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OneVox Creative Solutions
The Testosterone Epidemic: Why Has the Demand for the Hormone Grown?
access_time August 23, 2019
The indiscriminate and increasing use of testosterone is of concern to the medical community. Multiple risks can arise from the misuse of testosterone, from stroke and heart problems to worsening behavior and psychological disorders.
Experts note that in recent years there has been an exponential increase in testosterone use, both prescribed and illegally. According to the American, Brazilian and European societies of endocrinology, there has been a more than 200% increase in testosterone prescriptions in 10 years. The expectation of the person seeking the male hormone is to have improved libido, ambition, and vitality, as well as decreased body fat and increased muscle mass. What few know is that the benefits of hormone therapy tend to occur only in those who actually have low testosterone levels, to begin with.
Both the excessive demand and the significant increase in testosterone prescriptions by physicians have become a matter of concern for the medical community, whether in fact these drugs would be used when necessary, that is with a proven hormone deficiency, whether recreational use and aesthetics were responsible for these increases. Men who are most likely to have low testosterone are those who are obese, or over 50 to 60 years old, or previously used anabolic steroids.
Indiscriminate use of testosterone and its derivatives, especially when used above normal levels in men, can cause stroke, heart attack, thrombosis – especially if they have blood thickening, a consequence almost always present with the use of testosterone, spread of prostate cancer and various behavioral problems such as irritability, physical violence and sexual promiscuity. "That's why every patient needs to be evaluated. Because if testosterone levels are normal, the man would not have the promised benefits," warns Flávio Cadegiani, Endocrinologist, Master and Doctor (PhD) in Clinical Endocrinology by Unifesp / EPM.
For the Endocrinologist Flávio Cadegiani, there are eight major reasons that can explain the rapid increase in hormone use.
Doctor Endocrinologist Flavio Cadegiani
A more accurate diagnosis – "Much of the rise in the testosterone prescription was due to both the exponential increase in the number of testosterone tests requested and the increased suspicion by physicians that certain symptoms, even if not typical, could be caused by low testosterone. In the past, patients with low testosterone were treated in psychiatry because they did not have the correct diagnosis," says Cadegiani.
The obesity epidemic – According to the doctor, the growing epidemic of obesity has boosted the prevalence of low testosterone levels. Anywhere from 30% to 90% of obese men may have hypogonadism, which is the name given to low testosterone in men, depending on Body Mass Index (BMI). "The more obese, the greater the chance of having low testosterone, and often the drop in testosterone leads to additional weight gain, leading to a vicious cycle, an endless snowball," he explains.
The aging population – Men's aging leads to reduced testosterone production as an expected effect of aging. But unlike in the past, older people now demand a better quality of life, performance, independence, cognitive activity, and most of all, to enjoy this phase of their life. "Older people have a high prevalence of low testosterone, and often can benefit from using it," he explains.
Endocrine disrupters – Endocrine disruptors are all substances in the environment, from plastic for storing food, pesticides, pollution, and even soaps, which compromise hormone production or testicular formation. As exposure to literally thousands of endocrine disrupters has intensified, younger generations have experienced precipitous drops in testosterone and fertility levels. Today the average testosterone of men in their 20s is lower than that of men in their 50s, due to the difference in generations. "That is, low testosterone is not unique to those who are overweight or older, but in much of today's young men. To make matters worse, if testosterone is used in this population, their fertility drops further," says Cadegiani.
Undoing the stigma – In the past, there was a taboo with testosterone use, even when formally administered, because of alleged risks of prostate cancer and cardiovascular disease. Today, however, it is well established that testosterone use does not cause cancer and when correctly administered may in some cases even reduce the risk of a heart attack.
Prescriptions for those who need it – Doctors have always been afraid to prescribe testosterone, even for those who should use it, because of the supposed risks. In the past, most patients with hypogonadism and no contraindications to testosterone use received no treatment because of comfort, unreasonable thinking, and a mutual practice among physicians that it is better not to treat (or rather neglect) a patient with low testosterone than prescribing it.
Today, due to the widespread debunking of the myths surrounding testosterone, and knowing that the benefits far outweigh the risks, when properly indicated, patients who need testosterone are now properly prescribed. And not prescribing in these cases can be considered medical malpractice.
Quality of life – Cadegiani reports that, during consultations, as patients requested, the quality of life issue has been increasingly taken into consideration. "Today, if a patient has low testosterone and clinical symptoms such as depressed mood and low energy levels (symptoms that are more specific to indicate low testosterone than sexual desire itself), we would not hesitate to prescribe testosterone if there are no contraindications. Until recently we had prescribed testosterone only in the worst-case scenario.
The quest for youthfulness – "We are not yet able to healthily deal with aging." With this statement, the doctor refers to the false promise that testosterone use will guarantee them youthful performance for the rest of their life. The search for a replacement in order to control libido may also come into this motive. "Both are misleading and deleterious promises," reports the doctor.
Finally, the Endocrinologist explains that sexual desire goes far beyond testosterone levels. These days, stress and tiredness are far more responsible for the drop in libido than the hormone levels themselves. "A simple question can lead to a reflection on whether or not testosterone is needed. Just ask yourself, if you are traveling alone with your partner to a quiet place, and without having any day to day worries on your mind, if by chance the libido does not improve then it is very likely to be low testosterone as the culprit. If it gets better, the answer to the lack of libido was stress and daily routine," contextualizes Cadegiani.
Testosterone, great for those who need it, harmful for those who don't.
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Q: passing a function into JSON.stringify I'm currently studying javascript by following the series "you dont know js".
In the section "types & grammer", when discussing "JSON.stringify" function, the author mentioned

var a = {
  b: 42,
  c: "42",
  d: [11,22,33]
};

JSON.stringify( a, ["b","c"] ); // "{"b":42,"c":"42"}"

JSON.stringify( a, function(k,v){
  if (k !== "c") return v;
} );
// "{"b":42,"d":[11,22,33]}"

Note: In the function replacer case, the key argument k is undefined
  for the first call (where the a object itself is being passed in). The
  if statement filters out the property named "c". Stringification is
  recursive, so the [1,2,3] array has each of its values (1, 2, and 3)
  passed as v to replacer, with indexes (0, 1, and 2) as k.

So I have came out with the following code, aimed at removing the value 22 from the JSON.stringify result

var a = {
  b: 42,
  c: "42",
  d: [11, 22, 33]
};

var result = JSON.stringify(a, function(k, v) {
  //since each index 0, 1, 2 of property "c" will be passed into function as "k",
  //therefore if "k !== 1" should filter out value 22
  if (k !== 1) {
    return v;
  }
});

console.log(result);

I was expecting the result to be "{"b":42,"c":"42","d":[11,33]}".
However, the result was instead "{"b":42,"c":"42","d":[11,22,33]}" (as you can see, the value 22 at index 1 of property c is not filtered out)
Did I miss understood what the author said? Am I missing something?

A: Property names are always strings. 1 !== "1". Compare to a string instead of a number.

var a = {
  b: 42,
  c: "42",
  d: [11, 22, 33]
};

var result = JSON.stringify(a, function(k, v) {
  if (k !== "1") {       // "1" not 1 here
    return v;
  }
});

console.log(result);

A: The key will be string representing the property name and when iterating through the array properties it will be a string representing the array indexes.
The JSON.stringify iterator work in a way that the function is being executed for all elements in the object starting from the top element itself.
For example having the object you showed:
var a = {
  b: 42,
  c: "42",
  d: [11,22,33]
};

The function supplied for the JSON.stringify will run for the following keys and values:

*

*The all object {b: 42, c: "42", d: [11,22,33]} doesn't have a key since it the top level element, so in this case the k variable will be undefined.

*The 42 value accessed by the key b.

*The "42" value accessed by the key c.

*The [11,22,33] value accessed by the key d.

*The 11 value accessed by the key 0.

*The 22 value accessed by the key 1.

*The 33 value accessed by the key 2.

redpajama_set_name: RedPajamaStackExchange


Can anyone advise me on a good Sky TV installer?
Needed asap as have watch every DVD ever made!
1) Can second the opinion about Martin - he is excellent. He can be slow returning calls so be patient - worth waiting!
Contact: Martin Hull 0494478050 He is excellent and sky is his business.


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Canaport LNG issues statement over Worker Dispute
Canaport LNG has weighed in on the dispute between their contractor, local tradesman and non-unionized workers from out of town. The company issued a statement tonight saying it's in their best interest to see it resolved quickly.
Canaport LNG says they encouraged the contractor, SNC Lavalin, to use local construction companies where it was possible to do so. The project was even divided up into smaller packages to give local contractors the chance to bid.
Canaport LNG says it encouraged the contractor to use the local workforce and they did with 85% of the skilled workers at the site being from Saint John and surrounding area.
At peak construction times, 1600 workers were on site and 90% of the construction hours used to build the facility so far were performed by unionized workers.
A Slow Commute Today for Saint John Motorists
Several callers telling CHSJ news about a few traffic tie-ups for the drive home.
Traffic is at a crawl eastboound on Route 1 by the Circle K. A Truck and SUV are in the median.
There was another accident at Crown and Union Streets in the intersection. Two vehicles and several emergency personnel on scene. Police say it's still moving slow and two women were sent to hospital to get checked out
And there was an earlier slowdown Highway 1 westbound near Haymarket Square because of paving.
Injunction Against Unemployed Workers Extended
The wording is different but the meaning of a court-ordered injunction remains the same. Justice Hugh McLellan has extended the paper-work against un-employed labourers when it comes to their demonstrations at the Hotel Courtney Bay. The big difference is instead of 500 meters they are ordered to stay 100 meters away from the property. There are several stipulations that go along with the injunction including no threat of force or interfering with anyone trying to leave or come on to the property. The hotel is represented by James LeMesurier who tells CHSJ News, this is what his client was looking for.
The injunction is valid until Jan.2nd of next year or until further order of the court or trial date is set. The company SNC Lavalin and it's contractor Intregal Energy Services, who brought in the workers from Alberta, has had their injunction extended until Monday. It
Second Injunction Extended
The court has also extended an injunction on behalf of the company SNC Lavalin and it's contractor Intregal Energy Services, who brought in the workers from Alberta. The wording is very similar to the one regarding the hotel property with stipulations to stay away from the front entrance of the Canaport LNG site or prohibit any worker from leaving a hotel or motel to go to the work site.
The lawyer representing the companies says attempts were made to serve the un-employed labourers with court papers of the injunction and a chance to have their say in court. He says they were cursed at and threatened with the hearing to continue on Monday of next week.
Visit a Local Farm on Sunday
Wanna milk a cow or feed a chicken this weekend?
You can as part Open Farm Day on Sunday.
37 New Brunswick farms are participating in the Maritime-wide event that gives city folks a glimpse of country life.
The 8th annual agricultural awareness event is also taking place in PEI and Nova Scotia and is a way for the public to learn about local food production.
For a list of Open Farm Day locations in New Brunswick, visit www.gnb.ca
Update on the HINI Pandemic
The Department of Health continues to make plans for a province-wide vaccination program to prevent the spread of the pandemic HINI. Chief Medical Officer of Health Dr. Eilish Cleary says this is a positive move by the Graham Government even if the cost is over $17 million dollars because it will reduce the number of those who get sick, hospital visits and those who die.
Dr. Cleary adds they are still finalizing their vaccine plan but have determined the pecking order for the shot. It includes First Nations Communities, those under 65 with chronic conditions, pregnant women, health care workers and healthy children six months to five years old.
Posted by CHSJ News at 10:54 AM
Upgrade at Golden Ball Irving
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MacLeod says the work includes a fresh coat of paint and some offices being expanded. The work is expected to finish up in the next few weeks.
Quispamsis Supports Climate Program
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The goal of the collaborative is to ensure provincial and municipal decision makers consider climate change adaptation in their day to day decisions.
Inflation Rate Edges Up Slightly
Saint John's inflation rate is still below the zero mark. The port city's rate of inflation grew to negative 0.2 per cent in August compared with negative 0.4 per cent in July. That's the same as the province.
Stats-Canada says the national inflation rate edged up slightly to negative 0.8 per cent last month. Lower gas prices continue to drive the inflation rate down. It cost just over a dollar a litre on average to fill up last month, compared with average prices of a-dollar-27 at the pumps last August.
Break and Enters Overnight
City police dealing with a couple of break and enters last night. Both the Dairy Queen on Welsley Avenue in the North End and the Peel Plaza field office uptown were broken into. Police say windows were broken at both locations, but nothing was stolen.
UNBSJ Gets a Major Donation
(UNBSJ campus at Tucker Park - file photo)
UNB Saint John has recieved an unexpected donation of 1.1 million dollars. The bequest comes from the late Violet Woodroffe and has been used to establish five 40 thousand dollar scholarships. The Foley-Woodroffe Scholarships are open to high academic achievers entering the local campus.
Woodroffe, who lived to be 106, did not attend UNB--but--her cousin, Joan Alarie, says she was generally interested in young people furthering their education.
Gas Prices Drop Two Cents
The price of gasoline has dropped two cents as the Energy and Utilities Board releases its maximum price schedule for the next week. Regular self-serve gas can sell for up to 94.6 cents a litre-- plus a possible two cent delivery charge. Most gas stations in greater Saint John are selling fuel for 94.9.
Diesel fuel has gone up per centage points to land at 94.1--plus delivery; while furnace oil is selling for a maximum of 81.2 and propane is about one cent cheaper at 96.6 cents a litre---including the possible two cent delivery charge.
Concert Complaints
If you have a question or complaint about the Sean Kingston show at Harbour Station on Tuesday night, hopefully this will clear things up for you. Some parents and ticket holders are upset the show didn't finish up until after eleven o'clock and got started one hour late. Jack Livingston is owner of SRO Promotions that brought the show to Saint John and tells CHSJ News, they had a decision to make.....cancel the show or fix a computer problem with a delay in the start time.
Livingston says he made the final call so if there is anyone to point the finger of blame at.....it is him.
Sea Dogs Strive for Greater Ticket Sales
A self-imposed dead-line for the front office of the Saint John Seadogs is closing in. About a month ago, they stated they would like to have 2500 season tickets sold before the puck drops for this season's home-opener. The game is Saturday and President Wayne Long tells CHSJ News, they are close and the clock is still ticking.
Long says he will not be disappointed if they don't reach the 2500 mark knowing the economy hasn't been the best but happy with their effort in promoting the team.
Update on Kent Hills Wind Farm Fire
We have an update today on that fire at the Kent Hills wind farm last month. Investigators have ruled out a lightning strike as the cause of the blaze which did considerable damage to one of the over 30 turbines. Energy Minister Jack Keir tells CHSJ News, nothing has been pinpointed yet.
Even with a lightning strike ruled out, Minister Keir says he isn't worried about a manufacturing defect with the turbines.

redpajama_set_name: RedPajamaCommonCrawl


Marilyn and I actually got up early and headed out to a bazaar that had been recommended to us over in Washington state. We didn't buy much, but enjoyed looking. We ran into our friend Jodi while there.
We stopped at McMenamins Cornelius Pass Roadhouse for lunch. We both ate vegetarian choices, which were quite good! It was a fabulous lunch and good start to our vacation.
Then we dropped by the office briefly, where we saw and chatted with Jeff.
After that we headed to inner SE Portland to Don's genealogy class. Finding parking was a bear. But we both enjoyed hearing him.
Finally we stopped for popcorn on the way home. And we got here in time for our usual METV shows on Saturday night.
Roasted brussels sprouts appetizer - yummy!
I had hemp sliders with a walnut compote - delicious!
My dessert was bread pudding (which I love) in whiskey sauce!
We had a fire tonight at home. The cats and me.
A lovely and busy day.
Wow, nice day. Cozy home and fire. I would find it hard to leave. I like to be home where everything is comfy.
Sweet dreams to you too!


2019 is already looking to be another stellar year for South Carolina's growing solar industry.
Earlier this month, Renewable Properties announced the construction of seven new solar facilities in Spartanburg County. These new solar facilities amount to $22.7 million in state investments that will have a significant economic impact and generate revenue for local schools.
This is just the latest in a succession of mostly good news over the past few years. South Carolina's solar energy industry has been in the midst of a growth spurt due to 2014's Distributed Energy Resource Program Act, which created a framework that allowed for a net-metering system and created nearly 3,000 jobs in just a few years.
With that legislation in place, businesses and homeowners have been able to earn credit for the excess power their solar panels produce. Unfortunately, the Act also established a 2 percent cap on net metering as a sort of test run in order to get a wide range of stakeholders to agree to try more solar on a limited basis. So, the industry is essentially a victim of its own success as it reached that limit much faster than anyone imagined.
Last year, an effort was made to remove that cap, but it was killed at the last minute due to a technicality.
However, voices at the state capitol continue to grow in support of new legislation geared towards further bolstering the industry. If passed, Senate Bill 332 will lend support to businesses and homeowners looking to make the switch by providing much-needed transparency and adjusted net-metering policies.
The new bills proposed in the house would raise the net-metering caps and safeguard future solar investment in the state. The bills were sponsored by Senator Tom Davis (R-Beaufort), who understands that his state's energy industry is best served with a free-market approach, where consumers choose the winners, not restrictive legislation.
In a recent announcement, top players in South Carolina's solar industry urged state lawmakers to consider the great economic benefit these new bills would mean for the state.
Both Democrats and Republican consumers in South Carolina consumers share this view. CRES Forum recently conducted a poll that supports these trends nationwide: Conservatives are getting behind solar because they recognize the further potential for economic growth and job creation. Republican leaders like Governor Henry McMaster and Congressman William Timmons, who represents Spartanburg, have been enthusiastic supporters of the solar industry in the state.
Investments like the ones Renewable Properties is backing are vitally important for the health of South Carolina's economy, and we sincerely hope that the state legislature decides to support their citizen's energy freedom by passing the new bills. After all, ensuring that industries compete on a level playing field is what the free market has always been about.


text:
Lifestyle Archives
Were such lyrics inspired by the ladies in his life? There's little question that, in the late-1970s, when Van met Danish woman Ulaa Munch, she grew to become his muse. They lived on the fourth ground of a nondescript condo block with no carry in the Vanlose district of Copenhagen. Surely, one of many saddest images ever printed of Van and Michelle - the last time they have been photographed collectively in public - was at Violet's funeral. The look on Van's face seemed as a lot of profound unhappiness on the loss of his mother as, in a way, the loss of the other woman most expensive to him on the planet, Michelle Rocca.
Obviously nobody is speaking at big corporate events in the meanwhile but Jeremy Lee, of the speaker bureau JLA, says that the market for digital speaking by way of platforms corresponding to Zoom is holding up well. Virtual gigs, he provides, are usually discounted, often by 50 per cent, and there are not one of the pricey extras corresponding to flights for the speaker and their individuals. Moscow's notorious Ivan the Terrible most likely didn't get as onerous a time from his critics as Belfast's well-known Van the Man.
Behind these attempts to open up poetry to new audiences there's a sense by which the pageant had, for some time a minimum of, misplaced its way. The programming of the 70s over-cooks the American beef, and that of the 80s is extraordinarily UK-centric – every thing that Hughes had been towards. What could be seen as the trendy period of Poetry International began in its re-launch in when the National Poetry Library moved from its residence in Piccadilly to the fifth floor of our Royal Festival Hall. The poet Maura Dooley was Head of Literature at the time and she or he noticed the potential for this collision of two great institutions to mix their legacies and bring the competition into a new era. Southbank Centre's longest operating competition, Poetry International, celebrates 50 years this 12 months by joining with London Literature Festival for the first time.
"My mom was what you'll describe as a free thinker," Van once said. Violet and her husband George's only baby, George Ivan Morrison, was born on August 31, 1945.
"For some time, a brief encounter, that was all," Van stated. A few years later, in 1966, during Van's time in America, Pat Egan recalled receiving "a beautiful letter" from Violet in Belfast, "thanking me for including him in my column in New Spotlight each week". He also talked about his mother to Michelle and me one night at their base in Clyde Lane in Dublin. You'd generally marvel that, after Michelle, the true love of Van Morrison's life was his mom, Violet Stitt. In his gruff speaking method, he stated, "Drop right down to the home tonight and have dinner." Pat asked Van to repeat the invitation as he did not consider it.
read what he said For while Sir Van Morrison, who's seventy five on Monday, has thousands of devoted fans in Northern Ireland, there's additionally a sizeable minority of naysayers who hardly ever have an excellent word to say in regards to the province's largest musical star. Inspired by his love of Ulaa and his new residence life, Van wrote the song Vanlose Stairway about discovering the Gita and a stairway that "reaches up to the moon and comes proper again to you".
Retrieved from "https://historydb.date/index.php?title=Lifestyle_Archives&oldid=586090"


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Ка́рло Фа́сси (; 20 декабря 1929 года, Милан—20 марта 1997 года, Лозанна) — итальянский фигурист, двукратный чемпион Европы (1953 и 1954 годы), бронзовый призёр чемпионата мира 1953 года, участник зимних Олимпийских игр в 1948 году, а также выдающийся тренер по фигурному катанию. Среди его учеников — Пегги Флеминг, Дороти Хэмилл, Робин Казинс.

Биография
Карло Фасси — единственный итальянский одиночник, выигрывавший чемпионат Европы (1953 и 1954 годы).

По окончании любительской спортивной карьеры в 1954 году Фасси начал работать тренером в Италии. Одной из его первых учениц была немецкая фигуристка Криста фон Кучковски, которая вышла за него замуж и стала матерью троих детей: Рикардо, Моники и Лоренцо.

В 1961 году, после авиакатастрофы под Брюсселем, в которой погибли сборная США по фигурному катанию, направлявшаяся на чемпионат мира, а также лучшие тренеры страны, Карло Фасси был приглашён на тренерскую работу в город Денвер, штат Колорадо.

Он тренировал олимпийских чемпионов и чемпионов мира Пегги Флеминг, Дороти Хэмилл, Джона Карри, Робина Казинса. Он также работал со Скоттом Хамильтоном и Полом Уайли на ранних этапах их карьеры. Фигуристы со всего мира съезжались в тренировочный лагерь Карло Фасси для консультаций. Этот тренер охотно использовал все новинки в методике занятий, широко применял помощь хореографов. Алексей Мишин стажировался у Фасси в начале своей тренерской карьеры.

Карло Фасси скончался в 1997 году от сердечного приступа в швейцарской Лозанне, в дни проведения там чемпионата мира, на котором он присутствовал в качестве тренера чемпионки США Николь Бобек. Он умер за час до выхода одного из его фигуристов на каток.

Спортивные достижения

См. также
 Фигурное катание на зимних Олимпийских играх 1952

Примечания

Ссылки
 Большое чудо маленькой феи (Шелухин А.) — Пегги Флеминг
 Т. А. Тарасова «Четыре времени года» Выдающиеся тренеры

Родившиеся в Милане
Умершие в Лозанне
Фигуристы Италии
Фигуристы на зимних Олимпийских играх 1948 года
Фигуристы на зимних Олимпийских играх 1952 года
Тренеры по фигурному катанию

redpajama_set_name: RedPajamaWikipedia


I wonder when she started dating Richard Spencer?
Will Nancy reign her in? Can She? She went so far this time that even Chelsea Clinton condemned her.
Makes me wonder if some of these nuttier Dems will end up split off in to a new party.
I see, you're not a fan of the Jews... sad.
The one with the POTUS, Sentate and SCOTUS? Sorry but we're not accepting anti-semites.
Only one Jew hater (oldfool) chimed into this thread, the rest have better judgement.
No wonder the Klan wear pointy hoods. It's to keep their narrow minds from exploding.
Is that what the Democrats were thinking when they came up with those outfits?
Maybe I should write a letter to Governor Coonman in Virginia, he has experience with KKK robes.
donald is a fan of the Jews, right, but it's OK for him to say what ever he wants ???


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Martin, Micheál
Deputy Micheál Martin
MichaelMartin
Micheál Martin
1CE26F7A2AD4FA0680257B0A00466504
Ar son Pháirtí Fhianna Fáil agus ar mo shon phearsanta féin, déanaim comhbhrón le clann Shane McEntee, go háirithe le Kathleen, Aoife, Vincent, Helen, Sally agus a mháthair, Madge, agus déanaim comhbhrón le Páirtí Fhine Gael. Níl aon amhras ann gur duine den chéad scoth ab ea Shane McEntee. Polaiteoir den chéad scoth a bhí ann. Táimid go léir brónach as ucht a bháis. Ta a fhios againn go léir gur oibrigh sé go dian dícheallach, Domhnach is dálach, ar son muintir na tíre seo mar Theachta Dála agus Aire Stáit.
It was in the hectic days prior to the build-up of Christmas there came the sudden news of the tragic death of Shane McEntee. It was a truly shocking moment that caused all of us in this House to take stock, to stop and to pause. That dark news gave the entire nation a reminder of the frailties of life and those of us who knew him were left with a deep abiding sadness at the loss of a true gentleman of Irish politics. He had those qualities - a true gentleman whenever one met him.
There are no words that we can offer to Shane's family to console them in their loss. The irreplaceable space left at the heart of their home is a void that can never be filled. We offer his wife Kathleen, his children Aoife, Vincent, Helen and Sally, his brothers and sisters and his mother, Madge, our support and heartfelt sorry. Our thoughts and prayers are with them and will always be with them. I pray and hope that the memory of a life well lived, of a loving and generous soul, will not only ease their grief but will sustain them in the days, months and years ahead.
Since his election to the Dáil eight years ago, Shane impressed me with his generosity, his quiet dignity and his sense of humour and commitment to his work. His commitment to public service was a clear and defining feature of his life. From his father he inherited a deep appreciation of the land and worked tirelessly with the IFA for the vitality of the family farm. He brought those qualities to his role as Minister of State and those of us on this side of the House welcomed his openness, responsiveness and engagement and the energy he brought to his role.
It is fair to say that all who enter public life do so with a deep sense of commitment to improve the well-being of their community, county and country, and it was clear that was at the heart of Shane's commitment to and participation in politics. From the outset, he was deeply involved in many facets of his local community. We are all here to try to make a difference. Shane was here to make a difference to the quality of life of the people he represented, and he did that in so many ways.
His lifelong enthusiasm for the Gaelic Athletic Association, perhaps, was the earliest manifestation of that deep sense of community commitment. After his local playing career, his talent for coaching players shone through, both at local level and nationally for the royal county at minor level. As a Cork man, suffice it for me to say that the name McEntee struck terror in our hearts on many an occasion on the playing fields of Croke Park but there was also a deep respect for the McEntee commitment and contribution to Gaelic games, to sport and to Irish life. That deep underlying respect is still there. He gave up his oars to help ensure that players reached their potential and that the vibrancy of a community club was kept alive. His drive in the GAA is a testament to his generosity of spirit and it was that commitment to public service that he brought with him to the Dáil and politics in general.
He was Fine Gael from the backbone out. His family links to the party stretch back to the foundations of the State and he was very proud of that. He loved the Fine Gael Party and it is fair to say that Fine Gael loved Shane, as reflected in the Taoiseach's moving eulogy at the graveside some weeks ago. It was through Fine Gael that he pledged himself to public service. There is a deep sense of loss felt on all sides of the House, but particularly among all on the Fine Gael benches who worked with him for years as a Deputy and Minister and who were inspired by his commitment, loyalty and work. I hope all will be heartened that his spirit will be kept alive by his colleagues who continue the work to which he gave himself.
Political life can be a bear pit of rivalry, argument, debate and so forth and sometimes it can slide into rancour and pettiness, but fundamentally we are all bound together by a deeper commitment to improve the lot of citizens and society. Working together collectively in this House, we seek to make the life of citizens that bit better than we found it on coming into the House. That motivation is what inspired the late Shane McEntee to go into political life. It is that spirit, which he personified, that must be cherished and remembered. All Members of this House are bound together by that commitment. We share in its costs and we can reflect upon its triumphs.
It is his family we thank, in particular, for sharing Shane with us. Politics places an enormous burden on families. There is no question about that. We thank the family for their contribution in that regard, for the huge endeavour and support that they gave Shane throughout his life, and particularly his political life. As long as this work goes on, the patriotic spirit of the late Shane McEntee will endure and his commitment to public service will go on. I trust that Shane's family, friends and many colleagues can draw strengthen from that reality. Ar dheis Dé go raibh a anam dílis.


Verloh, Niklas, Utpatel, Kirsten, Haimerl, Michael, Zeman, Florian, Beyer, Lukas, Fellner, Claudia, Brennfleck, Frank, Dahlke, Marc H, Stroszczynski, Christian, Evert, Matthias and Wiggermann, Philipp (2018) Detecting liver fibrosis with Gd-EOB-DTPA-enhanced MRI: A confirmatory study. Scientific Reports 8 (1), p. 6207.
Strong correlations between the grade of fibrosis and cirrhosis, classified using the Ishak scoring system, and the uptake characteristics of Gd-EOB-DTPA with the relative enhancement (RE) of the liver parenchyma have been reported. To confirm the results of a retrospective analysis, patients undergoing liver surgery were prospectively examined with Gd-EOB-DTPA-enhanced liver 3 Tesla MRI to determine the degree of liver fibrosis. Correlations between the grade of fibrosis and cirrhosis, classified using the Ishak scoring system, and RE were investigated and compared with those derived from an initial retrospective study. After validating the cut-off values in the retrospective study (Ishak ≥ 1, RE-cut-off 0.90; Ishak ≥ 2, RE-cut-off 0.79; Ishak ≥ 4, RE-cut-off 0.60; and Ishak = 6, RE-cut-off 0.47), we showed that Gd-EOB-DTPA has a high sensitivity (≥86%) and a high positive predictive value (≥86%). These results support the use of Gd-EOB-DTPA-enhanced liver MRI as a non-invasive method for determining the degree of liver fibrosis and cirrhosis.


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A young market vendor sells peanuts in Urozgan, a central province of Afghanistan. © UNICEF/Omid Fazel
1 Opinion Social Issues South and Central Asia
Afghanistan Faces Funding Shortfall Amid Deepening Humanitarian Crisis – OpEd
July 17, 2021 July 17, 2021 IDN 0 Comments
By IDN
By Radwan Jakeen
Nearly 18 million Afghans or half the population of the South Asian country require assistance. A third of the country is malnourished, while half of all children under five are experiencing acute malnutrition.
In view of this critical situation, Ramiz Alakbarov, UN Resident and Humanitarian Coordinator for Afghanistan, has urged donors to step up support for the country.
Mr Alakbarov said a $1.3 billion appeal, launched earlier this year, is less than 40 per cent funded. The $450 million received so far, half of which came from the United States, falls far short of what is needed.
"Our plan is to provide assistance to at least 15.7 million people, and right now it will not be possible without these additional contributions," said Mr. Alakbarov, speaking via videoconference to journalists in New York on July 15.
The developments are occurring as the deadline for foreign troops to fully withdraw from the country approaches. The drought, the second in three years, and ongoing military response in the wake of a "spring offensive" by the Taliban have uprooted some 270,000 people who have fled rural areas for urban centres.
According to UN News, in the northern city of Kunduz, for example, roughly 35,000 displaced people are being housed in schools and public buildings, and need food, water and sanitation. The fundamentalist Taliban who have been fighting the internationally-recognized central Government for years, have taken over all districts surrounding the city.
Meanwhile, neighbouring countries, such as Iran, have been deporting Afghan refugees from their territories. Humanitarians are also witnessing "very intensive" population movements in areas near the borders with Iran and Pakistan, which are now largely closed.
The closures have not yet affected humanitarians as aid stocks are sufficient to last through the end of August.
Over several weeks, Mr. Alakbarov has visited five regions of Afghanistan. The UN official was particularly concerned about the plight of women and girls, who are facing "very difficult conditions".
He recalled speaking with the head of a household in Kandahar, located in the south, where families are moving in groups comprising some 50 to 60 relatives.
"I have asked how many women there were pregnant and delivered in the last three months while they were there on the move," he said. "In that extended family, four women have delivered babies. Three of them died."
Although humanitarians continue to operate in most of Afghanistan's 405 districts, Mr. Alakbarov reported an increase in access difficulties and in violence.
Twenty-five humanitarian workers have been killed since the start of year, and 63 injured, a 30 per cent increase over 2020. Victims have included women health workers and de-miners.
More than 1,000 "interferences", threats and access impediments have been reported so far this year, which is equal to the 2020 total.
← Taliban Force Kyrgyz To Flee To Tajikistan – OpEd
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IDN-InDepthNews offers news analyses and viewpoints on topics that impact the world and its peoples. IDN-InDepthNews serves as flagship of the International Press Syndicate Group, partner of the Global Cooperation Council.


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As a Platinum College Partner, the University of Rochester is dedicated to supporting our Chicago Scholars with financial support, strong academic advising, and leadership opportunities from the time Scholars enroll until they graduate from college. We commit to the following:
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College Horizons is a pre-college program for Native American high school sophomores and juniors. Each summer, students work with college admissions officers, college counselors, essay specialists, and other educators in a five-day "crash course" on the college application process. The University of Rochester has been privileged to host the program in 2011 as part of our partnership and look forward to hosting again in the future. We send Admissions representatives each year to be a part of the program off campus.
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The IMPACT Program began in 2006 as a way to boost college persistence for YES Prep graduates from Houston, TX. Since 2006, 84% of IMPACT Scholars have graduated from or are currently enrolled in their original IMPACT Partner or Affiliate institution. As a university partner, the University of Rochester commits to:
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To find out how you can become a designated IMPACT scholar please contact your college counseling staff at your YES Prep campus. For general information regarding the program, please visit YES Prep.
Kings is an international education group that helps international students with higher education pathways, transitions to college, and English language instruction.
Kings programs help students achieve personal growth, achievement and the best learning outcome for their individual circumstances, ability and needs.
Our partnership with the Kings is a Guaranteed Outcome (GO) transfer program for students that start at a Kings affiliated school and then transfer after meeting requirements.
Our partnership includes working with them to identify courses and develop specific academic pathways, so that students maximize transfer credit and are on the path to completing their BA/BS in two years, it may take longer depending on interests and foundation.
MasterCard Foundation Scholars Program
The MasterCard Foundation Scholars Program is a $500 million, 10-year initiative to educate and prepare young people, particularly from Africa, to lead change and make a positive social impact in their communities. Rochester has partnered with the MCFS program through ALA and seeks to ensure that highly-qualified Africans from the most disadvantaged backgrounds on the continent have the opportunity to continue their education at top-tier universities around the world. Partner institutions make generous contributions to the overall costs of these students. In exchange, the partner universities benefit from annual enrollment of a cohort of the best and brightest young leaders of Africa to impact the classroom and campus life.
The National Consortium of Secondary STEM Schools
The National Consortium of Secondary STEM Schools (NCSSS) was established in 1988 to provide a forum for specialized secondary schools focused on science, technology, engineering, and mathematics (STEM) disciplines to exchange information and program ideas.
Celebrating their 25th anniversary in 2013, the Consortium now includes approximately 100 member schools (high schools), many "ranked" as the best in the country, along with 55 affiliate members (colleges, universities, summer programs, foundations, and corporations) located in 32 states that share the goals of transforming mathematics, science, and technology education.
The Posse Foundation
The Posse Foundation has identified, recruited and trained 6,275 public high school students with extraordinary academic and leadership potential to become Posse Scholars. Since 1989, these students have been receiving four-year, full-tuition leadership scholarships from Posse's partner institutions of higher education. Posse partner colleges and universities are helping to transform the landscape of leadership in the United States by committing critical resources to diversifying their campuses, making their climates more welcoming to all students, and ensuring that Posse Scholars graduate with the finest education in the country. Most importantly, Posse Scholars persist and graduate at a rate of 90 percent and make a visible difference on campus and throughout their professional careers. The University of Rochester became a Posse school in 2013 for student in the DC area. As a Posse partner we:
Work together with The Posse Foundation to select 10 DC Posse students each year.
Provide a minimum of a full-tuition grant to each selected student.
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Say Yes to Education is a nonprofit that revitalizes communities by helping them give every Say Yes public high school graduate access to college or other post-secondary scholarships. The Say Yes Higher Education Compact, which began in 2008, has added more than 60 private colleges and universities since 2013. The University of Rochester is one of these 60 schools and as a National Partner College, we agree to:
Ensure that Say Yes students whose annual family income is at or below $75,000 are eligible to receive scholarships covering the full cost of tuition, provided they successfully navigate the institution's regular admission process.
Assist Say Yes students whose family income is above $75,000 and who are enrolled in a Compact institution are eligible to receive annual grants, from the organization itself, of up to $5,000.
Strive for College
Strive for College believes that every student who deserves a shot at college should get one, and our mission is to connect those students with the know-how and support they need to prosper.
Strive is a free online community where aspiring college students connect with dedicated mentors to receive one-on-one guidance and support through the college admissions and financial aid application process. In addition to a dedicated mentor, Strivers also have access to exclusive, data-based college matching tools and custom resources specifically for first-generation college students—and it is all accessible anytime, anywhere!
United World Colleges
UWC (United World Colleges) is a global education movement that makes education a force to unite people, nations, and cultures for peace and a sustainable future.
Our partnership requires us to actively recruit, admit, and enroll UWC graduates each year. Failing to enroll any UWC graduates during any two consecutive years jeopardizes our partner school status. All UWC graduates who enroll must be designated as "Davis UWC Scholars" at the University of Rochester whether funded using our financial aid resources or not.
University of International Business and Economics (IAC Pre-College Program Students)
The University of International Business and Economics (UIBE), situated in the northeast of Beijing, was founded in 1951. UIBE is a national key university jointly-sponsored by the Ministry of Education and the Ministry of Commerce, and is the top university in the fields of economics and business.
The partnership between UIBE and the University of Rochester enables graduates of the IAC Pre-College Program at UIBE to be eligible for admission to the University of Rochester without requiring SAT or ACT scores.
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Yes Prep Public Schools will increase the number of students from underserved communities who graduate from college prepared to lead.
The IMPACT partnership agreement between the University of Rochester and YES Prep Public Schools dedicates at least three to five spaces for YES Prep students to attend MVP at the expense of the university. It also commits to providing 100% of the fly-in cost of all admitted YES Prep students that did not get the opportunity to attend MVP and meets the full demonstrated need of all admitted students. In addition, we will set aside at least one space of the annual counselor program for a YES Prep counselor and/or cover the costs of flying of at least one YES Prep counselor to accompany the students to the fall or spring fly-in program.
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Q: Prove that the series $\sum_{n=1}^\infty \frac{3n^2+x^4\cos(nx)}{n^4+x^2}$ converges. Prove that the series $\sum_{n=1}^\infty \frac{3n^2 + x^4\cos(nx)}{n^4+x^2}$ converges to a continuous function $f :\mathbb R \rightarrow \mathbb R$
My attempt: Let $f_n(x)=\frac{3n^2+x^4\cos(nx)}{n^4+x^2}$
$|f_n(x)|\leq\frac{3n^2+x^4}{n^4}$.  Let $a_n=\frac{3n^2+x^4}{n^4}$ and $b_n=\frac{1}{n^2}$.
$\lim_{n\rightarrow \infty} \frac{a_n}{b_n}=3$. By comparison test both the series converge or diverge together.
By $p$ test $ b_n=\frac{1}{n^2}$ is convergent. This implies $a_n$ is convergent.
By WM test $\sum f_n(x)$ converges uniformly. We know that it converges to a continuous function.

A: I think you should localize to an arbitrary fixed closed interval $[a,b]$, and then apply Weierstrass M-Test, the upper bound is then $\dfrac{3n^{2}+b^{4}}{n^{4}}$, there should not be involved with any $x$.
So it converges uniformly on $[a,b]$ and hence the series is continuous on $[a,b]$, and then one can extend $[a,b]$ to include every point to be a continuity point.


As you are likely aware, at FWAG SW we are keen to highlight the fantastic environmental conservation that farmers across the region achieve every year on their farms. As a way of celebrating this and seeking out these farms, we hold county competitions. This year was no different with stiff competition across the Cornwall Otter, Devon Bronze Otter and Gloucestershire Silver Pintail!
The FWAG SouthWest competitions capture a snapshot of farming for the environment, wildlife as well as maintaining a successful farm business. They are as much about the soil, the crops and livestock as they are about the attitude and values of the farmer.
The competition was strong with three diverse finalists each with their own considerable strengths. This year's finalists were Philip and Faith Hambly of Lethytep, Rob, Sandra and Sam Trudgian of Savath Farm and Chris Jones of Woodland Valley Farm.
Chris Jones triumphed in this year's competition! The judges (INSERT) were really impressed by the huge range of ground-breaking initiatives Chris has taken in agri-environment, biodiversity, soil and water management, renewable energy and more. The extent of monitoring and recording is exceptional, as is his knowledge of environmental issues and development. Chris will be hosting a Farm Walk in spring 2019, so keep an eye out for the date in the New Year.
After one for the hardest autumn and winter periods for many years and on top of the uncertainty of Brexit, the three shortlisted farms showed resilience and presented their very different, but still incredibly effective, ways of managing the land. This years finalists were John Perkin of Parsonage Farm, Philip Short of Chubbs Farm, and Glen Bealey and family at Week Farm near Torrington. The panel of judges, Heather Harley from Exmoor National Park Authority, Tom Stratton from the Duchy of Cornwall, John Whetman, Devon farmer and trustee of FWAG and also Paul Cottington from the NFU were given a hard time with the task of judging such different and quality finalists.
Philip Short's farm has an organic dairy enterprise which the judges felt worked with the land. The varied soils meant that an all grass approach worked best and as a result of careful management provided a number of important wildlife habitats. The closed herd of British Freisians were perfectly suited to the set up and whilst working within the organic regime caused some challenges, it meant the farm was thriving during volatile times. A worthy winner for 2018!
The Barn Owl Trophy is FWAG SouthWest's regional award. After the County competitions have taken place, each winning farm gets put forward for the Barn Owl award, along with the nominated farms from each county that does not host an award. The Barn Owl trophy is awarded annually to the farm that our judges consider to be the best commercial farm entrant delivering wildlife conservation and environmental sustainability across the South West region.
Our wonderful team of Barn Owl judges, Ruth Kimber, Hugh Warmington and Richard Belding travelled across the region visiting each county finalist in August 2018.
The Barn Owl Finalists for 2018 are: Chris Jones, Woodland Valley Farm (Cornwall), Philip Short, Chubbs Farm (Devon), John Martin, Deverel Farm (Dorset), Richard Butler, East Wick Farm (Wiltshire),and Michael Bentley, Castle Fruit Farm (Gloucestershire).
The Barn Owl Celebration will be kindly hosted by Ashton Hawker of Gardner's Farm, the Barn Owl winners for 2017. We will have a farm walk of Gardner's farm, then reconvene at the Hullavington Arms for lunch and the presentation of the 2018 award. The event will be held on Friday 25th January 2019, we would be thrilled for you to come along. You can find the event listed on our events page, take a look now to book on!
A huge thank you to all involved in making our competitions what they are each year; to all our fantastic judges for their time, energy and diligence, to the farmers for your dedication to the future of our farming landscape and to anyone who has helped celebrate with us and raise awareness of the competitions!


Ms. Holmstrom is a member of the International Council of Shopping Centers (ICSC).
Patty Holmstrom joined Winick Realty Group in 2014 following a successful career in the fashion industry where she gained strong interpersonal and sales experience that she brings to her role at Winick Realty Group. Because of her years working with retailers, Ms. Holmstrom is able to guide tenants through the process of looking at an empty store and seeing the potential for their retail flagship. She is focused on bringing new retail tenants to Manhattan, with a particular emphasis on large-format retail tenants in Midtown.
Ms. Holmstrom has been part of the leasing team responsible for many high-profile leasing transactions, including Saint Laurent at 3 West 57th Street. She represented SL Green at 3 Columbus Circle, signing a lease with Nordstrom, as well as repositioning the Chase Bank location in the building. She also worked with SL Green to bring high-end omakase restaurant Ginza Onodera to 461 Fifth Avenue. Ms. Holmstrom continues to work with many of New York's most prominent property owners, including The Chetrit Group and Amsterdam Hospitality. In addition, Ms. Holmstrom is currently representing Wasabi Sushi & Bento in their Manhattan expansion.
Ms. Holmstrom holds a Bachelor's Degree in Sociology and Business Management from the University of Missouri. She is an avid golfer, surfer, skier, SCUBA diver and runner, having competed in the New York City Marathon on behalf of local charities.


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Jul-Aug 2010 Issue
Thinking on Paper: Documenting Decision Making
The third article in our series on Medicare's documentation guidelines will help you determine whether what's on your mind is what's on the patient's record.
Robert L. Edsall and Kent J. Moore
Fam Pract Manag. 2010 Jul-Aug;17(4):10-15.
This content conforms to AAFP CME criteria. See FPM CME Quiz.
Diagnoses and management options
Quantifying diagnoses and management options, data and risk
Where medical decision making is concerned, Medicare's Documentation Guidelines for Evaluation and Management (E/M) Services are more striking for what they leave unsaid than for what they say. They do tell you what a reviewer would look for in determining the level of your decision making. However, unlike the guidelines for documenting history and exam, they don't tell you enough to figure out the level yourself, thereby leaving you to guess whether your documentation supports the claim you submit.
But somebody other than you has to be able to determine the level of decision making – and if you're audited, somebody will. The purpose of this article is to help you document and quantify what you're thinking about during patient encounters, so that you and a reviewer might reach the same conclusion about the level of decision making your note supports and so that you can confidently claim the payment you're entitled to. If you'd like to review the rest of the guidelines, see the articles on history documentation in our March/April 2010 issue and exam documentation in our May/June 2010 issue. The table below shows how medical decision making combines with history and exam to determine code selection.
SUBSECTIONS OF THE DOCUMENTATION GUIDELINES
Severity of presenting complaint
Problem focused
Minor or self-limited
Expanded problem
Low complexity
Low to moderate
Moderate complexity
Moderate to high
High complexity
Table applies to established patient office visits.
Jump to section +
As you know, the CPT manual considers the level of complexity of medical decision making to be a function of three variables, and this division is also reflected in the documentation guidelines:
The number of potential diagnoses and management options that must be considered during an encounter,
The amount and complexity of data to be reviewed as a result of the encounter,
The risk of complications, morbidity and mortality associated with the encounter.
We can call these three elements diagnoses and management options, data and risk.
The guidelines follow CPT in recognizing four levels of each of these elements, and four corresponding levels of medical decision making overall (see "The elements of medical decision making"). The level of medical decision making for a given visit actually depends on the highest two out of these three elements. If you find that confusing, remember that the level of medical decision making is the same as either the second-highest of the three elements if they're all different or the tied elements if they're not. That's the easy part, though. The challenge lies in properly documenting diagnoses and management options, data and risk and in figuring out the level of each that a given note represents.
THE ELEMENTS OF MEDICAL DECISION MAKING
Type of decision making
Diagnoses or management options
Data to be reviewed
Minimal or none
At least two criteria must be met or exceeded.
Determining the number of potential diagnoses and management options you have to deal with in an encounter is harder than it sounds. The guidelines suggest that this factor depends on each of the following:
The number of problems you deal with in the encounter,
How uncertain you are about the diagnosis,
The number of management options you have,
How uncertain you are about which management option to choose.
You can document the number of problems you deal with simply by listing them, as you probably do anyway. The guidelines do not require that you actually put down a number. The documentation of diagnostic uncertainty and management options is a little more involved, but it's also something you probably do already. If you understand what the guidelines are looking for in each of these areas, however, you may be more likely to cover all the bases.
Diagnoses. How good a handle you have on the diagnosis of each problem is the crux of the issue here; according to the guidelines, "decision making with respect to a diagnosed problem is easier than for an identified but undiagnosed problem." Actually, the guidelines suggest the following spectrum of diagnostic uncertainty, from least to most uncertain:
An already-diagnosed problem that is now improved, well-controlled, resolving or resolved,
An already-diagnosed problem that is now inadequately controlled, worsening or failing to change as expected,
An identified but undiagnosed problem for which the history and physical are sufficient to establish a probable diagnosis,
An identified but undiagnosed problem for which you need information beyond the history and physical (lab tests, for instance, or a consultation).
While almost anything you say about a problem will suggest where it falls on this spectrum, you may save yourself trouble in an audit if you keep these categories in mind and always make it clear which category a given problem falls into. As with most of their other recommendations, the guidelines do not insist that you identify the category explicitly, only that it be clearly implied. For instance, the fact that you document ordering lab tests or referring a patient for a biopsy should make it clear enough to any reader that you're dealing with an undiagnosed problem for which the history and physical don't provide enough information. Similarly, if your assessment says, "IDDM – controlled," it should be clear to any reviewer that you're dealing with a problem at the low end of the uncertainty spectrum.
When the history and physical aren't enough to pin down a probable diagnosis, it's important to document what you did to get more information, in part because it can help indicate the degree of uncertainty you're dealing with. As the guidelines say, "The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses," and "The need to seek advice from others is another indicator of complexity of diagnostic or management problems." The guidelines ask, reasonably enough, that when you refer a patient, request a consultation or ask for advice, you specify whom you referred the patient to, requested a consultation of or asked for advice.
A caution: While noting that you've ordered a lab test can imply something about the diagnosis or diagnoses you're considering, it's probably worth taking time to add an explicit comment to the assessment. Something as brief as "hypothyroidism vs. anemia" can be enough. You can't write "ECG and a Chem-21 profile" and expect a reviewer to know what you were thinking. A test you order may indeed help a reviewer determine the level of medical decision making if it really does indicate your line of thinking, but to do so, it has to be fairly specific.
The point is to convey that you have thought of a range of diagnoses and selected one based on the information above. This is what you tend to do in your head, but the guidelines require that it be indicated on paper.
Management options. In addition to implying that the need to seek advice about treatment suggests a higher level of medical decision making, the guidelines include one point about treatment: "The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies and medications."
The guidelines don't get directly at the issue of how many management options are open to you in a given situation – something you would expect to be important given that one element of the medical decision making guidelines is the number of diagnoses and management options. Still, saying what option you picked will presumably imply something about the options that were open to you.
When the guidelines talk about "the amount and complexity of data to be reviewed," they refer to information gathered from sources other than the history and physical – lab tests, imaging, other diagnostic services, old records and history from sources other than the patient. Generally speaking, the guidelines ask that you record the decision to seek additional information and, if you have obtained the information, the results of your review of it. The rationale is that any such step implies an increase in the complexity and volume of the data you need to winnow. Specifically, they ask that you make sure the documentation reflects the following:
The nature of any diagnostic service you order, plan, schedule or perform at the time of the encounter.
Any review of diagnostic test results that you perform. "An entry in the progress note such as 'WBC elevated' or 'chest x-ray unremarkable' is acceptable," as is your simply initialling and dating the reports of test results.
Any decision to review old records or obtain history from sources other than the patient.
Relevant findings from any review of old records or from any additional history you obtain – or a note to the effect that you carried out such a review but found no additional relevant information. "Old records reviewed" or "additional history obtained from family" is not enough. You need to give relevant findings or say explicitly that there were none.
The results of any discussion you have with the physician who carried out or interpreted a diagnostic test or service. That the guidelines talk about "discussion of contradictory or unexpected test results" (emphasis added) at least suggests the possibility that carriers might question such a discussion of results unless they were contradictory or unexpected.
Your "direct visualization and independent interpretation of an image, tracing or specimen" that has been or will be interpreted by another physician. Again, the guidelines suggest that such independent checking is not expected to be a regular thing, but rather something that happens only "on occasion."
The guidelines consider risk to the patient in determining the level of medical decision making – risk of significant complications, morbidity and mortality – and they recognize three gauges of this risk: the presenting problems, any diagnostic procedures you choose and any management options you choose.
The guidelines include only a few points under documenting risk, but much of the information needed for assessment of the level of risk is already called for in other parts of the guidelines. These are the additional points:
Comorbidities, underlying diseases and other factors that increase risk should be documented.
All surgical procedures and invasive diagnostic procedures performed or planned should be documented as specifically as possible. That is, if you perform such a procedure during the E/M encounter, you should document "the specific procedure," and if you request, plan or refer for such a procedure, you should document "the type of procedure, e.g. laparoscopy."
If you refer for or decide to perform such a procedure urgently, that urgency should be clearly communicated by the record.
The guidelines give no help in defining what minimal, limited, multiple and extensive mean when applied to the number of diagnoses and management options, or what constitutes minimal, limited, moderate or extensive review of data. Since the guidelines were first introduced, a number of worksheets have emerged that auditors, coders and physicians use to help fill this gap by assigning points for documentation elements and defining each level of diagnosis and management options and data in terms of point ranges. Today Medicare contractors use a variety of such worksheets to audit claims. Because there is no standard, you should check with the contractor in your region to find out what system to measure your medical decision making against. (This isn't the only area where Medicare contractors differ in their application of the documentation guidelines; see "Is Your Medicare Payer Playing by the Rules?" to learn about others.)
The guidelines do provide a useful table for quantifying the four levels of risk (see "Quantifying the risk of complications, morbidity and mortality"). The table lists common examples of problems, diagnostic procedures and management options classified by level of risk. It is intended as a ruler against which to loosely measure the risk inherent in problems and procedures not listed. Clearly, the quantification of risk is not an exact science, any more than the quantification of uncertainty. The guidelines do attempt to contain the problem by specifying limited periods over which to estimate risk. Where risk is related to presenting problems, you are to assess the amount of risk the patient will be subjected to "between the present encounter and the next one." When risk is related to your decisions and actions – that is, when it is related to diagnoses and management options – the guidelines ask you to assess the risk "during and immediately following any procedures or treatment." To use the table, find the categories in which the patient's presenting problems and your diagnostic and therapeutic actions seem to fit best. The highest individual level of risk determines the overall level. Consider this encounter with a hypertensive patient:
S: A 55-year-old male established patient returns today for follow-up of hypertension. Has done well since last visit w/o Sx consistent w/ angina or CHF. His only complaint is increased fatigue over past 1–2 months w/o DOE or other constitutional Sx. Current meds include nadolol 20 mg qd, HCTZ 25 mg qd.
O: BP 126/86, P 82, Wt 190, HEENT: PERRLA. EOMs intact, TMs nl, oropharynx benign. NECK: supple w/o JVD, bruits or thyromegaly. CHEST: BS clear to percussion and auscultation. EXT: w/o edema, pulses intact.
A: 1. Stable hypertension.
2. Fatigue most likely secondary to hypertensive meds – rule out electrolyte abnormality.
P: 1. Continue nadolol 20 mg qd.
2. Discontinue HCTZ and monitor BP and Sx.
3. Consider changing nadolol if fatigue persists.
4. CBC/SMA 7 today.
5. Return for follow-up in 3–4 wks.
The presenting problem, hypertension with fatigue probably resulting from antihypertensive therapy, seems to fit in the moderate risk level as "one or more chronic illnesses with mild exacerbation, progression or side effects of treatment." The diagnostic procedures seem to fall into the minimal risk level as "laboratory tests requiring venipuncture." The management option, modifying a prescription drug, falls into the moderate risk category as "prescription drug management." Since the highest risk identified is moderate, that is the risk associated with the visit.
You may find it useful to examine the table for patterns and characteristics that will help impress the categories in your mind. For instance, under diagnostic procedures, note the four-step progression of imaging studies from chest X-rays and ultrasound to noncardiovascular studies involving contrast, to cardiovascular studies involving contrast and no identified risk factors, to cardiovascular studies involving contrast with identified risk factors.
One remarkable characteristic of the table is that it puts prescription drug management on a par with elective major surgery as a moderate-risk intervention. Remembering that any visit that involves a prescription is at least a moderate-risk visit can simplify the process of establishing a risk level.
QUANTIFYING THE RISK OF COMPLICATIONS, MORBIDITY AND MORTALITY
Presenting problems
Management options selected
One self-limited or minor problem, e.g., cold, insect bite, tinea corporis
Laboratory tests requiring venipuncture Chest X-rays Urinalysis Ultrasound (e.g., echocardiography) KOH prep
Rest Gargles Elastic bandages Superficial dressings
Two or more self-limited or minor problems One stable chronic illness (e.g., well-controlled hypertension or non-insulin-dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain)
Physiologic tests not under stress (e.g., pulmonary function tests) Non-cardiovascular imaging studies with contrast (e.g., barium enema) Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies
Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
One or more chronic illnesses with mild exacerbation, progression or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis) Acute complicated injury (e.g., head injury with brief loss of consciousness)
Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test) Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization) Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)
Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation
One or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries that may pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure) An abrupt change in neurologic status (e.g., seizure, TIA, weakness, sensory loss)
Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiologic tests Diagnostic endoscopies with identified risk factors Discography
Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis
Medical decision making seems to have a special role in determining the level of a patient encounter, even though it's supposed to be weighted evenly with the history and exam.
Indeed, reviewers are likely to regard the medical decision making component as a reality check on the other two key elements. While any two of the three can determine the overall level for an established patient visit, the physician who consistently documents a high-level history and a high-level exam on a patient with a minor problem is asking for trouble.
But even if the obvious ethical considerations did not militate against subversion of the guidelines, good sense argues against it. A claim supported by documentation that obeys the letter of the guidelines while violating their spirit can still be challenged by the carrier on the grounds of medical necessity. The trick is to push the guidelines exactly as far as accuracy requires – no more, no less.
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Robert Edsall is editor-in-chief of Family Practice Management. Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to FPM. Author disclosure: nothing to disclose.
Send comments to fpmedit@aafp.org
Editor's note: To enrich our online archive with some particularly useful "pre-web" articles, we are publishing updated versions of them. This article first appeared in 1995.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.
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Sigalapang Julu is een bestuurslaag in het regentschap Mandailing Natal van de provincie Noord-Sumatra, Indonesië. Sigalapang Julu telt 1340 inwoners (volkstelling 2010).

Plaats in Noord-Sumatra


Introducing Coach House, a trade only supplier of quality trend inspiring furniture, lighting and home décor.
With unique collections that span from traditional designs right through to contemporary, including furniture, lighting, design-led accessories, artificial florals, Indian antiques and festive products, it's no wonder why Coach House is one of the industry's largest and most trusted names.
Their recent 2019 collection features an injection of colour and a variety of textures. Their 2018 Autumn Fair saw the release of 5 new furniture ranges, including Mayfair, Wellington, Berkley Blue, Mirage and Toronto – Most of which can be found in their new furniture catalogue which features 1,200 new products!
Coach House began with very humble origins, in a small old coach house in Yorkshire selling antiques. Once established they then expanded into the reproduction market out of fluke and good fortune and have evolved ever since.
Coach House aims to carry on doing what they do best but endeavouring to do it better!
The family-run business is constantly sourcing new and exciting products from all over the globe as well as designing the antiques of the future. It is the extensive breadth of product they offer which makes Coach House both an inspirational company to be a part of and an inspiring company to be a customer of.
The Coach House showrooms, which you can visit in Lancashire consist of 40 individually styled rooms, holding over 12,000 product lines.
As a customer friendly company, they offer a personal experience for customers, with services that include free weekly deliveries throughout the UK and Ireland. Plus, an optional point of contact with one of their knowledgeable business development executives who travel around most areas of the UK.


This is a 2-hour arm knitting class, and everyone will go home with their own, homemade infinity scarf! No experience is necessary, and we'll walk you through the steps together.
All of the supplies are included with artist instruction!
We use premium bulky yarn for the highest quality, extra soft scarves. You will be able to choose your 2 colors when you arrive, and the colors will be first come first serve. We offer beige, grey, red, yellow, and blue. Our studio is BYOB, so feel free to bring your own wine, snacks, drinks, etc. We'll provide the cups, bottle openers, and paper plates.


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Troy - Steelbook Edition (UK EDITION)
The Lord of the Rings Trilogy - 4K Ultra HD
Blade - Zavvi Exclusive 4K Ultra HD Steelbook (Includes 2D Blu-ray)
Marvel's New Mutants - Zavvi Exclusive 4K Ultra HD Steelbook (Includes 2D Blu-ray)
Zavvi - The Home of Pop Culture
Brad Pitt picks up a sword and brings a muscular, brooding presence to the role of Greek warrior Achilles in this spectacular retelling of The Iliad. Orlando Bloom and Diane Kruger play the legendary lovers who plunge the world into war, Eric Bana portrays the prince who dares to confront Achilles, and Peter O'Toole rules Troy as King Priam. Director Wolfgang Petersen recreates a long-ago world of mighty warships, clashing armies, the massive fortress city and the towering trojan horse. 'If love is worth fighting for, it has known no greater battle than this.' It's known no greater action-epic movie either.
Adoni Maropis
Number of Discs:
English, Castilian Spanish, Danish, Dutch, Finnish, French, German, Italian, Norwegian, Portuguese, Swedish
156 mins approx.


It's official, Esso brainwashed the Welsh into supporting England at the 1970 World Cup. We should sue.
As a vulnerable, easily-led, seven-year-old in Llangunnor, Carmarthen, I collected the coins via my old man, who visited the Esso just the other side of the bridge out of the town centre .
Even now, I still look at the spot with anticipation without immediately realising why.
Then I remember – the petrol station visits were hugely exciting at a time when I'd fallen in love with football and Cardiff City, then tearing up the Second Division and looking certain to make it back to the First.
Dad was a keen driver and we must have piled up a fair number of the coins. The collection helped fuel interest in the 1970 event, the first one I remember.
David Coleman's terse commentary and the atmospheric Mexican buzzing bee hum of the matches stay with you.
Obviously, the Esso mind control has worn off and Panini have cornered the market in this sort of thing with their stickers.
But the coins and the hardboard are still an attractive, evocative item of football memorabilia. Not worth a great deal by the look of it – an internet search put it at maybe £25.
And, er, if you've got a spare Alan Mullery, then that would complete my set.


This Limited Edition collection designed by Dana Willard is filled with creamy cones in vibrant colors, candy dots, playful hand lettering and plenty of geometric shapes, you are guaranteed to be screaming for ice cream. Just pick your flavour and 'eat it all'! Another vibrant and fun print from this collection.


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How to Reduce Stress In Large Crowds - Beat The Fear With Joe Leonardo (E2)
Giant video display boards, human sized cartoon characters, subway stations, police on horseback, the Naked Cowboy, 42nd Street, massive New Year's Eve celebrations… there's only one Times Square. All this and being in the heart of New York City makes it an exciting destination … unless you have a fear of crowds. In this episode of Beat The Fear, host Joe Leonardo plunges himself into these streets at "the crossroads of the world" to test some techniques for dealing with the stress of being around so many people in such a small space.
With the help of fellow comedian and filmmaker Orli Matlow, they attempt to walk through the throng while discussing what they are both feeling, on the inside. "When I'm stressed, my head gets light, and it's like being drunk without any of the fun," Orli explains. "But my body feels like it's being weighed down by rocks. It's hard to strike a balance in the middle."
Joe's reaction to crowd stress is more mental than physical. "The biggest problem is that thought becomes irrational," he shares. "It's like your brain is screaming at you all the time even though you know you are safe and fine."
It's hard not be anxious just watching their discomfort as the cars and people and bustle and noise swirls around them. But, stick around. Joe and Orli both offer some suggestions about what they do when they feel that stressful feeling coming on. Who knows, it may work for you, too!
Follow Joe on Twitter at: https://twitter.com/imjoeleonardo
Learn more about Orli at: https://www.orlimatlow.com/