ingredients and just a little bit of prep work, and you'll soon be cooking yuca like a pro. If you'd like some culinary inspiration, then you'll want to check out the author's recipe for Yuca and Beef Patties to get started in cooking with this unique and starchy vegetable. You'll definitely want to start cooking with this plant today!
Yuca is a staple in many South American homes, especially in the coastal towns of the Andes and the tropics. Often it is used as a substitute for potatoes.
If you love this recipe, check out even more South American sample recipes from this wonderful book.
If using fresh yuca, you need to buy about 1½ pounds because of the trimming that has to be done. To peel, cut crosswise into 2- to 3-inch pieces. With a sharp paring knife, cut lengthwise through the bark and the pink skin under the bark. Place the knife under the skin to loosen it and pull off the skin and bark. Rinse the yuca and place in cold water so it doesn't discolor.
To cook, place fresh or frozen yuca in a 4-quart saucepan. Add salted cold water to cover by 2 inches and the lemon juice. Bring to a boil over medium heat, reduce the heat to low, cover, and simmer for 20 minutes. At this time, start testing with a fork; if it goes in easily, the yuca is done. The cooking time for each piece may vary.
Using a slotted spoon, transfer to a colander, drain, and let cool. When cool enough to handle, cut in half lengthwise and, using a paring knife, remove the fibrous cord in the center.


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The Walking Dead 'Here's Negan' Ending Explained
Josh Stringer/AMC
By Robert Balkovich/Updated: April 1, 2021 10:29 am EST
Contains spoilers for The Walking Dead season 10, episode 22 — "Here's Negan"
From a harrowing look into the psyche of Princess (Paola Lázaro) to Daryl (Norman Reedus) and Carol's (Melissa McBride) heartbreaking conflict, The Walking Dead's season 10C episodes have been intimate and engaging. In fitting fashion, the season finale puts the spotlight on one of the show's most notorious villains: Negan (Jeffrey Dean Morgan), the former leader of the Saviors, longtime Alexandrian prisoner, and Carol's personal assassin.
Available to watch now on AMC+, "Here's Negan" reveals the complex history that made him who he is, employing a series of flashbacks that give viewers a revealing look at Negan's life in the earliest days of the apocalypse. We not only learn the origins of Negan's signature weapon Lucille, but we also meet the baseball bat's namesake and gain a deeper insight into how Negan's relationship with his long-dead wife shaped him as a person.
The episode begins with Carol taking Negan to a cabin in the woods to be exiled because of his feud with Maggie (Lauren Cohan). Although it's Negan's past that takes center stage in the Walking Dead season 10C finale, the episode does also manage to tease how that conflict could play out in The Walking Dead's 11th and final season.
Without further ado, here's what went down in "Here's Negan."
Negan's exile gives him time for reflection
While in exile, Negan has a vision of himself in the past — around the time viewers first met him at the end of season 6. The presence of this previous version of Negan seems to imply that while he's clearly changed a bit since Rick (Andrew Lincoln) defeated him and he was locked away, parts of his old self are still there. Past-Negan chides present-day-Negan for trying to win over the Alexandrians by playing nice, telling him, "It's time to face the facts, old man: You are nothing without her." The "her" here refers to Lucille, Negan's trusty baseball bat. But, of course, it also refers to Lucille (Hilarie Burton-Morgan), Negan's wife for whom the bat is named.
Negan appears disturbed by the vision, but the next day, he goes to the tree where he believes Lucille the bat was buried after his climactic showdown with Rick in season 8. He digs around for a bit, and as soon as his shovel hits wood, we get our first flashback. Twelve years in the past, Negan is tied to a chair and a gang leader called Baxter (Rodney Rowland) is interrogating him. Baxter found Negan traveling with a supply of chemo drugs, which is somewhat of a rarity in the post-apocalypse, and is eager to know how he got them.
An important thing to note is that the Negan who viewers see in the flashbacks isn't the one we've come to know in The Walking Dead. He's less self-assured, has a hard time even killing walkers, and doesn't quite have that swagger that has come to define his character. This is very evident when Negan begins to tell the story of how he got the chemo drugs, which occasions another flashback.
Meet Lucille
The drugs Negan is carrying came from a mobile medical clinic. In the flashback, he makes a feeble attempt to rob the doctors who work there, but a clinic staffer with a baseball bat quickly knocks him out (put a pin in that for now). When Negan comes to, he tells Franklin (Miles Mussenden), the head of the operation, the story of why he needs the drugs, which begins flashback number three.
We're now six weeks further in the past. In the early days of the outbreak, Negan is living with his wife Lucille, who's undergoing chemotherapy. Negan is an attentive and loving husband. However, he and Lucille are quickly running out of supplies, and even though Lucille only has a few rounds of chemo left, their remaining stash of drugs spoils during a fridge malfunction. This is what forces Negan to rob the medical clinic.
When Negan finishes telling his story to the clinic workers, they're remarkably generous and kind to him. They feed him and give him the drugs he needs, telling him they only want to help people. Negan seems genuinely moved by their generosity. One of the most engaging aspects of "Here's Negan" is the fact that viewers get a remarkably panoramic look at the eponymous character. Thanks to the cascading flashbacks, fans can glimpse aspects of Negan's personality that were obscured or fully buried in the years that followed. He's more vulnerable in these early scenes — without allies, real weapons, or survival skills — and it changes how he interacts with the world.
Negan's pre-apocalypse life is revealed
As Negan is leaving the clinic, the staff gives him the baseball bat they'd previously used to knock him out. That is one part of Lucille's origin story, but there's still more to the tale. In the midst of the scenes detailing Lucille's chemo troubles, there's yet another flashback (the fourth, for those keeping count). This one takes viewers to the earliest days of the outbreak, before society had collapsed and the news was merely reporting on a series of strange cannibalistic murders. It also introduces a different moment in Negan's personal growth.
Pre-collapse Negan, as it turns out, is a bit of a lout. He loses his job as a high school gym teacher after getting arrested for beating someone up, and he's now spending his days playing video games. He's also cheating on Lucille with one of her friends, something that prevents him from being with her when she first receives her cancer diagnosis.
This particular flashback seems to be illustrating how much Lucille's cancer changed Negan as a person — or, rather, how much his love for Lucille changed him. In the post-collapse times, Negan weeps while Lucille recounts how she learned about his affair, but she tells him, "I want you to know that you made up for it." Negan's love and devotion for Lucille in these scenes is powerful, and the episode demonstrates just how transformative those emotions were for him during the earliest days of the apocalypse. However, it does beg the question: How did he then go on to become the Negan we know?
We get an answer to that question when we're back in the first flashback with Baxter, the gang leader. Negan is desperate to bring the fresh chemo drugs he's carrying back to Lucille, so he gives up the location of the mobile clinic. After the gang rounds up the doctors, they let Negan go.
The birth of Negan
Before Negan leaves on his mission to find more chemo drugs, Lucille begs him to forget trying to save her life and instead merely stay with her until she dies. When he finally arrives back at home with the drugs, Negan discovers that he should have listened to her. Lucille's zombified body is on the bed in their room. She appears to have purposefully overdosed on pills and zip-tied one arm to the headboard to prevent her from later attacking Negan. Written on the outside of the door is a harrowing phrase: "Please don't leave me like this."
This is obviously a crushing moment for Negan, who has spent the entirety of his time in the apocalypse thus far trying to keep Lucille alive. After sitting with her zombified form for a while, he goes outside to a nearby fence and uses some barbed wire to put the final touches on Lucille the bat. Once he's said goodbye to Lucille the person, he burns down the house.
Back at the gang hideout, Franklin is being tortured for information about where he gets his medical supplies from. Negan puts a stop to it by killing each of the gang members except for Baxter, whom he ties up.
It's here where viewers get their first glimpse of the Negan they know and loathe. Dressed in his signature leather jacket and brandishing his bat Lucille, Negan performs a soliloquy in front of Baxter. He tells Baxter about the man he beat up who got him fired, then concludes, "There were consequences to me seeing red. Seeing red was a bad thing then. But see, now nobody's suing anybody, nobody's getting fired. Hell, nobody's keeping score. Now, when I see red, it's just a question of what I am capable of. See, I am starting to think that I am capable of damn near anything."
What "Here's Negan" means for The Walking Dead season 11
Back in the present day, Negan digs up Lucille the bat and brings it home to his cabin. He tenderly speaks to it as though it's Lucille herself. He tells her, "I am sorry that I left you. I couldn't face the pain of losing you, so I ran away. And then I made myself not feel anything because I didn't want to feel the shame." He even apologizes for naming his "stupid baseball bat" after her. Negan then places Lucille the bat into his fireplace and watches it burn, tears rolling down his eyes.
This would seem to signal a significant change in him, but, as we see in the final scene of the episode (and thus of The Walking Dead season 10), things aren't quite that cut and dry. The next day, Negan strolls back into Alexandria. When Carol confronts him, he tells her that he's not interested in living in exile. Carol says that Maggie will kill him if he moves back, and makes it clear that now that she's tried to help Negan, she won't intervene. Negan agrees and continues on, looking at a shocked and horrified Maggie as he walks by. The mischievous grin he wears while he observes her suggests that Negan's new chapter won't necessarily include peacemaking.
Based on how The Walking Dead season 10 ends, it feels inevitable that the conflict between Maggie and Negan will boil over during season 11 — and that it won't be pretty. While Negan's past reveals that he's a complex character and that his propensity for violence is just one facet of his personality, it also demonstrates that violence is something that has always existed within him, even if it's hidden under the surface.
It's too soon to say exactly how that will all come to a head in the final season of The Walking Dead, but it will no doubt be bracing.


Dollywood's Splash Country Water Adventure Park is located in Gatlinburg, Tennessee. The location is fun for students of all ages. Your student group can ride 23 different slides. Featured rides include the following: RiverRush, the Bear Mountain Fire Tower, Big Bear Plunge, Fire Tower Falls, Mountain Scream, Mountain Twist, and Raging RiverRapids. During the Mountain Scream ride, the students will have a choice to race down winding corkscrew tunnels or thrilling quadruple-drop slides. Fire Tower Falls is an exhilarating ride and is the park's tallest set of slides. There are other entertainment attractions for students to explore. Options include the following: Daredevil Falls, the Chasing Rainbows Museum, Barnstormer, Demolition Derbi, the Dizzy Disk, and Blazing Fury. The Chasing Rainbows Museum contains artifacts, awards, and elaborate costumes from Dolly Parton herself. Do your students enjoy fun adventures? If so, the park features an exciting zip line tour known as "Skyzip." The experience includes four treks ranging in length from 700 to 1,000 feet. In addition, the students will teeter above the treetops on a 100-foot-long swinging bridge. The tour is an hour in length. Come with your student tour and visit this one-of-a-kind entertaining attraction!


text: Amy Jade Winehouse (14 September 1983 – 23 July 2011) was an English singer and songwriter. She was known for her deep, expressive contralto vocals and her eclectic mix of musical genres, including soul, rhythm and blues and jazz. A member of the National Youth Jazz Orchestra during her youth, Winehouse signed to Simon Fuller's 19 Management in 2002 and soon recorded a number of songs before signing a publishing deal with EMI. She also formed a working relationship with producer Salaam Remi through these record publishers. Winehouse's debut album, Frank, was released in 2003. Many of the album's songs were influenced by jazz and, apart from two covers, were co-written by Winehouse. Frank was a critical success in the UK and was nominated for the Mercury Prize. The song "Stronger Than Me" won her the Ivor Novello Award for Best Contemporary Song from the British Academy of Songwriters, Composers, and Authors. Winehouse released her follow-up album, Back to Black, in 2006, which went on to become an international success and one of the best-selling albums in UK history. At the 2007 Brit Awards it was nominated for British Album of the Year, and she received the award for British Female Solo Artist. The song "Rehab" won her a second Ivor Novello Award. At the 50th Grammy Awards in 2008, she won five awards, tying the then record for the most wins by a female artist in a single night and becoming the first British woman to win five Grammys, including three of the General Field "Big Four" Grammy Awards: Best New Artist, Record of the Year and Song of the Year (for "Rehab"), as well as Best Pop Vocal Album. Winehouse was plagued by drug and alcohol addiction. She died of alcohol poisoning on 23 July 2011, at the age of 27. After her death, Back to Black temporarily became the UK's best-selling album of the 21st century. VH1 ranked Winehouse 26th on their list of the 100 Greatest Women in Music.


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U.S. labor law and the future of labor-management cooperation
U.S. labor law and the future of labor-management cooperation final report. by
Published 1989 by U.S. Dept. of Labor, Bureau of Labor-Management Relations and Cooperative Programs in Washington, D.C .
Industrial management -- Employee participation -- Law and legislation -- United States.,
Labor laws and legislation -- United States.,
Industrial management -- Employee participation -- United States.
Other titles US labor law and the future of labor-management cooperation
Contributions United States. Dept. of Labor. Bureau of Labor-Management Relations and Cooperative Programs
Pagination ii, 244 p. ;
Download U.S. labor law and the future of labor-management cooperation
U.S. Labor Law and the Future of Labor-Management Cooperation Stephen I. Schlossberg Deputy Under Secretary of Labor for Labor-Management Relations and Cooperative Programs U.S. Department of Labor Washington, D. C. Steven M. Fetter* Executive Assistant to the Deputy Under Secretary U.S. Department of Labor Washington, D. C. 3. See Schlossberg & Fetter, U.S. Labor Law and the Future of Labor-Management Cooperation, 3 THE LAB. LAW. 11, 12 (). 1 Glick: Labor-Management Cooperative Programs: Do They Foster or Frustrat Published by Scholarly Commons at Hofstra Law, GRAMS, U.S. DEPARTMENT OF LABOR, U.S. LABOR LAW AND THE FUTURE OF LA-BOR-MANAGEMENT COOPERATION 2 (). Unfortunately, the Bureau does not reach a conclusion regarding the means to resolve the conflict between labor-management cooperation and the traditionally adversarial employer-employee relationship under the NLRA. U.S. Department of Labor, Pub. No. BLMR , U.S. Labor Law and the Future of Labor-Management Cooperation, Second Interim Report—A Working Document 80 () (hereinafter Second Interim Report) (statement of the National Association of Manufac.
Labor Law, Industrial Relations, and Employee Choice 5. Just as employers became concerned about the state of industrial relations in the late s and early s concerns that were reflected in the Taft-Hartley Act unions have also developed . labor law and the future of labor-management cooperation, 1, , () (First Intermin Report, BLMR ) [hereinafter LABOR LAW REPORT] (comments of Donald R. Sazama and J. Bruce Johnston).Author: Perritt, H Henry. The U.S. declares war on Germany and its allies on April 6. Congress creates the War Labor Administration to organize wartime production, giving the Labor Department an important role in the subsequent victory. Artist & model pose with a Department of Labor wartime poster. — U.S. Department of Labor. International Labor Comes to the Capital. February Understanding the labor-management relationship in Germany. In Holding the Shop Together, author Steven J. Silvia unifies years of research to deliver the most up-to-date survey on the state of German industrial of Silvia's book is an authoritative weave of historical and qualitative narrative that also displays his impeccable grasp of the German .
The discussion also traces the legal evolution of U.S. labor law and policy dating back to the Philadelphia Cordwainers' case of (generally recognized as the first American labor case), through the National Labor Relations Act of and the Fair Labor Standards Act of , to the Civil Rights Acts of and , and, finally, to. programs, u.s. dept. of labor, u.s. labor law and the future of labor-management cooperation (blmr , ). see also bureau of labor-man-agement relations and cooperative programs, u.s. dept. of labor, first interim report (blmr , ) on . New Directions in Labor-Management Relations. Stepp, John R. // Labor Law Journal;Aug86, Vol. 37 Issue 8, p The article discusses key issues and trends in labor-management relations. Industrial relations abhors a vacuum. If unions cease to be a viable counterweight, a stronger role for government will be assured. This would be disastrous. labor legislation in encouraging labor-management cooperation in order to enhance the global competitiveness of U.S. firms. In response to this accumulation of concerns, the Secretaries of Commerce and Labor in created the Commission on the Future of Worker-Management Relations, often referred to as the Dunlop ComAuthor: Richard N. Block, John Beck, Daniel H. Kruger.
The women in the Gospel of John
For This I Went to COL
Enjoying ourselves
Writing mechanics, 1969-1974
vanity and mischeife of the old Letany
Implicit functions and solution mappings
Collected Poems and Prose
Defining the struggle
Criminal justice?
Foreign direct investment in the United States
blessings of liberty
Contemporary World Architects


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December 15, 2018 | Publications | Research
Doing Business with Congress
Lincoln White Paper
Of the three branches of the federal government, Congress is the most responsive to the American people. On a daily basis, congressional offices hear from constituents, industry groups, civil society organizations, and other stakeholders across a broad range of issues. While digital tools have lowered barriers to communication with our elected representatives, Congress's information technology (IT) infrastructure and staffing have failed to keep up with the new influx of information. The Members and Committees that oversee the governance of IT often have other priorities and limited technical depth. Opaque and fragmented rules also make it difficult for prospective vendors to do business, or for public interest technologists and civic hackers to meaningfully contribute.
This paper gives an overview of the governance structure, technical policies, and acquisitions processes for information technology infrastructure in Congress. The first section offers a brief history of the adoption of electronic communications and information technology in Congress. The second section provides an overview of the governance structure for information technology in the U.S. House of Representatives, the U.S. Senate, and other legislative branch entities. The third and final section provides an overview of technology acquisitions categories and procurement processes in each chamber. At the end of this paper, you will also find appendices listing information relevant to technology acquisitions that, in most cases, is not otherwise publicly available.
IN THIS WHITEPAPER, YOU'LL LEARN
How information technology is handled in different parts of the legislative branch
About the policies and procedures for information technology acquisitions in the House and Senate
What Congress can do to improve its information technology infrastructure and vendor ecosystem
DOWNLOAD THE FULL PAPER HERE
Ken Ward is an expert in, among other things, civic technology. A long time ago, in a galaxy far, far away, he was a staffer on Capitol Hill who gained an in-depth understanding of the technical and logistical challenges faced by Congressional offices. He went on to become the founding CEO of Fireside21, where he was instrumental to the expansion of the company's product offerings as well as their successful adoption on the Hill. This fifteen years of experience gave him a front row seat to the challenges and opportunities of providing services to the legislative branch. Despite the difficulty of making change in government (download), Ken continues to be an optimist for the future of our democracy.
Zach Graves is head of policy at Lincoln Network, where he works on technology and governance issues. Prior to joining Lincoln in July 2018, he was founder and former director of the technology and innovation policy program at the R Street Institute, a free-market think tank. Prior to joining R Street in 2013, he worked at the Cato Institute. In addition to his work at Lincoln, Zach is a Technology and Democracy Fellow at the Ash Center for Democratic Governance and Innovation at Harvard Kennedy School, a visiting fellow at the National Security Institute at George Mason University's Antonin Scalia Law School, a fellow at the Internet Law and Policy Foundry, and an associate fellow at the R Street Institute. He is also co-founder of the Congressional Data Coalition. Zach holds a master's from the California Institute of the Arts and a bachelor's from the University of California at Davis.
Pictured above: Rep. Carl Albert tries out the House's new computer in front of Speaker John McCormack and other Members. Photography Office, U.S. House of Representatives.
Tags: IT modernization, Modernizing Congress


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Q: Image mask animation in two stages – possible with jQuery? I did a search and can't find this exact question answered anywhere (please let me know if it has been and I've missed it!)
I'm trying to create an animation where four images are faded in over a background image in two stages – ideally using jQuery, and ideally jQuery which will work in IE8 and up.
It's a little bit difficult to describe exactly the effect i'm intending to create, so I've done up an example gif animation to give a sense of it. The gif, obviously, loops the animation, but I'm only intending for it to load and play once, on page load. Check it out here: http://i.imgur.com/udnFqja.gif
I've tried looking around for combinations of .animate() with image masking/revealing, which also blurs the edges of the image as they are revealed – but no luck so far!
If you have any ideas about the best way to proceed with this, I'd be very grateful to hear them.
Thanks.
(Edit! Alternatively, it would be possible to use the left-to-right wipe transition provided by the cycle plugin, and layer up three jpegs, but in this case there would still need to be some way to blur the edges of the images as they swipe out)

A: This method will only use jQuery animations and CSS.
You can simply have two divs on top of the one that has the background image. Set their initial width to zero and when the page loads, animate the width of the first one. Then use the callback function of that animation to animate the width of the second (the topmost) one.
To get the blurry effect - set the transparent blur gradient as an image or as another div background with height 100% and background repeating on Y axis. Do this for each of the two layer divs. They need to have higher z-index than the layer divs.
And lastly the guitars: they can be just the background images of each of the two layer divs, or even images, it's up to you. Just don't forget to make the top layer have a bigger z-index.
To clear it up, here is the pseudo structure:
<div> Main div that contains the bg image
    <div> First layer div with the first guitar image (Duo-Sonic)
        <div> Div (or <img>) with the blur image floating on the right
    </div>
    <div> Second layer div with the second guitar image and has a higher z-index than the first layer div (Jaguar)
        <div> Div (or <img>) with the blur image floating on the right
    </div>
</div>


It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.
Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.
Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.
Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.
Stroke is a catastrophic illness with long term sequelae of disability, dependency and other emotional, psychosocial and financial issues. Globally, about 16 million first stroke cases occur annually with 5.7 million deaths . Over the past two decades, the absolute numbers of stroke cases and the DALYs lost due to it have been increasing . In Singapore, stroke was the 10th most common cause of hospitalization in 2012 and was one of the top five causes of death in 2013, accounting for 8.9% of the total mortality [3, 4]. Stroke not only causes pain and suffering to the patients and their families, but also taxes the economies worldwide, and is accountable for almost 4% of direct healthcare costs in developed nations .
A recent study in Singapore reported significant economic strain attributable to direct medical cost of stroke, with mean annual cost being SGD12,473.70. More than 90% of this amount was accounted by inpatient service use, about 5% by outpatient services and less than 2% by emergency services . From a public health perspective, this holds particular significance in Singapore context with rapidly aging population, declining citizen old age support ratio and decreasing fertility rate. Singapore would be home to 900,000 elderly citizens by 2030 and consequently there would be an increase not only in the prevalence of stroke, but also healthcare services utilization (HSU) by both the patient and the caregiver and the associated costs to the healthcare system and society [7, 8].
Furthermore, advancements in medical management strategies have led to decreased stroke attributable deaths, leading to a greater number of survivors, with half of them having residual physical disabilities and cognitive deficits [9, 10] resulting in increased use of healthcare resources.
Considering the economic strain attributable to stroke, researchers have reported the magnitude of stroke associated costs across different settings. Adopting a societal perspective, Bastida and colleagues reported the stroke related average cost per person in Spain to be €17,618 over 1 year. This cost was inclusive of medical costs, informal care costs and productivity loss related costs . Another study focusing on direct costs reported mean hospital related costs per person to be €3624.9 . Within USA, Taylor and colleagues reported lifetime cost per ischemic stroke survivor to be $90,981 . A recent systematic review synthesized the costs associated with post stroke care and reported mean cost per patient month after stroke to be $1515 for studies including both inpatient and outpatient care services and $820 for studies focusing only on outpatient care services. Moreover, they concluded USA to have the highest post-stroke care associated costs, followed by Denmark, Netherlands and Norway. Italy, UK and Germany had one of the lowest post-stroke care associated costs .
Temporal trends of index-stroke hospitalization , recurrent stroke admissions [16, 17], inpatient rehabilitation utilization  and associated risk factors  have been described previously, however papers studying post-stroke care trajectories are sparse . Focusing on the index stroke admission, researchers explored the temporal trends over a decade in UK setting and further explored the influence of patient socio-demographic (race and age) and functional characteristics on inpatient acute care and indicators of provision of rehabilitation . Studying aggregated summary estimates at episode level does not provide information on utilization at individual level which is necessary to improve healthcare delivery, reduce unnecessary consumption and improve outcomes for stroke patients. Past work supports significance of first year post-stroke from financial perspective with associated higher consumption and costs [6, 22].
A prospective study in Sweden examined the utilization of different healthcare resources and rehabilitation outcomes over 1-year period in 258 stroke survivors. They reported age of stroke patient and stroke severity as significant covariates .
With population of stroke patients (N = 674) who underwent inpatient rehabilitation in US setting, Ottenbacher and colleagues examined the prevalence of hospitalizations after index stroke over a 3-month time period. They also studied the association of socio-demographic and clinical covariates with rehospitalization and reported functional dependence and perceived social support to be significantly associated with rehospitalizations .
Another study focusing on stroke survivors discharged home in US, was among the select few internationally, which explored the role of caregivers in healthcare seeking post-stroke and reported having a co-residing caregiver being associated with variations in HSU . In concordance with these findings, Roth et al. studied association of co-residing caregiver with HSU after stroke and reported having a co-residing caregiver was associated with reduced length of hospitalization, fewer emergency department visits and fewer primary care visits .
Among post-stroke HSU studies done in an Asian setting [6, 27–31], the focus varies with some describing only healthcare services [27, 28], some quantifying financial burden [6, 31] whereas others focusing on both aspects. Only one focused on a post-stroke year-long period  while the rest focused on either the index episode [28, 31–33] or duration of 3 months or less after stroke. Commonly described covariates were patient related [12, 23, 24, 31, 34–37] with little focus on caregiver covariates. Addressing above gaps, the aim of our study was to describe the trajectory of HSU by stroke patients and associated costs over 1-year post-stroke and examine the role of caregiver identity. The objectives were: (i) to describe the HSU and cost trajectory across four post-stroke quarters for inpatient, emergency department (ED), specialist outpatient clinic (SOC) and primary care (PC) services, (ii) to study the association of HSU with caregiver identity and patient covariates, (iii) to explore if patient covariates modified the utilization and cost trajectory.
We hypothesized: (i) the use and associated costs of acute (inpatient and ED) services would decrease over time as patient's condition would stabilize, while the use of outpatient (PC and SOC) services would increase, (ii) social support (caregiver availability and type) would decrease the utilization of acute services and increase the utilization of outpatient services, and (vi) the strength of association of patient covariates with acute and outpatient services will change across time.
Singapore has a mixed healthcare delivery system where public, private and non-profit healthcare institutions deliver inpatient and ED services, intermediate and long-term care (ILTC) as well as specialist and primary ambulatory care. The public sector is the dominant provider of inpatient, ED and specialist outpatient services in tertiary hospitals accounting for more than 80% of market share in these services. The ILTC sector comprises of step-down care, nursing homes and hospice facilities. The sector also includes day services like day rehabilitation, home care services and others. Ministry of Health is the overarching regulatory body responsible for provision and regulation of healthcare services. Stroke patients present with acute symptoms at ED of any of the 5 public tertiary hospitals and are subsequently stabilized and transferred to ward. They undergo rehabilitation and following discharge, are referred to outpatient services to continue care in the community.
This was a prospective study in Singapore with recruitment period extending from December 2010 to September 2013. Stroke patients and their caregivers were recruited from all five tertiary hospitals of Singapore during that period, which ensured representativeness of our sample. Stroke patients were eligible if they were: (i) Singaporean or permanent resident, more than 40 years old and residing in Singapore for the next 1 year, (ii) stroke must be: recent diagnosis (i.e. stroke symptoms occurring within 4 weeks prior to admission) with diagnosis made by clinician and/or supported by brain imaging (CT or MRI) and (iii) not globally aphasic. A caregiver could be an immediate or extended family member or friend, more than 21 years (the legal definition of adult in Singapore), providing care or assistance of any kind and taking responsibility for the patient, as recognized by the patient and not fully paid for caregiving.
Within each of these tertiary hospitals, on-site research nurses reviewed the list of admitted stroke patients on a daily basis to screen eligible subjects and invited them to participate in the study. Written informed consent was obtained from all participants after explaining the study and procedures involved in the language they understood. They were informed that at any point during the follow-up period of 1 year, they can withdraw from the study, if they wished. Participants (including both the stroke patients and their caregivers) were interviewed via face-to-face interviews at baseline, 3-month and 12-month time points and only caregivers were interviewed via telephone interviews at 6-month and 9-month time points. Self-reported data was collected broadly under health, social and financial domains. To ensure good compliance, reminders were sent 1 week prior to the scheduled follow-up in the form of mails, phone calls or text messages. Interviews were scheduled over weekends or evenings of weekdays for participant's convenience and adherence. Multiple attempts were made to contact participants before categorizing them as lost to follow-up. Training of first generation research assistants was conducted by main investigators, covering the content and appropriate method of data collection. The recordings of these training sessions were used to train subsequent research assistants to standardize data collection process. We pilot tested our survey with 40 participants from two of the five sites and made necessary amendments and finalized the survey forms.
For current study, while outcome variables were extracted from the national claims record, independent variables were taken from the survey conducted in Singapore Stroke Study at recruitment. National claims record is a nation-wide database of healthcare services utilization and associated costs maintained at the Ministry of Health, Singapore. All Singapore citizens and permanent residents are assigned a unique identification number which is used in almost all administrative contexts, including healthcare utilization. Linkage across multiple databases can be successfully accomplished using this identifier. For current study, adopting this approach the match rate was more than 95%.
Our main independent variable was quarter, a categorical variable representing each 3-month period post-stroke ranging from quarter 1 (Q1) to quarter 4 (Q4). Other covariates, collected from the study were socio-demographic, clinical, functional and caregiver related. The variables included under the socio-demographic group were: patient's age, gender, ethnicity, religion, marital status, comorbid status and ward class (proxy for socio-economic status). Ward class referred to type of hospital ward stroke patient stayed in during the index stroke hospitalization. In Singapore, based on fulfilling means tested eligibility criteria, patients can be admitted in wards ranging from A, B1, B2 and C with different level of government subsidy. We binarized this ward class variable into two categories of subsidized and non-subsidized ward class.
Those under clinical group were: stroke type, recurrence and severity measured on the National Institute of Health Stroke Scale (NIHSS). Functional status was assessed using two scales, Modified Rankin Scale (mRS) and Barthel Index (BI) [38, 39]. No collinearity was observed between BI and mRS and both were included as covariates. Patients' cognitive status was recorded using mini-mental state examination (MMSE) , while depression was assessed using Center for Epidemiological Studies Depression scale (CES-D-11 scale) . Primary caregiver was an immediate or extended family member or friend, designated by the patient as the person providing physical care and their responses were categorized as none, spouse, child, sibling or others (includes distant relatives and friends).
HSU and associated cost data were extracted from the national claims record, over 3-monthly periods or quarters to study the trajectory and associated variation in HSU and associated costs over one-year post-stroke. Our HSU outcome variables were counts of visits per quarter for inpatient and ED service (excluding the index-stroke event), SOC and PC visits. We extracted total costs (inclusive of subsidies and out-of-pocket components) for inpatient, ED and PC visits.
Liang and Zeger  introduced the Generalized Estimating Equation (GEE) approach for analyzing data with repeated measures for Generalized Linear Models which provides population average estimates. For the count data, we chose poisson or negative binomial distribution with a log link function pending on whether there was evidence of over-dispersion . Gamma distribution with a log link was used for cost data. We specified working correlation matrix corresponding to an autoregressive order 1 correlation structure and used the Huber and White sandwich estimator to obtain robust variance estimates even if the working correlation matrix is misspecified [42, 44, 45].
A simple model was run initially to obtain the unadjusted HSU or associated cost trend across the four quarters post-stroke (and is referred as Model 1). Covariates with p-value less than 0.1 in the bivariate analysis were considered in the multiple regression models. Backward variable selection was performed to determine the most parsimonious main effects model by removing the most insignificant variable (except for quarters, and age, gender and ethnicity of patient) until only the variables with the p-value < 0.05 remained in the model (and is referred as Model 2). With this adjusted model or Model 2, we further added interaction terms between the quarter variable and time-invariant covariates found significant in Model 2 using forward variable selection approach until the remaining interaction terms that did not enter the model had p-value > 0.05 (referred as Model 3). Model 2 and 3 were adjusted for patient's demographic factors (age, gender and ethnicity). Significance level was set at 5%. All statistical analysis was performed in Stata 14.
Five hundred ninety-two stroke patients were available for current analysis, after matching across both databases and exclusion of patients with deaths within the follow up period. For participant flowchart, please refer Additional file 1. As shown in Table 1, majority of the participants were less than 65 years old, Chinese, married males. About 88% had ischemic stroke and 61, 35 and 4% were mild, moderate and severe strokes respectively. About half of the caregivers providing physical care to the stroke patients were spouses (50.8%), followed by sibling (26%), child (6%) and others (6%) and about 11% of the current cohort reported as having no caregiver.
Compared to first quarter post-stroke, the unadjusted incidence rate ratio (IRR) of acute hospitalization in subsequent three quarters was 0.74 (95% CI: 0.54, 1.02), 0.65 (95% CI: 0.48, 0.88) and 0.67 (95% CI: 0.47, 0.96) respectively. The IRR estimates remained almost unchanged after adjusting for covariates. A decreasing trend of acute hospitalization associated cost was observed with adjusted exponentiated cost estimates from Q2 to Q4 being 0.52 (95% CI: 0.32, 0.83), 0.40 (95% CI: 0.23, 0.68) and 0.33 (95% CI: 0.20, 0.54) when compared with Q1 suggesting expected acute hospitalization associated cost decreased by 48, 60 and 67% for Q2, Q3 and Q4 respectively when contrasted with Q1. Both adjusted acute hospitalization and associated cost post-stroke showed a statistically significant linear trend effect that decreased with time since stroke, with greater decrease in the cost compared to number of visits (Fig. 1). Compared to first quarter, the adjusted IRR of ED service use in subsequent quarters was 0.91 (95% CI: 0.70, 1.19), 0.76 (95% CI: 0.58, 0.99) and 0.82 (95% CI: 0.57, 1.17) respectively. Both ED visit and associated cost showed a decreasing trend till third quarter post-stroke, but the linear trend effect was not statistically significant (Fig. 1). Compared to first quarter post-stroke, the unadjusted IRR of SOC service use in subsequent three quarters were 1.00 (95% CI: 0.89, 1.13), 0.75 (95% CI: 0.67, 0.84) and 0.74 (95% CI: 0.65, 0.85) respectively. After adjustment, the IRR of SOC service use had a similar significant linear trend with utilization still being the highest in the first 6 months and decreasing subsequently (Fig. 1). PC service utilization had a significant overall trend where the highest utilization was in the quarter immediately post-stroke and then decreased subsequently with adjusted IRR of PC visits per quarter being 0.93 (95% CI: 0.81, 1.06), 0.93 (95% CI: 0.79, 1.09) and 0.78 (95% CI: 0.67, 0.90) respectively in Q2 to Q4 when compared with Q1. The PC service associated cost showed a significant linear trend that had an opposite trend to PC visits with adjusted, exponentiated cost estimates in Q2, Q3 and Q4 being 1.33 (95% CI: 1.14, 1.54), 1.35 (95% CI: 1.15, 1.59) and 1.36 (95% CI: 1.15, 1.62) when compared with Q1 suggesting expected PC associated cost increased by 33, 35 and 36% for Q2, Q3 and Q4 respectively when contrasted with Q1 (Fig. 1). While both cost and service usage decreased across post-stroke quarters for inpatient and ED services, the service usage decreased, and cost increased across post-stroke quarters for PC services.
Caregiver identity was associated with acute inpatient and ED visits and their associated costs only. The IRR of acute hospitalization decreased by 51, 40, 11 and 1% for patients having spousal, sibling, child and others as caregivers respectively when compared with those having no caregiver (p = 0.017). Like hospitalization, acute hospitalization related costs for those with any related caregiver were lower than those with no caregiver. Having a spousal caregiver was associated with the lowest acute hospitalization costs with exponentiated cost estimate being 0.16 (95% CI: 0.09, 0.29) when compared with no caregivers suggesting expected hospitalization cost decreased by 84% when contrasted with no caregivers (p < 0.001) (Fig. 2).
The interaction term between quarter and disability (measured on mRS) was statistically significant (p < 0.001) in SOC service utilization model suggesting the utilization trend was different among varying levels of disability in stroke patients. Though the SOC utilization trend was decreasing across post-stroke quarters for both no or slightly disabled (mRS: 0–2) and moderate or severely disabled groups (mRS: 3–5), the decrease was steeper for the group with no or slight disability (Fig. 3) where the linear trend of SOC utilization across 4 quarters post-stroke in both groups were statistically significant (Table 3).
The PC costs across post-stroke quarters varied by stroke type and severity. Figure 4(a) illustrates the PC cost trend having an increasingly pronounced positive linear trend as we progressed from mild, moderately severe to severe ischemic stroke subgroups although the linear trend of PC associated cost was statistically significant only for moderately severe ischemic group with borderline significance (p < 0.15) for severe ischemic group (Table 3). Figure 4(b) illustrates the PC cost trend for mild, moderately severe and severe non-ischemic stroke subgroups. For all three groups, compared to cost in Q1, there was an increase in Q2, Q3 after which the increase in Q4 was slightly lower than Q3. However, the magnitude of increase across Q2 to Q4, compared to Q1 was increasingly pronounced as stroke severity increased where the linear trend for PC service associated costs was statistically significant for moderately severe and severe non-ischemic groups with borderline significance (p < 0.15) for mild non-ischemic group (Table 3). The overall results are summarized in Table 4.
Our study is the first to establish the association of caregiver identity with acute hospitalization and associated costs post-stroke. Our results supported the hypothesis of presence of caregiver being associated with decreased hospitalization and its associated costs only. Possible explanation is hospitalization episodes being unplanned, could be a proxy of unmet social needs rendered to stroke patient because of the absence of a caregiver. A study done in Taiwan, concluded higher rehospitalization for elderly participants with caregivers reporting support needs . In contrast, PC and SOC services are voluntary services whose utilization may not be affected by caregiver covariate but be more driven by health needs or clinical stroke characteristics.
Chuang et al.  explored association of caregiver factors with post-stroke readmission but found disability level, first-stroke, nursing needs and care arrangements post-discharge being significant predictors of rehospitalization within the 30-day observation period instead of caregiver covariates. Possible explanations could be a short observation period (1-month) and sample limited to stroke patients being functionally impaired at discharge. With longer observation period and inclusion of all stroke patients, caregiver factors may achieve greater significance, as observed in our case.
Roth and colleagues reported the role of co-residing caregivers in stroke survivors' use of healthcare services over a 6-month period in the United States of America and they concluded having a co-residing caregiver was associated with reduced healthcare consumption after index stroke episode . While the literature on association of caregiver characteristics with HSU in stroke population is still in the nascent stage, there is supporting evidence for this association among other population subgroups like elderly or heart failure patients. Prior work involving frail elderly in Italy reported odds of hospitalization being 2.59 times in those living alone as compared to those living with an informal caregiver . Another study involving heart failure patients concluded presence of spouse or legally registered domestic partner to be associated with reduced risk of readmission within 3 months of index hospital admission .
Caregivers can also be viewed as constituents of stroke patient's social support system and researchers have reported social support to be associated with reduced hospitalizations in both stroke and non-stroke patient population. In concordance with our results, a study done in the United States of America on hospital readmissions within 3 months of discharge from inpatient rehabilitation setting after stroke reported social support to be significantly associated with rehospitalizations. Specifically, those stroke patients having lower social support being 2.28 times more likely to be hospitalized as compared to those with high social support .
Another point to note is past efforts are limited to one type of caregiver, mainly children of elderly care recipients [49–51]. However, with aging population and decreasing fertility ratio, it is necessary to expand this analysis to different types of caregivers, especially spouse and sibling whose numbers and importance would increase with time. Since our sample comprised of different categories of caregivers, we not only reported on presence of caregiver and HSU but also found that presence of spousal or sibling caregiver was significantly associated with a decrease in acute hospitalization risk and cost where spousal caregiver had the largest drop. The differentiation across caregiver identity is an interesting and novel finding which is worth exploring further in-depth.
Wolff and colleagues studied the elderly population and association of caregiver characteristics with risk of being hospitalized and with delayed discharge. They reported on bivariate analysis a significant association between caregiver identity and hospitalization, with lower percentage of spousal caregivers (as compared to child and others) in the ever hospitalized group (p = 0.032) . Hanaoka and colleagues described association between children caregiver related factors and elderly care recipient's use of long-term care in Japan. They showed that lower opportunity cost of caregiving and caregivers co-residing with care recipients decreased recipients' utilization of long term care services . Assuming spousal or sibling caregivers to be older and less likely to be working compared to children caregivers, both would have lower opportunity costs of caregiving and this might explain their association with lower use of acute healthcare services. A recent qualitative study, reported a better match between caregiver's capacity and care recipient's needs would enable better adaption to the new role, better coping, less strain and improved patient outcomes. Moreover, they mentioned protective factors exhibited by some caregivers, such as, "self-awareness" (know own physical, emotional limitations) and "self-advocacy" (not hesitating to ask for help) which help them cope well with the new role and potentially would lead to the dyad's well-being . Based on our results, we propose that these findings may present differently in different caregiver types, with spousal or sibling caregivers potentially being more self-aware and asking for help sooner compared to children caregivers.
Our results have potential implications, since acute hospitalization constitutes the bulk of the financial burden related to stroke. Future research efforts should be directed to study in-depth the role of caregivers in stroke patient's acute healthcare utilization to garner evidence in support of programs benefitting caregivers. From healthcare financing perspective, bundled payment models are explored to finance such acute and post-acute episodes of care to reduce costs, improve care quality and incentivize vertical integration enabling care coordination . Currently, the scope of such initiatives is limited to developing bundles of care across different clinical settings, mostly limited to acute episodes, with recent interest in post-acute period of care [56, 57]. In light of our finding of family caregivers reducing hospitalization risk post-stroke, studies exploring bundled payment models post-stroke should consider inclusion of social sector or informal caregiving and ascertain the role caregivers can play in such arrangements.
Interestingly, caregiver covariate was only significantly associated with acute service utilization and not with use of outpatient services. Rather index stroke characteristics were associated with utilization and costs of outpatient services. Disability level modified the SOC usage trajectory with SOC usage declining among severely disabled sub-group but less pronounced when compared with mildly disabled group. This finding adds new knowledge to previous literature which reports association of stroke related disability with overall mean level of healthcare service utilization and costs [34, 37, 58]. Potential practical implication will be to focus on severely disabled stroke sub-population during acute or intensive care phase to minimize functional dependence and resultant use of SOC services. Efforts should be aimed at stabilizing the patient and enabling transition in the community.
Index stroke type and severity was significantly associated with PC utilization and further modified the PC cost trajectory across post-stroke quarters (Table 4). For non-ischemic group, the increase in PC cost was observed upto Q3 and a drop in Q4 for all three severity groups, with the linear trend being significant for moderately severe and severe sub-groups. While for ischemic group, the trend was comparatively less pronounced, with the increase in PC cost observed up to Q2, Q3 and Q4 for mild, moderately severe and severe sub-groups. This trend could be explained by the fact that severe cases will take more time to recover, stabilize and their transition to PC setting occurs later compared to milder cases. We also observed that while the PC visit trajectory for the whole stroke cohort showed a decreasing trend over time, the PC visit associated cost trajectory showed an increasing trend over time. Possible explanation of this observation could be in the interaction we observed in the PC cost trajectory model whereby overall more severe stroke sub-group have more steeper increasing cost trend as compared to the less severe stroke sub-groups across subsequent quarters. Thus, it might be the case that more severe stroke patients use more primary care services across subsequent quarters post stroke. Moreover, more severe stroke sub-group will be having more complex healthcare needs and even with overall reduced number of PC visits, this subgroup might be driving up the overall cost associated with use of PC services over time.
Overall, the highest utilization and associated costs (except PC costs) occurred in the first quarter post-stroke across all service types and then decreased with time, though the degree of decrease varied with different services. Similar results were reported previously, with highest hospitalization risk closer to index-event and subsequent decrease with time . Another study described highest outpatient rehabilitation service use in first quarter post-stroke with subsequent drop . Though authors have highlighted the importance of first-year post-stroke from a financial and healthcare perspective [6, 22, 59], by reporting quarterly variations within first post-stroke year, with first 3-months being most crucial, we described distinct utilization trajectories across sub-groups of stroke patients based on clinical characteristics.
Our study has several strengths. We had the advantage of temporality as covariates were collected prior to tracking of healthcare outcomes. While we cannot comment from causality perspective, we can comment on directionality of our findings whereby we are reporting influence of various caregiver characteristics on subsequent healthcare utilization and associated cost trajectories of the stroke patients. Our study had the strength of leveraging on two data sources with one being a national claims record and hence an objective source of healthcare utilization and cost data. With nationwide coverage extending across different healthcare sectors, national claims record provided reliable estimates of utilization and costs data. Moreover, compared to proxy-reported utilization and cost estimates captured in Singapore Stroke Study, estimates taken from national claims record were more accurate being free of reporting bias. Another advantage of using national claims record as a source of outcome variables over the follow-up period was the fact that our reported estimates were not affected by loss to follow-up of study participants. The follow-up rates for study participants were 65.5% at 3 months and 55.8% at 12 months. Our independent variables were obtained from Singapore Stroke Study from the baseline survey and hence using national claims record to capture dependent variables at subsequent time points enabled us to overcome this issue of attrition of study sample over time. Our findings highlight the role of caregiver identity in acute hospitalization and associated costs post-stroke, index stroke characteristics can modify the trajectories of SOC service utilization and PC costs resulting in the identification of different sub-groups within the stroke cohort. Past studies highlight the financial and healthcare implications of first post-stroke year, however we report the quarterly variations within this first-year, with highest utilization occurring within the first 3-months.
Following are some of the limitations of our study. We wanted to quantify the trajectory for stroke patients alive at the end of observation period of 1 year, therefore we excluded those who died during follow-up, which was a relatively small proportion (6%). We conducted sensitivity analysis to compare the baseline characteristics of included and excluded sample of stroke patients with excluded sample mainly comprising of stroke patients who died during follow up. (Refer Additional file 2) Taking both the initial objective to quantify trajectory of stroke survivors and the results from our sensitivity analysis, generalizability of our results will be limited to stroke survivors who are alive 1 year after index stroke.
While national claims record has comprehensive coverage of inpatient, ED and SOC utilization, the PC data coverage was limited to the public sector, since private sector utilization might not be completely captured by national claims record. Potential implication on our findings is we might be underestimating the PC utilization and associated costs. However, since our primary aim was to study the trend or trajectories of healthcare utilization and associated costs across subsequent quarters, and not quantifying the exact consumption of services, our trend estimates will not be affected by this limitation to a significant extent. Moreover, patients who seek care in public sector generally continue to seek care in same setting across subsequent time periods and the same might be applicable for follow up in private setting. Therefore, our reported PC utilization and cost trajectory findings might be applicable to sub-group of stroke patients seeking primary healthcare in public sector. Lastly for the purpose of current study, we incorporated all healthcare utilization and associated costs post index stroke and did not specifically focus on utilization and costs attributable to post-stroke care management plan. Along the same lines, one of the areas we intend to explore in our future publications is the impact of specific comorbidity on healthcare utilization and associated costs.
We described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association of caregiver identity with utilization and costs. Contrary to our hypothesis, we found decreasing utilization and cost trajectories for all services except PC utilization associated costs which showed increasing trend across subsequent quarters post-stroke. Highlighting the quarterly variations within first post-stroke year, with the importance of first 3 months, we reported distinct utilization trajectories across subgroups of stroke patients based on clinical characteristics. Our results supported the hypothesis of social support in the form of caregiver availability and type being associated with decreased hospitalization and its associated costs only. We did not find any significant association of caregiver availability and type with utilization of outpatient services. PC and SOC service utilization and cost trajectories were driven more by clinical and functional stroke variables. We reported distinct SOC utilization trajectories across stroke patient subgroups with varying functional disability (as measured on Modified Rankin Scale) and distinct PC cost trajectories across stroke patient subgroups of different stroke type and varying stroke severity. Our finding of caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce with further incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care in future.
We would like to thank the medical staff at the public tertiary hospitals for assisting with the recruitment of patients and their caregivers. We would also like to thank all the participants in our study for their participation and cooperation.
The Singapore Stroke Study was funded by a Health Services Research Competitive Research Grant from the National Medical Research Council, Singapore. The funders were not involved with the data collection, analysis and writing of this manuscript. This research is supported by the Singapore Ministry of Health's National Medical Research Council under the Centre Grant Programme - Singapore Population Health Improvement Centre (NMRC/CG/C026/2017_NUHS).
ST was involved in conceptualization and design of the study, analysis and interpretation of data, original draft preparation and incorporating revisions in manuscript based on critical inputs from other co-authors. GCHK was involved in conceptualization and design of the study, acquisition of data, drafting of the manuscript and providing critical inputs to revision of manuscript along with supervision of the study. NL was involved in conceptualization and design of the study, acquisition of data, drafting of the manuscript and providing critical inputs to revision of manuscript. KBT was involved in conceptualization and design of the study, acquisition of data, drafting of the manuscript and providing critical inputs to revision of manuscript. HH made substantial contributions to conception and design of the study specifically with provision of expertise in medical domain and was involved in revising the manuscript critically for intellectual content. DBM made substantial contributions to conception and design of the study specifically with provision of expertise in medical domain and was involved in revising the manuscript critically for intellectual content. JY made substantial contributions to conception and design of the study specifically with provision of expertise in financial domain and was involved in revising the manuscript critically for intellectual content. EAF made substantial contributions to conception and design of the study specifically with provision of expertise in financial domain and was involved in revising the manuscript critically for intellectual content. KEL was involved in acquisition of data and in revising the manuscript critically for intellectual content. NV was involved in acquisition of data and in revising the manuscript critically for intellectual content. EM was involved in acquisition of data and in revising the manuscript critically for intellectual content. KMC was involved in acquisition of data and in revising the manuscript critically for intellectual content. DADS was involved in acquisition of data and in revising the manuscript critically for intellectual content. PY was involved in acquisition of data and in revising the manuscript critically for intellectual content. BYT was involved in acquisition of data and in revising the manuscript critically for intellectual content. EC was involved in acquisition of data and in revising the manuscript critically for intellectual content. SHY was involved in acquisition of data and in revising the manuscript critically for intellectual content. YSN was involved in acquisition of data and in revising the manuscript critically for intellectual content. TMT was involved in acquisition of data and in revising the manuscript critically for intellectual content. YHA was involved in acquisition of data and in revising the manuscript critically for intellectual content. KHK was involved in acquisition of data and in revising the manuscript critically for intellectual content. RS was involved in acquisition of data and in revising the manuscript critically for intellectual content. RAM was involved in acquisition of data and in revising the manuscript critically for intellectual content. HMC was involved in acquisition of data and in revising the manuscript critically for intellectual content. TTY was involved in acquisition of data and in revising the manuscript critically for intellectual content. CN was involved in acquisition of data and in revising the manuscript critically for intellectual content. AC was involved in acquisition of data and in revising the manuscript critically for intellectual content. YLN was involved in acquisition of data and in revising the manuscript critically for intellectual content. CST was involved in conceptualization and design of the study, analysis and interpretation of data, drafting of the manuscript and providing critical inputs to revision of manuscript. All the authors have read and approved the final version of the manuscript to be published and are agreeable to take accountability of all aspects of the work involved in the manuscript.
Ethics approval was taken from the National University of Singapore Institutional Review Board, SingHealth Centralized Institutional Review Board and the National Health Group Domain Specific Review Board. Written informed consent was taken from all participants in S3.
Principle causes of death, Ministry of Health (MOH), Singapore [19 August 2017]. Available from: https://www.moh.gov.sg/resources-statistics/singapore-health-facts/principal-causes-of-death. Accessed 16 Nov 2018.