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Research Article | Open Access
Volume 2014 |Article ID 187280 | https://doi.org/10.1155/2014/187280
Sanne Rasmussen, Jens Søndergaard, Pia Veldt Larsen, Kirubakaran Balasubramaniam, Sandra Elnegaard, Rikke Pilsgaard Svendsen, Rikke Sand Andersen, Anette Fischer Pedersen, Peter Vedsted, Dorte Ejg Jarbøl, "The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals", International Journal of Family Medicine, vol. 2014, Article ID 187280, 10 pages, 2014. https://doi.org/10.1155/2014/187280
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The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals
Sanne Rasmussen ,1 Jens Søndergaard,1 Pia Veldt Larsen,1 Kirubakaran Balasubramaniam ,1 Sandra Elnegaard ,1 Rikke Pilsgaard Svendsen,1 Rikke Sand Andersen,2 Anette Fischer Pedersen,2 Peter Vedsted,2 and Dorte Ejg Jarbøl1
1Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9A, 5000 Odense C, Denmark
2The Research Unit for General Practice, Danish Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
Academic Editor: Christos D. Lionis
Received09 Dec 2013
Revised14 May 2014
Accepted08 Jul 2014
Published23 Jul 2014
Introduction. In order to develop strategies to prevent delay in diagnosis, it is important to gain knowledge of symptoms and healthcare-seeking processes in the population. This paper describes a combined survey and register-based study with (1) focus on development of a questionnaire concerning experience of symptoms and subsequent consequences and (2) feasibility of the study. Methods. The study is a nationwide cohort study of 100 000 individuals randomly selected from the Danish general population. A comprehensive questionnaire concerning experience of symptoms and subsequent consequences was developed. The methodological framework for the development included defining the domains to be measured, identification of previous items, scales and questionnaires in the literature, and pilot and field testing. Results. A total of five domains and 16 subdomains were defined covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. In total, 49 706 questionnaires were completed, yielding a response rate of 52.2%. Conclusion. We developed a comprehensive questionnaire used in a large combined survey and register-based study concerning experience of symptoms and subsequent consequences of symptom experiences. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort.
Symptom experiences among people in the general population are common. Studies have shown that over three quarters of adults have experienced a symptom within the past two weeks, and up to 15% have experienced an alarm symptom of one of the four most frequently occurring cancers within the preceding year [1, 2].
Symptom experiences are embedded in a complex interplay of biological, psychological, and cultural factors and may reflect a variety of interpretations of sensations, which are not necessarily expressions of underlying disease. Many people manage symptom experiences privately without consulting the healthcare system. Thus only some symptom experiences are presented to the healthcare system, a phenomenon referred to as the "symptom iceberg" [3, 4]. From a medical perspective some of these symptoms might be alarming and indicating serious disease that ought to be examined by a physician. The issue of proper healthcare-seeking is often raised in connection with serious diseases, in particular in terms of patients' awareness and knowledge of symptoms and the "patient interval," that is, the time elapsed from a patient experiencing a symptom until seeking healthcare [5].
Some of the factors which can affect the decision to seek healthcare are symptom characteristics, impact on daily activities, personal experience with or witnessing of symptoms and disease, health perceptions, and network and social context [1, 6–8]. In spite of the existing literature on possible determinants of healthcare-seeking, understanding of symptom experience, interpretation, and management in everyday life is still deficient. Most of the existing research is based on retrospective studies on selected groups of patients making it difficult to generalize to the general population [5, 7].
Providing timely and effective healthcare in relation to serious diseases is an important task for the healthcare system. In order to develop strategies to prevent delayed diagnosis, it is important to gain knowledge of the symptoms occurring in the general population and knowledge about factors important for the healthcare-seeking process. The purpose of this paper is to describe the development of a comprehensive questionnaire concerning experience of symptoms, interpretation, and subsequent consequences of symptom experiences. The specific objectives are (1) conceptualization of "symptom experience" and "healthcare-seeking," defining the domains to be measured, identification and inclusion of previously used and validated items, scales, and questionnaires, and development of single symptom items pilot and field testing of the comprehensive questionnaire and (2) the feasibility of the study.
2. Methods
The study was designed as a nationwide cohort study of 100 000 people randomly selected from the general population and with baseline data collected in a web-based survey. All Danish citizens are registered in the Danish Civil Registration System (CRS) with a unique personal identification number enabling accurate linkage between national registers. In Denmark researchers are prohibited by law to contact persons who have declined to participate in research-related inquiries. These persons were excluded prior to sampling, based on information in the CRS. From the CRS, 100 000 adults aged 20 years or above were randomly selected and invited to participate in the survey. The individuals received a postal letter explaining the purpose of the study. In the letter a unique 12-digit login for a secure webpage was included.
2.1. The Study Population, Recruitment, and Logistics
Due to the large sample size the study population was randomly divided into four equally sized groups. The groups were invited with two-week time intervals, except the first two groups who were invited with a four-week interval because of the holiday season. A reminder letter followed the initial invitational letter to nonrespondents after two weeks. After additional two weeks the nonrespondents were contacted by telephone and encouraged to participate. A private telemarketing company conducted the latter reminder procedure. In this procedure the participants were offered the opportunity to receive an e-mail with a direct link to the questionnaire.
In order to prevent the exclusion of people with no access to a computer, tablet, or smartphone we offered the participants the opportunity of the survey being conducted as a telephone interview. A group of trained interviewers were assigned to conduct the telephone interviews. The interviewers were instructed to read the questions and prespecified options out loud, not contributing with their own interpretation of the questions. We drew lots for 10 iPads among all the respondents as gratuity for their efforts.
2.2. Electronic Platform
The questionnaire was designed in the web-based online platform SurveyXact [9]. To access the questionnaire, the respondent had to open a webpage and enter the provided 12-digit login. The electronic format of the questionnaire made it possible to construct a leap structure, so the respondents were directed through the questionnaire according to the answers already given and hereby skipping irrelevant questions.
2.3. Developing the Questionnaire
The conceptual objective of the study was to measure the prevalence of symptom experience in the general population and the individual's interpretation of symptoms and subsequent healthcare-seeking behaviour. Data concerning self-reported experience of symptoms and subsequent consequences together with personal and social characteristics were collected using a comprehensive questionnaire. The questionnaire is based on standard rating scales, previously validated questionnaires, and ad hoc items.
The methodological framework for developing the questionnaire included the following steps [10]:(1)based on the objective, defining the constructs and conceptual framework, and exploring the literature on these concepts with the purpose of defining the domains to be measured;(2)identification of previous items, scales, and questionnaires in the literature followed by item generation and item reduction;(3)pilot testing with regard to content validity, relevance, acceptability, and feasibility;(4)field testing within a pilot study on 500 randomly selected people from the general population testing data quality and floor and ceiling effects and assessing the distribution of the answers in the various categories. Besides field testing the pilot study was used to test study procedures, resources, time scale, and estimation of the recruitment rate.
2.3.1. Defining the Constructs and Conceptual Framework and Exploring the Literature regarding Measuring Instruments Fulfilling the Objective
The first step in the process was to define the concepts of "symptom experience" and "healthcare-seeking behaviour."
The term symptom as presented in the discipline of medicine is influenced by a desire to predict underlying diseases and risks of negative effects on health. In medicine, it is common to distinguish between subjective health complaints (symptoms) and signs with the latter being objectively verifiable (e.g., blood in the urine or jaundice), whereas symptoms often refer to subjective complaints. The WONCA Dictionary of General/Family Practice defines a symptom as "any subjective evidence of a health problem as perceived by the patient" [11]. The fact that symptoms are subjective complaints should be emphasised when exploring symptom experiences. In this study, we define subjectively reported symptom experiences as multidimensional constructions embedded in a complex interplay of biological, psychological, and cultural factors. This definition implies that symptom experiences are not viewed as objective, clinical phenomena but are seen as the result of the patient's own interpretation process, in which bodily sensations or changes are transformed into signs of ill health [6, 12, 13].
Current literature on healthcare-seeking often presents a dichotomous approach: either you seek medical advice or you do not seek medical advice. In this study we wanted to approach healthcare-seeking behaviour in a multifactorial context [14]. A group of experts from different disciplines in symptom research was established. The group comprised a psychologist, an anthropologist, and six medical doctors. Based on the literature from the three different disciplines and discussions in the group, the constructs "symptom experience" and "healthcare-seeking behaviour" were defined and a conceptual framework for both constructs was formed, resulting in a combined formative and reflective model.
The Developing Process of the Questionnaire. The developing process involved several meetings in the group comprising the three different disciplines: psychology, anthropology, and medical science. The development of the domains as well as the item generation in each domain was based on the literature of symptoms and healthcare-seeking and related factors. Overall the discussion in the group concerned (1) reflections on which symptoms to include where the emphasis was on frequency and severity, (2) recall periods, and (3) operationalising the conceptual framework.
Domains in the Questionnaire. Based on our conceptual framework, a core content of domains was developed to be included in the questionnaire. A total of five domains were identified (Table 1).
Domains Subdomains Items
(1) Symptom experience Specific and nonspecific cancer alarm symptoms Alarm symptoms covering the following areas
Lung, gastrointestinal, gynaecological, and urogenital cancer
General, frequent symptoms
Feeling unwell
Feeling ill
Abdominal symptom-based conditions Symptoms based on the consensus classification regarding dyspepsia and irritable bowel syndrome (the Rome III criteria)
Symptoms forming the basis for diagnosis of gastroesophageal reflux disease (Montreal criteria)
Bodily distress syndrome Items identified to classify BDS, covering the following areas
General symptoms
(2) Symptom experience characteristics Debut First occurrence of the symptom experience
Impact on daily life Impact of the symptom experience on daily life activities
Concerns The respondents' concerns regarding the symptom experience
(3) Reactions in response to symptom experience Use of social network Discussion of symptom experience with friends, acquaintances, and family
Contact with the GP, other therapists, hospital doctors, community nurses, physiotherapists, etc.
Considerations about contact with the GP Decisions of four barriers towards healthcare-seeking using the ABC (awareness and beliefs about cancer)
"It would be embarrassing for me"
"I would be worried about wasting the doctor's time"
"I would be worried about what the doctor might find"
"I was too busy to find time to go to the doctor"
(4) Selected factors with potential influence on the symptom experience and healthcare-seeking Life style Smoking
Access to social network Frequency of contact in terms of telephone conversations and/or communion with others
Concerns for the respondent The GP's and surroundings' reaction and concern for the respondent
Experience with illness Experience with serious illness in the immediate family and close friends
(5) Personality characteristics in relation to symptom experience and healthcare-seeking Attitude towards risk-taking Attitude towards risk in relation to health and finances
Self-rated health Respondents assessment of own health
Coping strategies Respondents assessments of coping with problems using The Brief Approach/Avoidance Coping Questionnaire
Domains in the questionnaire.
Three domains consider the symptom experience and actions taken in response to the symptom experience.(i)The first domain addresses the occurrence of different "symptom experiences" during the preceding four weeks.(ii)The second domain concerns symptom experience characteristics in terms of time point for first symptom experience, concerns, and impact on activities of daily living.(iii)The third domain explores the reactions and actions taken in response to symptom experiences, for example, discussion with friends and family, healthcare-seeking behaviour, and potential barriers to seeking medical advice.
The remaining two domains were included in order to explore how various factors may influence symptom experience and healthcare-seeking.(iv)The fourth domain concerns the potential influence of a number of selected factors on the symptom experience, for example, lifestyle, social network, the GP's and the surroundings' reactions to—and concern for—the person's health, and experience of illness in the immediate family and circle of friends.(v)The fifth domain considers the respondents' personality characteristics such as self-rated health, coping strategies, and their attitude towards risk taking.
2.3.2. Item Generation and Item Reduction
Domain 1: Symptom Experience. We created a large item bank with various predefined symptoms. In relation to the conceptual framework we aimed to include a variety of bodily symptom experiences. From a medical perspective some of these are categorized as alarm symptoms, but also a variety of symptoms that are frequently occurring and categorized as benign were included. The following subdomains were identified: (1) specific and nonspecific cancer alarm symptoms, (2) general, frequent symptoms, (3) abdominal symptom complexes, and (4) bodily distress syndrome.
Re 1. For representativeness of symptoms that from a medical perspective are defined as indicating a serious disease, we selected a number of specific and nonspecific alarm symptoms covering the following areas: lung, gastrointestinal, gynaecological, and urogenital cancer. The symptoms were selected based on a review of literature, national and international cancer referral guidelines, and descriptions of cancer pathways [15–17].
Re 2. We included a number of general symptoms based on the knowledge that cancer patients in addition to presenting a specific alarm symptom often also present vague and uncharacteristic symptoms [15, 18]. The selection of these symptoms was based on retrospective studies of cancer patients' registration of symptoms prior to their first contact [5, 7].
Re 3. As an example of an organ-specific area, we chose abdominal symptoms, because abdominal symptoms are frequently occurring in the population, are often occurring in frequent healthcare-seekers, and are associated with a range of definable symptom-based conditions, for example, dyspepsia, gastroesophageal reflux disease, and irritable bowel syndrome. Further, there are symptoms which both occur in cancer referral pathways and in the functional abdominal symptom complexes. The selection of symptoms was based on the latest symptom-based consensus classification regarding dyspepsia and irritable bowel syndrome (the ROME III criteria) [19–21], while the symptoms forming the basis for diagnosis of reflux disease were defined by the Montreal criteria [22].
Re 4. Symptoms not attributable to any medical diagnosis challenge the concept of diagnosis. Patients with symptom experiences from numerous organ systems and with a high symptom burden are referred to in a number of different ways in the literature, for example, unexplained medical disorders, psychosomatic disease, or somatisation. These symptoms are now assembled in one classification called bodily distress syndrome (BDS). Items already identified to classify BDS were included [23].
Based on the subdomains, we created items asking whether people had experienced one or more of the predefined symptoms within the preceding four weeks.
Domain 2: Symptom Experience Characteristics. In the second domain we wanted to explore the time point for each symptom experience, concerns in relation to the symptom experience, and impact on activities of daily living.
People are more likely to seek healthcare if symptoms are perceived as severe or incapacitating [3]. The persistence of a symptom may also influence the way people interpret it differently [24]. The literature emphasises symptom severity as a phenomenon that should involve integration of patient-reported severity ratings in combination with clinical measures, such as daily functional status or concurrent psychosocial features [25, 26]. Therefore, items regarding when the symptoms were experienced for the first time and how the symptoms had influenced the respondents' daily activities were included. Additionally, an item asking whether the respondents had had concerns regarding their symptom experience was included.
Domain 3: Reactions in Response to Symptom Experience. Studies have shown that use of and access to social network, for example, telling and interacting with others when experiencing symptoms or asking for advice, influences healthcare-seeking [27]. Viewed from a psychological perspective the use of social network in relation to illness and stressful situations is often characterized by the following two types of social support: instrumental support in terms of practical help, advice, and emotional support in the form of confidentiality, empathy, and love [28]. The use of social network in relation to help and healthcare-seeking is from a social science viewpoint based on the theory that people generally neither make a single choice nor plan a set of choices. When experiencing potential signs of illness, they will ask for advice and seek help from a wide variety of lay, professional, and semiprofessional others until the situation is resolved or options are exhausted [26]. In combining social science and psychological approaches we therefore developed items on whether the respondents had consulted their family, friends, coworkers, and so forth and/or their GP, other doctors, community nurses, physiotherapists, and so forth when experiencing a symptom.
Studies have shown that people often experience one or more barriers to seek healthcare. The respondents were asked to decide on four of the most common considerations in relation to healthcare-seeking [29]. Moreover, we included a free text box encouraging the respondents to add additional considerations regarding contact to their GP in relation to every symptom experience.
Domain 4: Selected Factors with Potential Influence on the Symptom Experience and Healthcare-Seeking. The fourth domain was developed based on the hypothesis that the symptom experience and healthcare-seeking behaviour may be influenced by a number of external factors. We therefore included items from existing questionnaires on lifestyle factors, for example, smoking and alcohol consumption, and items about general contact to the social network as well as the GP's and social network's expressed concern for the respondent's health. Moreover, we included items exploring experience of illness in the immediate family and circle of friends [30].
Domain 5: Personality Characteristics in relation to Symptom Experience and Healthcare-Seeking. One of the aims of the study is to examine possible associations between personality facets, symptom experiences, and healthcare-seeking behaviour, respectively. Risk-taking attitudes as well as dispositional coping strategies have shown to be associated with various types of health-related behaviours in different patient populations [31–35]. In the fifth domain we therefore included a number of items on self-rated health and attitude towards risk-taking. Additional to these items, we included a scale assessing the prevailing tendency to use approach or avoidant coping strategies. The coping scale was available only in English and was therefore translated into Danish according to standardised methods [36].
On the last page of the questionnaire we added a commentary box encouraging respondents to add additional comments and to report any comprehension problems in the questionnaire.
2.3.3. Pilot Testing
The aim of the pilot testing was to test the content validity, that is, relevance, acceptability, and feasibility. Before conducting the first test, the questionnaire was discussed by a multidisciplinary expert panel comprising a psychologist, an anthropologist, a biostatistician, two GPs, and five medical doctors. Further, the questionnaire was sent out to a group of 25 persons from an academic setting (all researchers in healthcare, natural sciences, and humanities) and was further discussed in this academic setting. This resulted in both alterations in the order of the items and clarification of introductory captions to each of the domains.
The pilot testing was conducted in two stages, the first with seven women and four men aged 22–61 years who were observed as they completed the questionnaire. The people participating in the pilot testing were recruited at a train station outside a public library. Trained interviewers asked the participants to read each item and answer it while thinking out loud, highlighting problems, and expressing their attitude to the question.
The second round of pilot testing included 11 new participants, four men and seven women, with an age range of 20–78 years.
2.3.4. Field Testing
A pilot study was conducted among 500 Danish adults aged at least 20 years and randomly selected using the CRS. We used the electronic platform SurveyXact and offered the possibility of completing the questionnaire by a telephone interview. Field testing of the questionnaire was incorporated in the pilot study. We assessed the mean and standard deviation of each item, median, and extent of floor and ceiling effects.
The Regional Scientific Ethics Committee for Southern Denmark evaluated the project and concluded that the project was not notifiable and could be implemented without the permission from The Regional Scientific Ethical Committee for Southern Denmark according to Danish law. The participants in the study were clearly informed that there would be no clinical follow-up and that they should contact their own GP in case of concern or worry. The project has been approved by the Danish Data Protection Agency (journal number 2011-41-6651).
4.1. Development of the Questionnaire
A conceptual framework with regard to symptom experience and healthcare-seeking was developed. The final questionnaire consisted of five domains with 16 subdomains. Table 1 shows the domains and subdomains. A total of 44 single symptoms were included (Table 2). Content validity, that is, relevance, acceptability, and feasibility of the comprehensive questionnaire, was assessed in the pilot testing. The first round of pilot testing identified items where the participants' understanding differed from the intended meaning as well as items causing confusion or uncertainty. This stage of pilot testing resulted in alterations in the caption of the first domain. The second round resulted in alterations in layout and wordings and exclusion of items with poor feasibility, for example, items about "worrying about illnesses" which the participants found difficult and aggravating.
Tiredness Erectile dysfunction
Night-time urination Pelvic pain
Lack of energy Shortness of breath
Headache Hoarseness
Back pain Urge incontinence
Abdominal bloating Loss of appetite
Memory problems Blood in stool/rectal bleeding
Abdominal pain Pelvic pain during intercourse
Coughing Fever
Concentration problems Difficulty swallowing
Change in stool texture Weight loss
Dizziness Incontinence without stress/urge
Feeling unwell Pain/burning when urinating
Constipation Lump/swollen lymph node
Increase in waist circumference Black stool
Change in stool frequency Repeated vomiting
Diarrhea Vaginal bleeding after intercourse
Nausea Postmenopausal bleeding
Swollen legs Blood in urine
Difficulty in emptying the bladder Blood in semen
Frequent urination Coughing up blood
Stress incontinence Blood in vomit
The 44 included single symptom experiences.
Field testing of the questionnaire was performed in a pilot study on 500 people resulting in alterations in formulations of questions and introductory captions.
4.2. Feasibility of the Study
A pilot study was conducted as a part of the feasibility assessment. In the pilot study a total of 182 of the 500 subjects completed the questionnaire, yielding a response rate of 36.4%. The final questionnaire was adjusted in light of the pilot and field testing. Changes primarily consisted of alterations in formulations of questions and introductory captions.
The response rate of 36.4% in the pilot study resulted in the hiring of a telemarketing company to perform reminder phone calls. The pilot study also provided an estimate on how many telephone interviews as well as incoming calls with questions from the respondents would be expected.
Of the 100 000 randomly selected subjects, 4 474 (4.7%) were not eligible because they had either died, could not be reached due to unknown address, were suffering from severe illnesses (including dementia), had language problems, or had moved abroad. Information on severe illness and subjects who had moved abroad was obtained through contact with family or relatives in the reminder procedure. Of the 95 253 (95.3%) eligible subjects, 49 706 subjects completed the questionnaire, yielding an overall response rate of 52.2% (Figure 1). The median age of the respondents was 52-year IQR (40–64) compared to 50-year IQR (36–67) for nonrespondents.
Study cohort.
The pilot study provided information with regard to the logistics resulting in the division of the study into four waves.
Table 3 shows the results of the four waves in terms of the number of invited participants in each wave and the cumulated response rate after the invitational letter (30.4%), after the reminder letter (43.7%), and after telephone reminder (52.2%), respectively. In addition, Table 3 shows the response rate for telephone interviews and the age and gender distribution.
Wave 1 Wave 2 Wave 3 Wave 4 Total
Invited for participation 25 000 25 000 25 000 25 000 100 000
Men (%) 12 203 (48.8) 12 180 (48.7) 12 348 (49.4) 12 179 (48.7) 48 910 (48.9)
Women (%) 12 797 (51.2) 12 820 (51.3) 12 652 (50.6) 12 821 (51.3) 51 090 (51.1)
Dead (%) 25 (0.1) 78 (0.3) 85 (0.3) 127 (0.5) 315 (0.3)
Addresses unknown (%) 247 (1.0) 252 (1.0) 236 (0.9) 226 (0.9) 961 (1.0)
Suffering from severe illness (including dementia) (%) 556 (2.2) 480 (1.9) 468 (1.9) 468 (1.9) 1 972 (2.0)
Language problems (%) 233 (0.9) 228 (0.9) 195 (0.8) 229 (0.9) 885 (0.8)
Moved abroad (%) 53 (0.2) 172 (0.7) 188 (0.8) 201 (0.8) 614 (0.6)
Excluded (% of invited) 1 114 (4.5) 1 210 (4.8) 1 172 (4.7) 1 251 (5.0) 4 747 (4.7)
Eligible for the study (% of invited) 23 886 (95.5) 23 790 (95.2) 23 828 (95.3) 23 749 (95.0) 95 253 (95.3)
Respondents (%) 12 361 (51.7) 12 763 (53.6) 12 298 (51.6) 12 284 (51.7) 49 706 (52.2)
Men (%) 5 718 (46.3) 5 911 (46.3) 5 815 (47.3) 5 796 (47.2) 23 240 (46.8)
Women (%) 6 643 (53.7) 6 852 (53.7) 6 483 (52.7) 6 488 (52.8) 26 466 (53.3)
Median age (IQR) 52 (40–64) 52 (40–64) 52 (40–64) 52 (39–64) 52 (40–64)
Completed by telephone interview (% of respondents) 342 (2.8) 308 (2.4) 286 (2.3) 272 (2.2) 1 208 (2.4)
Men (%) 129 (37.7) 110 (35.7) 93 (32.5) 106 (39.0) 438 (36.3)
Women (%) 213 (62.3) 198 (64.3) 193 (67.5) 166 (61.0) 770 (63.7)
Completed after initial letter (% of respondents, cumulative) 6 437 (26.9) 7 583 (31.9) 7 559 (31.7) 7 353 (31.0) 28 932 (30.4)
Completed after reminder letter (% of respondents, cumulative) 3 925 (43.4) 3 130 (45.0) 2 713 (43.1) 2 908 (43.2) 12 676 (43.7)
Completed after telephone reminder (% of respondents, cumulative) 1 999 (51.7) 2 050 (53.6) 2 026 (51.6) 2 023 (51.7) 8 098 (52.2)
Nonrespondents (% of eligible) 11 525 (48.3) 11 027 (46.4) 11 530 (48.4) 11 465 (48.3) 45 547 (47.8)
Not wishing to participate (indicated by telephone/email or postal contact) (%) 6 880 (28.8) 6 287 (26.4) 6 407 (26.9) 6 116 (25.8) 25 690 (27.0)
Indicated "other reasons" for nonparticipation (%) 11 (0.04) 85 (0.4) 99 (0.4) 123 (0.5) 318 (0.3)
Nonrespondents (no achieved contact in the reminder procedure) (%) 4 634 (19.4) 4 655 (19.6) 5 024 (21.1) 5 226 (22.0) 19 539 (20.5)
Results from the four waves.
5.1. Measuring Symptom Experiences
Well-known medical symptoms and bodily sensations including cancer alarm symptoms formed the base of the questionnaire. The survey was based on a limited number of predefined symptoms, leaving some respondents in a situation where they could not express all their symptoms. Instead, we opted to gather a more comprehensive analysis of the impact of the symptom on functioning and how the respondent's social network is utilized with respect to the symptom. To allow respondents to elaborate on their symptom experience in their own words and to learn more about the respondents' understanding of symptoms, we added a commentary box encouraging respondents to add additional comments, creating a possibility of evaluating the comprehension of the questionnaire.
In designing the questionnaire we included anthropological, psychological, and medical paradigms. To our knowledge no previous surveys on symptoms have used a similar multiperspective approach. Using this approach, we believe that symptom experiences in the general population can be analysed in a more nuanced way and with greater precision. In an attempt to minimise recall bias, we chose to ask about symptoms experienced within the last four weeks.
5.2. Response Rate and Participant Characteristics
The large sample of 100 000 subjects with 49 706 completed baseline questionnaires makes it possible to estimate prevalence of, for example, cancer alarm symptoms and of some rarer conditions with good statistical precision.
The subjects invited to participate in the study were randomly selected using the Danish Civil Registration System, which reduces the risk of selection bias. The response rate in the study (52.2%) was slightly lower than in previous Danish population-based surveys [37]. This could be due to the fact that the questionnaire was web-based and not available in hard copy. However, the invitational letter did encourage people with no access to computer, tablet, or smartphone to contact us by telephone for the possibility of completing the survey by telephone interview.
5.3. Telephone Interviews
A minority of the respondents (2.4%) responded to the questionnaire via telephone interview. It is possible that data from the interviews are different from the data derived from the online version. The difference was sought minimised by using trained interviewers who were instructed only to read the questions out loud and ask the respondent to choose between the available answers. The interviewers were explicitly instructed not to engage in the interpretation of the questions with the respondent. However, the fact that the telephone respondents were not able to see the questions and answers themselves and reflect on the answers in private might have affected their answers. The respondents who participated by telephone interview were mainly women in the older age groups. Obtained data may differ between self-administered questionnaires and telephone interviews. It is, however, not possible to determine whether differences would be caused by selection due to variations in age, sex, health status, or socioeconomic position or whether the differences would be due to the answering method.
We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort. Conducting the study in four waves solved the logistic challenges in terms of making it possible to handle both incoming calls with questions and conducting telephone interviews. The use of a telephone reminder procedure was implemented due to the poor response rate in the pilot study. The increase in the response rate of 8.5 percentage points from the reminder letter to the telephone reminder was a result in line with what we had expected. A similar procedure may well be applied in other large population-based studies.
5.5. Linkage to Register Data
To explore possible selection bias linkage to register data allows us to compare respondents and nonrespondents with regard to sex, age, socioeconomic status, and healthcare utilisations. Moreover, we are able to compare early and late respondents based on available information on the distribution date of the questionnaire and on the date the questionnaire was filled in.
5.6. Implications for Research and Practice
Early diagnosis and prompt treatment are generally presumed to be a key to a better prognosis of most illnesses. To improve early diagnosis it is important to gain knowledge about which symptoms, groups of symptoms, and related factors lead to healthcare-seeking. Information from this study will provide important knowledge on symptom experiences as well as on relationships between specific symptom experiences and, respectively, personal characteristics, subsequent healthcare-seeking, and the patient's interaction with the healthcare system. This large cohort of individuals will be followed for a number of years with complete follow-up on development of diseases by linkage with register data on socioeconomic status, health care utilisation, and hospital based diagnosis. By gaining this knowledge it will be possible for healthcare providers to form better and more precise referral pathways and hereby minimising delay in diagnosis.
We developed a comprehensive questionnaire consisting of five domains with 16 subdomains covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort. With 49 706 having completed the questionnaire, an overall response rate of 52.2% was achieved.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This study is financially supported by The Novo Nordisk Foundation and the Danish Cancer Society, "The Danish Research Centre for Cancer Diagnosis in Primary Care (CaP)," DKK 30,000,000, the Region of Southern Denmark, DKK 1,420,000 (Grant nos. 12/6437 and 12/21459), and Eva and Henry Frænkel Memorial Fund, DKK 100,000. The funders have not been involved in the design or development of the study. This survey is conducted in collaboration with the University of Southern Denmark and Aarhus University. The project is part of the research portfolio at the Research Centre for Cancer Diagnosis in Primary Care (CaP). The authors would like to thank Lise Keller Stark for proofreading the paper.
A. McAteer, A. M. Elliott, and P. C. Hannaford, "Ascertaining the size of the symptom iceberg in a UK-wide community-based survey," British Journal of General Practice, vol. 61, no. 582, pp. e1–e11, 2011. View at: Publisher Site | Google Scholar
R. P. Svendsen, H. Støvring, B. L. Hansen, J. Kragstrup, J. Søndergaard, and D. E. Jarbøl, "Prevalence of cancer alarm symptoms: a population-based cross-sectional study," Scandinavian Journal of Primary Health Care, vol. 28, no. 3, pp. 132–137, 2010. View at: Publisher Site | Google Scholar
D. R. Hannay, "The "iceberg" of illness and "trivial" consultations," Journal of the Royal College of General Practitioners, vol. 30, no. 218, pp. 551–554, 1980. View at: Google Scholar
A. M. Elliott, A. McAteer, and P. C. Hannaford, "Revisiting the symptom iceberg in today's primary care: Results from a UK population survey," BMC Family Practice, vol. 12, article 16, 2011. View at: Publisher Site | Google Scholar
R. P. Hansen, F. Olesen, H. T. Sørensen, I. Sokolowski, and J. Søndergaard, "Socioeconomic patient characteristics predict delay in cancer diagnosis: a Danish cohort study," BMC Health Services Research, vol. 8, article 49, 2008. View at: Publisher Site | Google Scholar
R. S. Andersen, B. Paarup, P. Vedsted, F. Bro, and J. Soendergaard, "'Containment' as an analytical framework for understanding patient delay: A qualitative study of cancer patients' symptom interpretation processes," Social Science and Medicine, vol. 71, no. 2, pp. 378–385, 2010. View at: Publisher Site | Google Scholar
U. MacLeod, E. D. Mitchell, C. Burgess, S. MacDonald, and A. J. Ramirez, "Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers," British Journal of Cancer, vol. 101, no. 2, pp. S92–S101, 2009. View at: Publisher Site | Google Scholar
A. F. Pedersen and R. S. Andersen, "From symptoms to seeking doctor," Ugeskrift for Laeger, vol. 173, pp. 1709–1712, 2011. View at: Google Scholar
Survey Xact [computer program], 2013, http://www.surveyxact.dk/videnbank/versionsopdateringer.
H.C. W. De Vet, C. B. Terwee, L. B. Mokkink, and D. L. Knol, Measurement in Medicine, Cambridge University Press, 2011.
N. Bentzen and C. Bridges-Webb, "An international glossary for general/family practice," Family practice, vol. 12, article 267, 1995. View at: Publisher Site | Google Scholar
M. Lock, "Menopause in cultural context," Experimental Gerontology, vol. 29, no. 3-4, pp. 307–317, 1994. View at: Publisher Site | Google Scholar
K. J. Petrie and J. Weinman, "Why illness perceptions matter," Clinical Medicine, vol. 6, no. 6, pp. 536–539, 2006. View at: Google Scholar
S. M. Campbell and M. O. Roland, "Why do people consult the doctor?" Family Practice, vol. 13, no. 1, pp. 75–83, 1996. View at: Publisher Site | Google Scholar
R. Jones, R. Latinovic, J. Charlton, and M. C. Gulliford, "Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database," British Medical Journal, vol. 334, no. 7602, pp. 1040–1044, 2007. View at: Publisher Site | Google Scholar
Nice Guidelines, "Referral for suspected cancer," 2005, http://www.nice.org.uk/cg27. View at: Google Scholar
Nice Guidelines, Ovarian cancer (GC122), 2011, http://www.nice.org.uk/guidance?action=byID&o=13464.
T. N. Nielsen, R. P. Hansen, and P. Vedsted, "Symptom presentation in cancer patients in general practice," Ugeskrift for Laeger, vol. 172, no. 41, pp. 2827–2831, 2010. View at: Google Scholar
D. A. Drossman, "The functional gastrointestinal disorders and the Rome III process," Gastroenterology, vol. 130, no. 5, pp. 1377–1390, 2006. View at: Publisher Site | Google Scholar
G. F. Longstreth, W. G. Thompson, W. D. Chey, L. A. Houghton, F. Mearin, and R. C. Spiller, "Functional Bowel Disorders," Gastroenterology, vol. 130, no. 5, pp. 1480–1491, 2006. View at: Publisher Site | Google Scholar
J. Tack, N. J. Talley, M. Camilleri et al., "Functional gastroduodenal disorders," Gastroenterology, vol. 130, no. 5, pp. 1466–1479, 2006. View at: Publisher Site | Google Scholar
N. Vakil, S. V. van Zanten, P. Kahrilas et al., "The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus," The American Journal of Gastroenterology, vol. 101, no. 8, pp. 1900–1920, 2006. View at: Publisher Site | Google Scholar
P. Fink and A. Schröder, "One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders," Journal of Psychosomatic Research, vol. 68, no. 5, pp. 415–426, 2010. View at: Publisher Site | Google Scholar
M. Ramos, M. Arranz, M. Taltavull, S. March, E. Cabeza, and M. Esteva, "Factors triggering medical consultation for symptoms of colorectal cancer and perceptions surrounding diagnosis," European Journal of Cancer Care, vol. 19, no. 2, pp. 192–199, 2010. View at: Publisher Site | Google Scholar
D. A. Drossman, L. Chang, N. Bellamy et al., "Severity in irritable bowel syndrome: a rome foundation working team report," American Journal of Gastroenterology, vol. 106, no. 10, pp. 1749–1759, 2011. View at: Publisher Site | Google Scholar
B. A. Pescosolido, "Beyond rational choice: the social dynamics of how people seek help," American Journal of Sociology, vol. 97, pp. 1096–1138, 1992. View at: Publisher Site | Google Scholar
A. J. Ramirez, A. M. Westcombe, C. C. Burgess, S. Sutton, P. Littlejohns, and M. A. Richards, "Factors predicting delayed presentation of symptomatic breast cancer: a systematic review," The Lancet, vol. 353, no. 9159, pp. 1127–1131, 1999. View at: Publisher Site | Google Scholar
C. P. H. Langford, J. Bowsher, J. P. Maloney, and P. P. Lillis, "Social support: a conceptual analysis," Journal of Advanced Nursing, vol. 25, no. 1, pp. 95–100, 1997. View at: Publisher Site | Google Scholar
A. E. Simon, L. J. L. Forbes, D. Boniface et al., "An international measure of awareness and beliefs about cancer: development and testing of the ABC," BMJ Open, vol. 2, no. 6, Article ID e001758, 2012. View at: Publisher Site | Google Scholar
The National Health Interview S. Hvordan har du det?, http://www.si-folkesundhed.dk/upload/sundhed_og_sygelighed_2010,_med_sidetal.pdf.
W. T. Dalton III, L. M. Klesges, L. Henderson, G. Somes, L. Robinson, and K. C. Johnson, "Gender, smoking status, and risk behavior attitudes explain adolescents' patterns of nicotine replacement therapy use," Addictive Behaviors, vol. 35, no. 2, pp. 147–151, 2010. View at: Publisher Site | Google Scholar
E. L. Idler and S. Kasl, "Health perceptions and survival: do global evaluations of health status really predict mortality?" Journals of Gerontology, vol. 46, pp. S55–S65, 1991. View at: Google Scholar
E. L. Idler and Y. Benyamini, "Self-rated health and mortality: a review of twenty-seven community studies," Journal of Health and Social Behavior, vol. 38, no. 1, pp. 21–37, 1997. View at: Publisher Site | Google Scholar
K. M. King, C. M. Norris, M. L. Knudtson, and W. A. Ghali, "Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study," BMC Cardiovascular Disorders, vol. 9, article 36, 2009. View at: Publisher Site | Google Scholar
A. F. Pedersen, F. Olesen, R. P. Hansen, R. Zachariae, and P. Vedsted, "Coping strategies and patient delay in patients with cancer," Journal of Psychosocial Oncology, vol. 31, no. 2, pp. 204–218, 2013. View at: Publisher Site | Google Scholar
A. Finset, S. Steine, L. Haugli, E. Steen, and E. Lærum, "The brief approach/avoidance coping questionnaire: development and validation," Psychology, Health and Medicine, vol. 7, no. 1, pp. 75–85, 2002. View at: Publisher Site | Google Scholar
A. I. Christensen, O. Ekholm, M. Davidsen, and K. Juel, "Sundhed og sygelighed i Danmark 2010.[in danish]," http://www.si-folkesundhed.dk/upload/sundhed_og_sygelighed_2010,_med_sidetal.pdf. View at: Google Scholar
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text:
\section{Introduction}
Bound states in the continuum (BIC) is initially proposed in quantum mechanics \cite{Neumann1929}, which trapped or guided modes with their frequencies in the frequency intervals of radiation modes \cite{Hsu2016}. Most recently, BIC has already been introduced for optical systems for the high-resonant phenomenon, such as photonic crystals \cite{Gao2016, Gansch2016, Yang2016, Bulgakov2008, Paddon2000, Pacradouni2000}, plasmonic structures \cite{Azzam2018}, optical waveguide coupler \cite{Yu2019, Chen2019, Lee2020}, Bragg gratings \cite{Bykov2019, Gao2019} and metamaterial \cite{Koshelev2018, Miroshnichenko2010, Kupriianov2019, Abujetas2019, Cong2015, Liang2020}. There are many practical applications for photonic systems, such as lasers \cite{Kodigala2017, Ha2018}, sensors \cite{Liu2017, Romano2018}, high-sensitive medical devices \cite{Khanikaev2013, Tittl2018} and filters \cite{Foley2014}.

The BIC phenomenon can vastly increase the Q-value resonance, especially for the metamaterial, due to the high loss of a single metamaterial structure. The BIC comes from the substantial coupling between the two adjacent single metamaterial structures. Two uniform metamaterial structures have the same frequency and phase of lossy electromagnetic waves, and the lossy waves of two metamaterials have strong interference between each other. Therefore, two lossy electromagnetic waves interfere destructively, which produces the infinite Q-value resonance in the theoretical. In the practical metamaterial, two lossy electromagnetic waves can not be the same due to fabrication. Thus, we can not fabricate infinite Q-value resonance for the metamaterial. However, it can still provide a very high Q value for the metamaterial device, and can widely be used in various applications.

Due to this widely practical BIC metamaterial application, the theory to understand BIC metamaterial is increasingly essential. Currently, there are few different theories to discuss the BIC in the photonic system, such as topological theory \cite{Zhen2015, Zhen2014}, Fano resonance theory \cite{Limonov2017,Gallinet2011}, Temporal Coupled-Mode Theory (TCMT) \cite{Yu2019, Chen2019, Lee2020} and coupled theory \cite{Cong2015}.
However, those theories have their shortcomings. The topological theory employs the topology to explain where the infinite Q-valve comes from, but it can not predict how much Q-valve is. Fano resonance theory can predict the Q-valve, whereas it requires a fitting number q (Fano asymmetry parameter) which is not a physical and fundamental parameter for the metamaterial. TCMT comes from the two coupled mode of waveguides system, and the parameters of TCMT is not essential parameters for the metamaterial. Thus, TCMT is more suitable for the optical system.
Recently, a remarkable paper \cite{Cong2015} employs the fundamental coupled theory for metamaterial to predict the Q-valve. However, they use the same idea for electrical impedance tomography (EIT), which only considers coupling between one bright mode and one dark mode.
It brings the big issue which only works for low Q-valve situations because when the two metamaterial structures are becoming identical, the Q-value is increasingly larger and the external EM field excites two metamaterial structures. Thus, two metamaterial structures become two bright modes and the previously coupled theory \cite{Cong2015} is not valid anymore.
The coupled theory is very fundamental theory and it widely used in many systems \cite{Huang2014, Huang2019, Huang2020, Huang20202}.

\begin{figure*}[htbp]
	\centering
		\includegraphics[width=0.32\textwidth]{fig1a.pdf}
		\includegraphics[width=0.325\textwidth]{fig1b.pdf}
		\includegraphics[width=0.32\textwidth]{fig1c.pdf}
	\caption{(a) The configurations of cut wires (CWs) BIC. (B) The configurations of split ring resonators (SRRs) BIC. (c) The schematic figures of input THz wave and transmission spectrum.}
	\label{Fig1}
\end{figure*}

This paper proposes a brand universal coupled theory for metamaterial BIC, which contains the coupling between two bright modes with phase. Therefore, our theory can predict a very high Q-valve situation and the parameters of our view come from the fundamental physical parameters of metamaterial, such as the resonance frequency $\omega_1$, $\omega_2$ for each single metamaterial structure, the loss $\gamma_1$, $\gamma_2$ for each single metamaterial structure and the phase $\phi_1$ and $\phi_2$ with each resonance frequency for each single metamaterial structure. The coupling strength $g$ comes from the physical configuration of two metamaterial structures. The beauty of our theory is that the resonance frequencies, the loss and the phases are obtained by the spectrum of each signal metamaterial structure, and coupling strength describes the connection of two metamaterial structures.

To demonstrate our theory, we employ two different types of BIC, such as coupling between two cut wires (CWs) \cite{zhang2014} (see Fig. \ref{Fig1} (a)) and two split ring resonators (SRRs) \cite{Cong2015} (see Fig. \ref{Fig1} (b)). We predict the frequency of BIC and Q-value from the spectrum of transmission THz wave, as shown in Fig. \ref{Fig1} (c).

\begin{figure*}[htbp]
	\centering
		\includegraphics[width=0.4\textwidth]{fig2a.pdf}
		\includegraphics[width=0.405\textwidth]{fig2b.pdf}
		\includegraphics[width=0.4\textwidth]{fig2c.pdf}
		\includegraphics[width=0.4\textwidth]{fig2d.pdf}
	\caption{Full-wave simulations of (a) transmission spectrum of single left CW structure, (b) transmission spectrum of single right CW structure, (c) the phase of single left CW structure and (d) the phase of single right CW structure. }
	\label{Fig2}
\end{figure*}

\begin{figure}[htbp]
	\centering
		\includegraphics[width=0.45\textwidth]{fig4.pdf}
	\caption{The black line is the full-wave simulations of cut wires (CWs) BIC (see the smaller figure) and our predict the transmission spectrum of cut wires (CWs) BIC by employing our theory, as shown in red line. }
	\label{Fig3}
\end{figure}

\begin{figure*}[htbp]
	\centering
		\includegraphics[width=0.4\textwidth]{fig3a.pdf}
		\includegraphics[width=0.4\textwidth]{fig3b.pdf}
		\includegraphics[width=0.4\textwidth]{fig3c.pdf}
		\includegraphics[width=0.4\textwidth]{fig3d.pdf}
	\caption{Full-wave simulations of (a) transmission spectrum of single left SRR structure, (b) transmission spectrum of single right SRR structure, (c) the phase of single left SRR structure and (d) the phase of single right SRR structure. }
	\label{Fig4}
\end{figure*}

\begin{figure}[htbp]
	\centering
		\includegraphics[width=0.45\textwidth]{fig6.pdf}
	\caption{The black line is the full-wave simulations of split ring resonators (SRRs) BIC (see the smaller figure) and our predict the transmission spectrum of split ring resonators (SRRs) by employing our theory, as shown in red line. }
	\label{Fig5}
\end{figure}

\section{Universal coupled theory}

In this section, we present a brand \textit{universal coupled theory} to describe the BIC in the metamaterial. The idea of our theory comes from the spectrum of transmission THz wave, which is the linear superposition of the transmission spectrum of each metamaterial structure. The linear superposition has a very close relationship with energies in each metamaterial structure. We take the $|a|^2$ and $|b|^2$ as the energies in each metamaterial structure. Furthermore, the energies in each metamaterial structure can be well described by coupled theory. Besides, the phases of each metamaterial structure become increasingly important for strong coupling and BIC. Thus, we should introduce the phase information into the coupled theory. Finally, we obtain our \textit{universal coupled theory} as following,

	\begin{equation}
\left[
	\begin{matrix}
	\ w-w _{a}-i\gamma_{a} & \Omega \\
	\Omega & \ w-w _{b}-i\gamma_{b}%
	\end{matrix}%
	\right] \left[
	\begin{matrix}
	a \\
	b%
	\end{matrix}%
	\right] =\left[
	 \begin{matrix}
	 \sqrt{\gamma_{a}}E \\
	 \sqrt{\gamma_{b}}e^{_{i\phi}}E%
	 \end{matrix}%
	 \right],
	\end{equation}%

where $\omega$ is the frequency of input THz wave. $\omega_a$ and $\omega_b$ represent the frequencies of the metamaterial structures, which is the same as resonant frequency of corresponding  metamaterial structure ($\omega_a$ = $\omega_1$; $\omega_b$ = $\omega_b$). $\Omega$ is the coupling strength with loss, due to the loss of transferring energy from one metamaterial structure to another, with $\Omega = g-i\sqrt{\gamma_{a} \gamma_{b}}e^{_{i\phi}}$, where $g$ is the coupling strength between two metamaterial structures. $\gamma_a$ and $\gamma_b$ are the loss terms of metamaterial structures, which is closely to $\gamma_1$, $\gamma_2$ for each single metamaterial structure ($\gamma_{a}=\gamma_{1}$;  $\gamma_{b}=(\gamma_{1} - \gamma_{2})/2$). $\phi$ is the phase information, which can be calculated by the phase $\phi_1$ and $\phi_2$ for each metamaterial structure ($\phi=(\phi_{1} - \phi_{2})d$, where $d$ is the width of metamaterial structure). $E$ is the amplitude of external exciting THz wave.

Subsequently, we can obtain the energy amplitudes $a$, $b$ of each metamaterial structure by solving the Eq. 1, as shown,
\begin{equation}
	a =\frac{ ((w-w _{b}-i\gamma_{b}) \sqrt{\gamma_{a}}-\Omega \sqrt{\gamma_{b}}e^{_{i\phi}})E} { ( w-w _{b}-i\gamma_{b}) (w-w _{a}-i\gamma_{a})-\Omega^{2}};
\end{equation}

\begin{equation}
	b =\frac{ ((w-w _{a}-i\gamma_{a}) \sqrt{\gamma_{b}}-\Omega \sqrt{\gamma_{a}})E} { ( w-w _{b}-i\gamma_{b}) (w-w _{a}-i\gamma_{a})-\Omega^{2}}.
\end{equation}

Then we calculate the effective susceptibility which is the linear superposition with energy amplitudes $|a|^2$ and $|b|^2$. the effective electric susceptibility of the metamaterial can be written as \cite{meng2012}

\begin{figure*}[htbp]
	\centering
		\includegraphics[width=0.32\textwidth]{fig5a.pdf}
		\includegraphics[width=0.31\textwidth]{fig5b.pdf}
		\includegraphics[width=0.316\textwidth]{fig5c.pdf}
		\includegraphics[width=0.32\textwidth]{fig5d.pdf}
		\includegraphics[width=0.315\textwidth]{fig5e.pdf}
		\includegraphics[width=0.315\textwidth]{fig5f.pdf}
	\caption{The black lines, blue lines and red lines demonstrate the full-wave simulations, the fitting results of previous theory \cite{Cong2015} and  the fitting results of our theory, respectively. The (a), (b) and (c) represent the low-Q, medium Q and high Q cases for CW BIC (see Fig. \ref{Fig1} (a)). The (d), (e) and (f) show the low-Q, medium Q and high Q cases for SRR BIC (see Fig. \ref{Fig1} (b)).}
	\label{Fig6}
\end{figure*}

\begin{equation}
\chi_{\text{eff}} =\frac{ \sqrt{\gamma_{a}}a+\sqrt{\gamma_{b}}e^{_{i\phi}}b} {\epsilon_{0} E }.
\end{equation}
Finally, we obtain the transmission spectrum with $T \approx 1- \text{Im}(\chi_{\text{eff}})$ \cite{Cong2015} , as shown,
\begin{widetext}
\begin{equation}
	T \approx 1-\text{Im}(\frac{ (w-w _{a}-i\gamma_{a}) \gamma_{b}e^{_{2i\phi}}+((w-w _{b}-i\gamma_{b}) \gamma_{a}-2\Omega \sqrt{\gamma_{a}\gamma_{b}}e^{_{i\phi}}} { ( w-w _{b}-i\gamma_{b}) (w-w _{a}-i\gamma_{a})-\Omega^{2}}).
\end{equation}
\end{widetext}

\section{Examples}
Firstly, we present the BIC with coupling between two CWs (as shown in Fig. \ref{Fig1} (a)) and we can obtain the resonance frequency ($\omega_1$, $\omega_2$), the loss ($\gamma_1$, $\gamma_2$) and phase with each resonance frequency ($\phi_1$, $\phi_2$) for each single metamaterial structure, as shown in Fig. \ref{Fig2}. We use the full-wave simulations of each metamaterial structure and put them together for BIC to get the corresponding transmission spectrum (see the black line of Fig. \ref{Fig3}).

From the results, we can obtain the resonance frequency  $\omega_1 = 0.256$ THz, $\omega_2 = 0.248$ THz, the loss $\gamma_1 = 0.028$ THz, $\gamma_2 = 0.03$ THz and phase with each resonance frequency $\phi_1 =0.297 $, $\phi_2 =0.31 $ for each single metamaterial structure. Therefore, $\omega_a = 0.256$ THz, $\omega_b = 0.248$ THz, $\gamma_a = 0.028$ THz, $\gamma_b = -0.004$ THz and $\phi =2.3 $. From the result of BIC (as shown in black line of Fig. \ref{Fig3}), we observe the BIC phenomenon with Fano resonance transmission spectrum with $Q=w_{BIC}/ \Delta w = 160$, where $\Delta w$  is the full width at half maximum (FWHM) of Fano resonance.

Due to complex analytic calculation of coupling strength $g$ between two metamaterial structures, we employ the fitting calculation by applying our universal coupled theory (Eq. 4) to obtain the coupling strength $g$, as shown in the red line of Fig. \ref{Fig3}. As we can see that the transmission spectrum of our theory (Eq. 4) is consistent with the Full-wave simulation of CWs BIC. Therefore, our theory can not only well describe and explain BIC for metamaterial but also can predict the frequency and Q-value of BIC.

In order to demonstrate the universality of our theory for different coupled metamaterial structures, we verify our theory by using coupling between two SRR as BIC as shown in Fig. \ref{Fig1} (b). We take the same steps above where get the Full-wave simulations of each single SRR (see Fig. \ref{Fig4}) and BIC (see Fig. \ref{Fig1} (b)) to obtain the corresponding transmission spectrum (the spectrum of each single structure see Fig. \ref{Fig4} and the spectrum of BIC shows black line of Fig. \ref{Fig5}). As we can see from Fig. \ref{Fig4}, $\omega_a = \omega_1 = 0.573$ THz, $\omega_b =\omega_2 = 0.636$ THz, $\gamma_a = \gamma_1 = 0.144$ THz, $\gamma_b = (\gamma_{1} - \gamma_{2})/2 = -0.008$ THz, $\phi = (\phi_{1} - \phi_{2})d =2.1 $ and the transmission spectrum of two SRRs BIC with $Q = 18$. Subsequently, we employ our universal coupled theory (Eq. 4) with those parameters by fitting coupling strength $g$ to calculate the transmission spectrum for BIC, as shown in red line in Fig. \ref{Fig5}. It is easy to find that our method is very closely to Full-wave simulations of two SRRs BIC. In other words, our universal coupled theory is valid for BIC with different types of metamaterial structures.

\section{Discussion}

Our method proposes the two bright modes coupling and employs it into the BIC metamaterial. Therefore, our theory can easily predict the transmission spectrum of BIC and much more suitable for high Q resonance cases comparing with previous research \cite{Cong2015}. In order to demonstrate the superiority of our theory, we employ full-wave simulations of low Q, medium Q and high Q cases for CW BIC and SRR BIC, respectively, as shown in the black lines of Fig. \ref{Fig6}. Subsequently, we apply the coupling of one bright mode and one dark mode \cite{Cong2015} and our theory (the coupling of two bright modes) to fit the full-wave simulations of low Q, medium Q and high Q cases respectively. The blue lines demonstrate the fitting results of the previous theory \cite{Cong2015} and the red lines show the fitting results of our theory in Fig. \ref{Fig6}.

From the results of Fig. \ref{Fig6}, we can easily obtain that the fitting results of the previous theory and our theory can both well predict the low Q case of the transmission spectrum of BIC, as shown in Fig. \ref{Fig6} (a) and (d). When the Q-value continuously increases, the fitting results of the previous theory start to have some errors in the medium Q cases, as shown in the blue lines in Fig. \ref{Fig6} (b) and (e). When the high Q-value cases for BIC (see Fig. \ref{Fig6} (c) and (f)) occurs, the previous theory of the coupling of one bright mode and one dark mode can not be valid anymore and the previous theory can not give the Fano spectrum of BIC at all. The reason for this phenomenon is that when the two metamaterial structures become increasingly uniform ($\Delta l$ turns smaller and smaller), the Q-value of BIC becomes larger and larger. When the high Q cases occur, two metamaterial structures can be excited by the input THz wave. Thus, the two metamaterial structures turn into two bright modes and the theory of one bright mode and dark mode can not be valid anymore. However, the fitting results of our theory have good performance of fitting results to predict BIC for low Q, medium Q and high Q cases, as shown in red lines of Fig. \ref{Fig6}. Therefore, our theory surpasses and contains the previous theory \cite{Cong2015}, especially for high Q-value resonance BIC.

\section{Conclusion}
In this paper, we propose a new theory to describe metamaterial BIC by employing the coupling theory of two bright modes with phase. Our new theory can universally explain metamaterial BIC and very accurately predict the frequency of BIC and Q-value of resonance, even for the very high Q case.

\section*{Acknowledgements}
This work acknowledges funding from National
Key Research and Development Program of China
(2019YFB2203901); National Science and Technology
Major Project (grant no: 2017ZX02101007-003); National
Natural Science Foundation of China (grant no: 61565004;
61965005; 61975038; 62005059). The Science and
Technology Program of Guangxi Province (grant no:
2018AD19058). W.H. acknowledges funding from Guangxi
oversea 100 talent project; W.Z. acknowledges funding from
Guangxi distinguished expert project.

redpajama_set_name: RedPajamaArXiv


text:
Toronto Van Attack Suspect Charged With Murder
Updated 04.24.18 10:57AM ET / Published 04.24.18 10:55AM ET
REUTERS/Stringer
The suspected driver in the Toronto van attack on Monday that killed 10 people and injured 15 others was charged with 10 counts of first-degree murder, according to CTV News. Alek Minassian, 25, also faces 13 counts of attempted murder. Minassian, who appeared in court Tuesday morning, allegedly drove a white van through a crowd of pedestrians on a sidewalk along a major Toronto thoroughfare. He was apprehended by police not long after the incident. One of the victims of the attack was identified as Anne Marie D'Amico, who "succumbed to her injuries," according to a statement from her employer obtained by CBC News.
Read it at CTV News


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text:
Q: Getting undefined value when I access value of an object Inside loginUser function, I want to access the value of accessToken which is in side the 'stsTokenManager' but when i try to access this value then i am getting 'undefind' value.
import React, { Component } from 'react';
import {
StyleSheet,
Text,
View,
Image,
Button,
TouchableWithoutFeedback, StatusBar, TextInput,
SafeAreaView, Keyboard, TouchableOpacity,
KeyboardAvoidingView
} from 'react-native';
import { CheckBox, Item, Label, Input } from 'native-base';
import * as firebase from 'firebase';

const firebaseconfig={
apiKey: " ",
authDomain: " ",
databaseURL: " ",
projectId: " ",
storageBucket: " ",
messagingSenderId: ""
};
firebase.initializeApp(firebaseconfig);

export default class Login extends Component{
// static navigationOptions = {
//     header: null
// }

componentDidMount() {
    firebase.auth().onAuthStateChanged((user) => {
      if (user != null) {
        console.log(user)
      }
    })
}
loginUser = (email, password) => {
    try {
      firebase.auth().signInWithEmailAndPassword(email, password )
      .then((response)=>{
        //here i want to access values of 'stsTokenManager'
        console.log(response.user.stsTokenManager);
        }
    }
    catch (error) {
      alert('Check your email or password')
    }
}

Please check my loginUser function because i am able to access email and other think but when i try to access stsTokenManager then i am getting undefind value.And, I am using firebase authentication.

A: response.user.toJSON().stsTokenManager works.

A: response.user doesn't have an stsTokenManager property.
As a matter of fact, according to the documentation signInWithEmailAndPassword(email, password) returns a firebase.Promise containing a non-null firebase.auth.UserCredential.
In turn, the UserCredential contains a firebase.User (that you get through response.user as you did) which does not have such a stsTokenManager property, see https://firebase.google.com/docs/reference/js/firebase.User

A: Do not depend on internal undocumented properties that are subject to change. Instead use public and official APIs that are already available. In your case, you can use response.user.getIdToken() to get the user's ID token, this also ensures the token you get is fresh if the cached one is expired.

A: JSON.parse(JSON.stringify(response.user)).stsTokenManager

or
response.user.toJSON().stsTokenManager

redpajama_set_name: RedPajamaStackExchange


text:
Home › Experiences › Our Stories › A Living Example
A Living Example
January 20, 1979 | Students of Yogi Bhajan
Categories: Our Stories
Written by Beant Singh Khalsa, Baltimore, Maryland and published on page 264 of the book, The Man Called the Siri Singh Sahib" in 1979.
"The one thing about the Siri Singh Sahib which has had the greatest impact on me is the way in which he sets an example by living his life for others. There are many stories and incidents which come to mind, but through the past three years that I have known the Siri Singh Sahib, it is his example of selfless living, of dedicating his efforts to helping others without thought of personal gain, which has been the greatest inspiration to me.
I remember often his words about how animals live with each other, but we as humans and as Khalsa should live for each other. As our teacher, he never failed to inspire us by living up to that teaching. His example of living the teachings of Sikh Dharma has been invaluable to me as a primary force in changing my life and directing me on the path of Truth."
2021 Addition from Beant Singh:
"In the remaining 25 years as my Spiritual Teacher (on this planet), the Siri Singh Sahib demonstrated to me one thing over and over. It was that he cared for nothing else but to push and inspire me, and every one who called themselves his student, to pursue our highest spiritual destiny, the identity of the Soul. He lived only to serve God's creation and deliver anyone who lived his teachings into the realm of God. He constantly poked, provoked, confronted and, in the end, elevated me. My gratitude to him is Infinite."


text:
IDF stops left-wing activists from touring Hebron as right holds rally against them
Protesters from Im Tirzu shout 'shame' at members of Breaking the Silence; confrontations come week after much-publicized confrontation between activists and soldiers
By Jack Mukand 3 December 2022, 6:42 pm Edit
Palestinian activist Issa Amro speaks to Israeli activists in the West Bank city of Hebron, Friday, Dec. 2, 2022 (AP Photo/Maya Alleruzzo)
HEBRON, West Bank — Some 300 left-wing activists were prevented from touring Hebron on Friday after right-wingers met to confront them, leading the military to declare a "closed military zone" in the area where the two groups gathered and keep the two groups apart.
The confrontation came a week after a much-publicized clash between soldiers and several left-wing activists, which saw a soldier beating one activist and a second one gloating to a camera about his belief that the incoming right-wing government would end the group's activities.
That soldier's subsequent punishment with several days' jail time led to an outcry by right-wing politicians and activists and sparked dueling condemnations and commendations in the press and on social media for the troops' behavior. The other soldier was not immediately punished, aside from being immediately suspended following the assault.
On Friday, the left-wingers came on buses charted by Breaking the Silence, an NGO that organizes tours of the Israeli-controlled section of Hebron. The tours are led by former IDF soldiers who seek to expose what they claim are abuses against local Palestinians by the army and settlers.
Dozens of protesters with the right-wing nationalist group Im Tirzu came to confront them, leading the military to declare the "closed military zone" around the parking lot where the left-wing activists had arrived on buses from various Israeli cities.
Im Tirzu protesters, some with megaphones, shouted "Shame on you," "Anarchists," "Marxists" and "Yalla, go home!" at the left-wing activists near the Tomb of the Patriarchs, a flashpoint holy site for Israeli-Palestinian tensions.
The two sides were not able to get close enough to each other for altercations to break out.
A Jewish settler waves the Israeli flag as protesters heckle activists on a solidarity tour in the West Bank city of Hebron, Friday, Dec. 2, 2022 (AP Photo/ Maya Alleruzzo)
"In light of the situation [on Friday], it was decided to declare a closed military zone in several places in the city of Hebron in order to prevent clashes there," the IDF said in a statement.
The closed zone prevented Breaking the Silence from carrying out its normal activities: bus tours around the 20% of Hebron that is under Israeli control, and the only part of the city where it's legal for Israeli citizens to be present.
In lieu of the tours, the left-wing activists split off into small groups, with each forming a circle around a guide who showed them images from Hebron. One of the images showed an empty Shuhada Street, a once bustling Palestinian commercial thoroughfare in Hebron that has been largely closed off to Palestinians through a gradual process beginning soon after the Jewish terrorist Baruch Goldstein killed 29 Muslim worshippers at the Tomb of the Patriarchs.
The IDF uses the same explanation for the closure of the Shuhada as it did for prohibiting the left-wing activists from venturing out of the parking lot on Friday — to prevent unrest and violence.
The military makes a common practice of setting a perimeter around areas where tensions are liable to devolve into altercations. While the cordoning ostensibly protects both sides, critics claim that the closed military zones are almost always imposed on Palestinians and their supporters.
Friday's dueling demonstrations also came two weeks after video-recorded incidents showed Jews accosting Palestinians during a religious festival.
The activists say that their tours and videos reveal the brutality of the Israeli occupation of the West Bank, described by some of them as a system of apartheid. Breaking the Silence has faced criticism from the right in recent years for collecting and publicizing mostly anonymous testimony of alleged IDF mistreatment of Palestinians.
Critics argue that the tours and the filming disturb soldiers as they protect civilians, both Israeli and Palestinian.
Right-wing nationalist activist with Im Tirzu. Next to the Israeli flags waves a flag for the far right-wing Otzma Yehudit party (Jack Mukand / Times of Israel)
Some 1,000 settlers live in H2, the area of Hebron controlled by the Israeli military, in uneasy neighborship with approximately 35,000 Palestinians. Hebron is thus the only city in the West Bank where Jewish settlers and Palestinians live side by side. A large Israeli military presence is deployed there to prevent hostilities — between Jews and Palestinians and, less frequently, between Jews on opposite ends of the political spectrum.
Palestinians in the area are restricted in their movement and claim arbitrary arrests and detentions, but settlers argue that these are necessary for security in a city where the mayor, Tayseer Abu Sneineh, was elected in large part by boasting of his participation in a 1980 terrorist attack that killed six Jews.
Some among the Breaking the Silence group speculated that Im Tirzu showed up on Friday so that the Israeli military would declare the closed military zone and prevent the group's tours.
Amir Ziv, a coordinator with Breaking the Silence, said he couldn't guess Im Tirzu's motives, adding, "They have a right to protest, just as we have a right to do our tours. That's how democracy works and that's great."
He claimed, however, that "the IDF has a close relationship with the settler movement and the Israeli right-wing… The IDF is a tool for the government, that's what an army is. It needs to get its policy from somewhere and its policy often comes from right-wing, pro-settler parties."
Israeli peace activists take part in a 'solidarity tour' of the West Bank city of Hebron, Friday, Dec. 2, 2022 (AP Photo/ Maya Alleruzzo)
The IDF has often been in conflict with far-right settlers but has also been seen standing by while settlers attack or harass Palestinians.
The spokesperson for Im Tirzu, Matan Boker, said, "The vast majority of Israelis" see the IDF as an essential part of the Jewish state, one that's above politics. Boker said members of Im Tirzu came out to Hebron to show support for the soldiers and hand them candy.
"When you're a soldier you need to be on your feet for hours, rain or shine, and you're protecting both Jews and Arabs. It's an almost impossible task," he said.
Boker expressed his belief that soldiers were being goaded into reactions under these already stressful circumstances by camera-carrying left-wing activists.
Activists from Breaking the Silence recorded the soldier in last Friday's confrontation as he made threats at them, shouting "Leftists, I will rearrange your faces" and "Ben Gvir is going to put some order into this place."
MK Itamar Ben Gvir, leader of the far right-wing Otzma Yehudit party, has been promised the newly created national security ministry in coalition negotiations with expected incoming prime minister Benjamin Netanyahu. If appointed, Ben Gvir, himself a settler, would have a major say in shaping security policy in parts of the West Bank under Israeli military rule.
Issa Amro, the Palestinian activist who made the video of last week's confrontation, has been ordered by a military court to stay away from his home in Tel Rumeida for a period of six days as punishment for "obstructing a police investigation."
Amro said that when police summoned him to the station to share videos of his interaction with the soldier, he handed them a flash drive instead of his phone, which he'd left at home. Amro said that in his 15 years of sharing videos with the police, they'd never before objected to his sharing them on a flash drive.
In this Sept. 10, 2017 file photo, prominent Palestinian activist Issa Amro speaks after his release from Palestinian Authority detention, in the West Bank city of Hebron (AP/Nasser Shiyoukhi, File)
Amro addressed the left-wing activists in the parking lot on Friday and drew applause when he delivered "a message" to Israelis that "your silence about the occupation and apartheid created Ben Gvir." Afterward, Amro was detained for an hour and a half by undercover police, according to Breaking The Silence. The military court order that barred him from his house also stipulated that he was to have no contact for a month with those who aided him in making the videos.
At Friday's rallies, Im Tirzu protester Eden Sisson, a 24-year-old from Florida who made aliyah to serve in the IDF, said that left-wing organizations pose a threat to Israel's security by "spreading hate and lies when the IDF has an important job to do."
She recalled that during her own service, left-wing activists called her a "Nazi" and a "terrorist" and that it was hard to keep her cool in such times.
In the parking lot, Oren, a man in his 20s who preferred to not share his last name, identified himself as a native Israeli who had refused to serve in the IDF and also a "non-Zionist."
Activists with the left-wing NGO Breaking the Silence gather in a parking near the Tomb of the Patriarchs in Hebron, December 2, 2022 (Jack Mukand / Times of Israel)
"On the physical level, worse things than Zionism have certainly happened to the Jewish people, but on the conceptual level Zionism is the worst thing to ever happen to Judaism," he asserted, arguing that Zionism forces Jews to commit against Palestinians the same kind of violence that was historically directed at them.
Two older men — one an American born the year before Israel's foundation, the other an Israeli the year after — stood on opposite sides of the perimeter and expressed to The Times of Israel opposite views on the situation in the West Bank.
Hanoch Rubel, a Brooklyn native born in 1947, said that anyone who "supports terrorism" or "preaches the destruction of the Jewish state" should be transferred out of the Holy Land, including from Palestinian population centers like Ramallah and Jenin.
Rubel, who voted Likud in the most recent election, said that antagonism toward Israel, not ethnicity, should be the sole criterion for expulsion and that far-left Jewish citizens should not be exempted from the policy. Rubel said that time has taught him that "the world's greatest injustice is the injustice against the Jew."
On the other side, Yehoshua Frenkel, a 73-year-old who arrived in the country from Czechoslovakia a year after his birth, has joined Breaking the Silence on several tours. His mother survived Auschwitz and then fled along with her family from Czechoslovakia in 1950 over the persecution of Jews by the country's ruling Communist party.
Frenkel fought in the Six Day War in 1967, and said that Israel's victory, after the existential threat it faced from its Arab neighbors, felt like "heroic deliverance." Still, he hoped for an Israeli withdrawal from the territories conquered in the war, both out of moral conviction and for practical reasons.
"I believed that it was inevitable that Palestinians would resist the Israeli presence," he said.
Frenkel, who has written about the history of Hebron, said "Jews certainly have an attachment to the story of Hebron, but that doesn't justify a military presence, with almost one soldier for each settler."
Despite the rightward shift in Israel's politics, Amir Ziv said he was "optimistic."
"If I weren't, I wouldn't do what I do. More and more people are coming to see Hebron with their own eyes. We have a fight to engage in and we need to change a lot more minds. That will take time because that's how democracy works."
Tensions have been high in the West Bank over the past year, with the IDF launching a major anti-terror offensive mostly focused on the northern West Bank to deal with a series of Palestinian attacks that have left 31 people in Israel and the West Bank dead since the start of the year. Hebron is in the southern part of the territory.
The operation has netted more than 2,500 arrests in near-nightly raids, but has also left more than 150 Palestinians dead, many of them — but not all — while carrying out attacks or during clashes with security forces.
Further stoking tensions, on Friday, a Palestinian man stabbed and wounded a Border Police officer in the northern West Bank town of Hawara, before being shot dead by Israeli forces, police and medics said.
right-wing activists
left-wing activists
Im Tirtzu
Backers, who include ex-executives at rabbinical seminaries, Jewish Federations, AIPAC and Conference of Presidents, warn against false antisemitism accusations at Israel critics
Medics say 50-year-old woman lightly hurt after falling while running for bomb shelter; police minister ties attack to move to close bakeries in prisons holding terror inmates
ToI podcast
TOI staff
Daily Briefing Feb. 1: When High Court intervention helped settlers, religious women
Legal correspondent Jeremy Sharon shares counterintuitive examples of the court's 'overreach'; investigative reporter Inna Lazareva sheds light on a three-decade-long scandal
Mahamat Deby's father decided to restore relations with Israel for the first time since 1972, as Israel works to expand ties in Africa
King Charles honors 99-year-old survivor in UK for her role in Holocaust education
Republican lawmaker says Democrat 'brought dishonor' to the House; her backers say effort to boot her from committee is motivated by vengeful politics
Doug Emhoff's trip to Poland and Germany brings him back to Jewish ancestral roots
US second gentleman describes meeting Holocaust survivors who recently fled war in Ukraine as 'emotional and intense,' recalls his own grandparents' flight to safety in America
France's updated plan to counter antisemitism will take students to sites of attacks
Women's soccer World Cup hosts urge FIFA not to sign Saudi sponsor
Iran protester on death row gets stay of execution


Teradata Corporation (NYSE: TDC) today announced that one of Poland's largest banking institutions, PKO Bank Polski, has selected Teradata technologies as the foundation upon which to build and power an enterprise intelligence marketing program.
The suite of advanced technology will enable the bank to integrate data from all bank systems in order to improve customer loyalty and value. The bank will utilize Teradata technologies including Teradata Data Warehouse Appliance and Teradata Relationship Manager (TRM), which manages cross-channel, multi-touch customer conversations. In addition, Teradata will provide a range of professional services.
Deployment of the new Teradata technologies will enable the bank to analyze consumer buying behavior, preferences and channel usage, in order to have a clearer view of each customer. Armed with this intelligence, the bank plans to drive highly personalized marketing offers for financial products and services. Teradata technologies are designed to allow rapid development of multi-phased marketing campaigns for multiple consumer channels with personalized offers. Personalized offers generate more sales than generic offers, while effectively utilizing marketing resources and budgeted funds. This will further the bank's initiative to increase the number of financial products purchased by each consumer, to grow revenue and improve the retention of existing customers.
PKO Bank Polski founded in 1919 is one of the largest and oldest Polish banks. For years, the bank has been a market leader – in business growth and financial results. This position strengthens the largest network of sales – PKO Polish Bank is a leader among the banks providing services to retail customers. The bank serves more than 6.15 million individuals with personal accounts, and the number of payment cards issued is nearly 7.2 million. The bank has a 25-percent market share of mortgage lending, which puts it into a leading position. PKO Bank Polski is also an important partner for small and medium enterprises, large corporations, and it has a significant market of municipalities, counties and provinces. PKO Polish Bank Group, in addition to traditional banking activity, provides professional services, and various financial products such as pension funds, product leasing, investments, and electronic payment services.
Teradata is the world's leader in data warehousing and integrated marketing management through its database software, data warehouse appliances, and enterprise analytics. For more information, visit teradata.com.
Tagged with: (NYSE: TDC) • Aster Data Systems • Banking • Business • Business intelligence • Companies • Data warehouse • Europe the Middle East and Africa • Financial Services • Industry • Markets • PKO Bank Polski • Polish Bank • PR Newswire • Technology • Teradata • Teradata Corp.


This is a very sleek Black Grenade knife from Extremely-Sharp. Strong spring and legal in all 50 states. Push on the thumb opener manually and the spring kicks in and shoots out the blade from the side.
Alpha Recon knives are leading the way in the realm of spring-assisted folding knives. Their spring-assisted knives are easily the most innovative and best value on the market today, without having to sacrifice any durability or functionality. These great knives will hold its own with any other knife that you might pay hundreds for. Alpha Recon knives feature thick and strong 440 stainless steel blades and are very sharp right out of the box. The blade is opened using the forefinger or thumb stud located directly on the blade itself. Just give it a light push and watch the blade spring open, ready for action.


text:
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One of the Most Dangerous Places in America
Doc's note: We first began publishing Retirement Millionaire Daily in October 2015. Since then, we've sent more than 200 issues to our readers.
We've also welcomed tens of thousands of new readers. So every Thursday this month, we're sending our favorite issues from October 2015. If you haven't read these issues, we hope you enjoy them. If you've already read them, use them as a refresher or share them with your friends and family.
The deadliest place you're likely to visit this year doesn't look all that scary…
It probably has a cheerful person sitting at a desk out front. Vibrant green, manicured lawns. And a well-educated staff that appears attentive to your needs.
I'm talking about American hospitals.
Most people have no idea how much risk they take by checking in. And the numbers keep getting worse with each revised study that comes out…
In 1999, the first study of its kind found that up to 98,000 people a year die because of mistakes in hospitals.
In 2010, the Office of Inspector General for the U.S. Department of Health and Human Services said that bad hospital care contributed to the deaths of 180,000 Medicare patients alone.
And more recently, a study published in the Journal of Patient Safety claims that as many as 440,000 people die every year from hospital errors, injuries, accidents, and infections… That's roughly one-sixth of all deaths that occur in the U.S. each year.
To help put that in perspective… About 40,000 Americans die in motor vehicle accidents each year, according to the National Safety Council.
Up to 10 times as many people die from medical mistakes than in motor vehicle accidents. But when we asked around the office, we heard far more concerns about injury on the roadway than in the hospital…
We can't eliminate deadly car crashes, but we do know how to keep many of these medical mistakes from happening. The U.S. Department of Health and Human Services found that hospitals could have prevented more than half of patient deaths by simply following proper procedures.
Having worked in the medical industry, I'm more than familiar with this problem. It's one of the reasons I left the medical industry.
But I've also had personal experience. After a surgery, my mom was recovering in the hospital and the nurse tried to give her a pill that could have killed her.
Thankfully, my mom realized the pill wasn't one she typically takes and she refused to take it.
Like my mom, your best defense in a hospital is to raise your concerns… And don't let anyone, no matter if it's a doctor or nurse, waive them aside.
Talk to someone immediately if you think an error may have been made.
And if you feel you're being given unnecessary medications or surgery, ask for a "patient advocate" or even a different doctor. Medicine is big business, and you deserve the best service available… not what will make it easy for the doctors.
Let us help you live a healthier, wealthier life. Sign up today!
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It's Finally 'Safer' to Go to the Hospital
Going to a "teaching hospital" in the months of June, July, and August is even more dangerous than usual…
If you or a loved one is considering any sort of hospital visit for an elective or nonemergency procedure, you should absolutely stay clear of any medical facility that is considered a "teaching hospital" during the summer.
Doctors in training, so-called "residents," start training every year on July 1.
So in June, the senior residents are about to leave for the real world and couldn't care less about taking care of you… They are thinking about getting out of there, finding a real job, and starting to pay down their six-figure debt.
The new doctors coming in on July 1 just graduated from medical school. Most can't yet find their way out of a paper bag.
But worse… the senior hospital staff doctors, called "attendings," who are supposed to supervise the new kids, are taking summer vacations. Most let the senior residents run the show.
The good news is that the problem is temporary.
Once September hits, the new docs have a few months of experience under their belts. And the attendings are back at work and supervising again… And the hospital is as safe as it gets.
There are now officially 70,000 ways to get sick and die.
Hospitals can almost always prevent this infection by following a simple checklist… so why don't they?
Six of the most common preventable mistakes you could experience in the hospital… and how to keep them from happening to you.
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text:
Serving Society
Coronavirus: general measures in force at UCLouvain
Responsible attendance strategy
UCLouvain hygiene measures
Health rules
Missions, vision, values
Partners and networks
IT service access
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Administrative and technical staff
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Welcome to UCL
Missions and governance
UCLouvain's international involvement isn't about mere statistics – numbers of exchanges, international students and staff. It's about placing its openness to the world at the heart of the university's missions. Indeed, teaching our students to think and act in both today's and tomorrow's worlds is to make them aware of and open to other cultures, and to endow them with the ability to communicate and collaborate in an international and intercultural context. Innovating in research, education and serving society – the university's three primary missions – is to understand what's going on elsewhere in the world and to think differently in order to find solutions.
Thus UCLouvain's international mission is integral to its broader missions, its vision and its values.
UCLouvain's international activity is premised on the commitment of everyone involved with the university. It's therefore part of a collective dynamic whose cohesion is ensured by the International Action Committee (CAI), supported by the International Relations Department (ADRI), and under the responsibility of Pro-Rector for International Affairs Dana Samson (photo).
An additional series of activities are carried out in close collaboration with the NGO Louvain Coopération.