text:
Asthma reviews in general practice
Jane Leyshon
Key learning points:
People with asthma should have a structured review with a health professional who has specialist asthma knowledge at least once a year
Frequent use of short-acting bronchodilators indicates poor control and increased risk of asthma death
Inhaler technique, adherence to preventer therapy and diagnosis should be checked before stepping up therapy
An estimated 5.4 million people in the UK have asthma1 and are mostly looked after in primary care, so asthma forms a significant proportion of general practice workload. There is good evidence2,3 to suggest that morbidity and mortality are significantly reduced by a proactive approach to asthma care through regular reviews and strategies for supported self-management.
Current guidelines4 recommend reviews at least annually by a health professional with appropriate expertise. Despite this, the Royal College of Physicians (RCP)5 review of asthma deaths found that 43% of people who died from asthma had not had an asthma review in the last year and only 23% had a personalised asthma action plan (PAAP).
As recommended by guidelines, the UK quality outcomes framework (QOF)6 incorporates the standard that all individuals with asthma should receive an annual review. Primary care nurses with appropriate asthma education are ideally placed to carry out these reviews working with patients and their families. This article will consider the key components of an adult asthma review including assessment of control, inhaler technique, adherence to preventer medication and the development of PAAPs.
Assessing asthma control
Poor control results in people being unable to perform their usual daily activities including paid work, and results in more intensive use of NHS resources with increased consultations and hospital admissions. The current asthma guidelines4 define good control as having no symptoms, no exacerbations and normal or near normal lung function. The presence of intermittent symptoms (twice a week or less) is potentially compatible with good control but night-time symptoms indicate loss of control.
In order to assess asthma control, the nurse should consider the presence of symptoms and review clinical records. Frequent requests for reliever medication in the form of short-acting ß2 agonists suggest poor control4 and have been linked to asthma death.5 The nurse should also look at records for evidence of acute exacerbations in the last year such as use of oral steroids or emergency attendances or admissions. This can indicate an increased risk of future attacks even in the presence of current good control.2
Guidelines3 recommend using a structured approach to eliciting information about symptoms and that a recognised tool should be used to quantify their impact. The QOF requires that the RCP's three questions7 (see table 1) are asked.
Other validated tools such as the Asthma Control Questionnaire (ACQ)8 or the Asthma Control Test (ACT)9 are available and can add a further dimension to the assessment. These both use a series of morbidity questions but the ACT includes a rating of overall control where a score of 20 or more indicates good control.
Although these can be administered during the review they have both been validated for self-administration. Some practices send them out for patients to complete at home and bring to the review while others may ask patients to complete the questions in the waiting room beforehand. It is important to consider where, when and how they are completed as this may affect the answers given.10
When reviewing the answers it is important that the nurse does not simply note the scores but uses the opportunity to explore underlying issues. Every person with asthma will have a different perception of their symptoms and the impact of their disease. Evidence11, 12 has consistently shown that patients and health professionals underestimate the importance of symptoms and their impact on daily life.
Nurses should also ask about smoking status. Smoking could indicate the presence of chronic obstructive pulmonary disease (COPD), either alongside the asthma, or possibly COPD that has been incorrectly diagnosed as asthma. Smoking also interferes with the action of inhaled corticosteroids (ICS) and smokers may require higher doses to get control.4
It is also useful to enquire about symptoms such as persistent runny or blocked nose. Rhinitis is a common co-morbidity in people with asthma. Although treating rhinitis has not been shown to improve asthma control, it may help to reduce the symptom burden.4
As part of the assessment of control, objective measures of lung function such as spirometry or peak expiratory flow rate (PEFR) should be considered.4 Reduced lung function values compared to previous best readings can indicate bronchoconstriction at that time or a longer-term decline warranting further assessment.4 It is important to remember that due to the variable nature of asthma a 'normal' reading may not rule out overall poor control and so lung function should always be considered in the context of the overall history taken at the review.
Adherence with preventer medication
It is widely recognised that irregular use of prophylactic ICS is an important reason for poor control and increases the risk of asthma death.4, 5 The nurse should encourage the individual to be open and honest about their use of regular medication. It can be useful to ask: "How often do you forget your ICS inhaler?" as this may give permission to be less than perfect. On the other hand, asking "How often do you take your ICS?" is more likely to make the patient restate the prescribed dose instead of disclosing what they really do.
Underuse of ICS can result in increased symptoms and poor control so this must be explored before therapy is stepped up.4 Increasing doses or adding in new medication will not tackle poor control if the medication is not taken as prescribed. So if poor adherence is identified the nurse will need to explore this with the patient to identify ways they can be supported.
Inhaler technique
Asthma treatments are delivered straight to the lung by inhalation, so correct use of an inhaler device is vital.13 Incorrect inhaler technique is common and is associated with poorer outcomes,13 so this element of care must be tackled during the review.
There are many different inhaler devices, varying in shape and size, containing a range of medications that require different techniques and different levels of manual dexterity. Nurses carrying out asthma reviews should ensure they are familiar with all the devices that are frequently prescribed in their area and options for individuals who are in difficulties. When working with a patient it is important that the nurse has practical experience in how the various devices work and is able to teach their correct use.
Assessment outcomes and treatment recommendations
If it is established that control is good there may be no need for any change. But it is still essential that the nurse works with the patient to ensure they understand how to spot deterioration. Their PAAP should outline how to respond if this occurs.
Once good control has been established, the aim should be to use the lowest possible dose of medication to remain symptom free. Stepping down of medication is an often overlooked element of asthma management and many people are on higher levels of medication than they need.4 It is important, therefore, that nurses always consider the possibility of stepping therapy down.
Guideines4 recommend that any reduction should be slow, since patients deteriorate at different rates. A reasonable approach is to consider reducing ICS dose by 25-50% every three months, and check that control is maintained.
If control is poor, contributing factors should be considered and dealt with.4 It is important to review the basis on which the original diagnosis was made and to consider if poor control could be due to a previously unrecognised diagnosis such as COPD in a smoker or gastro oesophageal reflux as a cause of cough etc.
Development of new co-morbidities such as cardiac disease should also be considered as potential causes of increased symptoms and ruled out before adjusting asthma therapy.14 Changes to therapy may involve change of inhaler device, restarting regular ICS or adding in further medication but must be in line with current guidelines.4 If the nurse carrying out the review is not a prescriber, they will need to liaise with the patient's GP about changes in treatment. If a new inhaler is required it is important that before prescribing the nurse teaches the patient to use the new device and confirms them as competent in its use.4
Development of PAAPs
British Asthma guidelines4 recommend that people with asthma should be offered individualised self-management education supported by a written action plan. The benefits of this approach are shown to include an improvement in quality of life and a reduction in hospital admissions, unplanned healthcare consultations, time lost from work and a decrease in night-time symptoms.4,15 Working in partnership with the patient enables the nurse to ensure that information can be tailored to the individual's own needs and preferences.
Guidelines4 suggest that brief simple education focused on patient goals is likely to be the most acceptable. Systematic reviews16,17 have provided advice on the best format for effective asthma action plans, which include written information with two to three clear action points on what to do if the condition deteriorates.
There is no evidence4 to suggest superiority of using either symptoms or PEFR as triggers for action. The guidelines4 suggest that in adults either may be used or a combination of both.
Asthma UK18 produces a PAAP based on these principles, which can be ordered in print format directly from Asthma UK, downloaded from the website or accessed via EMIS web.
The PAAP should be discussed and completed in relation to the specific needs of the patient, given to the patient and also stored in their records. As asthma is a dynamic condition subject to variation and change, it is important that that this PAAP is not seen as a static document but as one that should be reviewed and modified in light of any changes.
Tackling non-attendance at reviews
If nurses can create an atmosphere in which the patient feels valued and listened to, rather than part of a tick-box exercise, attendance at reviews will be valued and patients will be more likely to attend. But not all people will be willing to attend a pre-arranged appointment for a review,19 so it may be necessary for nurses to opportunistically review an individual's asthma when they attend for other reasons.
By reviewing repeat prescriptions the nurse can identify patients using high levels of bronchodilators. And a tool such as the RCP three questions7 could identify patients who may be poorly controlled, so the nurse could suggest a full review. While a telephone review cannot check inhaler technique there is evidence to suggest that they can help to identify those with poor control who can be encouraged to attend for a more detailed review.20
Asthma reviews in primary care are an important part of improving control and reducing morbidity and mortality.
Primary care nurses are ideally placed to ensure these reviews are carried out effectively. The key aim should be to enable people with asthma to be symptom free (or at least to have minimal symptoms) enabling them to participate fully in all aspects of their daily life.
Successful asthma reviews need to assess control in order to target care appropriately; identify reasons for poor control and adjust therapy accordingly; to explore individuals' own attitudes to their asthma in order to provide supported self-management to maintain control. In order to achieve these outcomes, nurses carrying out reviews need to have accessed appropriate training and be familiar with current evidence-based guidelines.
1. Asthma UK. Asthma facts and Statistics, 2016. asthma.org.uk (accessed 16 August 2016).
2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. ginasthma.org (accessed 16 August 2016).
3. Pinnock H, Epiphaniou E, Pearce G et al. Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies. BMC Medicine 2015;13:127. bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0361-0 (accessed 16 August 2016).
4. British Thoracic Society and Scottish Intercollegiate Guidelines Network. SIGN 141 British Guideline on the management of asthma, 2014. brit-thoracic.org (accessed 16 August 2016).
5. Royal College of Physicians. Why asthma still kills, The National review of asthma deaths, 2014. rcplondon.ac.uk (accessed 16 August 2016).
6. NICE. The NICE indicator menu for the QOF, 2016. nice.org.uk/Standards-and-Indicators/QOFIndicators (accessed 16 August 2016).
7. Pearson MG, Bucknall CE. Measuring clinical outcome in asthma: a patient focused approach. Royal College of Physicians, 1999.
8. Juniper EF, Bousquet J, Abetz L, Bateman ED. Identifying 'well-controlled' and 'not well controlled asthma' using the asthma Control Questionnaire. Respiratory Medicine 2006;100:616-621.
9. Schatz M, Sorkness CA, Li JT et al. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. Journal of Allergy and Clinical Immunology 2006;117:549-556.
10. Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluating patient-based outcome measures for use in clinical trials. Health Technology Assessment 1998;2(14):1-7.
11. Haughney J, Barnes G, Partridge M, Cleland J. The Living and Breathing study: a study of patients' views of asthma and its treatment. Primary Care Respiratory Journal 2004;13:28-35.
12. Juniper EF, Chauhan A, Neville E et al. Clinicians tend to overestimate improvements in asthma control: an unexpected observation. Primary Care Respiratory Journal 2004;13:181-184.
13. Melani A, Bonavia M, Cilenti V et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine 2011;105(6):930-938.
14. Thomas M, Price D. Impact of co-morbidities on asthma. Expert Review of Clinical Immunology 2008;4(6):731-742.
15. Adams RJ, Smith BJ, Ruffin RE. Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax 2000;55:566-573.
16. Gibson PG, Powell H, Wilson A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews, 2002.
17. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94-99.
18. Asthma UK. Asthma Action Plans, 2016. asthma.org.uk/professionals (accessed 16 August 2016).
19. Price D, Wolfe S. Delivery of asthma care: patients' use of and views on healthcare services, as determined from a nationwide interview survey. Asthma Journal 2000;5:141-144.
20. Pinnock H, Bawden R, Proctor S et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. British Medical Journal 2003;326 (7387):477-479.
Learning module: managing surgical wounds after an operation
Insect sting allergy – key facts for a Practice Nurse
Clinical: The recovery approach to life-changing conditions


text:
Students, faculty weigh in on city charter vote
Rose Skylstad • November 6, 2017
In addition to voting for a Mayoral candidate in tomorrow's election, Newton residents will decide 'yes' or 'no' on a newly proposed city charter which would impact the size of Newton's city...
Classes elect officers for next school year
by Hilary Brumberg Yesterday, the Class of 2013, 2014 and 2015 elected class officers for the 2012-2013 school year. For its senior year, the Class of 2013 elected Mike Safran as its president and Shelly...

redpajama_set_name: RedPajamaCommonCrawl


text:
Manor Fields is a private estate on Putney Hill in south-west London. Its 228 flats are grouped in 14 arts and crafts-influenced houses, created in the 1930s as homes of quiet refinement, and surrounded by the third-biggest private gardens in London.
The freehold of the estate is owned by The Manor Fields Estate Limited, or MFEL, a limited company, the shareholders of which are all the owners of flats held on 999-year leases. Some flats have shorter leases; lease extensions are available.
Most of the flats at Manor Fields are in purpose-built houses of three, four or five storeys and there are two cottages, which used to be the estate's own restaurant.
The houses are named mainly after Oxford and Cambridge colleges, in one case ‒ Harvard House ‒ after an American university in the Massachusetts city of Cambridge.
The houses are called Armstrong, Balliol, Bede, Girton, Glenalmond, Gonville, Harvard, Keble, Magdalene, Mansfield, Newnham, Ripon, Selwyn and Somerville.
Most of the flats have three bedrooms but there are some with one or two bedrooms and others with four or more. The largest house is Bede, with 32 flats on four floors.
Each flat has its own storage area and there is also storage space for bicycles. Additional storage areas can be rented through the estate office.
A security guard is on duty throughout the night and among other things, there is high-speed broadband for the Internet, email and some cable television services and a connection to television satellite dishes in all flats. Residents also have access to a meeting and functions hall called the Bunker and parking is free throughout the estate. Many flats have their own garages, though some are owned by the estate and can be rented.
Lessor's consents
Scheme of management
Manor Fields
Putney Hill
SW15 3NE
manager@manorfields.co.uk
Visitors to Manor Fields are welcome to park here, so long as they display a valid temporary pass. You should ask your host to obtain a pass from the estate office. There is a large plan of the estate at the main entrance.
Flats at Manor Fields come up for sale or rent from time to time and are widely advertised on the internet, in newspapers and by estate agents in and around Putney. The estate office does not deal with sales or lettings.
wwwwwwww
© The Manor Fields Estate Limited. Registered in England and Wales, number 1924651. Registered office: KFH House, 5 Compton Road, London SW19 7QA
The company has made all reasonable efforts to ensure that the information on this website is accurate and up-to-date, but makes no warranty as to its accuracy, completeness or currency. Nothing on this website is a representation to any person nor overrides the provision of any contract between the company (or any predecessor in title) and any person. Hypertext links to other websites are for convenience only and the company does not endorse and is not responsible for the content of any other website.
Privacy and cookie policywwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwwProduced by TPG Design and Michael Hardman


Heats up, but Gree light delays???
I've had my system for about 1.5 years. It has worked well about 1/3 of that time. I live in Anchorage, Alaska area so there are arctic challenges. When the system is working like it is suppose to, it heats up to temp and you will hear that first click (red light on ) a minute or so later depending on the temp and click-click Green light on.
Now, it heats up to temp, clicks (red light on) then maybe 10-15 more miles green light comes on. Funny thing is I don't think it clicks when it finally turns green. Now, if I stop, for 5-30 minutes and start it may take 10-20 minutes to turn on again (it use to trun on within 30 sec to a minute or two. The temp outside is 30-40 d's and last year at this time my system would come on in 2-3 minutes. It now takes 20-30 driving 65!. My T-state is high temp and only 6 months old. The temp gauge does its thing. Pressure Gauge is at 75-80. I clean the prescreen, check valve and Press Reg Valve weekly to make sure they don't get locked open or shut. Help....20 MPG makes is taking its toll.
Also, I have oil in my coolant. I have an idea that this might affect, but my system still seems to heat up ok. I had the injector cups replaced 1 year ago for this very reason. Anyone have any odeas on if this is a cracked block, seal, gasket, injector issue?


The Governing Body is composed of unpaid volunteers who have agreed to support and challenge the work of the school under the head teacher's leadership. Governors represent various interested groups as defined by law. We meet as a full governing body twice a term. We also have two committees that oversee Finance and Personnel and Curriculum and School Improvement. Each of these committees meet at least once a term. From time to time working parties are convened to undertake a particular task, such as self-evaluation. Governors also monitor the work of the school through visiting classes and attending school events.
The Annual Governance Statement below outlines some of the key information about our Governing Body and the work carried out by the different groups.


Baked french toast fills my house with swirling scents of cinnamon, Ruby and I are pajama clad-me with a cozy babycake nestled in with the hiccups-preparing for our cozy girl's night in. Topping the day off with a classy dose of television - The Bachelor - knitting, and some goodnight stories seems only appropriate.
Our weekend disappeared as rapidly as it came, but we enjoyed some quality family time. Ruby and I spent Saturday with Ama and Moo; a simple girl's day out complete with a Starbucks run, lunch, and plenty of perusing racks full of clothes I can only aspire to fit in at this point. Sunday should have been named Cookie Bowl Sunday rather than Superbowl Sunday because a) I spent an entire day making frosting, experimenting with frosting, eating frosting, and waiting for frosting to dry and b) seriously, the football game? I could hardly stand forcing my already tired eyes to watch such a drab game (with a messed up national anthem and horrible halftime show with zero amusing commercials).
The cookies are sitting in cellophane bags, adorned with ribbons and notes of thanks, waiting to be grabbed from the freezer on our way to meet Babycake. I wanted a fun, unique way of showing the hospital staff our thanks when the time comes.
Ruby has clearly watched too much Dora the Explorer. Lately, we have been looking for things (my glasses, her sock, my sister when we were shopping) and her problem-solving skills always lead her to taking the map route. It seems unfair for me to tell her imagination we can't use a map to locate her lost sock, so we pull out her map and locate the missing item.
When Ruby has been warned or asked to do something several times without listening, then she has to go sit. We always talk after she sits, but lately when she is asked to go sit, she says, "Talk Mama?" before sitting. It's worth a try in her little mind-remove the pesky sitting part, cut straight to the chase.
And the cheeser face. She knows this face by name-we are not sure where she picked it up from, but she flashes it at the funniest times. Impossible to resist.
in case you couldn't quite picture it.
And because I promised I would never be that mom, I'll just say this: Two thumbs up for potty training progress.
Babycake's impending arrival is never far from the forefront of my mind. Being breech seems to be a hobby of the past for the little one which has been a primary concern for weeks. Fingers crossed this remains a thing of the past.
I can't fathom how my sweet little family is about to change, but I'm ready to tackle the challenge knowing that I get to meet another precious little person very soon.
My Princess is 3 and she always wants to know how to get somewhere -which means pretend to be the "Map" and make up a route.


Paroba College has helped hundreds of individuals launch successful careers in Cosmetology, Barbering and Esthetics and assisted others to take their current careers to the next level. We are an accredited and state-licensed beauty and barber school in Washington state. 3-day per week schedules allow you the flexibility to balance work, children and other things life throws your way while you get the skills it takes to build a brighter future. We are open Monday through Friday, so weekend attendance isn't required.
An On-Site Salon, Spa, and Barber Shop, where you work hands-on with real clients.
Flexible Schedules that fit the needs of adult learners.
Extensive state board preparation to make sure you are ready to take your exams.
Industry Experienced Faculty, so you learn directly from industry professionals with years of experience working in the field and a true passion for helping new artists and beauty professionals.
Of course you'll cover the basics of haircutting, coloring, perming and styling or facials and waxing, but your education at Paroba College offers so much more than that. Our graduates set themselves apart with their ability to perform modern, in demand services. For example, cosmetologists have the opportunity to become certified in advanced relaxers such as the i-Straight Japanese Hair Relaxer and they learn makeup using MAC branded tools. Estheticians learn Sugaring, Microdermabrasion, airbrush makeup, and lash extensions. Master Estheticians practice with real lasers in a true medispa environment. Our barbers don't just learn shaving and haircutting but styling and hair tattooing.
Paroba is fully accredited which means Financial Aid is available for those who qualify. Our financial aid professionals can help you navigate the many options that may be available to you for paying for school.


text:
// Copyright (c) Microsoft. All rights reserved.
// Licensed under the MIT license. See LICENSE file in the project root for full license information.

using System;
using System.Threading;
using Microsoft.Spark.CSharp.Interop.Ipc;
using Microsoft.Spark.CSharp.Network;
using Microsoft.Spark.CSharp.Services;

namespace Microsoft.Spark.CSharp
{
    /// <summary>
    /// TaskRunner is used to run Spark task assigned by JVM side. It uses a TCP socket to
    /// communicate with JVM side. This socket may be reused to run multiple Spark tasks.
    /// </summary>
    internal class TaskRunner
    {
        private static ILoggerService logger = null;
        private ILoggerService Logger
        {
            get
            {
                if (logger == null)
                {
                    logger = LoggerServiceFactory.GetLogger(typeof(TaskRunner));
                }
                return logger;
            }
        }

        public int trId;  // task runner Id
        private ISocketWrapper socket;  // socket to communicate with JVM

        private volatile bool stop = false;

        // whether the socket can be reused to run multiple Spark tasks
        private bool socketReuse;

        public TaskRunner(int trId, ISocketWrapper socket, bool socketReuse)
        {
            this.trId = trId;
            this.socket = socket;
            this.socketReuse = socketReuse;
        }

        public void Run()
        {
            Logger.LogInfo(string.Format("TaskRunner [{0}] is running ...", trId));

            try
            {
                while (!stop)
                {
                    using (var networkStream = socket.GetStream())
                    {
                        byte[] bytes = SerDe.ReadBytes(networkStream, sizeof(int));
                        if (bytes != null)
                        {
                            int splitIndex = SerDe.ToInt(bytes);
                            bool readComplete = Worker.ProcessStream(networkStream, splitIndex);
                            if (!readComplete) // if the socket is not read through completely, then it can't be reused
                            {
                                stop = true;
                                // wait for server to complete, otherwise server may get 'connection reset' exception
                                Logger.LogInfo("Sleep 500 millisecond to close socket ...");
                                Thread.Sleep(500);
                            }
                            else if (!socketReuse)
                            {
                                stop = true;
                                // wait for server to complete, otherwise server gets 'connection reset' exception
                                // Use SerDe.ReadBytes() to detect java side has closed socket properly
                                // ReadBytes() will block until the socket is closed
                                Logger.LogInfo("waiting JVM side to close socket...");
                                SerDe.ReadBytes(networkStream);
                                Logger.LogInfo("JVM side has closed socket");
                            }
                        }
                        else
                        {
                            stop = true;
                            Logger.LogWarn("read null splitIndex, socket is closed by JVM");
                        }
                    }
                }
            }
            catch (Exception e)
            {
                stop = true;
                Logger.LogError(string.Format("TaskRunner [{0}] exeption, will dispose this TaskRunner", trId));
                Logger.LogException(e);
            }
            finally
            {
                try
                {
                    socket.Close();
                }
                catch (Exception ex)
                {
                    Logger.LogWarn(string.Format("close socket exception: ex", ex));
                }
                Logger.LogInfo(string.Format("TaskRunner [{0}] finished", trId));
            }
        }

        public void Stop()
        {
            Logger.LogInfo(string.Format("try to stop TaskRunner [{0}]", trId));
            stop = true;
        }
    }
}

redpajama_set_name: RedPajamaGithub


Good Mexican Food in DC?
Apparently my way to fill the void of not traveling every weekend is to eat. The last two weeks I've found myself dining out more than I usually do in two months! Fortunately ( I guess) it's all catching up on recommendations from friends and foodies I trust.
Today was "the best tacos in Washington, DC." Having spent many years in the South and a bit of time in Texas and California, I have yet to find good Mexican food in DC. I've eaten at plenty mediocre places, but nothing "good." The city is awash in excellent South American, El Salvadorean, etc options, but not Mexican.
However, my friend heard rave reviews about Taco El Chilango, a food truck near my office in Arlington, so we headed there today for lunch.
On 14th St between N Rhodes St and N Quinn St, it's a little off the beaten path, but clearly well known — as we pulled into a parking space across from the truck I saw several other business professionals getting into their cars, take out in hand.
Ordering was simple — they only do tacos and you have your choice of 7 fillings — beef, tongue, chorizo, pork, chicken, beef & pork, and an unadvertised vegetarian option.
I decided to try the chorizo and the pork, my friend did the same but added the tongue as well. While we were waiting for the food to be prepared, the owner/chef, Jesus introduced himself and gave us a free Al Pastor (pork) taco to munch.
It was topped with spicy pickled onions and peppers, radish and cucumbers (all optional) and I went with the hot salsa instead of the mild. Spicy but delicious.
Both were great, but I liked the chorizo best. Apparently the tongue taco was fine but less flavorful than the other two.
I've haven't had many tacos in DC, but these were some of the best. And Jesus's friendliness added to the great ambiance. The best part was the price — I was picking up the tab because I lost a bet and each taco was only $2.50!
Definitely worth a stop if you're in the area.
This experience may finally motivate me to make a trek to the gas station place in Elk Ridge, Maryland recommended by Tyler Cowen as the best Mexican food in the region.
Clearly, you've been hanging around Gary too much if you are now spending your non-travel time in DC searching for the best ethnic food!
My rule for Mexican food is only in states that touch Mexico, and then no more than 50 miles north of I-10. Living in Texas, you become quite picky about Mexican and Tex-Mex. I've never had the desire to try any elsewhere when it's so good at home.
youd be missing a bunch of good food in chicago then!
I haven't been there in ages but I used to love sitting on their outdoor roof deck with a pitcher of swirl margaritas!
My favorite Mex in the city is Taqueria Districto Federal (CHeights, hole in the wall but amazing Horchata), El Chilango (U St – and apparently a food truck too!), and El Rey (U St, amazing back patio with retractable roof). I've heard good things from El Centro (14th st and Gtown) but only have been for happy hour.
Have you found a good Chinese place?
Yes! China Star in Fairfax is amazing — as long as you don't order off the American Chinese menu. My favorites are the scallion-fried fish, and lamb in sizzling pot.


Stony Brook Men's Basketball picked up two key victories this week, winning 97-61 against the Molloy College Lions in the team's home opener at Island Federal Credit Union Arena on Wednesday, Nov. 21 and against Rhode Island on Nov. 24.
Redshirt-junior forward Andrew Garcia led the Seawolves with his first career double-double coming off the bench against Molloy, notching career highs in points with 20 and rebounds with 10 in 22 minutes on the court. Garcia shot perfectly from the field in the first half and ended the game shooting 60 percent from the field, 50 percent from three and 75 percent from the charity stripe. After dealing with serious knee injuries for two and a half years, Garcia talked about his return as well as his performance.
Tying Garcia for the team lead in points and rebounds was starting redshirt-junior forward Akwasi Yeboah. Yeboah notched a double-double with 20 points and 10 rebounds as well, tying his career-high with his second double-double this season. Yeboah shot 40 percent from the field and a team-high 87 percent from the line.
In addition to the clutch performances by Garcia and Yeboah, freshman guards Jules Moor and Miles Latimer added 10 and 14 points respectively in their first game at the Island Federal Credit Union Arena, and sophomore guard Elijah Olaniyi contributed eight rebounds. Head coach Jeff Boals was pleased with his team's performance.
Heading into the matchup, the Seawolves were focused on shutting out a potential scoring threat in Molloy junior guard Nick Corbett.
Corbett finished the matchup with 13 points and four assists, as well as four turnovers forced by the Seawolves defense.
Stony Brook struggled with keeping the momentum rolling at Rhode Island as the game opened up. The Rams took an early advantage and pulled away from a back-and-forth contest with a 7-2 run to take the lead by four.
However, the team's resilient effort, which has been a running theme this year, contributed to the Seawolves' explosive 16-3 run which began with 8:26 left in the first half. The run gave Stony Brook a 35-30 lead at the end of the first half. Moor started his first game for the Seawolves, accumulating three points, five steals and three rebounds in the matchup.
Stony Brook went into the locker room with an edge offensively, nailing two more 3-pointers than Rhode Island and shooting over 50 percent from the field. Rhode Island shot just 35 percent from the field in the half.
The Seawolves opened the half pushing their lead to nine with just under 14 minutes remaining in regulation. The Rams' shooting continued to bottle, as the team attempted 10 more 3-pointers and only nailed one. This was a key factor in the team's defeat, as the Rams finished the matchup shooting just 8 percent from beyond the arc and 35 percent from the field.
Sophomore guard Jordan McKenzie became a key player in the later part of the game. His seven points and two steals in the half helped propel Stony Brook to its fifth victory of the season. McKenzie's layup with five minutes remaining gave the team a 15-point lead. Rhode Island got the lead down to 67-58 with 33 seconds left, but time ran out on the attempted comeback.
Boals was pleased in his team's mental toughness and performance following its second victory of the week.
The team's next matchup comes against Norfolk State, a team they defeated at the Naismith Basketball Hall of Fame Tournament on Nov. 17. The game will take place on Tuesday, Nov. 27 at 7 p.m.


text:
Q: Problem involving supremum inequality I believe there is something wrong in my proof below because the result is not correct, can anyone help me spot that out?
$$ |f(x)|\geq f(x) \\ \text{So } |f(x)| \text{ is an upper bound of } f(x)
\\
|f(x)|\geq \sup f(x)
\\
\text{Also, } \sup |f(x)| \geq |f(x)|
\\
\sup |f(x)|\geq\sup f(x)$$

redpajama_set_name: RedPajamaStackExchange


One of our US-based clients decided to create a new cryptocurrency and to conduct the Initial Coin Offering (ICO) process in cooperation with L4A to facilitate business transactions.
An important part of the project was to ensure the ICO's cybersecurity, due to the fact that we were dealing with a cryptocurrency project for the financial sector and such projects are particularly vulnerable to cyberattacks.
An additional challenge (apart from technological details related to the design and generation of a new cryptocurrency) turned out to be the surrounding legal regulations and the creation of an appropriate capital collection process.
We based the new cryptocurrency on Ethereum and created a Smart Contract compliant with ERC20 standards, which was successfully audited by a company of experts.
To carry out the Initial Coin Offering, L4A developers created a custom tool to control the process of collecting payments from investors: an application that allows you to buy currency using Ethereum and Bitcoin. An external service for FIAT currency payments was also used.
However, due to legal changes in the US regarding ICOs, we had to dynamically adapt to the new regulations and give up direct funding through the application.
In order to implement the ICO, L4A developers had to create an additional application module that was intended to support the process of cryptocurrency allocation after the successful placement of the Smart Contract in the Ethereum blockchain.
After importing addresses of the wallets as well as the number of tokens purchased by a given investor, the client confirmed each transfer using MetaMask, allowing us to avoid storing private keys in the application itself.
Our technological support for the ICO helped thee client create a new cryptocurrency and successfully implement the Initial Coin Offering. We are currently in cooperation to develop the functionalities described in the client's whitepaper.


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After a decade of publicity as the sassy new kid on the block, platinum is growing strongly into its own category. Firmly established in the bridal sector (at least a quarter of all couples choose platinum for their bands, according to Platinum Guild International), platinum is using its consumer recognition to pave the way for growth in other sectors.
The fashion world may be consumed by yellow metal at the moment, but the fact remains that women are buying platinum bridal jewelry and also looking for fashionable everyday jewelry that will match their rings. In response to demand, designers and manufacturers are beefing up their supply of non-bridal platinum jewelry.


text:
Q: Show the inverse laplace transform in general My problem is, show that:
$L^{-1}(\dfrac{s}{(s+a)(s+b)})=\dfrac{ae^{-at}-be^{-bt}}{a-b} $
MY ATTEMPT:
I think that i have to use the convulution theorem, so
$F(s)=\dfrac{1}{s+a}$
$G(s)=\dfrac{s}{s+b}$
then
$f(s)=L^{-1}F=e^{-at}$
$g(s)=L^{-1}G=-be^{-bt}+1$
but when i try to integrate, it doesn´t work, i dont get what the problem says. Can someone help me please? I´m kind of desperate. Thanks in advance

A: Let$$\frac{s}{(s+a)(s+b)} = \frac{x}{s+a}+\frac{y}{s+b}$$
At $s=-a$, $\frac{-a}{-a+b} = x$
At $s = -b$, $\frac{-b}{-b+a} = y$
So, $$\frac{s}{(s+a)(s+b)} = \frac{1}{a-b}\bigg[\frac{a}{s+a}-\frac{b}{s+b}\bigg]$$
So, $\mathcal{L}^{-1}\frac{s}{(s+a)(s+b)} = \frac{1}{a-b}\mathcal{L}^{-1}\bigg[\frac{a}{s+a}-\frac{b}{s+b}\bigg] = \frac{1}{a-b}(ae^{-at}-be^{-bt})$
Thus,

$$f(t) = \frac{ae^{-at}-be^{-bt}}{a-b}$$

A: $L^{-1}\{\dfrac{s}{(s+a)(s+b)}\}=L^{-1}\{\frac{1}{a-b}(\frac{a}{s+a}-\frac{b}{s+b})\}=\frac{1}{a-b} (ae^{-at}-be^{-bt})=\dfrac{ae^{-at}-be^{-bt}}{a-b}$
As $L(e^{at})=\frac{1}{s-a}$ and $L^{-1}(\frac{1}{s-a})=e^{at}$


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Harry Styles Reflects on Failed Relationship with Taylor Swift
SplashNews
Over three years after their split, singer Harry Styles is opening up on his past romance with Taylor Swift.
In the new issue of Rolling Stone, Harry reflected on their 2012 date in Central Park, which was caught on camera. He said, "When I see photos from that day, I think: 'Relationships are hard, at any age.' And adding in that you don't really understand exactly how it works when you're 18, trying to navigate all that stuff didn't make it easier."
"I mean, you're a little bit awkward to begin with. You're on a date with someone you really like. It should be that simple, right?" Styles went on. "It was a learning experience for sure. But at the heart of it — I just wanted it to be a normal date."
After their split, Taylor released her album "1989," featuring "Out of the Woods" and "Style," which are rumored to be about him. Of the songs, Harry said, "I mean, I don't know if they're about me or not… but the issue is, she's so good, they're bloody everywhere… They're great songs ... It's the most amazing unspoken dialogue ever."
"I write from my experiences; everyone does that. I'm lucky if everything [we went through] helped create those songs. That's what hits your heart," he pointed out. "That's the stuff that's hardest to say, and it's the stuff I talk least about. That's the part that's about the two people. I'm never going to tell anybody everything."
When asked if there was anything he wanted to say to his famous ex-girlfriend, Harry said, "Certain things don't work out. There's a lot of things that can be right, and it's still wrong. In writing songs about stuff like that, I like tipping a hat to the time together. You're celebrating the fact it was powerful and made you feel something, rather than 'this didn't work out, and that's bad.' And if you run into that person, maybe it's awkward, maybe you have to get drunk... but you shared something. Meeting someone new, sharing those experiences, it's the best sh*t ever. So thank you."
Styles is in the middle of promoting his new album, which comes out next month.
#CelebrityNews #HarryStyles #HookupsAndBreakups #TaylorSwift #TrendingStories
Watch Zayn & Taylor Swift Play Intense Lovers in 'I Don't Wanna Live Forever' Music Video
Tom Hiddleston Spills the Beans on Taylor Swift Relationship and That 'I Heart T.S.' Tank Top
Taylor Swift Surprises 96-Year-Old Fan with Personal Concert


text:
Nathalie María Viteri Jimenez (born 6 October 1974) is a lawyer and an Ecuadorian Assemblyperson. In 2021 she joined the fourth legislative period of the National Assembly.

Life
Viteri was born on 6 October 1974. Her parents are José Viteri Peña and Leonor Jiménez Campuzano, and her elder sister is Cynthia Viteri.

She worked in the mayor's office, and she served as an alternate councilor for Doménica Tabacchi, who became the vice mayor of Guayaquil.

In March 2007, the Supreme Electoral Court dismissed 57 deputies from the National Assembly. Viteri was one of these politicians. The deputies appealed against the decision twice, and they were successful. However, their places were no longer available. The Inter-American Commission on Human Rights granted over 50 of them compensation; , the money had not been paid.

However, Viteri was again elected to the National Assembly in 2021. Viteri is from Guayaquil where her sister, Cynthia Viteri, is the mayor.

In November 2021, she was one of the 81 politicians who abstained from voting, which allowed the Economic Development and Fiscal Sustainability Law to be passed. Other abstainers included Jessica Castillo, Rosa Cerda, Ana Herrera, Gissella Molina and Patricia Sánchez.

In 2022, during a debate, she spoke of sodium chloride being used to cause an abortion. This does not happen according to the World Health Organisation. Viteri makes a high number of interventions in the assembly. On average, members of the assembly made about ten interventions each during the first ten months of the new session's plenaries. However, Viteri made over 40, putting her in the top five for interventions up to March 2022.

Private life
Viteri is married to Oscar Crow; they have two children.

References

1974 births
Living people
People from Guayaquil
21st-century Ecuadorian women politicians
21st-century Ecuadorian politicians
Members of the National Assembly (Ecuador)
Women members of the National Assembly (Ecuador)

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text:
Michael J. Rusing
6363 North Swan Road, Suite 151 Tucson, Arizona 85718
mrusing@rusingandlopez.com
Firm: Rusing Lopez & Lizardi, P.L.L.C.
Rusing Lopez & Lizardi, P.L.L.C.
Attorney Mick Rusing heads up the firm's litigation section, which covers virtually every area of civil litigation. A lawyer for over thirty years, Mr. Rusing has tried well over 100 cases in federal and state courts in diverse areas such as breach of fiduciary duty, contract, ERISA, employment, environmental, insurance bad faith, insurance coverage, legal malpractice, medical malpractice, patent infringement, products liability, securities, trusts and estates, will contests, and wrongful death. He has argued cases before the Arizona Court of Appeals, the Arizona Supreme Court, the Nevada Supreme Court, the Bankruptcy Appellate Panels, and the Ninth Circuit Court of Appeals. Although Mr. Rusing still maintains a significant part of his litigation practice in the injury area, including products liability and malpractice, in recent years his focus has been on significant business litigation frequently involving the prosecution and defense of fraud actions, partnerships disputes or other business entity litigation among principals, and matters involving real estate or construction.
Mr. Rusing has been a Fellow of the American College of Trial Lawyers since 2004, and is the current State Chair for the State of Arizona. Mr. Rusing was also selected by his peers to be included in The Best Lawyers in America for Commercial Litigation. The Chambers and Partners USA Survey of America's Leading Business Lawyers recognized Mick as a top litigator in Arizona. According to the survey, "Rusing is no stranger to multi-million dollar disputes…" and peers acknowledged him as "one of the finest: he has all the right attributes you want in a lawyer." In the first Arizona Super Lawyer poll Mick was chosen as an Arizona Super Lawyer, and one of the top 50 lawyers in Arizona. Mr. Rusing is "AV Preeminent Peer Review Rated" through the Martindale Hubble PEER REVIEW RATINGS Process.
Fiduciary Duties
Large Case Litigation
Litigation - Labor and Employment
Mass Tort Litigation / Class Actions - Plaintiffs
Personal Injury Litigation - Defendants
Personal Injury Litigation - Plaintiffs
Personal Injury Litigation - Defendants, Tucson (2017)
2013 Top Rated Lawyer in Energy/Environmental, American Lawyer Media
Father of the Year, presented by Fathers Day Council Tucson, 2010
Best Lawyers in America (Commercial Litigation, Personal Injury Litigation - Plaintiff, Personal Injury Litigation - Defense, Banking & Finance Litigation, Intellectual Property Litigation, Real Estate Litigation, and Regulatory Enforcement Litigation)
Chambers USA, America's Leading Lawyers for Business Litigation
Southwest Super Lawyers, Litigation, One of Top 50 Lawyers in Arizona in Inaugural Edition
Benchmark America's Leading Litigation Firms and Attorney, One of Seven "Litigation Stars" in Arizona
Fellow, International Academy of Trial Lawyers
Fellow, American College of Trial Lawyers
Environmentalist of the Year, Arizona Game and Fish Commission
University of San Francisco, B. A.
6363 North Swan Road, Suite 151
What is your relation to Michael J. Rusing? Consulted Attorney Current Client Former Client Other


Membership of Peannairí currently costs €35 (which includes use of the Library) and costs €25 for country members.
Regular classes and workshops are held throughout the year in various locations in Dublin. For these locations and times go to "classes" and "workshops" on the menu above. These will also appear on our facebook page.
Why not come to one of our monthly meetings or join a class?
Whether you're a calligrapher with experience or someone who is simply curious to learn more, you will find a worthwhile and absorbing craft awaits you.
Jane Connolly, 44 The Park, Kingswood Heights, Tallaght, Dublin 24.
2) You can pay in cash at meetings and workshops.


text:
Home Current Issue Ahead of print Editorial Board Archives Symposia Guidelines Subscriptions Login
Apul Goel
Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh, India
Date of Web Publication 29-Jun-2018
Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh
DOI: 10.4103/iju.IJU_199_18
Goel A. Round up. Indian J Urol 2018;34:170-1
Goel A. Round up. Indian J Urol [serial online] 2018 [cited 2020 Jan 19];34:170-1. Available from: http://www.indianjurol.com/text.asp?2018/34/3/170/235532
Vesicovaginal fistula (VVF) severely restricts the quality of life, while hysterectomy is one of the most common causes of VVF formation. The optimal time duration for repair is not well defined but most urologists would wait for 2–3 months before repair. As a result, the patient's life remains miserable during this waiting period. Giusti et al. reported their experience of successfully treating 16 women with posthysterectomy VVF with transperitoneal extravesical laparoscopic approach (100% success).[1] Instead of tissue interposition between the sutured urinary bladder and vagina, they report the use of commercially available absorbable fibrin sealant patch to save operative time. All the VVFs were secondary to abdominal radical hysterectomy and the fistula had supratrigonal location. The mean time between hysterectomy and VVF correction was 9 days (range 4–17). Their data support early repair in simple posthysterectomy VVFs. Similar results were also reported by Xiong et al. involving 18 women including some with complex fistulas.[2]
5-alpha reductase inhibitors (5ARIs) are widely used for the treatment of benign prostate enlargement (BPE).[3] This drug was also evaluated as a chemopreventive agent for cancer prostate.[4],[5] However, a study showed that its use was associated with higher risk of detection of high-grade cancer prostate.[6],[7],[8] In a population-based study involving a cohort of 214,272 men over a 19-year observation period, Wallner et al. compared the risk of mortality among men treated for BPE with 5ARI to those men treated with alpha-blockers alone in community practice settings.[9] With 543,523 person-years of follow-up reported, the authors recorded 35,266 deaths during the study period, of which 18.9% were 5ARI users, while 20.4% were on alpha-blockers alone. After adjusting for age, medication initiation year, race, region, prior alpha-blocker intake history, Charlson score, and comorbidities, the authors found that 5ARI use was not associated with an increased risk of mortality when compared to alpha-blocker use (adjusted hazard ratio: 0.64, 95% confidence interval: 0.62, 0.66). This study reassures that the use of 5ARI is safe.
Patients with muscle-invasive bladder cancer are often treated by radical cystectomy. The two common methods for urinary diversion include ileal conduit and orthotopic neobladder. Apart from the other morbidities associated with these procedures, urinary tract infections (UTIs) are one of the most common problems encountered in the postoperative period. Mano et al. compared the incidence rate of UTIs and associated pathogens between patients receiving either ileal conduit or orthotopic neobladder urinary diversion following radical cystectomy.[10] The authors reviewed the records of 179 patients treated between 2006 and 2011 and collected data regarding postoperative UTI. The authors also identified the preoperative predictors for developing UTI using the Cox regression analysis. During the study duration, 130 patients underwent ileal conduit, while 49 had orthotopic neobladder. Within the first 3–3 months, 29% patients with neobladder developed UTI as compared to 8% patients with ileal conduit (P = 0.001). The rates of UTI did not differ in subsequent follow-up. Diversion type was not significantly associated with the occurrence of UTI on the multivariate analysis after adjusting for age, Charlson comorbidity index score, and presence of diabetes mellitus.
Extracorporeal shock wave lithotripsy (SWL) is an important treatment modality for managing pediatric renal stones. Onal et al.[11] and Dogan et al.[12] in 2013 and 2015, respectively, proposed nomograms for predicting the success rate of SWL in individuals <18 years of age. These nomograms predict the successful outcome based on parameters such as age, stone size, history of stone treatment, gender, stone location, and stone number. Yanaral et al., in a retrospective analysis, analyzed the data of 219 children aged <18 years.[13] The mean age of the study population was 82.7 months. The authors found that both Onal et al. and Dogan et al. nomograms were independent predictors of stone-free rate following SWL in children. Although both the nomograms predicted the outcomes of SWL, the authors felt that there were limitations in both the nomograms and a better nomogram was needed. They suggested that addition of parameters such as stone density, renal abnormalities, degree of obstruction, and setting of lithotripters can further improve the predictive power of these nomograms.
Sacral neuromodulation (SNM) using an implanted device is one of the treatment options for management of conditions such as overactive bladder. Traditionally, magnetic resonance imaging (MRI) is contraindicated in individuals with devices, especially if the device is implanted near the area of imaging. Patients with InterStimTM II device can only undergo 1.5 Tesla head MRI using a radiofrequency transmit-receive head coil, while MRI for other body parts is not recommended by the manufacturer. The problems include heating of the device during MRI, shock-like stimulation, permanent damage to device, change in device settings, and implant movement.[14] Due to these concerns, radiologists usually refuse to perform MRI on such individuals. The literature documenting the safety of MRI in individuals with SNM device is scarce. Guzman-Negron et al. prospectively evaluated the safety of performing 1.5 Tesla MRI of the lumbosacral spine in 11 participants.[15] They reported no significant adverse events in patients and the therapeutic efficacy of SNM remained unchanged 1 month after imaging.
Urethral stricture recurrence is not uncommon after urethroplasty and is often managed by urethral dilatation (UD), direct vision internal urethrotomy (DVIU), or repeat urethroplasty. Sukumar et al. share their experience of treating 53 men who developed stricture recurrence after bulbar urethroplasty and were managed by either UD or DVIU.[16] They compared the outcomes between UD and DVIU. Furthermore, they evaluated the results based on the type of initial urethroplasty (excision and primary anastomosis [EPA] versus substitution urethroplasty). At a median follow-up of 5 months, the success after UD was only 10% as compared to the success rate of 49% with DVIU (P < 0.001). The results after DVIU were better in men who had undergone substitution urethroplasty (53%) as compared to men who had undergone EPA (13%; P = 0.005). The authors speculate that this observation could be because of the different mechanisms of recurrence for EPA (ischemic) versus substitution urethroplasty (nonischemic).
Financial support and sponsorship:
Conflicts of interest:
Giusti G, Lucci Chiarissi M, Abate D, De Vita G, Angioni S, De Lisa A. Early repair of post-hysterectomy vesicovaginal fistulae through a laparoscopic transperitoneal extravesical approach. Experience of a single center. Urology 2018. pii: S0090-4295(18)30539-9.
Xiong Y, Tang Y, Huang F, Liu L, Zhang X. Transperitoneal laparoscopic repair of vesicovaginal fistula for patients with supratrigonal fistula: Comparison with open transperitoneal technique. Int Urogynecol J 2016;27:1415-22.
McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011;185:1793-803.
Andriole GL, Bostwick DG, Brawley OW, Gomella LG, Marberger M, Montorsi F, et al. Effect of dutasteride on the risk of prostate cancer. N Engl J Med 2010;362:1192-202.
Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med 2003;349:215-24.
Azoulay L, Eberg M, Benayoun S, Pollak M. 5α-reductase inhibitors and the risk of cancer-related mortality in men with prostate cancer. JAMA Oncol 2015;1:314-20.
Murtola TJ, Karppa EK, Taari K, Talala K, Tammela TL, Auvinen A. 5-alpha reductase inhibitor use and prostate cancer survival in the finnish prostate cancer screening trial. Int J Cancer 2016;138:2820-8.
Preston MA, Wilson KM, Markt SC, Ge R, Morash C, Stampfer MJ, et al. 5α-reductase inhibitors and risk of high-grade or lethal prostate cancer. JAMA Intern Med 2014;174:1301-7.
Wallner LP, DiBello JR, Li BH, Van Den Eeden SK, Weinmann S, Ritzwoller DP, et al. The use of 5-alpha reductase inhibitors to manage benign prostatic hyperplasia and the risk of all-cause mortality. Urology 2018. pii: S0090-4295(18)30553-3.
Mano R, Goldberg H, Stabholz Y, Hazan D, Margel D, Kedar D, et al. Urinary tract infections after urinary diversion-different occurrence patterns in patients with ileal conduit and orthotopic neobladder. Urology 2018;116:87-92.
Onal B, Tansu N, Demirkesen O, Yalcin V, Huang L, Nguyen HT, et al. Nomogram and scoring system for predicting stone-free status after extracorporeal shock wave lithotripsy in children with urolithiasis. BJU Int 2013;111:344-52.
Dogan HS, Altan M, Citamak B, Bozaci AC, Karabulut E, Tekgul S, et al. A new nomogram for prediction of outcome of pediatric shock-wave lithotripsy. J Pediatr Urol 2015;11:84.e1-6.
Yanaral F, Ozgor F, Savun M, Agbas A, Akbulut F, Sarilar O. Shock-wave lithotripsy for pediatric patients: Which nomogram can better predict postoperative outcomes? Urology 2018. pii: S0090-4295(18)30303-0.
Medtronic Inc. MRI guidelines for InterStim Therapy Neurostimulation Systems. Available from: http://www.mriquestions.com/uploads/3/4/5/7/34572113/interstim_contrib_214172.pdf. [Last accessed on 2018 Jan 23].
Guzman-Negron JM, Pizarro-Berdichevsky J, Gill BC, Goldman HB. Can lumbosacral magnetic resonance imaging be performed safely in patients with a sacral neuromodulation device? An in vivo prospective study. J Urol 2018. pii: S0022-5347 (18) 43272-7.
Sukumar S, Elliott SP, Myers JB, Voelzke BB, Smith TG 3rd, Carolan AM, et al. Multi-institutional outcomes of endoscopic management of stricture recurrence after bulbar urethroplasty. J Urol 2018. pii: S0022-5347(18)43084-4.
Goel A
Article in PDF (316 KB)
© 2006 - Indian Journal of Urology | Published by Wolters Kluwer - Medknow
Online since 1st January, 2006


- Flash Paper: 5 minute (no more than 5 slides). We particularly welcome proposals from emerging scholars in this category.
This conference has been designed to coincide with Classic Week at Christie's in July 2019.
Christie's Education is a specialist provider of higher and continuing education, and an internationally recognised centre of academic excellence in the study of art business and the art market, art history and art world ecosystems, curating and connoisseurship. Our teaching philosophy is rooted in a knowledge culture that respects original enquiry and learning and that reflects a commitment to principles of equality, diversity and inclusivity.
Christie's Education offers master's degrees in London and New York, and is dedicated to preparing students for entry into the art world, placing great importance on analytical skills, object-based learning, research and scholarship, and the practical experience of art and business as the keys to professional success. Studies are reinforced with a rigorous professional development course and all students are offered an integrated art world work placement as part of their degree.
Christie's Education also offers a wide range of continuing education opportunities in London, New York and Hong Kong, designed to introduce the fundamentals of art, collecting and art business, as well as advanced and certificate courses for those with an appetite to study at a deeper level. In addition, our online courses provide a fully immersive experience of the art world, enabling anyone in the world to access learning at the click of a button.
CFP: Recycling Luxury (London, 5 Jul 19). In: ArtHist.net, Jan 24, 2019 (accessed Apr 22, 2019), <https://arthist.net/archive/20015>.


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Crossdraw, Yakima and a devilish horse
WHAM, WHOOMP, THUD!! The Crossdraw Kid's butt bit the dust once again. His horse, a beautiful young palomino, Golden Rule, had, as he always did, thrown The Kid into the mud and sand of the old Los Angeles river. The Kid, a good rider, taught by the best, had never ridden his horse without getting thrown at least once.
It seemed to The Kid that a nefarious plot was working against him.
He might have been right.
All the facts on how the Kid acquired his colt have never really been known, and may never be. As the story grew over the years, Wild Bill Elliott lost him in a card game to Sonny Tufts at The Kid's house, one Saturday in June. Not having a place to keep him, Sonny traded the palomino, on the spot, to either Ward Bond, Clark Gable or Yakima Canutt, for a Mossberg over and under 12 gauge shotgun that Sonny coveted. Whoever did the trade, missed one small detail. The shotgun in question was hanging over the fireplace in The Kid's living room.
Needless to say, it belonged to The Kid's dad, who at that moment was on his way home from working on a Republic western in Apple Valley.
The rot gut haze had lifted by the time the missing shotgun was discovered. Apparently neither Yakima, Mr. Gable or Mr. Bond would admit to the deed. So somehow, The Kid ended up with Golden Rule, the Horse From Hell. Because of the events to follow, the Kid always felt that Yakima was probably the very savvy horse trader. He obviously recognized the devil in horseflesh, and a poor unsuspecting 12-year-old's ego and rear end suffered for several years because of it.
Enos Edward (Yakima) Canutt, movie actor, stunt man and Hollywood action director, was first and foremost a cowboy, one of the very best among the early day roughstring riders. Born in Colfax, Washington, Nov. 29, 1895. He was reared on a ranch and couldn't recall when he was ever without a horse. When he was 11, he rode his first bucking bronco... one that had just thrown his older brother ... and "made a good horse out of a bad one." At 16, he won the five-day Colfax County Fair bronco riding, his first such event. After serving stateside in the Navy during WWI, he returned to his first love, rodeoing.
Enos got his moniker after allowing he would hold up the reputation "of Yakima" in the bucking horse try‑outs at Pendleton, after three disastrous attempts to qualify by riders who bragged they were "from Yakima." After his success, the Round‑Up announcer and local press began to call him, "Yakima" Canutt. The Nickname stuck. Following an extraordinary 10‑year period when Yak won the All‑Around Championship of the World, work lead him to Hollywood.
A rodeo in Los Angeles culminated in a meeting with Tom Mix, who got him work as a cowboy extra. Canutt's skill as a rider and stunt fighter led to a contract starring in a series of over 40 western silents. However, a case of flu had damaged his vocal cords, and when sound came into vogue, his raspy voice was unsuited to the heroics performed by cowboys in sound films. He focused on stunt work and, although he continued to play roles as heavies, quickly became known as Hollywood's premier stuntman during the 1930s. He and John Wayne created a new technique for filming screen fights more believably, and Canutt created or refined most of the stunt techniques used in westerns and action films for years to come.
Canutt was severely injured performing stunts in "Boom Town" and again in "Old Oaklahoma" in 1943, and after that film he retired from active stunting and concentrated on directing second units, the crews responsible for filming stunts, action sequences and other scenes not necessarily requiring the principal cast members. He created some of the most dynamic and memorable action sequences in film history, culminating in the famed chariot race in "Ben Hur." He was awarded a special Oscar in 1966 for his contributions to film.
Sometime between working together in "Gone With The Wind" in 1939, when The Kid was really just a baby and "The Showdown" in 1949, Yak also had the kindness and found the time and patience to help teach Crossdraw and the rest of the kids on the Republic lot how to ride. Every time The Kid watches some old western he was in from the early 1950s he can almost hear Yak and the crew laughing in the background. It never failed, thanks to Yak, The Kid was always riding the biggest most barrel chested horse in the whole San Fernando Valley.
With his short little legs, one wearing a post polio high topped shoe/boot, sticking almost straight out to the side, The Kid looked a bit like a broken wishbone in a cowboy hat. But again, thanks to Yakima, he could ride like the wind.
None of this impressed The Kid the first time he faced death on the back of the Horse from Hell. But, we're getting ahead of the story. To pay the boarding fees at his orthodontist, Dr. Van Meeter's small farm, The Kid cleaned the stables on weekends, after he had his wires tightened. The doctor's farm was between Lankershim and Vineland Blvd., about halfway between Universal and Republic Studios. A trail led down to the riverbed that ran along side both studios between Lankershim and Vineland Blvd., about halfway between Universal and Republic Studios. A trail led down to the riverbed that ran along side both studios.
The Kid's dad, the good doctor and Yakima (see, he's still causing trouble) all decided that it was time to geld the palomino, and the Kid drew the short straw. Did anyone ever notice that when you're 12 and dealing with grown‑ups, all the straws are short.
While the offending adults held Golden Rule, Crossdraw mimicked a scene he had witnessed in fascination many times. A quick slash with a odd-curved bladed knife, a wack in the vacated area with a hot tar brush amidst a flurry of flashing hooves, and the deed was done. It escaped The Kid's attention that while he was causing the colt to loose his stallion‑hood, the Horse From Hell was looking The Kid right in the eye. Events to follow proved elephants aren't the only animals that never, ever forget.
It was also decided that because it was his horse and he was the smallest and lightest, The Kid would have the great pleasure of saddle breaking the young colt. Much to The Kid's surprise, this went very well. (This was all part of the Devil Horse's evil plan!) Soon, it was obviously time to ride right on over to Republic and show Yak and the wranglers his handy work.
At almost exactly the point of no return in the river bed, and also the only really wet and rocky area in miles, the colt threw The Kid into the water like a dead tick, and raced back to the barn. Dazed, the Kid picked himself up and tried to decide what to do. Start walking to the Studio and face the jeers of the Heroes of his youth, or go back to the farm and kill and eat the horse? No contest. By the time he got back to the barn, Crossdraw was so wet and miserable, he forgot about his vendetta.
The dreaded old "Get Right Back On" syndrome took effect, and for days, weeks and eternity, The Kid tried in vain to ride the whole way to the studio. Short of tying himself to the saddlehorn, he could never stay on board. But, here's when the Horse From Hell's devilment really started. The doctor, Clark Gable, (yeah, really) The Kid's dad, Yak, in fact everyone he knew offered to ride along and see what on earth he was doing wrong. Yep!, nothing ever happened. That horse would ride like he was in the Rose Parade. But, the second he was alone with The Kid, BAM!!, into the water.
Sadly, there is no happy ending to this saga. Crossdraw's dad finally sold the colt and put the money in the bank for him. A lifetime later, The Kid's wife will, every once in a while, wake him from a terrible nightmare. He keeps screaming, over and over, "Which bank?!, Dad, which bank?!" The Horse From Hell is still compounding his misery … daily. But, The Kid did have the privilege of standing in the shadow of the finest cowboy stuntman who ever lived, Yakima Canutt... And called him, "Friend." Two of his children, Tap Canutt and Joe Canutt, followed him into the stunt profession. Yakima Canutt died in 1986, the most famous and respected stuntman of all time.
St. George resident Patrick Curtis is the Crossdraw Kid.


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text:
Commission Investigation to Identify and Develop Performance Metrics, and Potentially, Incentives for Xcel Energy's Electric Utility Operations
BEFORE THE PUBLIC UTILITIES COMMISSION
Katie Sieben Chair
Dan Lipschultz Commissioner
Valerie Means Commissioner
Matthew Schuerger Commissioner
John Tuma Commissioner
In the Matter of a Commission Investigation to Identify and Develop Performance Metrics,
and Potentially, Incentives for Xcel Energy's Electric Utility Operations
Comments of the R Street Institute
The R Street Institute (R Street) appreciates the opportunity to submit these comments in response to the Minnesota Public Utilities Commission's (Commission or PUC) Notice for Comment Period issued on November 1, 2019.1 R Street participated in the workshop hosted by Xcel and facilitated by the Great Plains Institute (Great Plains) on October 1, 2019, and provided comments to Xcel and Great Plains in advance of that workshop. R Street thanks Xcel and Great Plains for their openness in engaging with stakeholders during these discussions. R Street found the conversation and content informative and provided a tremendous opportunity for a rich dialogue amongst those in attendance.
R Street congratulates the Commission for the on-going interest in performance-based regulation (PBR), and the recognition of the importance of PBR to the future of electricity ratemaking. R Street's participation in these discussions is focused on identifying metrics that can best bring about meaningful change to the existing cost-of-service ratemaking framework by adopting metrics and incentives that change the interest of utilities away from capital projects but towards a model of performance. As such, R Street reiterates its position from prior comments submitted in this docket that merely collecting
metrics for the sake of collecting metrics will not be a successful result of this initiative.2 Furthermore, the number of metrics adopted by the Commission in its September 18, 2019 Order and submitted by Xcel on October 31, 2019 are simply too many to result in reasonable changing of the ratemaking model towards one based on performance. For PBR to be successful, the number of metrics must start with as few as possible and be focused on utility behavior, which will incentivize action towards performance. R Street appreciates the time and attention provided by the Commission and Commission Staff to this
initiative and will now address the questions identified in the Notice for Comment Period.
1. Are there calculation or data sources proposed by Xcel that do not adequately measure utility performance as identified in the Commission's September 18, 2019 order? If so, please describe in your comments as follows:
a. Please list each metric by outcome and include Xcel's proposal and where it does not correspond to the Commission's request. If possible, include modifications to better align it with the Commission's order.
b. Parties are asked to be as specific as reasonably possible with any proposed modifications including source information.
R Street believes several of the metrics do not adequately measure utility performance. Some of the metrics are salvageable and some are unsalvageable.
Affordability Metric 2- Average monthly bills for residential customers
Xcel proposes to calculate this metric as simply dividing total residential class revenue divided by 12 months by total number of residential customers served. As was discussed in the workshop, this simple calculation can easily misrepresent the intent of this metric, which is to ensure that residential rates are "reasonable." As R Street has recommended several times, this metric fails to consider any other economy-wide metrics to show how customer's bills are reflective or not reflective of the economy as a
whole. Furthermore, other parties during the workshop noted that with the focus on electrification, a "higher" average residential customer bill may frustrate initiatives related to electric vehicle shopping or electrification of greater amounts of residential customer services, such as heating, laundry, or cooking. As R Street stated previously, "A valid metric on affordability must, by definition, consider how far a consumer's dollar gets her, as well as the efficiencies that firms economy-wide are obtaining in the provision of services to those consumers. If a metric on affordability were to exist only in relation to a
national utility average, it would be unduly referential to a utility's costs and not to what customers can afford and are paying for elsewhere in the economy."3 We reiterate that average customer bills remain a valid metric, but without an associated balancing metric it may not provide the Commission and the public as valuable information as it could.
Customer Service Quality Metrics 1 and 2-
1. Initial customer satisfaction metrics:
a. Existing multi-sector metrics, including ACSI and J.D. Power – NEW METRIC
Calculation Proposed: We recommend reporting from the Company's subscription to J.D. Power and public information published by ACSI.
2. Possible future customer satisfaction metrics
a. Commission-approved utility-specific survey – POSSIBLE FUTURE METRIC
R Street harbors significant concerns as to the benefit or purpose of either of these metrics to provide useful information to the Commission or the public, and whether these metrics should be used at all for future performance incentives. Xcel is a vertically-integrated monopoly with a captive customer base.
As a result, Xcel is not subject to competitive pressure that would naturally push a company to be more customer responsive. Where there is some amount of competition, such as via Minnesota's successful community solar garden program, a metric such as customer satisfaction may lead to Xcel exercising its monopoly power to weaken that program in order to raise its customer satisfaction number. Furthermore, as a monopoly provider of service to a captive customer base, a customer's perspective of
Xcel may simply be focused on reliability, which is already a metric included here. Absent competition, a customer has no real sense as to whether their rate is reasonable or not since the customer has no competing offer to compare it against. Lastly, the presentation from Xcel at the October 1 meeting on the JD Power methodology exposed significant weaknesses in its viability as a reasonable source of this metric. In essence, R Street does not believe that the JD Power methodology adequately captures a meaningful measurement of customer satisfaction with their utility. Xcel's alternative proposal suffers from the same flaws as JD Power's methodology in that it is simply not a sufficient representation of a customer's satisfaction with its utility, not the least of which is due to the lack of choice or competition to allow a customer to compare the service and offerings from Xcel to a competitor. As such, R Street does not believe these metrics themselves, nor the underlying methodology to support these metrics should be used by the Commission for consideration in this docket.
Cost-Effective Alignment of Generation and Load
R Street believes that this topic has the most potential related to identifying metrics that can best be tailored towards a PBR regime. A more cost-effective alignment of generation and load should focus the utility on utilizing all available resources to meet demand, including non-utility resources. This shift away from centralized power plants and towards more distributed resources, including non-wires alternatives, has the potential to yield the greatest benefit to customers through lower bills and better utilization of the distribution system. Unfortunately, at present it does not appear that Xcel is wellsuited to implementing this direction. As described in the October 31 report, Xcel's use of demand response is almost entirely dedicated towards Midwest ISO emergency conditions and not towards a better utilization of its system or towards a more cost-effective alignment of generation and load.
R Street appreciates the Commission's reference towards the LBNL report on demand response potential in California by 2025. However, as evidenced in the October 1 report, participants, including R Street, struggled to translate the terminology from the LBNL report to the Minnesota context, especially considering the LBNL report had not been part of the stakeholder discussion until raised by the Commission towards the end of their August 16, 2019 Open Meeting. R Street supports broadening the
definition and use of demand response to be more than traditional AC cycling programs and other curtailment programs tied to the MISO market. R Street supports using demand response, and a host of other distributed energy resources, as part of their everyday resource mix which would get much closer to the Commission's goal of a cost-effective alignment of generation and load.
As such, R Street recommends that the Commission be more explicit in how it views "demand response" in the context of both the LBNL report and how it can result in a more cost-effective alignment of generation and load. For example, does demand response encompass all distributed energy resources? Is demand response limited only to traditional utility demand response programs, or can this be used to encourage Xcel to engage in procuring resources from demand response aggregators, customers, or other providers? To what extent should Xcel move to more time and location-based procurements based on distribution needs? What programs or measures should be taken that would result in demand response (and distributed energy resources) being used more meaningfully than only in an emergency? These questions are raised merely to note that much more work is needed before this topic can result in meaningful metrics that get at the Commission's intent to more cost-effectively align generation and load.
2. Are there metrics that do not have an agreed-upon formula or data source that requires further development? If so, please explain.
R Street notes two metrics that may benefit from better information sources or program development to enhance the metric.
Utility Performance Metrics 3c- Number of customer complaints – EXISTING METRIC
Calculation Proposed: In our 2015 multi-year rate case, we proposed that the number of Customer Complaints be based on the number of complaints per 1,000 customers to regulatory agencies to ensure that performance is measured in relation to its total customer base.
R Street agrees that number of customer complaints is a valid metric for Xcel to report to the Commission. However, R Street, and other attendees at the October 1 workshop, were surprised that this metric is based on complaints to the Commission as opposed to complaints fielded by Xcel. In an effort to make this metric more meaningful, R Street notes that there are differing types of complaints and it is unclear what is the definition of a complaint being recorded for this metric. To illustrate this, it
may be useful to use an example from California.
In 2011-2012, the California Public Utilities Commission (CPUC) held stakeholder working group meetings to develop a set of metrics related to Smart Grid investments and utility performance. The CPUC was clear that these metrics were for reporting only, but that parties could use the information in other proceedings. A metric that was agreed upon related to customer complaints. However, all parties agreed that there was a need to differentiate the quality of complaints received by the utility. The consumer advocate in California recommended that the metric report "Escalated Complaints" and track the type of complaints.4 The use of escalated complaint was to report on those complaints that were more than minor complaints and resulted in additional utility effort to address the complaint. The CPUC ultimately agreed with the parties on use of escalated complaint as the metric and agreed with the consumer advocate to require the utilities to track and report on the type of complaint.5
In order to make the customer complaint metric more meaningful to the Commission and the public, R Street suggests that the data source for this metric make clear that the complaints being reported are worthy and quality complaints about utility service, including billing complaints, that the report include complaints fielded by Xcel customer service representatives, and that they be tracked by type, such as billing complaints, service complaints, and so forth.
Utility Performance Metric 4- Equity metric – customer service quality by geography, income or other relevant benchmarks – NEW METRIC
R Street takes no position on this metric but highlights it here to note Xcel specifies the use of a Minnesota area code to track service. With the growth of homes without landlines and an increasing number of residents coming from outside of Minnesota, it is likely that Xcel will see an increase in nonMinnesota area codes as the main number for its customers. R Street does not believe that Xcel is engaging in any nefarious treatment of customers based on area codes but does expect Xcel to have a
plan in place to ensure that customers, regardless of the area code of their phones, are treated equally.
3. Are there reporting schedules that should be modified from Xcel's proposal so the resulting data would better represent utility performance? If so, please propose modification(s) and provide substantiation.
R Street provides no comment on this question.
4. The September 18, 2019 Order set out five additional guiding elements listed below for stakeholders and Xcel. Does Xcel's proposal align with them? Please highlight areas where Xcel's proposal may be inconsistent.
a. Utility performance metrics should be focused on results and outcomes. Metrics should not prescribe detailed or specific tools or tactics. This will provide the utility the opportunity to be flexible and tailored to its unique system and customers' needs.
Consistent with its comments above and previously in this proceeding, many of the metrics meet this requirement.
b. Metrics should not support the deployment of specific technologies such as only one type of electric generation, unless such information is needed for a utility to comply with statutes.
R Street does not believe that these metrics are sufficient to shift utility interest away from utilityowned capital projects. The metrics identified in cost-effective alignment of generation and load do not lay out a path towards better system utilization and better utilization of customer-side resources. Part of R Street's concern is that Xcel simply does not have the pieces in place today or the incentives to shift their interest towards better utilization of demand response or distributed energy resources generally at the expense of their own resources. Historical demand response programs have focused on MISO emergency demand rather than as resources that can be used on a daily basis as part of the utility's resource mix. Existing cost of service models encourage utility ownership of resources; PBR is one step to disaggregate that relation. A second step, not part of this proceeding, is to implement full decoupling. Combined, decoupling and PBR, would start the state, and Xcel, on a path towards a more responsive and performance-based system and away from a capital-intensive, sales based structure that is in place today.
c. Metrics identified to gauge environmental performance should directly measure environmental emissions and impacts.
R Street provides no comments.
d. Parties should develop measurement methodologies and future metrics with an eye toward development of a utility performance dashboard.
If the purpose of these metrics is to provide a simple accounting of utility performance, then a dashboard may be of use. During the October 1 workshop, stakeholders raised questions related to costs, hosting, and upkeep of a dashboard. Additionally, during the presentation of Michael O'Boyle, it was noted there are a variety of quality dashboards across the industry where dashboards have been implemented. R Street has no opinion as to the benefit of a dashboard at this point in the proceeding
until a final list of metrics is developed.
e. Metrics directed by the Commission at this stage of the process are not to be viewed as the final, exclusive list. As stakeholders work forward through the PIM process they may propose reshaping or adding to the metrics outlined above.
R Street appreciates the Commission's work to date on the proceeding and development of a record on metrics. R Street understands the Commission's intention to work through the process but leaves stakeholders struggling to determine how much focus should be provided on these metrics. R Street believes that metrics that lead to PIMs should be limited in number, so this process should lead to fewer metrics than what has been proposed so far.
5. Are there other concerns the Commission should consider as it establishes performance metrics for Xcel's electric utility operations?
R Street thanks the Commission for the opportunity to provide these comments on the proposed metric methodology on performance-based metrics. We look forward to continuing the conversation with the Commission and all stakeholders on this very important topic.
___/s/ Christopher Villarreal____
Christopher Villarreal
Non-Resident Energy Policy Fellow
The R Street Institute
1212 New York Ave. NW Suite 900
Chris Villarreal
Electricity Policy
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Mary and John married in 1860 in Mare Street Congregational Chapel in Hackney. Mary Crellin was a brave woman. Their first home together was in the main accommodation block of the Asylum, where they had a living room, a bedroom and a kitchen. Everleigh their first son was born in 1861 and Lilian, their only daughter in 1863. A second bedroom was now a matter of necessity. With this small addition to their married quarters they managed their modest domestic life. Mary threw herself into the life of the Asylum. She was a willing volunteer. She worked unpaid in the school room and in addition she organised entertainments. She had artistic flair and when the Langdon Downs came to leave Earlswood her last contribution was the writing of a prologue for a concert. The prologue was delivered by Langdon Down himself.
Lilian died tragically at the age of 2 years. Her symptoms suggest that she had suffered from a viral brain infection. Her parents were devastated and the inscription on her tombstone in Reigate Cemetery reads: "In ever loving remembrance of a dear little Lilian who departed this life June 1st 1865 age 2 years. Happy soul to the sight of Jesus gone". The Langdon Down's son Reginald was also born in Earlswood in 1866.


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- To ensure that the overall Quality Objectives of the Company in respect of carrying out job responsibilities are met.
- Post holder must understand the need for confidentiality when dealing with customer information.
- Post holder must understand contractual requirements to maintain integrity of data and the availability of the service at all times.
When you press apply, you will then immediately receive an email with a link to the employers career page. Only applicants who follow the link and complete the application form will be considered for this position.