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text:
Keywords: Broad ligament, jejunal loop herniation, small bowel obstruction
Rajasekharan D, Shanthakumar D, Subbarayappa S, Nagaraja JB. A rare case of small-bowel obstruction due to broad ligament herniation. Indian J Colo-Rectal Surg 2018;1:57-9
Rajasekharan D, Shanthakumar D, Subbarayappa S, Nagaraja JB. A rare case of small-bowel obstruction due to broad ligament herniation. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2020 Jan 18];1:57-9. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/2/57/271747
Small-bowel obstruction is a common cause of acute abdomen. According to incidence, the most common causes of mechanical obstruction of small bowel include adhesions, tumors, and herniae. Internal hernia as the cause of small-bowel obstruction is exceedingly rare and accounts for about 1% of all acute obstructions.[1] Of this internal herniation through defects in the broad ligament, either congenital or iatrogenic is very rare.[2] It was first reported in 1861 as an autopsy finding.[3] There are <70 cases reported in literature.[4] The patient's symptoms are same as that of small-bowel obstruction. It is seldom diagnosed preoperatively, with most cases recognized intraoperatively. In this case report, we present a case of jejunal loop herniation into broad ligament presenting as acute intestinal obstruction.
History and examination
A 43-year-old female presented with a history of diffuse abdominal pain and bilious vomiting for 4 days. There was no history of constipation, diarrhea, or fever. The patient had a history of cesarean section 19 years ago and appendectomy 15 years ago. On examination, the patient was tachycardic and had mildly distended abdomen with diffuse tenderness. The scars of previous surgeries were noted. There was no guarding or rigidity. Erect X-ray abdomen suggested small-bowel obstruction. After initial resuscitation, a trial of conservative management was attempted. The patient failed to respond to conservative therapy. Contrast-enhanced computed tomography (CECT) abdomen showed intestinal obstruction with dilated small-bowel loops, the zone of transition being at distal jejunal/proximal ileal level in the pelvis, and minimal ascites. After optimization with fluids and antibiotics, she was taken for exploratory laparotomy.
Operative course
On laparotomy, dilated jejunal bowel loops with collapsed ileal loops were noted. There was a left-sided broad ligament herniation of terminal jejunal loop [Figure 1] and [Figure 2] through a 3 cm × 4 cm defect [Figure 3] which appeared to be congested and obstructed. A hemorrhagic cyst in the right ovary was also noted. Adhesiolysis was performed. The obstruction was released. The bowel was found to be viable and hence was preserved. The rent in the broad ligament was repaired using 3-0 Vicryl sutures. The hemorrhagic cyst was excised, and after a thorough lavage, the abdomen was closed.
Figure 1: Intraoperative image of broad ligament and jejunal loop
Figure 2: Broad ligament herniation of terminal jejunal loop
Figure 3: Rent in the broad ligament
Postoperative course
Postoperatively, the patient was observed in the intensive care unit for a day. She was managed with antibiotics, analgesics, intravenous fluids, and other supportive measures. She was started orally on postoperative day 1 and stepped up. The patient tolerated the treatment well and was discharged on postoperative day 4. On follow-up after 1 week, the patient is comfortable, asymptomatic, and leading a normal life.
The most common causes of small-bowel obstruction include adhesive obstruction, compression due to tumors, and obstructed inguinal or femoral herniae.[4],[5],[6] Internal hernia is one of the rare causes of small-intestinal obstruction. Among internal herniae, paraduodenal and those occurring through the foramen of Winslow rank highest. Internal hernia through defect in the broad ligament is extremely rare.[4],[7]
Internal herniae are broadly classified into two types: those that occur through an opening in the peritoneal fold and those that occur through a defect in the mesentery or omentum.[4],[8] Broad ligament herniation may be congenital or acquired with congenital causes having an embryological basis leading to a developmental defect in the supports of uterus and acquired causes following previous insults to the abdomen or iatrogenic.[1] Another classification based on the anatomical position with Type I defect caudal to the round ligament, Type II defect above the broad ligament, and Type III between the round and broad ligaments.[1] They have also been described as fenestra type (involving both leaves of the broad ligament) and pouch type (where either anterior or posterior leaf is involved).[2],[9]
Preoperative diagnosis of this condition is difficult in spite of the advances in imaging technology. CECT scan is the imaging modality of choice.[10] Most cases are still diagnosed intraoperatively. The onus, thus, lies on the surgeon to have a high index of suspicion. The complications such as bowel gangrene and perforation secondary to prolonged herniation are well documented.[4],[11],[12]
There are several reasons for a broad ligament defect, which include operative trauma, prior pelvic inflammatory disease, birth trauma during delivery, and congenital abnormalities.[1],[4],[6] As the patient in this case had previous cesarean section and appendectomy, it stands to reason that operative trauma might have been the cause of broad ligament hernia.[4]
Although small-bowel obstruction due to small-bowel herniation into broad ligament is uncommon, it may develop into a life-threatening condition if not recognized early on. Early diagnosis and treatment is essential. A high index of suspicion has to be maintained regarding rarer sites of obstruction.
Kanbur AS, Ahmed K, Bux B, Hande T. Jejunal obstruction and perforation resulting from herniation through broad ligament. J Postgrad Med 2000;46:189-90.
Gupta N, Boler L, Blankstein J. Bowel herniation through broad ligament mimicking ovarian torsion: A novel presentation. J Clin Gynecol Obstet 2013;2:93-5.
Baron A. Defect in the broad ligament and its association with intestinal strangulation. Br J Surg 1948;36:91-4.
Lu HF, Chang DY, Chen MJ, Chen SU, Ho HN, Yang YS. Internal herniation through a defect in the broad ligament of the uterus. Taiwan J Obstet Gynaecol 2005;44:273-5.
Livaudais W Jr., Hartong JM, Otterson WN. Small bowel herniation through a defect in the broad ligament. Am J Obstet Gynecol 1979;133:927-8.
Simstein NL. Internal herniation through a defect in the broad ligament. Am Surg 1987;53:258-9.
Cleator IG, Bowden WM. Bowel herniation through a defect of the broad ligament. Br J Surg 1972;59:151-3.
Bertelsen S, Christiansen J. Internal hernia through mesenteric and mesocolic defects. A review of the literature and a report of two cases. Acta Chir Scand 1967;133:426-8.
Hiraiwa K, Morozumi K, Miyazaki H, Sotome K, Furukawa A, Nakamaru M. Strangulated hernia through a defect of the broad ligament and mobile cecum: A case report. World J Gastroenterol 2006;12:1479-80.
Suzuki M, Takashima T, Funaki H, Uogishi M, Isobe T, Kanno S, et al. Radiologic imaging of herniation of the small bowel through a defect in the broad ligament. Gastrointest Radiol 1986;11:102-4.
Armstrong CP, Drummond A. Small bowel obstruction and perforation through a defect in the broad ligament. J R Coll Surg Edinb 1983;28:333-4.
Ishihara H, Terahara M, Kigawa J, Terakawa N. Strangulated herniation through a defect of the broad ligament of the uterus. Gynecol Obstet Invest 1993;35:187-9.

redpajama_set_name: RedPajamaCommonCrawl


text:
Dr Jessica White
UQ Amplify Associate Lecturer
School of Communication and Arts
jessica.white@uq.edu.au
Dr Jessica White is an ARC DECRA Postdoctoral Research Fellow. Her project, 'From the Miniature to the Momentous: Georgiana Molloy, Life Writing and Environment in 1830s Western Australia' is an ecobiography that depicts the life of Western Australia botanist Georgiana Molloy (1805-1843), as well as the human and non-human lives with which she interacted.
Jessica is also a writer of fiction and non-fiction. Her first novel, A Curious Intimacy (Penguin/Viking 2007) won a Sydney Morning Herald Best Young Novelist award, shortlistings for the Western Australia Premier's award and the Dobbie award for a first published work by an Australian woman writer, and was longlisted for the international IMPAC award. Her second novel, Entitlement, was published by Penguin/Viking in 2012. Her short fiction, essays and poetry have won awards and shortlistings and appeared in a wide range of literary journals. Jessica is also the recipient of funding and residencies from Arts Queensland and the Australia Council for the Arts.
Nineteenth century women's writing
Ecocriticism
Bachelor of Creative Arts/Bach Arts (Hon), W.gong
Master of Arts in Writing, University of Technology Sydney
PhD in Humanities and Cultural Studies, University of London
Book Chapter: Gardening in the Anthropocene: Wilding, Eco-Memoir and Biodiversity
White, Jessica (2019). Gardening in the Anthropocene: Wilding, Eco-Memoir and Biodiversity. In Naomi Milthorpe (Ed.), The Poetics and Politics of Gardening in Hard Times (pp. 71-86) Lanham, MD, United States: Lexington Books.
Book: Hearing Maud
White, Jessica Hearing Maud. Crawley, WA, Australia: University of Western Australia Press, 2019.
Journal Article: K. and the NDIS
White, Jessica (2019) K. and the NDIS. Westerly, 7 (Special Issue) DisAbility: 49-58.
Vernacular Criticism: The Democratisation of Critique
(2017–2018) UQ Early Career Researcher
Georgiana Molloy, Life Writing and Environment in 1830s Western Australia
(2016–2019) ARC Discovery Early Career Researcher Award
Fiona Foley Provocateur: An Art Life
The Tang of Resilience: George Paul and his Japanese House
(2019) Master Philosophy
Kismet: Dressing Characters for Authenticity in Historical Fiction
Hearing Maud
White, Jessica Entitlement. Melbourne VIC: Viking/Penguin, 2012.
A Curious Intimacy
White, Jessica A Curious Intimacy. Camberwell, Vic., Australia: Viking/Penguin, 2007.
Gardening in the Anthropocene: Wilding, Eco-Memoir and Biodiversity
The Cry of the Gull (1994) by Emmanuelle Laborit
White, Jessica (2019). The Cry of the Gull (1994) by Emmanuelle Laborit. In Thomas G. Couser and Susannah B. Mintz (Ed.), Disability experiences: memoirs, autobiographies, and other personal narratives (pp. 142-145) Farmington Hills, MI USA: Macmillan Reference USA.
Eco-Memoir: Protecting, Restoring, and Repairing Memory and Environment
White, Jessica (2018). Eco-Memoir: Protecting, Restoring, and Repairing Memory and Environment. In Bunty Avieson, Fiona Giles and Sue Joseph (Ed.), Mediating Memory: Tracing the Limits of Memoir (pp. 141-156) New York, NY United States: Routledge. doi:10.4324/9781315107349-10
'I Felt This Landscape Knew I Was There': The Lake's Apprentice and Ecobiography
White, Jessica (2018). 'I Felt This Landscape Knew I Was There': The Lake's Apprentice and Ecobiography. In Donna Lee Brien and Quinn Eades (Ed.), Offshoot: contemporary life writing methodologies and practice (pp. 121-135) Crawley, WA, Australia: University of Western Australia Publishing.
'The inexhaustible properties of a Lady's Pen': the literary craft of Georgiana Molloy
White, Jessica (2017). 'The inexhaustible properties of a Lady's Pen': the literary craft of Georgiana Molloy. In Devaleena Das and Sanjukta Dasgupta (Ed.), Claiming space for Australian women's writing (pp. 181-196) Cham, Switzerland: Palgrave Macmillan. doi:10.1007/978-3-319-50400-1
Inscribing landscapes in Patrick White's novels
White, Jessica (2014). Inscribing landscapes in Patrick White's novels. In Cynthia vanden Driesen and Bill Ashcroft (Ed.), Patrick White centenary: the legacy of a prodigal son (pp. 141-150) Newcastle upon Tyne, United Kingdom: Cambridge Scholars Publishing.
Intimacy and Distance across the Globe: The Literary Relationship between Georgiana Molloy and Captain James Mangles
White, Jessica (2009). Intimacy and Distance across the Globe: The Literary Relationship between Georgiana Molloy and Captain James Mangles. In Alejandro Cervantes-Carson and Beatriz Oria (Ed.), Intimate Explorations: Reading Across Disciplines (pp. 175-183) Oxford, United Kingdom: Inter-Disciplinary Press.
K. and the NDIS
Melissa Fagan, What will be worn: a McWhirters story
White, Jessica (2019) Melissa Fagan, What will be worn: a McWhirters story. Queensland Review, 26 1: 188-190.
White, Jessica (2018) Intertwining. Sydney Review of Books, .
'Paper talk,' Testimony and Forgetting in South-West Western Australia
White, Jessica (2017) 'Paper talk,' Testimony and Forgetting in South-West Western Australia. JASAL: Journal of the Association for the Study of Australian Literature, 2017 No. 1 Empire/Dissent: .
A great many capital foreign things
White, Jessica (2017) A great many capital foreign things. Southerly, 76 2: 155-168.
Nadia Buick and Madeleine King (eds), Remotely fashionable: a story of subtropical style, Brisbane: the fashion archives, 2015, ISBN 9 7809 9443 2209, 177 pp., $45.00.
White, Jessica (2016) Nadia Buick and Madeleine King (eds), Remotely fashionable: a story of subtropical style, Brisbane: the fashion archives, 2015, ISBN 9 7809 9443 2209, 177 pp., $45.00.. Queensland Review, 23 2: 272-273. doi:10.1017/qre.2016.35
Old Honey
White, Jessica (2016) Old Honey. Online, adda.
Medium/Machine: the writing of Rosa Praed and Nancy Harward
White, Jessica (2016) Medium/Machine: the writing of Rosa Praed and Nancy Harward. Hecate: An Interdisciplinary Journal of Women's Liberation, 42 1: 69-83.
Stargazing with Rosa Praed
White, Jessica (2016) Stargazing with Rosa Praed. Sydney Review of Books, .
White, Jessica (2016) Unfurling. Melbourne, VIC, Australia, Griffith Review: Our Sporting Life, Text Publishing Company.
White, Jessica (2016) Melliodora. Australia, Review of Australian Fiction.
White, Jessica (2015) Hearing Maud. Spike the Meanjin blog, .
'Can I Do My Words?': on the poetics of deafness
White, Jessica (2015) 'Can I Do My Words?': on the poetics of deafness. Cordite Poetry Review, 50: .
Georgiana Molloy, botanical networks and naming in 19th century Western Australia
White, Jessica (2015) Georgiana Molloy, botanical networks and naming in 19th century Western Australia. Australasian Journal of Ecocriticism and Cultural Ecology, 5 .
When the world shivered
White, Jessica (2015) When the world shivered. Australia, Review of Australian Fiction.
"I Actually Hear You Think of Me": Voices, Mediums and Deafness in the Writing of Rosa Praed
White, Jessica (2015) "I Actually Hear You Think of Me": Voices, Mediums and Deafness in the Writing of Rosa Praed. Journal of the Association for the Study of Australian Literature, 15 1: .
"The Native Seeds of Augusta" Georgiana Molloy's botanical exchanges in 19th century Western Australia
White, Jessica (2014) "The Native Seeds of Augusta" Georgiana Molloy's botanical exchanges in 19th century Western Australia. Griffith Review, 47 215-222.
A Mercurial Man
White, Jessica (2014) A Mercurial Man. Hobart, TAS, Australia, Island Magazine.
Fluid Worlds: Reflecting Climate Change in The Swan Book and The Sunlit Zone
White, Jessica (2014) Fluid Worlds: Reflecting Climate Change in The Swan Book and The Sunlit Zone. Southerly: A Review of Australian Literature, 74 1: 142-163.
Ghostliness and Un/Belonging as a Hard-of-Hearing Writer
White, Jessica (2014) Ghostliness and Un/Belonging as a Hard-of-Hearing Writer. New Scholar, 3 1: 109-118.
"Since my dear Boy's death": Grief, botany and gender in 19th Century Western Australia
White, Jessica (2013) "Since my dear Boy's death": Grief, botany and gender in 19th Century Western Australia. Journal of the Association for the Study of Australian Literature, 13 2: .
From the Miniature to the Momentous: Georgiana Molloy and the craft of collecting
White, Jessica (2013) From the Miniature to the Momentous: Georgiana Molloy and the craft of collecting. Island Magazine, 135 34-39.
White, Jessica (2012) Unearthed. Australia, Review of Australian Fiction.
The Country of Boats
White, Jessica (2011) The Country of Boats. Sydney, NSW, Australia, English Association Sydney Branch.
"The one absolutely unselfish love": spiritualism and the collaborative writing of Rosa Praed and Nancy Harward
White, Jessica (2010) "The one absolutely unselfish love": spiritualism and the collaborative writing of Rosa Praed and Nancy Harward. Southerly, 70 2: 110-123.
White, Jessica (2010) Body language. M/C: A Journal of Media and Culture, 13 3: .
'I Know, but Cannot Share It': Landscape and the Emigrant
White, Jessica (2008) 'I Know, but Cannot Share It': Landscape and the Emigrant. Philament, 11 181-191.
'So many sparks of fire': Dorothy Cottrell, modernism and mobility
White, Jessica (2016) 'So many sparks of fire': Dorothy Cottrell, modernism and mobility. Queensland Review, 23 2: 164-177. doi:10.1017/qre.2016.27
The Sea Lovers
White, Jessica (2010) The Sea Lovers. Hobart, Tas, Australia, Island Magazine.
Dr Melissa Harper
Associate Professor Kim Wilkins
White Swan Black: Fonteyn, Guillem and Copeland
Professor Bronwyn Lea
Adjunct Professor Glynn Cochrane
Centre for Social Responsibility in Mining
Dr Adam Kay
Dr Charlotte Rose Millar
Institute for Advanced Studies in the Humanities


The Federal Water Pollution Control Acts Amendment of 1972 addressed the growing concern of many Americans about the degrading quality of water in lakes, streams, oceans, etc. In 1977, the act was amended and became known as the Clean Water Act. This act helps to regulate the amount of pollutant discharge from industries and set safety requirements for water. In addition, the law makes it a federal crime to discharge any pollutants without a permit. Over the years, there have been many amendments and modifications to the Clean Water Act.
What Are Some Types of Water Pollutants?
Pesticides - There are occasions in which homeowners that use household pesticides or other cleaners don't properly dispose of these chemicals.
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An experienced environmental attorney can be extremely helpful in addressing any issues regarding water pollution. In addition, businesses or neighbors that have not taken proper safety measures in discharging pollutants or chemicals may be liable for a negligence action.


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text:
Four More Athletes Qualify for ...
Climb Injury Free: Shoulder Impingement ...
by International Federation of Sport Climbing December 22, 2020
Two Continental Championships—Africa and Oceania—took place this past weekend. The top placing male and female athletes from each event earned Olympic berths for the 2020 Games. Added to the now complete roster for Sport Climbing are Tom O'Halloran and Oceana Mackenzie from Oceania, and Christopher Cosser and Erin Sterkenburg from Africa.
"You only get one go in your life to try and be an Olympian," said O'Halloran shortly after the finals. "I had some pretty serious ups and down with my motivation. I nearly pulled out, because it was just too difficult. The training, the juggle with work and family life, missing out on time with my daughter and partner. The thing that kept me going was What am I going to feel like the morning of the competition when I'm not there? I feel really proud of the work that I've put in, regardless of the result."
O'Halloran, 28, has been competing in IFSC competitions on and off since 2007. He placed thirty-second in the Hachioji Lead World Championships.
Mckenzie waves to the crowd after topping the final Lead route and clinching her win. Photo Nathan McNeil/IFSC
Mackenzie, 18, made waves last year after placing sixth in the Meiringen Bouldering World Cup.
"It was very stressful, but I'm so happy," said Mackenzie following finals. "I was a little nervous warming up and getting all my stuff together, but once I started climbing I was like 'Okay, this is good!'. I had a very good time. Now we'll get back into training, seeing where we can travel to next year to compete at a high level, doing a couple of world cups per discipline."
Sterkenburg, 17, has the least competition experience of the qualified athletes. She has previously competed in three Youth World Championships in Bouldering and Lead. Cosser has been competing in the circuit since 2014. The 20-year-old's best placement was fourteenth in the 2019 Combined Youth World Championships.
The final ranking of the men's Combined at the 2020 IFSC Oceania Championships in Sydney is as follows:
Tom O'Halloran (AUS) 8.0 ranking points
Ben Abel (AUS) 15.0
James Kassay (AUS) 18.0
Thomas Farrell (AUS) 18.0
Ned Middlehurst (AUS) 80.0
Chase Gatland (NZL) 120.0
Hugo Hornshaw (AUS) 392.0
Campbell Harrison (AUS) DNF
The final ranking of the women's Combined at the 2020 IFSC Oceania Championships in Sydney is as follows:
Oceania Mackenzie (AUS) 1.0 ranking points
Angie Scarth-Johnson (AUS) 12.0
Ella Easton (AUS) 42.0
Siobhan Dobie (AUS) 64.0
Lucinda Ann Stirling (AUS) 147.0
Mia Weeda (AUS) 150.0
Cirrus Tan (NZL) 240.0
Leah Jeffries (AUS) 384.0
The final ranking of the men's Combined at the 2020 IFSC Africa Championships in Cape Town is as follows:
Christopher Cosser (RSA) 4.0 ranking points
David Naude (RSA) 6.0
Calrin Curtis (RSA) 24.0
Oliver Marx (RSA) 48.0
James Barnes (RSA) 105.0
Tony Flynn (RSA) 150.0
Christopher Wallace (RSA) 294.0
Matthew Grunewald (RSA) 512.0
The final ranking of the women's Combined event at the 2020 IFSC African Championships in Cape Town is as follows:
Erin Sterkenburg (RSA) 1.0 points
Georgiana Dorward (RSA) 16.0
Tegwen Oates (RSA) 27.0
Catherine Honegger (RSA) 56.0
Caitlyn Burwood (RSA) 144.0
Alyssa Meyer (RSA) 175.0
Danielle Visser (RSA) 210.0
Credo Kasemiire (UGA) 512.0
Videos from Africa Continental Championships may be found here.
Feature image by Nathan McNeil/IFSC
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text:
Home Billionaires Top 30 Successes & Failures Of Elon Musk
Top 30 Successes & Failures Of Elon Musk
TristaAugust 6, 2020
It only makes sense that one wealthy person would support another, but things quickly changed. Shutterstock.
7. A Cautious Supporter Of Donald Trump
Musk has some well-developed political views, and he considers himself to be half-Democrat, half-Republican. Seeing as he is trying to facilitate colonization of Mars, he has already developed a plan for its government – a direct democracy in which the people have a direct say in the goings-on of their government.
He initially expressed criticism of Donald Trump, due to what he saw as a flawed character that lacked the integrity necessary to lead the country on a global stage. Nevertheless, he softened his stance and later became a member of two councils that advised the president.
Elon Musk cares a lot about climate change. Shutterstock.
6. The Paris Climate Agreement
The Paris Climate Agreement is an international treaty in which countries agree to plans that will prevent the world from heating up by more than two degrees Celsius. The goal is to slow down climate change and hopefully begin to reverse it.
When President Trump withdrew the United States from the Paris Climate Agreement, Musk left the two advisory councils that he served on. He insists that climate change is real, and addressing it needs to be a foremost concern for any government in the world today. Many of his business ventures are designed to move society away from fossil fuels to help reverse climate change.
If you care about having a cleaner environment, SpaceX might be able to help. Shutterstock.
5. Developing Greener Fuels
NASA and SpaceX have been partnering to use greener fuels with fewer emissions and less toxicity to power people and rockets into space. This achievement is certainly noteworthy, but also a point of criticism for Musk, an ardent advocate for reversing our dependence on fossil fuels.
Many of SpaceX's rockets have used kerosene, a by-product of oil processing, as fuel, and even the cleaner fuels still have emissions that are dangerous for the environment. Some people think that if Musk is going to follow through on his commitment to the environment, he has to develop fuels that are emission-free.
The alternative energy company is based in Palo Alto, California.
4. A Fortune 500 Company
Tesla, what looked like a small-town start-up back in 2003, is now one of the most successful companies in the world. Its emissions-free cars have become so popular that factories are operating around the clock to keep up with orders. In 2017, the company was inducted into Fortune 500.
However, with this immense success comes the criticism that the working conditions at Tesla factories are unsafe. Workers are forced to work long hours without taking enough breaks, and at one point, Musk admitted that he was sleeping on the floor in his office.
Elon Musk is only human, which means he has said some controversial things that not everybody likes. Shutterstock.
3. Under Fir
In 2017, Musk announced that he wanted to take Tesla private, which would mean a massive restructuring of the company. Some shareholders complained that he was making misleading claims to increase the share price, and the Securities And Exchange Commission got involved. Tesla remains a publicly-traded company.
Following his role in the rescue attempt of a group of boys who became trapped in a cave in Thailand, lawsuits were filed against Musk for defamation. Specifically, he made a Tweet accusing one of the rescuers of being a pedophile. The accusation was false, and Musk later deleted the Tweets.
Interviews and Twitter often get people in trouble. Shutterstock.
2. Doesn't Mix Well With Success
Though Musk has been the CEO of Tesla since 2008 and is the longest-serving CEO of an automobile company, the Securities And Exchange Commission requested that Musk not be allowed to serve as CEO in a publicly-traded company. This action is due to some public comments that Musk made about Tesla. A board now oversees him and his communications.
Maybe his dreaming works best when he is beset by failures and setbacks and has to muster up the courage to continue pursuing what he loves. Visionaries don't work for financial success, and acquiring a vast fortune has turned previous visionaries into business people.
Without Musk, the internet, automobiles, and exploration would be completely different. Shutterstock.
1. Shaping The Twenty-First Century
Musk's dreams have become a reality, from launching an internet payment service to building rockets because he got spit on by a Russian official. From helping to develop concept electric cars to imagining something called a Hyperloop. All of these have taken society far into the future.
He has mainstreamed the possibility of using technology not requiring fossil fuels and developing infrastructure that supports renewable energy. He encourages progress that does not harm the environment and create additional climate change, making him a man of his century.
"A Timeline of Elon Musk's Achievements!" V12 Society.
"Elon Musk." Wikipedia.
"Elon Musk's Failure Timeline Shows a History of Overcoming Setbacks." Inverse. May 18, 2018.


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HomePrivate: Making it happenCo-productionCo-production (Working Together) ToolkitOur experience in north Cumbria
Tool Kit Home Page
What We Have Learned...
In 2016 there was a public consultation over the future of several health services across north Cumbria.
The community was concerned there had been little chance to shape the options, were angry about the potential loss of services and felt there was little they could do to shape the outcome.
The NHS heard this loud and clear and when it made decisions, it included a commitment to involve people in shaping the implementation of the changes and in any future planning.
Since then there has been a commitment to work together – through co-production – to make changes utilising everyone's ideas and energy.
It hasn't been easy.
Where services have changed the community has in some cases remained very angry and mourned the loss of some parts of the service.
Sometimes the NHS has felt that involving people in change has given some people licence to put the organisation under attack.
The NHS has also learned that involving people and sharing information early can be helpful.
Some issues are beyond all our control. There is only so much money, recruitment is a national challenge and safety is regulated.
Sometimes new ideas have developed and something special has been created.
Some problems are so deep rooted no easy solutions can be found.
We are still working together.
We have started from a difficult position with a limited scope and a history of failed attempts to implement change.
We have had people working together who disagree about the decisions and potential solutions and who remain worried about their healthcare.
We haven't been able to look in a textbook when we have faced problems, we have worked through them together.
In Cumbria we have found that co-production can be very difficult but there are some things we all agree on.
We have also found, particularly in service improvement as against strategic change, engaging the public, patient and carer voice has been highly productive
We don't have all the answers but we have put together a toolkit which may help people as they get involved in co-production.
This is our first attempt to create a guide to what can help co-production put down roots and grow.
Please tell us what has been helpful, what we are missing and give us some feedback
Via email enquiries@northcumbriaccg.nhs.uk
If you want to hear more about our experience or talk further also email: enquiries@northcumbriaccg.nhs.uk


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Phoenix Blog
Career Development Programs
Amina Grace Speech & Language Program – Learn more and enroll
Thank you Corporate Partners
Fry's Community Reward Program
Super Fest Football & Cheer Camp – February 11, 2023
Anniversary Celebration – February 25, 2023
Gala – January 20, 2023
GiGi's Playhouse Phoenix/Scottsdale Teentastic Program (13-17 yrs.)
By Cathy Judge | August 17, 2016 | 2
Teens, we hope you will plan to join in on a fantastic evening of music at GiGi's Playhouse Phoenix/Scottsdale at our Teentastic Program this Friday evening, August 19th from 6:00-8:00PM.…
GiGi's Playhouse-Kids Club/Playhouse Pals (5-12 yrs.)
We hope to see you at GiGi's Playhouse Phoenix/Scottsdale this Sunday, August 14th from 2:00-3:00 pm for the Kids Club/Playhouse Pals Program. This program encourages positive peer interactions through creative…
GiGi's Playhouse-Busy Bodies Program (2 and under yrs.)
Bring your toddler and join us at GiGi's Playhouse Phoenix this Saturday from 10:00-11:00am for the Busy Bodies Program. This program is designed to increase positive social interactions among peers…
GiGi's Playhouse Phoenix/Scottsdale Little Sports Program (4-8yrs.)
By Cathy Judge | August 2, 2016 | 0
We hope you will join in on some sporting fun at GiGi's Playhouse Phoenix/Scottsdale, August 6th from 10:00am-11:00am. This program is designed to develop gross motor skills, build muscle, and…
GiGi's Playhouse Phoenix/Scottsdale Fantastic Friends Program (18+yrs)
Join in on a fun night of music at GiGi's Playhouse Phoenix/Scottsdale on Friday, August 6th from 6:00-8:00 pm. We have a very Special Guest, Charlotte Stewart who will be…
Exemplifying Generation G: The Arenas share their why behind support of GiGi's Playhouse
We're grateful for the friends we meet along the way!
The Ripple Effect of Inclusion – "You are Beautiful and Pretty"
It's the Friends we meet along the way that help us appreciate the journey . . . . .
Cathy Judge on The Ripple Effect of Inclusion – "You are Beautiful and Pretty"
Jennifer Smith on "It's the Friends we meet along the way that help us appreciate the journey . . . . ."
Jenna Harris on "It's the Friends we meet along the way that help us appreciate the journey . . . . ."
Brett Schatzman on "It's the Friends we meet along the way that help us appreciate the journey . . . . ."
Susana Contreras on The Power of a Peer Buddy
9160 E. Shea Blvd Suite 103B
phoenix@gigisplayhouse.org
Monday thru Thursday: 9am-3pm
Friday: 9am-Noon
GiGi's Playhouse Phoenix is a non-profit, 501(c)(3) organization and is solely funded by donations. IRS identification number 47-1746104


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Access All Scareas!
On the 28th October the studio did an event called "Access All Scareas" which was a Halloween themed evening, the studio and the members to the studio really put so much effort into this night, and as someone who attended this evening, I can say that they're effort and hard work was well placed.
On the big stage there was fog, and Halloween themed lights, there were decorations, webs and pictures of ghosts. There were four acts who played at the event, Me, Springbok, Haze and The Metal Head Monkeys.
I played six of my songs at this event, I announced my new E.P. and played a new song.
When I went off, Springbok came on, they were amazing to watch, they played four songs, including a new song.
Then Haze came on who played amazingly and got the crowd really excited, they also interacted with the audience which is a very key thing while performing.
Then came on the "Metal Head Monkeys" they played all covers, and they made the songs they're own. While Tom played guitar and did backing singing, Rhys sung, while he also asked for audience participation. This included clapping, singing along and asking the audience to swing their arms.
When they went of the studio played a radio recording of a horror story. This was wrote and acted out by members of the studio.
The night was a great success and it was a lot of fun to play and watch. The studio members and staff did a lot to make that evening and they made it a brilliant night, thank you to any one who came, and I hope you had a happy Halloween!
Written by James Swift- Musician and Writer for the Press Gang


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For your new pastime room you may now devote your massive furniture items. Maybe you got a new new sectional couch and massive screen Telly. This will be heave along with your new deluxe carpeting as well as freshly decorated walls. Forget about dark paneling or dingy outdated carpeting to steer on.
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The most dangerous impacts of adjusting climate globally includes excessive temperatures, transforming landscapes, animals risk, droughts, deluges, and thunder storms and increasing heat associated diseases. Another fact that ought to be revealed here's, the international locations under the poverty line are generally least to blame for the air pollution generated inside the environment and they are the ones that tend to be affected by this pollution as they are not wealthier enough to square stubborn contrary to the natural disasters in which occur globally. They are the most affected is afflicted with for the explanation which they are generally least dependable. The the western world are the main culprits to the change in the weather.
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It is a difficult task to decide on if you should purchase garbage cans or even rent a dumpster. A lot of people and company owners have this condition. However, exactly what most people don't understand is that people/homeowners performing repairs on their own houses will manage to benefit more when they rented any dumpster. There are many crucial elements to look at when you decide to rent any dumpster when improving your home or business, but not only the price. The length of the dumpster is but one factor you must think of before choosing the corporation you'll be renting your dumpsters from. A huge business will be needing an enormous waste materials disposal system compared to a small company or residence because these huge businesses produce a lot of waste materials and garbage.
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So how does the DoD discriminate based on familial status? In privatized military housing, a single person with one or more children pays more rent than a single person without kids. And if the person without a kid decides to have a kid, then the rent increases for the house he or she is already in. (It's the same house. It didn't get bigger. It didn't get nicer. But the member has to start paying higher rent based solely on the fact that he or she now has familial status. That is illegal.) — Some will point out that the member also starts receiving a larger housing allowance. That is true, but it doesn't change the fact that it is illegal for a company to charge more based on familial status. Simply put, it is illegal to charge more rent based on familial status.
The DoD also gives preference based on familial status. To illustrate this, let's say two people join the Air Force on the same day; they go to basic training and technical school together; and they get assigned to the same base. Airman Smith is a single parent. Airman Jones is single and does not have familial status. In accordance with Air Force Instruction (AFI) 32-6007, Privatized Housing Management, Airman Smith meets the definition of a "target tenant" (paragraph 4.1) and will receive "first priority" for privatized housing (paragraph 4.6). Airman Smith will receive allowances for housing and food. He will have the option to live off base (paragraph 4.3.2) and start building home equity. Years later, when Airman Smith sells his house to move to another base, that home equity will turn back into cash that will help him buy his next house.
By contrast, in accordance with AFI 32-6005, Unaccompanied Housing Management, Airman Jones is required to live in the dorms for the first three years of his career (paragraph 1.4.1.4), is not authorized to receive a housing allowance (paragraph 2.4.2), and will only receive an allowance for food if his work schedule regularly prevents him from eating at the chow hall three times a day, seven days a week, for years on end. Being forced to live in the dorms prevents Airman Jones from building home equity, even if he outperforms Airman Smith in every possible metric. Even if Airman Jones shows up to work early every day, gets recognized as an outstanding performer, wins quarterly and annual awards, earns his Associate's and Bachelor's degrees, saves a child from a burning building, and gets wounded in combat against an armed enemy of these United States of 'Merica!… No matter what Airman Jones does, he will stay in the dorms until he has served out his time as a dorm rat (a very common term used when referencing dorm residents). The only way to get an early release from the dorms is to earn an early promotion to the rank of Senior Airman, and even that's not a guarantee. Meanwhile, the most mediocre, underperforming member with dependents will get a house, garage, yard, multiple closets, possibly a storage shed (or at least the option to buy one), and most important, a reasonable degree of privacy.
As shown above, our housing policies codify discrimination and preference based on familial status, both of which are explicitly forbidden by the Fair Housing Act. The agency charged with interpreting and enforcing the Fair Housing Act is the Department of Housing and Urban Development (HUD). HUD's Final Rule on the Implementation of the Fair Housing Act's Discriminatory Effects Standard states, "A practice has a discriminatory effect where it actually or predictably results in a disparate impact on a group of persons or creates, increases, reinforces, or perpetuates segregated housing patterns because of… familial status." I have already described the disparate impact created by our housing policies, and segregated housing patterns are abundantly obvious given that we have "family" housing for those with familial status, and dorms for those who are single and do not have familial status.
You may wonder why I chose this venue (the internet) to discuss the matter. You may think it would make more sense and be more productive to address these concerns through the Equal Opportunity office, chain of command, Legal, or (if all else fails) the Inspector General. I once thought that, too. I have exhausted all of those lines of effort and then some.
As it turns out, the Equal Opportunity regulations (Air Force Policy Directive 36-27, Equal Opportunity and AFI 36-2706, Equal Opportunity Program Military and Civilian) make no mention of "familial status". Therefore, Equal Opportunity offices won't process reports on this particular form of unlawful discrimination. (I have tried at three bases. Yokota Air Base and Little Rock Air Force Base flat out refused to take a report. Travis Air Force Base took a copy of the report, but did not act on it.) It seems a striking coincidence that Equal Opportunity publications fail to mention "familial status" when it happens to be the one legally-protected category that DoD policies violate. One might conclude that they know it's illegal and have selectively chosen to omit it so they don't have to deal with it. The tactic seems to be working. They've gotten away with it for thirty years.
I have also tried to address this through the chain of command. DoD Directive 1020.2E (paragraph E2.2.b.(2)) and DoD Directive 1350.2 (paragraph 4.3) both state that the chain of command is the "primary and preferred" channel to identify and correct unlawful discriminatory practices. Those are directives (i.e. not optional) from the Deputy Secretary of Defense (i.e. civilian leadership), yet the chain of command has repeatedly made an informed choice to ignore this form of unlawful discrimination.
When I spoke with the Legal office, I was told that "What the law says doesn't matter." That's coming from an Air Force lawyer/commissioned officer. So it would seem the official position of the Air Force is that laws passed by legislators elected by the people of this country don't matter.
Even the Inspector General (IG) has made an informed choice to be silently complicit in this violation of federal law.
I have done my due diligence to have this issue addressed through appropriate channels. None of the appropriate channels have worked, so I created this website to raise awareness about the issue. The American People deserve to know that the U.S. military is violating its Constitutionally-mandated obligation to obey civilian leadership.
Dale Nyhus is a 24-year veteran. He joined the Army in January 1995 and served as an Airborne Infantryman for four years, then cross-trained to be an Apache helicopter Crew Chief for three years. He separated from the Army in November 2001 and enlisted in the Air Force in February 2002. He has served as a C-130 Loadmaster for 17 years. He has deployed seven times (1x Bosnia; 6x OEF/OIF). He also repatriated the remains of a World War II B-24 bomber crew and flew humanitarian missions in Japan immediately after the devastating 2011 earthquake and tsunami. In 2017, he led teams supporting relief operations for Hurricanes Irma and Maria, resulting in 70 tons of aid delivered to Americans impacted by the worst hurricane season on record. He has earned two Meritorious Service Medals, ten Air Medals, and both the Air Force and Army Commendation Medals. His website is FamilialStatus.org.


This property offers good value for money and is located in a lively area of central Madrid, just 50 meters from the Plaza Mayor. It offers 24-hour reception and simple rooms with free Wi-Fi.
The Casa de la Plaza is located at Plaza San Miguel, where there is a daily market. The Royal Palace is a 4 minute walk. The Opera Metro station providing easy access to the rest of the city. Rooms at La Casa de la Plaza have wooden floors. A TV and a shared bathroom with hairdryer. Some have balconies.
The cancellations are to be made with 48 hours of anticipation in order not to be charged. If not, the 100% of the first night will be charged. In case of No Show the 100% of the first night will be charged.
Ein Hostel in super Lage! Leider hatte mein Zimmer kein Fenster, was aber kaum auffiel, da ich ohnehin kaum dort war. Alles war sauber und ich habe mich dort sehr wohl gefühlt. Allgemein würde ich dieses Hostel auf jeden Fall wieder besuchen und weiterempfehlen.
Das Preis-Leistungsverhältnis ist gut. Die Übernachtungen sind am besten für Leute, die das Nachtleben gerne haben, da es auch mal lauter wird oder einen Kurztrip für 1-2 Nächte.
You literally pay for a bed and that's it, but that is ok. Bare in mind that the rooms without air conditioning are very hot in summer. Otherwise the location is the best, close to all tourist attractions. My room lacked a window and I didn't like it, but this is what happens when you travel on a budget. As a solo traveler for a short time, I found this place just right.
Für ein paar Tage, wenn man den ganzen Tag unterwegs ist, ist es sehr gut. Ich würde wieder Buchen.
A room barely large enough to fit a bed in, without a window or any fresh air supply is known as a broom closet. You should certainly not rent it out to actual humans. Besides that, the house was run down, the showers were dirty, and the staff who kindly kept my luggage for the day almost handed me the backpack of someone else. Careless... Really, location is the only thing going for this place. It's unbeatably central.


Momma got us new tags and OMG they are simply fabulous! We had a photoshoot this morning because we can't get enough of how gorgeous we look with our new tags :) Oh, look! Even momma got her own dog tags with our photos on it!
We got these beauties from Bruce's Custom Engravings, and they are truly beautiful. Enjoy our photos!
Wow, you guys look fantastic with your new bling!


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CBS All Access and CBS Sports to be English-language home of Champions League in US
Written by Stuart Thomson
10th July 2020 @ 12:18
ViacomCBS has struck a multi-platform agreement with UEFA for subscription streaming service CBS All Access and CBS Sports to serve as the exclusive English-language home in the US of Champions League, Europa League and Europa Conference League football until 2024, beginning in August.
CBS All Access will stream every UEFA club competition match live each season, featuring all Champions League and Europa League matches, along with the Super Cup, and from 2021-2022 all Europa Conference League matches.
CBS will air select key matches on the CBS television network and CBS Sports Network over the length of the deal, which it said would feature the most UEFA matches ever on US broadcast television.
Originally set to be a three-year deal starting with the 2021-2022 season, CBS and UEFA agreed to add the COVID-19-delayed conclusion of the 2019-2020 season as well as the entire 2020-2021 season.
Coverage will begin in August with the remaining Round of 16 matches for the 2019-2020 UEFA Champions League and UEFA Europa League, followed by the quarter-finals, semi-finals and final, with every game on CBS All Access and select games on CBS Sports Network.
US rights to the Champions League were previously held by Turner, which had originally intended to continue to stream the competition until the end of the 2020-21 season.
Spanish language rights are held by Univision.
CBS Sports Network, CBS All Access and CBS Sports Digital will deliver additional coverage and original programming, including live coverage of matches during the knockout rounds and primetime replays throughout the season on CBS Sports Network and CBS All Access, as well as archival matches on CBS Sports Network.
"This is a landmark acquisition for CBS as we add the world's most popular sport to our extensive portfolio of marquee properties. We're excited to be the new home of the UEFA club competitions and looking forward to showcasing the best soccer in the world with a first-class presentation serving both the passionate and casual soccer fans, starting in August. Using a multi-platform approach across our broadcast, cable and digital assets, this partnership will leverage the power of ViacomCBS and CBS Sports to elevate and grow UEFA's reach in the United States," said Sean McManus, chairman, CBS Sports.
"The addition of all UEFA Champions League, UEFA Europa League and UEFA Europa Conference League matches is a game changer for CBS All Access' growing lineup of sports programming, This partnership marks a major step in our service's expansion into exclusive sports content, and we're thrilled to deliver more than 300 UEFA matches each season, along with the highly anticipated resumption and completion of the current UEFA Champions League and UEFA Europa League seasons, directly to our subscribers and the clubs' loyal supporters. Additionally, we are excited about the young, diverse audience that these matches will bring to all of our platforms, especially as we embark on the expansion of CBS All Access with content from across ViacomCBS" said Marc DeBevoise, chief digital officer of ViacomCBS.
Tags: CBS All Access, UEFA Champions League, UEFA Europa League, US, ViacomCBS
FAST services used by more than half of CTV households


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Report: Next iPhone to have 1GB RAM, Siri-powered Assistant
Apple's next iPhone will feature 1GB of RAM, as well as a Siri-powered Assistant feature that will be exclusive to the device, according to a new report. Citing a source familiar with the iPhone's microprocessor manufacturing, 9to5Mac reports that these features will arrive alongside previously-rumored upgrades like an eight-megapixel camera, a dual-core A5 processor, and a Qualcomm Gobi baseband chip that will allow a single model to operate on both GSM and CDMA networks. The report goes on to claim that the new Assistant feature is dependent on the phone's A5 processor and extra RAM, and will therefore be unavailable to users of previous iPhones.
Powered by Nuance speech recognition technology, the Assistant feature is said to be a huge step up from iOS' current Voice Control feature, allowing users to perform tasks such as setting calendar events and reminders, getting directions, and sending text or email messages using nothing but their voice. In addition, the report claims that the feature will be able to communicate with the user in a conversation-like fashion, audibly asking for extra information such as which email address to use when contacting someone. The report goes on to claim that the feature also integrates into a new Find My Friends contact-locating feature, as well as Wolfram Alpha. Apple is expected to debut its next-generation iPhone at a special media event next week.


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Q: The endomorphism ring of a uniserial module over a right Noetherian ring or a commutative ring is local I found this example (Example 2.3 in Facchini's paper Krull-Schmidt Fails for Serial Modules) and couldn't quite understand the proof. The statement goes like this:

Let $U$ be non-zero uniserial right $R$-module. Then $U$ is a module
  such that End($U$) is local if at least one of the following conditions holds:
  (a) $U$ is projective; (b) $U$ is injective; (c) $U$ is artinian; (d) $U$ is noetherian; (e) $R$ is commutative; (f) $R$ is right noetherian.

I am particularly interested in the proof of (e) and (f). The proof is indeed short and it goes like this:

$Proof.$ (e) and (f). If a uniserial module $U$ is such that End($U$) is not local, then it has a surjective non-injective endomorphism $f$ and an injective non-surjective endomorphism $g$. These endomorphisms induce two isomorphisms  $F: U/ ker(f)\to U$ and $G : U \to g(U)$. It follows that $g(U)/g(ker(f))\cong U$, so that $U$ is a shrinkable module in the sense that it is isomorphic to a proper submodule of a proper quotient of itself. But since $U$ being a uniserial right module over a right Noetherian ring or a commutative ring is supposed to be nonshrinkable (this fact can be found in the paper Uniserial modules: sums and isomorphisms of subquotients, Corollary 3). This yields a contradiction.

Question #1: For the existence of $f$ and $g$: Because End($U$) is not local, for any $\varphi \in$End($U$), we know that $\varphi$ and $Id - \varphi$ are not units, i.e. not invertible. Am I right? But how do we know that $f$ is surjective only and $g$ is injective only?
Question #2: Why is $g(U)/g(ker(f))\cong U$ true? I feel like there is some universal property going on here, or is it simply because $g$ is injective so $g(U/ker(f)) = g(U)/g(ker(f))$?
Any help would be awesome! Thanks.

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Recently, Bryan appeared on Late Night with Seth Meyers to talk about American Idol.
It didn't take long for the conversation to shift to Shelton.
As you know, Shelton is on "The Voice" so naturally, the two are competing against one another.
Seth asked Luke if he had reached out to Blake regarding the American Idol offer.
The country star confirmed that he had indeed reached out to Blake, and also added that he's not really sure why he would ever recommend reaching out to him.
All kidding aside, Bryan said he did speak with Shelton on the phone about the offer and Blake reassured him how much he would love it.
At one point, the conversation shifted to that time Blake was named "Sexiest Man Alive" by the Oklahoman's "People" magazine. Of course, Bryan had something to say about that too!
Bryan said they were a bit confused by Blake being named the sexiest man alive, citing he looks good from a distance as the main source of the confusion.


Reprints: Alok D. Sharan, MD, MHCDS, WESTMED Spine Center, Yonkers, NY 10710 (e-mail: aloksharan75@yahoo.com).
On November 8, 2016 Donald J Trump was elected the 45th President of the United States. After a long and brutal campaign season, Trump's victory demonstrated the economic frustration many Americans have been experiencing. Many of the economic frustrations felt by Americans were due to perceived changes that resulted from the passage of the Affordable Care Act (ACA). President-elect Trump has stated that repealing and replacing the ACA will be one of his first priorities when he takes office. What does that mean for the future of health care in the United States?
Passing the ACA was a challenge for President Obama; implementing it has been an even greater challenge. Overall the goal of the ACA was to ensure that everyone has access to affordable health insurance, prevent insurance companies from denying insurance to individuals due to preexisting conditions, and allow individuals to receive health insurance through parent coverage up to age 26. In the discussion about how to reform the ACA, most individuals (including Trump), agree on these basic principles. The challenge becomes how to implement and achieve these goals without bankrupting the US economy.
The Trump campaign has released very limited policy proposals with respect to health care and health insurance. As a result it is difficult to understand which direction the Trump administration will choose to take. The policy positions released indicate that President Trump will support policies in line with the business principles that have made him successful—ensuring an adequate amount of competition and choice for the consumer as a mechanism to improve health care. Beyond that he has stated his desire to eliminate the individual and employer mandate, allow insurance to be sold across state lines, remove many restrictions on minimum coverage standards, convert Medicaid to a system of block grants, and explore options for obtaining pharmaceuticals from Canada. In terms of individuals and employers, the plan advocates for higher deductible plans and health savings accounts, which in theory encourage consumers to shop for the best value in health care.
Philosophically it seems that Trump will support the use of free market principles to achieve greater efficiency in the delivery of health. Markets work when a consumer has enough information to make an active choice about purchasing a product or service. The process of actively choosing results in increased competition among suppliers to deliver greater value for the consumer. Only those suppliers who understand what is of value to the customer and how that value can be delivered succeed while others tend to diminish due to decreasing volumes. In health care there are 2 markets—1 for insurance and 1 for health care delivery.
Health care is expensive, especially for complex surgical procedures and other hospital care. Health insurance is vital to the delivery of health care and the lifeblood of the industry. Government regulation, poorly constructed policy, or lack of regulation can have a disastrous impact on access to and quality of care. The value of insurance is that it mitigates the risk of financial loss due to illness or injury now and in the future. Consumers (employers and individuals) in comparing plans seek to minimize cost while maximizing access to quality care. A more competitive health insurance market place is seen as a way in which employers and individuals are provided greater choice and thus they can optimize value. The Healthcare Marketplace (insurance exchanges) was supposed to mimic a competitive market for individuals entering as a result of the individual mandate. However, the value proposition is far from clear for individuals who are young and healthy. This was the Achilles heel of the ACA—the "young invincible" have been reluctant to purchase insurance that is overpriced while those with preexisting conditions see the insurance premiums as a bargain.
Trump's plan also suggests that he would work with states to establish high-risk pools for such individuals. If this has the trickledown effect of lowering premiums for lower risk groups then more individuals may choose to be insured. Greater insurance participation is important to the maintenance of a healthy health care industry.
Price transparency has been identified as one of the aims of a Trump administration. With this transparency patients are becoming more active purchasers and consumers of care. Coupled with the increasing amount of financial burden patients are facing with health care insurance, there has been an increasing trend for patients to become more active "purchasers" of care.
There are several unanswered questions in the terse policy statements released by the President-elect and his emerging administration. Will his policies assure that the 20 million who have become insured as a result of the ACA continue to have access to affordable insurance? Will the additional 27 million still uninsured find better options in the competitive market envisioned by Trump? What will be the impact of high deductible plans paired with health savings accounts? How will this affect consumer choices? Missing in the discussion has been the profound effect of malpractice laws and the practice of defensive medicine. As providers comply with evidence-based guidelines will they be protected from frivolous lawsuits? It is clear that tremendous savings can be achieved with effective malpractice reform.
Government health policy and market trends have been forcing providers to increasingly compete on outcomes that are of value to the patient. Through price transparency and employer initiatives purchasers of care are better able to perceive value. How to achieve high value for consumers, purchasers, and providers will require changes in strategy, organizational structure, operations, and financial incentives among providers. Fundamentally it will require a change in the basic business model of health care delivery.
Since the launch of Clinical Spine Surgery, the mission of the journal has been to publish articles that are useful for the practicing spine care provider. Beyond the articles focused on scientific research on various spine topics, the Journal has published articles in the Business of Medicine section on topics that can help spine care providers understand the broader organizational and system level issues that affect the delivery of spine care. There is no question that spine care providers will face a tremendous amount of uncertainty over the ensuing 4 years. Regardless of which policy direction the Trump administration chooses, determining how to deliver greater value to the patient will continue to be the goal that our health care system needs to achieve.
Achieving that goal will not be easy—as Editors of Clinical Spine Surgery we are committed to publishing articles that will continually inform and empower our readers with the knowledge and information to succeed in this new era of value-based care.
Clinical Spine Surgery30(1):30-31, February 2017.


PACE Monmouth was nominated by Dianne Lyons. The program is a New Jersey State Governor's Jefferson Awards honoree in the category, Verizon Service Through STEM.
As Science, Technology, Engineering, and Mathematics (STEM) skills and careers become more important, many minority students find themselves disadvantaged by their schools' lack of relevant resources. PACE, the Program for Acceleration in Careers of Engineering, exposes African-American and Latino high school students to science and engineering minority professionals and provides instruction in STEM. The end goal for PACE Monmouth is to see more minority students graduate high school and college, and begin careers in math, science, or engineering. They also value self-esteem and awareness of African-American and Latino technical accomplishments.
Founded in 1982, PACE Monmouth has a proven formula for accomplishing its goals. They provide a myriad of opportunities including classroom instruction, mentoring, field trips, workshops, competitions, cultural celebrations, and guest speakers. Students get hands-on training in STEM from professionals who know which skills are the most relevant. Many of those that PACE Monmouth assists come from poorly funded school districts, which might not have the equipment and appropriate teachers to engage these left-brained students.
While the program recognizes that STEM skills are important, so is getting into college, and that requires building well-rounded students. PACE Monmouth understands this and tries to best prepare their students for college. Not only do students gain leadership experience, but they also develop logic skills, leading to better math and science grades. Additionally, PACE Monmouth encourages its students to volunteer in their communities and takes them on several college tours.
The real driving engine behind the program, however, are the PACE Monmouth professionals. Most of those who volunteer with the program are actually alumni themselves. After being empowered by past volunteers, current alumni pay it forward to the students and act as living success stories. As PACE Monmouth begins its 34th year, the continued alumni success and involvement is hopefully an indication that current students will experience similar achievement.
For more information on PACE Monmouth, please visit their website here.


Please note that this item is available in 5 different case colours, and you can also upgrade the graphics card to ensure you can play the games you want.
I found it cheaper to buy this than to build myself. Warranty too. Communication is great with Expertec and I will recommend and use again and again.


text:
Superligaen 2008/2009 var den 19:e säsongen av Superligaen, anordnad av Dansk Boldspil-Union för att kora danska mästare i fotboll. Serien spelades mellan 19 juli 2008 och 31 maj 2009, med vinteruppehåll. Titelförsvarare var AaB.

Danska mästarna kvalificerade sig för kvalspelet till Champions League 2009/2010. Tvåan och trean kvalificerade sig för kvalomgångarna till Europa League 2009/2010. Elvan och tolvan flyttades ner till 1. division. Ettan och tvåan i 1. Division flyttades upp till Superligaen. Ursprungligen var de fyra bästa tänkta att kvalificera sig för Royal Cup 2010, men på grund av ekonomiska problem avbröts den skandinaviska turneringen för tredje året i rad.

Upp- och nedflyttning
Följande lag flyttades upp till Superligaen efter Säsongen 2007/2008:
 Vejle BK (etta)
 SønderjyskE (tvåa)

Följande lag flyttades ner från Superligaen efter säsongen 2007/2008:
 Viborg FF (Elfte plats)
 Lyngby BK (Tolfte plats)

Lag och städer

Städer och arenor

Förändringar på tränarfronten

Matchställ

Tabeller

Poängtabell

Resultattabell

Mål
Källa: dbu.dk

Skytteligan

Självmål
 Frank Hansen (Esbjerg) för Vejle (27 juli 2008)
 Sladan Peric (Vejle) for AaB (2 augusti 2008)
 Morten Rasmussen (Horsens) för Midtjylland (3 augusti 2008)
 Michael Beauchamp (AaB) för Köpenhamn (21 september 2008)
 Alexander Östlund (Esbjerg) för OB (19 oktober 2008)
 Michael Stryger (SønderjyskE) för Randers (2 november 2008)
 Michael Jakobsen (AaB) för Esbjerg (16 november 2008)
 Jacob Stolberg (SønderjyskE) för Brøndby (22 november 2008)
 Søren Berg (Randers) för Brøndby (21 mars 2009)
 Kristijan Ipša (Midtjylland) för AGF (13 april 2009)
 Adam Eckersley (Horsens) för Köpenhamn (25 april 2009)
 Sölvi Ottesen (SønderjyskE) för Midtjylland (27 april 2009)

Hat-tricks

Säsongsstatistik

Målskytte
 Säsongens första mål: Bedi Buval för Randers mot AGF (19 juli 2008)
 Snabbaste mål i en match: Frank Kristensen (17 sekunder) för Midtjylland mot Brøndby (31 maj 2009)
 Högsta vinstmarginal: SønderjyskE 0–6 Brøndby (22 november 2008)
 Flest mål i en match: Brøndby 4–3 Horsens (3 november 2008) / Köpenhamn 5–2 Horsens (7 december 2008) / Nordsjælland 6–1 Randers (10 april 2009) / OB 6–1 AGF (4 maj 2009)
 Säsongens första hat-trick: Babajide Collins Babatunde för Midtjylland mot OB (10 augusti 2008)

Markeringskort
 Första gula kortet: Lee Nguyen för Randers mot AGF (19 juli 2008)
 Första röda kortet: Martin Pedersen för AaB mot Midtjylland (20 juli 2008)
 Snabbste röda kortet i en match: Michael Beauchamp (17 minutes) för AaB mot OB (17 augusti 2008)

Publiksiffror
Källa: hvemvandt.dk

Månadens spelare

Anmärkningslista

Källor

Externa länkar
 Officiell webbplats
 ligafodbold.dk
 haslund.info

2008 i Danmark
2009 i Danmark
Fotbollssäsongen 2008/2009
2008/2009

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