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Time trends (2001–2019) and sex differences in incidence and in-hospital mortality after lower extremity amputations among patients with type 1 diabetes in Spain
Ana Lopez-de-Andres1,
Rodrigo Jimenez-Garcia1,
Javier de-Miguel-Diez3,
José M. de-Miguel-Yanes4,
Ricardo Omaña-Palanco1 &
David Carabantes-Alarcon1
We examined trends in incidence (2001–2019), clinical characteristics, and in-hospital outcomes following major and minor lower extremity amputations (LEAs) among type 1 diabetes mellitus (T1DM) patients in Spain and attempted to identify sex differences.
Retrospective cohort study using data from the Spanish National Hospital Discharge Database. We estimated the incidence of the LEA procedure stratified by type of LEA. Joinpoint regression was used to estimate incidence trends, and logistic regression was used to estimate factors associated with in-hospital mortality (IHM).
LEA was coded in 6011 patients with T1DM (66.4% minor and 33.6% major). The incidence of minor LEA decreased by 9.55% per year from 2001 to 2009 and then increased by 1.50% per year, although not significantly, through 2019. The incidence of major LEA decreased by 13.39% per year from 2001 to 2010 and then remained stable through 2019. However, incidence increased in men (26.53% per year), although not significantly, from 2017 to 2019. The adjusted incidence of minor and major LEA was higher in men than in women (IRR 3.01 [95% CI 2.64–3.36] and IRR 1.85 [95% CI 1.31–2.38], respectively). Over the entire period, for those who underwent a minor LEA, the IHM was 1.58% (2.28% for females and 1.36% for males; p = 0.045) and for a major LEA the IHM was 8.57% (10.52% for females and 7.59% for males; p = 0.025).
IHM after minor and major LEA increased with age and the presence of comorbid conditions such as peripheral arterial disease, ischemic heart disease or chronic kidney disease. Female sex was associated with a higher IHM after major LEA (OR 1.37 [95% CI 1.01–1.84]).
Our data show a decrease in incidence rates for minor and major LEA in men and women with T1DM and a slight, albeit insignificant, increase in major LEA in men with T1DM in the last two years of the study. The incidence of minor and major LEA was higher in men than in women. Female sex is a predictor of IHM in patients with T1DM following major LEA.
Lower extremity amputation (LEA) is a major complication of diabetes and is associated with low quality of life and higher risk of short-term mortality [1]. People with type 1 diabetes mellitus (T1DM) have a higher risk of LEA [2]. A recent study showed a 40-fold greater risk of amputation in patients with T1DM than in the general population [3]. The risk of LEA in patients with T1DM is a result of the combination of several conditions whose key contributing factors include ageing, male sex, cardiovascular comorbidities, hyperglycaemia, hypertension, and hyperlipidaemia [2, 4].
Rates of LEA among adults with diabetes are an important index of comprehensive diabetes care. Population-based studies in Spain showed that the number of T1DM-related LEAs decreased between 2001 and 2008 and then remained stable through 2012 [5, 6]. A Swedish study also reported a decrease in the frequency of amputations in patients with T1DM between 2017 and 2019 [4]. Similar findings have been reported in Denmark [7]. However, a study performed in the United States found an increase in diabetes-related LEAs, predominantly among younger patients (aged 18–44 years) and middle-aged patients (45–64 years) [8].
Sex differences may play an active role in incidence and outcomes among patients with diabetes following LEA. Several studies indicate that male sex is associated with a higher incidence rate than female sex [5, 6, 9], although female sex is an independent predictor of surgical site infection and in-hospital mortality (IHM) following LEA [6, 10]. Data regarding the results of hospitalization following LEA among men and women with T1DM are scarce.
Reliable epidemiological data on trends related to LEA, sex differences, and associated mortality are useful for assessing whether the quality of care for people with T1DM has improved and for informing health policy makers and healthcare providers of where additional resources may be required to fill the care gaps. Therefore, we used administrative data from an entire country over an 18-year period to examine trends in the incidence, clinical characteristics, and in-hospital outcomes of LEA procedures (major and minor) among patients hospitalized with T1DM. We also attempted to identify possible sex differences. Furthermore, we investigated the variables associated with IHM according to the type of LEA.
Study design, setting, and study population
To achieve the objectives set, a retrospective cohort study was carried out based on hospital discharge reports collected through the Spanish Hospital Discharge Records Database of the Spanish National Health System (RAE-CMBD, Registro de Actividad de Atención Especializada. Conjunto Mínimo Básico de Datos, Registry of Specialized Health Care Activities. Minimum Basic Data Set) for the period running from 1 January 2001 to 31 December 2019. The discharge records are coded based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) from 2001 to 2015 and the 10th Revision (ICD-10) from 2016 until the present. Detailed information on RAE-CMBD are available online [11]. For purposes of the study, we excluded data from the year 2016, because this was the year the RAE-CMBD began the conversion from ICD-9 to ICD-10 and, according to the Ministry of Health, some degree of under-coding may be present [12].
The study population included patients with T1DM aged ≥ 18 years with a procedure code for LEA in their discharge records. The ICD-9-CM and ICD-10 codes used to identify the study population are shown in Additional file 1: Table S1. We defined as a minor amputation any LEA distal to the ankle joint and as a major amputation any LEA through or proximal to the ankle joint, as described in a previous study [6].
We excluded patients with a diagnosis code of type 2 diabetes mellitus (T2DM) and all those with traumatic LEAs based on any lower extremity trauma-related code or diagnosis or procedure position (Additional file 1: Table S1).
For patients with multiple LEAs during their stay, only the higher-level LEAs was used in the data analysis.
Study variables
The main study variables were the incidence of major and minor LEAs, clinical characteristics, length of hospital stay (LOHS), and IHM.
Incidence rates were calculated based on the Spanish population with diabetes mellitus grouped by age and sex according to the National Health Surveys conducted for the years 2001/2002, 2003/2004, 2006/2007, 2009/2010, 2011/2012, 2014/2015, and 2016/2017 and based on data from the Di@bet.es Study, which estimated the prevalence of diabetes in the Spanish population [13, 14]. Diabetic populations for the missing years (2005, 2008, 2013, and 2018) were estimated assuming that the growth rate was the same throughout the period.
The patient-level variables analysed included age and clinical condition present at admission or diagnosed during hospitalization. The clinical conditions analysed included those of the Charlson Comorbidity Index (CCI) calculated based on ICD-9 and ICD-10 codes, as described elsewhere [15]. The CCI was analysed as a continuous variable, divided into three categories (0, 1, and ≥ 2) and for each of the following specific conditions included in the index (ischemic heart disease, chronic kidney disease, stroke, heart failure, liver disease, dementia, chronic pulmonary disease, connective tissue disorder, peptic ulcer, cancer or metastatic cancer and, human immunodeficiency virus).
Furthermore, we specifically described and analysed a series of diseases owing to their high prevalence and importance in T1DM patients, as follows: peripheral arterial disease (PAD), infection, peripheral neuropathy, hypertension, and lipid metabolism disorders. (Additional file 1: Table S1). For the first three conditions ICD codes used were based in the recommendations of Lin et al. [16].
The period from 2001 to 2019 was divided into six two-year periods: 2001–2003, 2004–2006, 2007–2009, 2010–2012, 2013–2015, and 2017–2019.
Descriptive statistics for continuous variables were reported as mean and standard deviation (SD). We conducted the skewness and kurtosis normality tests (Stata command "sktest") for CCI and LOHS, finding that these variables are not normally distributed, so for these two variables medians with inter quartile range (IQR) are provided.
Categorical variables were reported as frequency and percentage. We performed this statistical analysis by stratifying LEAs as major and minor.
Continuous variables were compared using the t test (means) or Wilcoxon rank sum test (medians). Categorical variables were compared using the chi-square test.
Incidence was analysed using Poisson regression models adjusted for age. Incidence rate ratios (IRR) were reported with their 95% confidence intervals (95% CI).
We used log joinpoint regression to identify the period in which trends changes in minor and major LEA rates occurred for each year, as well as to estimate the annual percentage of change in each of the periods delimited by the points of change. The analysis started with the minimum number of joinpoints and tested whether the inclusion of one or more joinpoints was statistically significant [17]. In the final model, each joinpoint indicated a significant trend change, and the annual percentage of change was obtained in each of the segments delimited by the joinpoints using the weighted least squares technique. Joinpoint Regression Program, version 4.0.4, was used for the analysis.
We conducted multivariable logistic regression analysis to identify which demographic and clinical conditions present on admission were independently associated with IHM. We constructed models separately for minor LEA and major LEA. The variables included in these models were age, sex, year of admission and all those clinical conditions that showed a significant association with the IHM in the bivariate analysis.
The statistical analysis was conducted using Stata version 14 (Stata, College Station, Texas, USA), and significance was set at p < 0.05 (two-sided).
The RAE-CMBD is owned by the Spanish Ministry of Health and can be accessed freely upon request [18]. Given the characteristics of this registry, which is anonymous, and according to Spanish legislation, ethics committee approval was not required.
A total of 6,011 non-traumatic amputations (3,992 minor and 2,019 major, ratio 1.97) were identified in patients aged ≥ 18 years with T1DM in Spain between 2001 to 2019. The proportion of women was 27.31% (1,642).
Trends in incidence, clinical characteristics, and hospital outcomes for patients who underwent a minor LEA procedure
According to the results of the joinpoint analysis, we found that the incidence of sex- and age-adjusted minor LEA procedures in patients with T1DM decreased by 9.55% per year from 2001 to 2009. From 2010 to 2019, they increased by 1.50% per year, although not significantly (Fig. 1A). According to sex, we found that in women with T1DM, the incidence rate decreased by 14.93% per year from 2001 to 2007 and remained stable thereafter (Fig. 1B). Incidence decreased significantly in men by 9.46% per year from 2001 to 2009, with no change from 2009 to 2019 (Fig. 1C).
Joinpoint analysis of annual LEAS in patients with type 1 diabetes in Spain. A Joinpoint analysis of annual minor LEAs in women with T1DM in Spain, 2001–2019. B Joinpoint analysis of annual minor LEAs in men with T1DM in Spain, 2001–2019. C Joinpoint analysis of annual major LEAs in patients with T1DM in Spain, 2001–2019. D Joinpoint analysis of annual major LEAs in women with T1DM in Spain, 2001–2019. E Joinpoint analysis of annual major LEAs in men with T1DM in Spain, 2001–2019. APC: Annual percent change (based on rates that were sex and aged-adjusted using the Spanish National Statistics Institute Census projections) calculated using joinpoint regression analysis. ˆAPC is significantly different from zero (two-side P < 0.05)
As can been seen in Table 1, in patients who underwent minor LEAs, a significant increase was observed over time in the prevalence of men (70.94% in 2001/3 vs. 80.13% in 2017/9; p < 0.001).
Table 1 Hospital discharges after minor and major non-traumatic lower extremity amputations among T1DM patients (Spain, 2001–2019)
Using the age-adjusted Poisson regression model, we found that the incidence of minor LEA for the period 2001–2019 was 3.01-fold higher among men with T1DM than among women with T1DM (IRR 3.01; 95% CI 2.64–3.36).
The mean age for patients with T1DM who underwent a minor LEA decreased significantly from 62.38 years of age in 2001–3 to 53.12 years of age in 2017–19 (p < 0.001). Overall, comorbidity measured with CCI, increased significantly over time (p < 0.001). Specifically, a significant increment was observed in the prevalence of infection, (19.52% in 2001–6 vs. 23.31% in 2013–19; p < 0.001), peripheral neuropathy, (8.93% in 2001–6 vs. 28.93% in 2013–19; p < 0.001), ischemic heart disease (3.53% in 2001–6 vs. 7.3% in 2013–19; p < 0.001), chronic kidney disease (15.02% in 2001–6 vs. 32.23% in 2013–19; p < 0.001), lipid metabolism disorder (11.63% in 2001–6 vs. 30.48% in 2013–19; p < 0.001) and liver disease, (2.28% in 2001–6 vs. 4.28% in 2013–19; p = 0.002). However, the prevalence of PAD, (76.68% in 2001–6 vs. 50.91% in 2013–19; p < 0.001) and hypertension decreased (30.93% in 2001–6 vs. 30.48% in 2013–19; p = 0.013) (Table 2).
Table 2 Comorbidities among patients with T1DM who had a non-traumatic lower extremity amputation (Spain 2001–2019)
Regarding in-hospital outcomes, as can been seen in Table 1, the median LOHS decreased significantly over time (17 days in 2001–3 vs. 14 days in 2017–19; p < 0.001). The IHM was 1.58% throughout the study period, with no significant change over time.
Trends in incidence, clinical characteristics, and hospital outcomes for patients who underwent a major LEA procedure
The joinpoint analysis showed that among patients with T1DM who underwent major LEA procedures, the sex- and age-adjusted major LEA incidence rate decreased by 13.39% per year from 2001 to 2010 (Fig. 1D) and remained stable through 2019. In women with T1DM, the incidence decreased by 9.91% per year over the entire study period (Fig. 1E). In men, it decreased by 16.45% per year from 2001 to 2007 and then decreased by 4.87% per year from 2007 to 2017, although it increased, albeit not significantly (26.53% per year), from 2017 to 2019 (Fig. 1F).
As seen for minor LEAs, there was a significant increase in the proportion of men over time, from 63.49% for the first time period analysed to 77.45% for the last (Table 1).
The age-adjusted Poisson regression model showed that from 2001 to 2019, the incidence of major LEA was 1.85-fold higher among men with T1DM than among women with T1DM (IRR 1.85; 95% CI 1.31–2.38).
From 2001 to 2019, the mean age of patients with T1DM who underwent a major LEA decreased significantly (67.42 years of age vs. 56.46 years of age, p < 0.001). The distribution according to the median CCI showed a significant increase in patients with T1DM (p < 0.001). Patients with T1DM were characterized by an increased prevalence of infection, (12.8% in 2001–6 vs. 18.02% in 2013–19; p < 0.001), peripheral neuropathy, (8.43% in 2001–6 vs. 27.33% in 2013–19; p < 0.001), chronic kidney disease (16.46% in 2001–6 vs. 39.6% in 2013–19; p < 0.001), heart failure (18.39% in 2001–6 vs. 20.4% in 2013–19; p = 0.002), and lipid metabolism disorders (11.08% in 2001–6 vs. 28.51% in 2013–19; p < 0.001) (Table 2). However, the prevalence of PAD (85.87% in 2001–6 vs. 61.19% in 2013–19; p < 0.001) and hypertension (33.84% in 2001–6 vs. 28.125 in 2013–19; p = 0.024) decreased over time (Table 2).
Regarding in-hospital outcomes (Table 1), no significant changes were found over time for LOHS or IHM. Overall, median LOHS was 18 days, and crude IHM was 8.57%.
In-hospital mortality and predictors thereof after nontraumatic LEA
As can been seen in Table 3, after minor and major LEA, crude IHM was higher in older patients, women, and those with more concomitant conditions according to the CCI. After major LEA, IHM was highest when the hospital admission occurred in the 2001–3 period (9.54% in 2001–03 vs. 8% in 2017–19; p < 0.005).
Table 3 In-hospital mortality among patients with T1DM who underwent minor or major non-traumatic lower extremity amputations
For minor and major LEA, the IHM was significantly higher among those who suffered PAD, ischemic heart disease, chronic kidney disease and heart failure. Stroke and dementia were associated to increased IHM only after major LEA.
As can be seen in Table 4, after multivariable adjustment, the risk of dying in hospital among patients who underwent minor and major LEA increased with age and the presence of PAD, ischemic heart disease or chronic kidney disease. Higher IHM was associated with female sex (OR 1.37; 95% CI 1.01–1.84) and dementia only after major LEA. Whereas, heart failure increased the risk only for those who underwent a minor LEA.
Table 4 Predictors of in-hospital-mortality among T1DM subjects with minor or major non-traumatic lower extremity amputations
Finally, the time trend analysis showed no change in IHM from 2001–3 to 2017–19 in T1DM patients who underwent minor and major LEAs.
This nationwide registry and population-based observational study showed a decline in hospital admissions for minor and major LEAs in patients with T1DM from 2001 to 2009–10, with no subsequent changes. However, from 2017 to 2019, the incidence of major LEA seems to have increased among men with T1DM. The incidence rates of minor and major LEA in men with T1DM were higher than in women with T1DM. Female sex is a predictor of IHM in patients with T1DM following major LEA. In the fully adjusted model, women with T1DM had a 37% higher adjusted risk of dying following major LEA than men with T1DM.
According to our database, trends in incidence decreased significantly between 2001 and 2009 for minor LEA (9.55% per year) and between 2001 and 2010 for major LEA (13.39% per year) and subsequently remained stable for major LEA. However, for minor LEA the incidence increased, albeit not significantly, between 2010 and 2019. These findings have been reported elsewhere in Europe [4, 7]. In a population-based cohort study in Sweden, Hallstrom et al. [4] found that the frequency of amputation in patients with T1DM decreased between 1998 and 2019 and concluded that these changes are possibly related to an increased focus on risk factor management, advanced treatments to optimise glycaemic control, and further enhancements in the armamentarium of multidisciplinary diabetes foot clinics, including an increased use of invasive arterial reperfusion.
Although decreasing rates of LEA may reflect improved care, they may also reflect delayed presentation and early death in patients with foot ulceration or ischemia [19]. Consistent with these findings, the cross-sectional study of patients with T1DM and T2DM by Geiss et al. [8] performed in the USA found an increase in diabetes-related LEA rates between 2009 and 2015. This increment was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83–2.22] to 3.29 [95% CI 3.01–3.57], p < 0.001) and a smaller, but also statistically significant, 29% increase in major LEAs (from 1.04 [95% CI 0.94–1.13] to 1.34 [95% CI 1.22–1.45]). Furthermore, these increases were more pronounced among the young and middle-aged groups (age 18–64 years), raising concerns that preventive efforts were not reaching certain subgroups of people with diabetes who may have different disease characteristics and needs [8]. It has been suggested that young people with diabetes have less motivation for diabetes self-care than for other life priorities and are also more vulnerable to diabetes-related distress and other mental health problems, which adversely affect disease control and increase the risk of complications [20]. Regarding this point, the non-significant increase observed in the incidence of LEA in men with T1DM in recent years should be closely monitored to identify a possible change in trend.
As we expected, our results show a high ratio of minor LEA to major LEA among patients with T1DM, possibly because of more conservative limb salvage procedures and increasingly more aggressive treatment of peripheral arterial disease in this population [21].
The results of the present study are in line with those found in the literature, namely, an increasing male predominance in minor and major LEAs [2, 4, 6, 21]. Similar sex differences were reported in a study conducted using data from the IBM Market-Scan research database among patients with T1DM and T2DM [22]. Male sex appears to be a greater risk factor for LEA than age, probably because of the differential sex distribution of risk factors, such as smoking, which were not measured. In addition, the protective role of oestrogen could lead to differences in immune system function between males and females. Finally, the biological factors of diabetic foot ulcer, peripheral vascular disease, coronary artery disease, and peripheral neuropathy might account for the significant sex difference in the amputation rates [23, 24].
While the results of the present study indicate that hypertension decreased over time, the frequency of chronic kidney disease and lipid metabolism disorders increased in patients who underwent minor and major LEA. The association between LEA and person-level risk factors in individuals with T1DM has been studied elsewhere [2, 4, 22, 25]. Hallstrom et al. [4] recently described cardiovascular comorbidities, renal dysfunction, increased HbA1c, hypertension, and smoking to be associated with an increased risk of amputation in patients with T1DM.
IHM rates for minor and major LEAs did not change significantly between 2001 and 2019. The current results reinforce those previously found in Spain for the period between 2001 and 2012 [6]. This lack of improvement over time should be investigated to identify possible explanations and implement protective measures.
During admission for major LEA, women with T1DM had a higher IHM, which remained unchanged after the multivariable regression analysis. Results on the influence of sex on IHM following LEA are contradictory. Various studies found that amputation was more frequent in men than in women [25]; however, female sex was a predictor of in-hospital mortality after LEA in a previous study in Spain [6]. Gurney et al. [26] found little difference between the sexes in terms of the adjusted risk of postoperative mortality (90 days) and concluded that female patients who undergo amputation are similar to their male counterparts in terms of the underlying risk factors for postoperative mortality.
Gender differences in glucose control in T1DM subjects, with women showing a worst glucose control possibly due to pathophysiologic differences rather than the care provided, could also contribute to the differences observed [27].
It has been repeatedly demonstrated that the presence of diabetes increases the risk burden for cardiovascular complications among females. The mechanisms involved in the excess risk for vascular complications due to diabetes in females are the object of discussion and investigation and include hormonal factors, genetic predisposition linked to sex dimorphism, and sex-related inequalities in treatment or socio-economic status, which individually or together seem to contribute to the higher incidence in females [28, 29]. Indeed, in Spain, a sex gap has been reported in the impact of diabetes on IHM after major cardiovascular events [30]. The multifactorial causes for excess risk among women with T1DM require further investigation.
In our investigation, as reported in previous studies, the comorbidities that were significant predictors for death after LEA included PAD, ischemic heart disease or chronic kidney disease [31,32,33,34]. Morbach et al., found that the long-term survival after LEA is poor, especially among people with diabetes with concomitant PAD, renal insufficiency or the combination of both [31]. Diabetic patients with PAD, compared with those without PAD, have a higher risk of cardiovascular and all-cause mortality [32].
Interestingly, in our study neuropathy was not significantly associated with death as reported before [31]. Even more, Cascini et al. reported a protective effect of neuropathy on mortality after major LEA. We agree with these authors that a possible explanation is a differential under-reporting in hospital charts of peripheral neuropathy [33]. Indeed, the diagnosis of neuropathy is a complex process and requires expertise that is not always available [33].
The strength of our study lies in its large sample size (6,011 nontraumatic LEA procedures in patients with T1DM), coverage of an entire country (> 95% of all hospital admissions), and standardized methodology (extensively used for research in Spain, combined with the reliability of diabetes and LEA coding in the RAE-CMBD) [5, 6, 30]. Nevertheless, our study is subject to a series of limitations. Our data were obtained from an administrative database supported by the information that physicians recorded in the discharge report; therefore, the database lacks information on clinical characteristics, glycaemic control, medical treatments, and time with T1DM. Another limitation is that anonymity precludes the extraction of specific data that may affect the results (i.e., people who moved from one hospital to another could appear twice). However, Buckley et al. [35] detected high levels of agreement between hospital discharge data and medical records for LEA and diabetes and suggested that hospital discharge data are sufficiently reliable for monitoring trends in LEA in people with diabetes. In our opinion, the strengths of this study and its uniqueness clearly outweigh its limitations.
In conclusion, our data show a decrease in the incidence of minor and major LEA in men and women with T1DM and a slight but not significant increase in the incidence of major LEA in men with T1DM during the last years of the study. This possible change in the time trends must be closely followed in the future. The incidence of minor and major LEA was higher in men than in women. Female sex is a predictor of IHM in patients with T1DM following major LEA. As the study was based on administrative data, we lack relevant clinical data, thus making it necessary to take into account the effect of residual confounding. Our results should be interpreted with caution and confirmed using data from clinical studies. However, our results should be the starting point for future investigations that can confirm or reject our conclusions using more extensive and precise clinical data.
According to the contract signed with the Spanish Ministry of Health and Social Services, which provided access to the databases from the Spanish National Hospital Database (Conjunto Mínimo Basico de Datos; CMBD), we cannot share the databases with any other investigator, and we have to destroy the databases once the investigation has concluded. Consequently, we cannot upload the databases to any public repository. However, any investigator can apply for access to the databases by filling out the questionnaire available at http://www.mscbs.gob.es/estadEstudios/estadisticas/estadisticas/estMinisterio/SolicitudCMBDdocs/Formulario_Peticion_Datos_CMBD.pdf. (Accessed on 9 September 2021) All other relevant data are included in the paper.
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Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet. 2003;361:1545–51.
Ke C, Lau E, Shah BR, Stukel TA, Ma RC, So WY, et al. Excess burden of mental illness and hospitalization in young-onset type 2 diabetes: a population-based cohort study. Ann Intern Med. 2019;170:145–54. https://doi.org/10.7326/M18-1900.
Wu H, Yang A, Lau ESH, Ma RCW, Kong APS, Chow E, et al. Secular trends in rates of hospitalisation for lower extremity amputation and 1 year mortality in people with diabetes in Hong Kong, 2001–2016: a retrospective cohort study. Diabetologia. 2020;63:2689–98. https://doi.org/10.1007/s00125-020-05278-2.
Déruaz-Luyet A, Raabe C, Garry EM, Brodovicz KG, Lavery LA. Incidence of lower extremity amputations among patients with type 1 and type 2 diabetes in the United States from 2010 to 2014. Diabetes Obes Metab. 2020;22:1132–40. https://doi.org/10.1111/dom.14012.
Peek ME. Gender differences in diabetes-related lower extremity amputations. Clin Orthop Relat Res. 2011;469:1951–5. https://doi.org/10.1007/s11999-010-1735-4.
Ferranti KM, Osler TM, Duffy RP, Stanley AC, Bertges DJ. Vascular study group of New England Association between gender and outcomes of lower extremity peripheral vascular interventions. J Vasc Surg. 2015;62:990–7. https://doi.org/10.1016/j.jvs.2015.03.066.
Shin JY, Roh SG, Lee NH, Yang KM. Influence of epidemiologic and patient behavior-related predictors on amputation rates in diabetic patients: systematic review and meta-analysis. Int J Low Extrem Wounds. 2017;16:14–22. https://doi.org/10.1177/1534734617699318.
Gurney JK, Stanley J, Rumball-Smith J, York S, Sarfati D. Postoperative death after lower-limb amputation in a national prevalent cohort of patients with diabetes. Diabetes Care. 2018;41:1204–11. https://doi.org/10.2337/dc17-2557.
Manicardi V, Russo G, Napoli A, Torlone E, Li Volsi P, et al. Gender-disparities in adults with type 1 diabetes: more than a quality of care issue .A cross-sectional observational study from the amd annals initiative. PLoS ONE. 2016;11(10):e0162960.
Rossi MC, Cristofaro MR, Gentile S, Lucisano G, Manicardi V, Mulas MF, et al. Sex disparities in the quality of diabetes care: biological and cultural factors may play a different role for different outcomes: a cross-sectional observational study from the AMD Annals initiative. Diabetes Care. 2013;36:3162–8. https://doi.org/10.2337/dc13-0184.
Policardo L, Seghieri G, Francesconi P, Anichini R, Franconi F, Del Prato S. Gender difference in diabetes related excess risk of cardiovascular events: when does the "risk window" open? J Diabetes Complications. 2017;31:74–9. https://doi.org/10.1016/j.jdiacomp.2016.09.010.
de Miguel-Yanes JM, Jiménez-García R, Hernández-Barrera V, Méndez-Bailón M, de Miguel-Díez J, Lopez-de-Andrés A. Impact of type 2 diabetes mellitus on in-hospital-mortality after major cardiovascular events in Spain (2002–2014). Cardiovasc Diabetol. 2017;16:126. https://doi.org/10.1186/s12933-017-0609-4.
Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT, et al. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care. 2012;35:2021–7. https://doi.org/10.2337/dc12-0200.
Nativel M, Potier L, Alexandre L, Baillet-Blanco L, Ducasse E, Velho G, et al. Lower extremity arterial disease in patients with diabetes: a contemporary narrative review. Cardiovasc Diabetol. 2018;17:138. https://doi.org/10.1186/s12933-018-0781-1.
Cascini S, Agabiti N, Davoli M, Uccioli L, Meloni M, Giurato L, et al. Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems. BMJ Open Diabetes Res Care. 2020;8:e001355. https://doi.org/10.1136/bmjdrc-2020-001355.
Hoffstad O, Mitra N, Walsh J, Margolis DJ. Diabetes, lower-extremity amputation, and death. Diabetes Care. 2015;38:1852–7. https://doi.org/10.2337/dc15-0536.
Buckley CM, Kearney PM, Ali F, Bhuachalla CN, Casey C, Roberts G, et al. Concordance studies between hospital discharge data and medical records for the recording of lower extremity amputation and diabetes in the Republic of Ireland. BMC Res Notes. 2013;6:148. https://doi.org/10.1186/1756-0500-6-148.
This study is a part of the research funded by the: FIS (Fondo de Investigaciones Sani-tarias—Health Research Fund, Instituto de Salud Carlos III) and co-financed by the European Union through the Fondo Europeo de Desarrollo Regional (FEDER, "Una manera de hacer Europa"): grant no. PI20/00118. By: Universidad Complutense de Madrid. Grupo de Investigación en Epidemiología de las Enfermedades Crónicas de Alta Prevalencia en España (970970) and by: Convenio V-PRICIT de la Comunidad de Madrid y la Universidad Complutense de Madrid ("Programa de Excelencia para el Profesorado Universitario" INV.AY.20.2021.1E126).
Department of Public Health & Maternal and Child Health. Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
Ana Lopez-de-Andres, Rodrigo Jimenez-Garcia, Ricardo Omaña-Palanco & David Carabantes-Alarcon
Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty. Rey Juan Carlos University. Alcorcón, Madrid, Spain
Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
Javier de-Miguel-Diez
Internal Medicine Department. Hospital General, Universitario Gregorio MarañónUniversidad Complutense de MadridInstituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
José M. de-Miguel-Yanes
Ana Lopez-de-Andres
Rodrigo Jimenez-Garcia
Ricardo Omaña-Palanco
David Carabantes-Alarcon
ALdA and DC-A contributed to the study design and interpretation of the results. RJ-G, VHB, Jd-M-D, JMdM-Y, and RO-P contributed to the collection, analysis, or interpretation of data. ALdA, RJ-G and DC-A prepared the manuscript. VHB, Jd-M-D, JMdM-Y, and RO-P critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of the work, ensuring integrity and accuracy. All authors read and approved the final manuscript.
Correspondence to Rodrigo Jimenez-Garcia.
The authors declare that there is no conflict of interest.
International Classification of Disease, 9th edition (ICD-9-CM) and 10th edition, (ICD-10) codes for the clinical diagnoses and procedures used in this investigation.
Lopez-de-Andres, A., Jimenez-Garcia, R., Hernández-Barrera, V. et al. Time trends (2001–2019) and sex differences in incidence and in-hospital mortality after lower extremity amputations among patients with type 1 diabetes in Spain. Cardiovasc Diabetol 21, 65 (2022). https://doi.org/10.1186/s12933-022-01502-y
Amputation: Lower extremity
Sex differences


text:
Home News and Analysis Firms & Funds Coller emerges as buyer on large Ares fund revamp
Coller emerges as buyer on large Ares fund revamp
Ressler
Coller Capital is a lead buyer on a secondary restructuring deal of an older Ares Management fund valued at more than $1 billion, three people told Buyouts.
It's not clear if Coller is sole lead buyer or part of a group. Bill Mendel, a spokesman for Ares, did not respond to comment requests. A spokeswoman for Coller Capital declined to comment.
Ares is running the secondary process on Ares Corporate Opportunities Fund III, which closed on $3.5 billion in 2008. Lazard is working as secondary adviser on the deal.
Fund III is a strong performer, generating a 20.97 percent internal rate of return since inception as of Dec. 31, 2018, according to performance information from the Colorado Public Employees' Retirement Association. It produced a 2.1x multiple as of Sept. 30, 2018, according to performance information from the California Public Employees' Retirement System.
The sale process involves only several assets, so it is viewed as a concentrated bet on the underlying companies remaining in the portfolio, one of the sources said.
"Like all these deals, you get a billion-plus deal and it's pretty concentrated; there will certainly be other participants," a secondary source said.
Ares would move the assets into a continuation vehicle, allowing existing limited partners to cash out or roll their interests into the new fund. The deal will give Ares more time to manage the assets.
Antony Ressler co-founded Ares in 1997 along with John Kissick and Bennett Rosenthal. The firm went public in 2014, making it one of only a handful of private equity firms that have done so, including Blackstone Group, Carlyle Group, Kohlberg Kravis Roberts and Oaktree Capital Management.
Separately, Coller Capital has been in the market raising its eighth fund, targeting up to $9 billion.
Coller has been involved in several large deals this year, including a single-asset process being run by Revelstoke Capital Partners to move Upstream Rehabilitation out of its debut fund into a continuation vehicle, Buyouts previously reported. Coller also was a buyer on the large restructuring process involving Thomas H. Lee's sixth fund, Buyouts reported earlier this year.
The Ares process is one of the largest GP-led deals in the market. It represents another example of a high-profile GP turning to the secondary market to sort out an older fund. Other such GPs include Bain Capital, Blackstone Group, Insight Venture Partners, Oaktree, TH Lee Partners, TPG and Warburg Pincus.
GP-led deals have become a larger part of the overall secondary market, which produced an estimated $42 billion of volume in the first half of this year. Evercore and Greenhill Cogent believe total secondary activity could tally more than $90 billion this year.
Action Item: See Ares's Form ADV here: https://bit.ly/2MeUhXM
Insight Partners closes huge fund-restructuring totaling more than $1.5 bln

redpajama_set_name: RedPajamaCommonCrawl


Mi Chunche: WATER! Never take for granted life's basic necessities..
WATER! Never take for granted life's basic necessities..
This is day five without water in our little town of Atenas!
Last Friday night high winds knocked over a tree that broke the water main and the support below. The break is located over a local river and the only access is through a couple of farms on either side of the river. We currently have about 16,000 residents without water.
The national water company, AyA, has been delivering potable water to the various neighborhoods via tanker trucks with 4 or 5 spigots on the back end of the truck to fill multiple containers at once. Folks are toting water in every conceivable container they can find. I've seen 2 liter Coke bottles, buckets, pitchers, barrels and even trash cans lined with plastic bags.
There is also a new well in the central park where folks can go to get fresh water from 7 AM until 10 PM.
We are one of the lucky ones. We don't have a well, but we decided to install a 660 gallon water storage tank when we built our house back in 2011. City water feeds our storage tank so we are always circulating fresh water through the tank. We've had a few water shortages over the past few years, but never anything that lasted more than a day, so we've hardly ever needed to ration water. This time, however, the situation is severe.
In 2014, we installed a saltwater pool, without knowing how handy it would become in an emergency like the one we face today. We have been able to use pool water for flushing toilets, washing dishes, and even bathing (without soap of course). On the bright side, we are in the middle of our rainy season, so the pool is getting re-filled with rainwater daily. The water is circulated through the pool's filtration system every day, so it is always fresh. We've invited some of our neighbors over to fill buckets with pool water for their toilets, and they are getting their fresh drinking water from the daily tanker truck deliveries.
In spite of the dark clouds above us, there is one silver lining... The affected schools are closed due to sanitation issues and the kids are on an unexpected holiday.
There was an article in today's paper quoting our local mayor, and he said we may not have city water until Thursday of next week. That's 8 days from now, so it looks like we will be rationing water in the coming days, until this situation is resolved.
Never take water, one of life's most basic necessities, for granted!
As usual, you guys thought ahead and were in a position to be prepared. Hate to hear this, for the town, though.
I turn 59 this month, 3 more years until retirement. I plan to come back, before then, to look around some more. Atenas is still the best place, in my book.


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Your Rating 1 stars 2 stars 3 stars 4 stars 5 stars 6 stars 7 stars 8 stars 9 stars 10 stars
Movie - The Predator - 2018
The Predator (2018) المفترس
Release Date: 14 September 2018 (U.S.) (more)
Genre: Horror (more)
A ragtag crew of ex-soldiers come face to face with a monster in a desolate jungle, and one after the other, they get lost and become hanging bodies on the trees. So when the only survivor from a...Read more previous encounter with the same monster emerges, they discover they are in a much bigger problem than they had imagined.
Shane Black ()
Fred Dekker ()
Watch it on TV
Favourite Channel OSN MOVIES FIRST HD Monday 22 July 03:35 PM Reminder
Favourite Channel OSN MOVIES FIRST HD +2 Monday 22 July 05:35 PM Reminder
Augusto Aguilera
(The Predator) Trailer 01:47 337
Synopses:
A ragtag crew of ex-soldiers come face to face with a monster in a desolate jungle, and one after the other, they get lost and become hanging bodies on the trees. So when the only...Read more survivor from a previous encounter with the same monster emerges, they discover they are in a much bigger problem than they had imagined.
Egypt [19 September 2018]
U.S. [14 September 2018]
Censorship:
Is this a coloured title?:
808,717 (more)
The movie is a sequel to the 1987 sci-fi film "Predator".
[1 Topic]
"Predator" Ending Almost Had Ripley


text:
Campaigns and links
Futures thinking
Conflict resolution and Mediation
Governance development
Public Involvement and Employee Engagement
Integration Scheme in Aberdeen "vital to the future"
Mark Butler, Director of The People Organisation, has welcomed the Health and Social Care Integration Scheme for Aberdeen..
Mark Butler, Director of The People Organisation, has welcomed the Health and Social Care Integration Scheme for Aberdeen as a real chance to make necessary change happen for local people.
But Mark, one of the team from the Good Governance Institute which is working with the Integration Board on creating the structures, process, capacity and governance for this multi million pound new organisation, sees huge challenges in overcoming barriers that have traditionally got in the way of effective integration.
"Over the years there have been a number of attempts to bring health and social care together, but it has always been clear in the past that some deeply-held views on all sides get in the way. The success of these new integrated organisations, created by statute, will be more about cultural change than about the mechanics of accountability, even though these are important," he adds.
"One of the reasons I am now working on projects like this with GGI is new structures like the one in Aberdeen are vital to the future of public services and what GGI brings to them is a depth of knowledge and experience which my expertise in cultural change and public involvement complements very well. It would make no sense for The People Organisation to attempt to grow to match what GGI already does so well, as TPO's strengths lie elsewhere," he added.
Date: Sep 7, 2015 — Category: News — Posted by: admin
Contact us on +44 (0)787 621 6933 • © 2009-2016 The People Organisation


text:
Ash, swine flu and other causes of mass hysteria – how real is the danger?
Volcanic ash has left hundreds of thousands trapped in airports, paralyzing flight connections in Europe. As the airspace starts to reopen, some are wondering if the response to the ash cloud was an overreaction.
Many flights still remain cancelled. According to meteorologists, the skies over Europe are beginning to clear as the volcano ash cloud is pushed away from European airspace.
The situation for the UK still looks gloomy, as recent weather reports suggest the ash cloud is returning to British air space.
Airlines are cursing European regulators for red tape and bad risk assessment.
Travelers, left stranded all around the globe, wonder if it was more about hazard or hype.
Arkady Tishkov, from the Institute of Geography at the Russian Academy of Sciences, believes the ash panic was baseless.
"The overall hysteria surrounding this volcano eruption is totally unwarranted," Tishkov said. "This is not the largest volcano and often the plumes sent into the atmosphere reach even greater heights. The scale of this eruption is not that great. What we are witnessing now is an unnecessary apocalyptic reaction. But there are no grounds for it."
Grounds or no grounds, among the first things people heard about the ash cloud was that it could cause problems with teeth and bones, it is extremely dangerous for those with asthma and, of course, it could crash their planes. Only later did reports come that it is not that bad after all. However, the effect was already there. Many dubbed it another episode of hysteria in the 21st Century.
It took a year to realize that the outbreak of swine flu was not really an outbreak, and that normal, everyday seasonal flu kills many more people. Back in June last year, though, a mask seemed to be a must-have.
Drug firms cashed in on the panic, and the World Health Organization stands accused of announcing "a false pandemic".
But psychologists say it is not about scientists' wrongdoings.
"People believe TV, that's the problem," said Sergey Klyuchnikov, a psychologist. "Any event, when shared by the media, gets exaggerated by millions of times. Especially when it has to do with people's health and safety. Panic is contagious; people can't receive negative information and just keep it to themselves."
Now, when information is just a click away, spreading fear and capitalizing on fear has become much easier.
The impact of bird flu on humans has been assessed as very limited, but back in 2003, many thought it was going to claim millions of lives.
And at the beginning of the millennium, one part of the world sincerely expected everything from your clock radio to the Internet to nuclear power stations simply to stop working when all those zeros came in.
Unresolved apocalyptic scenarios are still lingering, one of them is global warming.
"We're being told there is an international scientific consensus on global warming," said Konstantin Simonov, the head of National energy security fund. "But that's not true! We don't have enough evidence. And what's more, we can't say that it's the carbon dioxide that could be causing the warming. But we are supposed to actually to take the two statements as a fact."
Psychologists say that people today are more exposed to mass hysteria, but they are also developing an emotional and psychological immunity. There are fears that people's reactions could become too numb to respond to any real danger.
The fear of perishing in a cloud of volcano dust is fading and now reasonable doubt arises as to whether or not paralyzing almost all air traffic in Europe for nearly a week was the right decision.
American radio host Michael Rivero believes the recent global warming scandal made British meteorologists overreact in a bid to try to regain the public's trust.
"A lot of people are thinking that the British meteorological office…in efforts to trying redeem itself in terms of usefulness to the public, may have in fact overreacted and over-emphasized the dangers of the volcanic cloud coming out of Iceland and declared a very wide-ranging no-fly zone that was inappropriate," Rivero told RT. "On the other hand, you can't be too careful with volcanic ash. Obviously, on the side of airlines and the travel industry as a whole – hotels and everything – money is very much on the line, there is a constant flow of tourism, and if it's not happening, if travel is not happening, money is being lost and most of Europe is already in severe financial stress, much as the United States is right now."
Watch full video with Michael Rivero
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Frank Furedi, professor of sociology at the University of Kent, Britain, says that shutting down the airspace was an over-reaction based on speculation rather than scientific evidence.
"It's very sad that in many respects the EU…finds it very difficult to do the most basic planning when it comes to such a major issue. I do think it's important to realize that many countries all over the world face volcanic eruption. For example, countries like Italy still manage to have air traffic just by taking sensible precautions," says Frank Furedi.
Watch full video with Frank Furedi
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Rotting from the inside: sex abuse and the Catholic Church
WikiLeaks shows reporter killings in Iraq
Icelandic volcano affects air traffic across Europe
Mother Nature gives Globalized Man a volcanic spanking
Icelandic eruption has price tag for airlines
Holocaust crimes equated to Communists' actions
Canned CNN reporter becomes the news after controversial tweet
Russian police: to be given new disguise or actual reform?
Building of mosques in Poland – sign of Islamisation or tribute to human rights?
Vatican rejects "chosen people" claim, calls on Israel to end "occupation"


The RMISocketFactory is used by the RMI runtime in order to obtain client and server sockets for RMI calls. The default implementation of the socket factory performs a three-tiered approach to creating client sockets. First, a direct socket connection to the remote VM is attempted. If that fails (due to a firewall), the runtime uses HTTP with the explicit port number of the server. If the firewall does not allow this type of communication, then HTTP to a cgi-bin script on the server is used to POST the RMI call. An application may set the source of sockets for RMI. In this case, the application is responsible for offering up sockets that will penetrate a firewall.
Create a server socket on the specified port (port 0 represents an anonymous port).
Returns the handler for socket creation failure.
Returns the socket factory used by RMI.
Set the failure handler to be called by the RMI runtime if socket creation fails.
Set the socket factory from which RMI gets sockets.
Set the socket factory from which RMI gets sockets. The RMI socket factory can only be set once. Note: The RMISocketFactory may only be set if the current security manager allows setting a socket factory; if disallowed, a SecurityException will be thrown.
Set the failure handler to be called by the RMI runtime if socket creation fails. The default implementation of this handler returns false (thus recreation of sockets is not attempted by the runtime).


Brennan Ward will be competing in the co-main event of Bellator 170, where he will be battling British striker Paul Daley. Ward, one of the top welterweight prospects in MMA, believes MMA is simply a sport.
Daley is arguably the biggest star that Ward has ever fought in his professional MMA career, something that doesn't affect the fighter.
Bellator 170 takes place on Saturday, January 21 from The Forum in Inglewood, California with Chael Sonnen and Tito Ortiz headlining, the main card airs live on Spike TV.


text:
What Is Pareve in Kosher Food?
Culinary Glossary
Eastern European Cooking
Kosher Cooking Basics
By Giora Shimoni
The Spruce / Miri Rotkovitz
According to Jewish law, there are certain foods that cannot be eaten, as well as some foods that cannot be eaten together. These kosher foods are divided into three categories: meat, dairy and pareve. Pareve (pronounced PAHR-iv) is the Yiddish term that refers to foods that contain no meat or dairy ingredients. Parve is the Hebrew term and is pronounced PAHR-vuh.
According to the Jewish dietary laws, or laws of kashrut, whereas meat and milk products may not be cooked or eaten together, pareve foods are considered neutral and may be eaten with either meat or dairy dishes.
Foods That Are Pareve
Anything that is not dairy or meat—and has not been prepared with dairy or meat—is considered pareve. All fruits, vegetables, pasta, grains, nuts, beans, legumes, and vegetable oils are pareve. Beverages such as soft drinks, coffee, and tea are pareve. Many candies and sweets are pareve as long as they are labeled as such. Even if there isn't dairy in the ingredients, the food may have been produced on dairy equipment, so checking labels is important.
Interestingly, though they are animal products, both eggs and fish are considered pareve as well. Note that in many Jewish Orthodox circles, while fish and meat may be eaten at the same meal, it is not considered permissible to cook fish and meat together, to serve or consume them from the same plate or to eat them during the same course of a meal.
Pareve products will have the word "pareve" and a letter U on their label. Alongside the kosher symbol, you may also see a D (for dairy) or D.E. (dairy equipment), as well as those foods that do not specifically note "meat."
With the exception of fish, pareve foods are inherently vegetarian and dairy-free. Therefore, many consumers with dietary restrictions who do not keep kosher for religious reasons may nevertheless seek out kosher pareve-certified products.
Cooking With Pareve Foods
For those who do keep kosher as a matter of religious conviction, pareve recipes make it easier to build menus around meat or dairy dishes. If you keep kosher you do not eat milk and meat products together (so no cheeseburgers, or steak with mashed potatoes that have dairy), and would, therefore, feature pareve foods with your meat dishes or your dairy meals.
People who keep kosher have two sets of dishes, utensils and serving pieces—one for meat and one for dairy—so the two types of food never come in contact with each other in any way. Since pareve is neither meat nor dairy, these foods can be cooked, served and eaten on either the meat or dairy set of plates.
There are also required waiting periods between the consumption of meat and dairy foods, so pareve foods such as fruits, vegetables, and nuts are useful for snacking between meals.
Replacing Margarine in Recipes
For many decades—particularly when it was assumed that all animal fats were unhealthy additions to the diet—kosher cooks embraced pareve stick margarine as a substitute for butter or schmaltz (rendered chicken fat). With the understanding that margarine is generally abundant in dangerous trans-fats, many have healthier pareve alternatives to margarine.
For savory recipes, olive oil or neutral oils such as grapeseed or canola are often favored. Baked goods can pose a greater challenge, as solid fats are often essential for achieving the desired texture. Coconut oil and non-hydrogenated solid shortenings made from palm oil are becoming increasingly popular in kosher recipes as pareve alternatives to margarine as well.
Jewish Dietary Laws
What Is Kosher Food?
Why Do People Really Keep Kosher, Anyway?
Guide to Kosher Symbols and Certifications
Kosher Wine for Passover
Eggs Are Not a Dairy Product
Top 10 Tips for Creative Kosher Cooking
Do All Jewish People Keep Kosher?
What Is Mehadrin?
10 Stuffed Foods to Make for Sukkot and Simchat Torah
What Is a Pescatarian?
The Jewish Sabbath Dinner
Can Vegetarians Eat Fish?
Coffee, Tea, and Religion
A Classic Kosher Thanksgiving Menu
Top 9 Kosher Cookbooks With Recipes
Get daily tips and expert advice to help you take your cooking skills to the next level.


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FALSE IMPRISONMENT. torts. Any intentional detention of the person of another not authorized by law, is false imprisonment. 1 Bald. 571; 9 N. H. Rep. 491; 2 Brev. R. 157. It is any illegal imprisonment, without any process whatever, or under color of process wholly illegal, without regard to the question whether any crime has been committed, or a debt due. 1 Chit. Pr. 48; 5 Verm. 588; 3 Blackf. 46; 3 Wend. 350 5 Wend. 298; 9 John. 117; 1 A. K. Marsh. 845; Kirby, 65; Hardin 249.
2. The remedy is, in order to be restored to liberty, by writ of habeas corpus, and to recover damages for the injury, by action of trespass vi et armis. To punish the wrong done to the public, by the false imprisonment of an individual, the offender may be indicted. 4 Bl. Com. 218, 219; 2 Burr. 993. Vide Bac. Ab. Trespass, D 3 Dane's Ab. Index, h. t. Vide 9 N. H. Rep. 491; 2 Brev. R. 157; Malicious Prosecution; Regular and Irregular Process.


text:
Q: Slow down player when colliding with "dirt" on ground Okay, so, currently within my game I have got 5 or 6 "police cubes" that chase after the player, and deduct health until eventually the player is dead. My player also has to pick up collectables in order to get to the finish line. My player is a rolling ball, and there is a main road for the ball to travel on. This road has a surrounding dirt environment, and I need a way for the speed to be deducted once the rolling ball comes into contact with it. If anyone could help me with this it would be greatly appreciated, thank you.
using UnityEngine;
using UnityEngine.UI;
using System.Collections;

public class _PlayerController : MonoBehaviour {

public float speed = 75.0f;
public Text countText;
public Text winText;

private Rigidbody rb;
private int count;

void Start ()
{
    rb = GetComponent<Rigidbody>();
    count = 0;
    SetCountText ();
}

void FixedUpdate ()
{
    float moveHorizontal = Input.GetAxis ("Horizontal");
    float moveVertical = Input.GetAxis ("Vertical");

    Vector3 movement = new Vector3 (moveHorizontal, 0.0f, moveVertical);

    rb.AddForce (movement * speed);
}

void OnTriggerEnter(Collider other)
{
    if (other.gameObject.CompareTag ("Pick Up")) {
        other.gameObject.SetActive (false);
        count = count + 1;
        SetCountText ();
    }
}

void SetCountText ()
{
    countText.text = "Count: " + count.ToString ();
    if (count >= 25) {
        Application.LoadLevel (2);

        }
    }
}

A: You could apply a Physic Material to the dirt and give it a Dynamic Friction value. The value you give it will depend on how much you want the dirt to slow the player down, try 0.5 as a starting point.
To create a Physic Material select Assets > Create > Physic Material from the menu bar. Then drag the Physic Material from the Project View onto a Collider in the scene. (Copy pasted from the linked page).

redpajama_set_name: RedPajamaStackExchange


The first Sri Chinmoy Centre was established in Puerto Rico in 1966. There are now centres in many different countries around the world. These include centres in Europe, The Former Soviet Union, Australasia, Africa, Asia and North and South America.
The Sri Chinmoy Centre is a place for students of Sri Chinmoy to come together for spiritually related activities such as meditation, music and service to the community. At the heart of the Sri Chinmoy Centre is the emphasis placed on meditation. Through meditation students seek to achieve inner peace and bring their own spirituality to the fore.
As well as meditation the Sri Chinmoy Centre is active in offering many community services. These include free meditation classes. In these classes students of Sri Chinmoy offfer an introduction to the basics of meditation. There are similarities with other types of meditation but Sri Chinmoy suggests the most effective place to meditate is on the spiritual heart. Therefore the classes focus on this technique as a way of silencing the mind. Sri Chinmoy is also a keen advocate of physical fitness and its importance in the spiritual life. To this end the Sri Chinmoy Marathon Team organise many running events, these include races from 2 miles to the world's longest race of 3,100 miles.
A recent development to the Sri Chinmoy Centre is the formation of OHTS a humanitarian service offering aid to various countries around the world.
The Sri Chinmoy Centre also sponsors Vasudevaservice for Plone. Vasudevaservice is the home for Sri Chinmoy,org and many other sites related to spirituality and Sri Chinmoy.


Build a dormitory for 180 orphans!
The St. Barnabas Orthodox Orphanage and school has 180 children that it cares for. This care includes almost everything for every child: feeding them two good meals a day (the ones who would go hungry on the weekend are also fed on the weekends also), taking care of their medical needs, educating them, teaching them about the Orthodox faith, and freely making baptism available to them. Most of the orphaned children who are educated here decide of their own free will to be baptized and the congregation is growing quickly.
Most of the children are orphans (109) – meaning that their parents are dead, or abandoned them, or do not have the ability to care for them. Most children are boarded at foster homes, each of varying quality. Only 20 boys live at the orphanage. Some of the homes treat the children as free labor, and with so many homes, there could be worse things. It is very hard to know, because there is very minimal supervision by the state.
Because of these children and the danger they are in, in collaboration with "Orthodox Africa", we plan to build a Dormitory, on land the Orphanage has purchased, and dug a well on. This land was formerly used as a school, so the buildings for the classes are there. Fr Methodius estimates that the building of a dormitory to house 180(!) children will cost at the most, $45,000. This amount is not large in the West, and some people have pickup trucks that cost more than this! It is a king's ransom in Kenya.
A "FOUNDER" of the orphanage dormitory is one who sponsors a child, for $250. We need 180 Founders to build the Dormitory. Anyone who gives any other amount is a "DONOR", and Fr Methodius (the Rector of St. Barnabas) and Priest Seraphim Holland (St. Nicholas Orthodox Church, McKinney Texas) have promised that we will commemorate all FOUNDERS and DONORS and their immediate family (spouse, children), whether living or dead, at every liturgy – in South Kinangop, Kenya, AND McKinney Texas USA, in perpetuity.
Time is not money here – it is safe or unsafe children.
The less time we take to finish this project, the sooner more children will be safe. Children need to be safe, and have enough food to eat, and have companionship and role models, and to be taught the Orthodox Christian faith. Every day without a dormitory will be a dangerous day for one of these children, as well as the others we do not yet know, because there is no room to take care of them and teach them.
We have many plans after the dormitory is built. There is enough water from the borehole that St. Barnabas will have ample water to irrigate their crops (this is very important during the dry season in Kenya when crops can fail because of lack of rain), and provide all of the water needs for the children and staff, and also sell water. There is enough land that we anticipate providing the vast majority of the children's food. After we build a greenhouse (another necessary part of our plan, because we are at such a high altitude that there are occasional freezes, which especially cause the staple crop, maize, to fail), it is very likely that we will have more than enough food and also be able to sell food in the market. We also plan to not only give free education to the orphans and at-risk children in the area, but also be a desirable school for parents from the city to send their children for boarding and education. This is a very popular thing in Kenya, and the paying children, along with the water and the produce, then eventually make this school self-supporting. Eventually, we plan to build a state-of-the-art school (including a high School), which will not only educate those children that cannot afford anything, but also provide desirable education for children whose parents are able to pay tuition.
We need financial help now, but the plan is that in the future we will stop asking for handouts, and be completely self-supporting. Of course, becoming self-supporting is a journey that may take several years, and we are asking those who are excited by our vision to be part of this journey.
Please do not forget to inform us of your donation (you may omit the amount if you wish), and send us the names of your immediate family (spouse, and children), so we can make good on our promise to pray for them for the rest of our lives. Your donation amount, and even your names will remain anonymous to anyone else, but we will know about you, so we can, with deep gratitude, pray for you.
This is all we have to offer you, but it is a lot. Of course, if you keep up with either Fr Methodius, Priest Seraphim, or Orthodox Africa, you will see many updates about St Barnabas, and many smiling faces – of children who are fed, and educated, and safe. Please remember also to pray for the mission.


How to Write a good Autobiography about yourself | What is the best way to write a good autobiography about yourself?
It is all these great details that really hold their complete "Life's Stories" together. Do not forget to make a smooth transition from the previous part! Faithfully follow yourself through your autobiography. David Sedaris' Day is an excellent example of an autobiography in vignette format. Each person wishes and deserves to look good in their professional environment.
Every person wants and earns to look good in their work. At LinkedIn or at an events, you make sure that you look good in front of others. Actually, it's your biography as a pro. You can see your biographies much more visibly than your CVs. It can be used on LinkedIn, Twitter, on your blogs or your website, as an organic writer and wherever you need to present yourself.
To put it briefly, organic professionals are your source of juice to strengthen your business networks. Now, you can find out how to make a five stars organic product by doing click here. However, you should first see some samples of first-class biographies. They can also see the short and longer versions of their bias in the same place.
There is no difference between a biography and a convincing biography, and Lena Alexson shows this with a very appealing biography. As a family and marital counsellor by trade, Lena uses the story of the first character throughout her biography and wonderfully depicts herself. You can find another copy of her Third Persons Narratives on her website and I have a B.A. in Human Psychotherapy from the University of Derby in the UK.
Animal Husbandry was originally written in 1998 by The Dial Press and became a bestselling nation. It' was made public in fourteen different states ('or more, she's not sure - see here) and in 2001 the movie, that' sourced from Someone Like You' (they altered the name at the last moment because they were worried that they wouldn't'understand' the significance of the real thing - not that they complained or so) with Ashley Judd and (excuse her as she droolled) Hugh Jackman, by Fox 2000.
In 2002 followed her second (thinly camouflaged autobiographical) novel, Big Bird Date, also released by The Dial Press, and her third (thinly camouflaged autobiographical) novel, Her, released by Knopf (where she once worked - an excellent irony). Their latest (thinly camouflaged, autobiographical) novel, Piece of Work, which will be released on September 25, 2006 by Warner Buch (finally, after four long years between the titles - maybe her folks will let her go now), is inspired by her (terrible, but entertaining) experience as a journalist and was selected by Tom Hanks' Playtone Pictures with My Big Fat Greek Wedding's Nia Vardalos (luff her) to write the script and play the film' stars (please let God do it).
Cass has an impressing biography. She also has great references like Anna and has credited her with her work. Use his biography. "Hello, my name is Jacob Cass and I am the creator of JUST Creatives, my own graphics post.
Specializing in logodesign, brandname, webdesign, I provide corporate designs to companies of all size around the globe and improve their results through creating effective and effective answers to their unique brand. Headquartered in Sydney, Australia, I have a Bachelor of Visual Communication (Graphic Design Major) from the University of Newcastle, with a Dean's Recommendation of Honours, and have more than 15 years of expertise in the visual communication industry with numerous honors, among them LinkedIn's "Best of Brand Design" award.
My whereabouts can be found on my JUST Globetrotting blogs. So here is a section to show you how awesome an About Us page of a firm can be (I couldn't help but show it to you because I'm in lover with it). So these are some great biographies that I want to tell you.
Hopefully it will help you create your first-class biography in your head and on film. It does not play a role as long as your contents are interesting. Look at your biography like any other write it down and make sure it's interesting. Don't boast too much about yourself and upset your audiences.
The tough chocolate, novel and adventure enthusiast, her goal is to write a novel built on her own lives.


text:
Q: SharePoint 2007: Is it possible to insert a Image map into a SharePoint List? How do we insert a image map into a SharePoint List such that when we clicked, the image map pop-up (with the help of JQuery)?

A: Refer Using calculated columns to write HTML. It may help you to place image links, in place of text links.

A: Actually, I found any way of doing it. Basically, it is by placing the variables such as the location of the image map, the coordinates and so on in the List.
Then using SPServices to retrieve the data and allow user to select. Once the user click a option, the image map and all information related to it will be displayed.


Brexiteers who reject the backstop are guilty of disrespecting the Good Friday Agreement.
As President Higgins also observed, the results of the election represented the greatest single shift in parliamentary representation and also foreshadowed divisions that would deepen on the island.
This seminal event – the last all-Ireland general election – led to the formation of the Irish Free State and the setting up of Northern Ireland and thus the tragic partitioning of this island into two separate political entities for the past 97 wasted years.
The election was called just after the end of the First World War and was the first general election since 1910. Between 1910 and 1918, Ireland had undergone enormous upheavals, including the brutal upheaval of the Great War, the Easter Rising of 1916 and the shelving by the British Government of the Home Rule Act of 1914.
In addition, the election was held under a radically new electoral franchise, where all men over 21 could vote and some women over 30, who had property rights, were entitled to vote as well. The new, expanded electorate increased to almost two million people from 700,000.
The election was a test of electoral strength between the moderate Home Rule Irish Parliamentary Party and the new revolutionary Sinn Fein, with its aim of an Irish republic, independent of and separated from Great Britain and the British Crown.
The Irish Parliamentary Party had dominated Irish nationalist politics for the previous 40 years. Despite the split over Charles Stewart Parnell's divorce, they had successfully reunited and became a formidable political machine. They maintained their political supremacy right up to the Easter Rising.
Against all the odds in 1914, they succeeded in winning Home Rule for Ireland from the British Government at Westminster with the passage of Home Rule Act, even though its implementation was delayed until the war was concluded.
Between 1917 and 1918, there had been a series of by-elections in which Sinn Fein leaders, such as Eamon De Valera, were successful in defeating candidates from the seemingly all-powerful Irish Parliamentary Party.
This was an ominous sign of some decline in its support. But, on the eve of the general election, it was still not clear which of the two parties would come out on top.
In the event, it was the republican Sinn Fein party that decisively humiliated the Irish Parliamentary Party, winning 73 out of the 105 seats in Ireland. The old Parliamentary Party were reduced to a mere six seats, with five of them in Ulster due, in the main, to a pact brokered by senior Catholic bishops between Sinn Fein and the Parliamentary Party.
This was done to prevent a split in the vote between the two nationalist parties that might have led to unionist candidates winning by default in certain seats. Nonetheless, unionists did well, coming in second overall and winning 29 seats, mostly in Ulster.
However, a victorious Sinn Fein rightly claimed that they had democratically won the right, through an overwhelming national mandate from the Irish electorate, to officially declare and establish an Irish Republic.
Today, many unionists and Conservatives emphasize the immutability of the Brexit mandate, which was determined by the consultative referendum on the European Union in 2016. Yet these same politicians – even today – are reluctant to recognize the clear national mandate given to Sinn Fein in 1918.
It was the failure by the British Government to respect the democratic mandate of the Irish people that led to the disastrous division of Ireland.
It was not until June 1998 that there was a similar national expression of political opinion in Ireland, north and south, in the referendums on the Good Friday Agreement. The agreement, crucially and importantly, received overwhelming support throughout Ireland and established a new basis for building an agreed and peaceful political future.
Hopefully, modern-day Unionists would not repeat the tragic mistake of 1918 and reject the clear and overwhelming democratic mandate of the Irish people.


Private coach hire in Bakewell. Huge selection of coaches and minibuses for hire throught Bakewell & Derbyshire. Get an online quote directly with the coach hire companies and book online.
Its a funny thing - the hire industry exists to make our lives easier, and yet its sheer size can make navigating it anything but. And if youre in the market for Coach Hire in Bakewell, youll likely have spent hours trawling the internet looking for the best deals. Luckily, you dont have to! At Anything for Hire, our experienced team will do all the legwork on your behalf.
Thats right! As an independent hire marketplace, its our job to track down the best deals in Bakewell and beyond. All you need to do is tell us what youre looking for and well take care of the rest, connecting you with a network of local Coach Hire providers in your area. From there, you can search, compare and book all the best deals at the touch of a button - transforming a stressful task into something that takes just minutes to complete.
Our hire comparison service is ideal for anyone wanting to source the best Coach Hire in Bakewell - without breaking the bank. Keen to find out more Speak to our team about a quote today.
We offer Cheap Coach Hire in all local areas including Matlock, Fairfield, Swadlincote, Bolsover, Heanor, Sandiacre, Darley Dale, Dronfield Woodhouse, Staveley, Eckington, Ilkeston, New Mills, Shallcross, Long Eaton, Hadfield, Belper, Alfreton, Buxton. Our visitors who search for Coach Hire also tend to search for London Bus, Tour Bus, Band Bus, Minibuses, Disabled Vehicle, School Trip, Coach Rental, Transport, Coaches, Coach Hire.


At Maverick Farms, we keep a flock of chickens for eggs. It seems axiomatic to me that the happier and healthier the birds are, the better the eggs will be. So if a salesperson showed up pitching a product that would, say, boost egg production by 5 percent, while making our birds sick, but just healthy enough to keep laying, I'd send him packing. Who wants to eat eggs from a sick chicken? And why would I intentionally harm the animals who provide my eggs?
The US meat industry has different ideas. Its main goals are to maximize production while minimizing costs. Animal health matters only to the extent that the animals need to be well enough to scuttle down the slaughter line (or produce eggs, in the case of hens). Thus the industry routinely feeds livestock stuff that makes them sick.


Dry roast the ingredients listed under 'Roast and powder'. Roast in low flame and then make a fine powder and set aside.
Clean and marinate the quail with chilly powder, turmeric powder, salt and ginger garlic paste. Cover and refrigerate for at least two hours.
Make a course mixture of shallots, ginger, garlic and green chilly.
Heat oil in a pan and shallow fry it till it is slightly crispy in the outside. Remove this from the oil and set aside.
In the same pan add curry leaves and sliced coconut. When coconut slices turn golden brown add thinly sliced onion and saute for two minutes.Into this add the crushed onion and ginger garlic mixture and saute till onions become golden brown. Add chopped tomatoes and cook till it turns mushy. Transfer the quail on top of the masala, mix and add 1/2 cup water.Cover and cook for 6-7 minutes in low flame. Sprinkle the roasted spice mix and allow the gravy to reduce and or till it is semi dry. Serve with rice, appam or chapati.


God invites. Are we willing to listen?
That's what the psalmist wrote in Psalm 46.
Like many of the psalms, the context of the lyrics refers to a powerful God in whom humanity is urged to find strength in the face of distress. But, there is another facet of messaging in those words that I find I prefer. Indeed, it's one I find I can't live without.
It is a message of comfort; of confidence; of connection. And, as a recent spiritual retreat hosted by the sisters of the Visitation Monastery of Minneapolis reminded us, it is one of openness and hospitality. Those who are willing to immerse themselves in the implication of the message are being offered a doorway into deeper encounter with God.
The sisters and those great spiritual guides who have long gone before call the practice of being still in order to know God, contemplative listening. What one may hear is never a certainty. But what becomes apparent in undertaking the practice is that it's very easy to lose God's signal for all the noises that surround us in our daily lives.
That the sisters should be particularly skilled in contemplative listening is no surprise. It is, after all, something of a staple of the monastic community they form. That they are so solid in their commitment to its practice where they happen to live is something that impresses me deeply. And that they extend that grace and invite us into their company so we can also be still and perhaps come to know God better, is a privilege.
That sense of privilege is one I know that is shared by the rest of the Visitation Companions who participated on this special day. As one of our group observed afterward, the experience of the retreat left her feeling like Mary sitting at the feet of Jesus. This companion admits that she is more often like Martha, planning, preparing, serving.
I would offer that so say we all who were able to partake.


INTRODUCING THE HOBBYHOUSE. The skylight allows natural light to flood into the interior of the shed, thus allowing you to carry out various crafts and pastimes from scrap booking to woodworking. Upgrade the two fixed windows to awning windows to bring in fresh air. For added security, upgrade the Dutch door to a solid cedar door with a lockable handset. There is a size to fit your your space as there are four sizes of garden hobby rooms to choose from.


text:
{-# LANGUAGE DeriveFunctor #-}
{-# LANGUAGE DeriveGeneric #-}
{-# LANGUAGE DeriveAnyClass #-}
module Data.IMap
    ( IMap
    , Run(..)
    , empty
    , Data.IMap.null
    , singleton
    , insert
    , delete
    , restrict
    , lookup
    , splitLE
    , intersectionWith
    , mapMaybe
    , addToKeys
    , unsafeUnion
    , fromList
    , unsafeRuns
    , unsafeToAscList
    ) where

import Data.List (foldl')
import Data.Monoid
import Data.IntMap.Strict (IntMap)
import GHC.Generics
import Control.DeepSeq
import Prelude hiding (lookup)
import qualified Data.IntMap.Strict as IM

-- | Semantically, 'IMap' and 'IntMap' are identical; but 'IMap' is more
-- efficient when large sequences of contiguous keys are mapped to the same
-- value.
newtype IMap a = IMap { _runs :: IntMap (Run a) } deriving (Show, Functor, Read, Generic, NFData)

{-# INLINE unsafeRuns #-}
-- | This function is unsafe because 'IMap's that compare equal may split their
-- runs into different chunks; consumers must promise that they do not treat
-- run boundaries specially.
unsafeRuns :: IMap a -> IntMap (Run a)
unsafeRuns = _runs

instance Eq a => Eq (IMap a) where
    IMap m == IMap m' = go (IM.toAscList m) (IM.toAscList m') where
        go ((k, Run n a):kvs) ((k', Run n' a'):kvs')
            = k == k' && a == a' && case compare n n' of
                LT -> go kvs ((k'+n, Run (n'-n) a'):kvs')
                EQ -> go kvs kvs'
                GT -> go ((k+n', Run (n-n') a):kvs) kvs'
        go [] [] = True
        go _ _ = False

instance Ord a => Ord (IMap a) where
    compare (IMap m) (IMap m') = go (IM.toAscList m) (IM.toAscList m') where
        go [] [] = EQ
        go [] _  = LT
        go _  [] = GT
        go ((k, Run n a):kvs) ((k', Run n' a'):kvs')
            = compare k k' <> compare a a' <> case compare n n' of
                LT -> go kvs ((k'+n, Run (n'-n) a'):kvs')
                EQ -> go kvs kvs'
                GT -> go ((k+n', Run (n-n') a):kvs) kvs'

-- | Zippy: '(<*>)' combines values at equal keys, discarding any values whose
-- key is in only one of its two arguments.
instance Applicative IMap where
    pure a = IMap . IM.fromDistinctAscList $
        [ (minBound, Run maxBound a)
        , (-1, Run maxBound a)
        , (maxBound-1, Run 2 a)
        ]
    (<*>) = intersectionWith ($)

-- | @Run n a@ represents @n@ copies of the value @a@.
data Run a = Run
    { len :: !Int
    , val :: !a
    } deriving (Eq, Ord, Read, Show, Functor, Generic, NFData)

instance Foldable    Run where foldMap f r = f (val r)
instance Traversable Run where sequenceA (Run n v) = Run n <$> v

empty :: IMap a
empty = IMap IM.empty

null :: IMap a -> Bool
null = IM.null . _runs

singleton :: Int -> Run a -> IMap a
singleton k r
    | len r >= 1 = IMap (IM.singleton k r)
    | otherwise = empty

insert :: Int -> Run a -> IMap a -> IMap a
insert k r m
    | len r < 1 = m
    | otherwise = m { _runs = IM.insert k r (_runs (delete k r m)) }

{-# INLINE delete #-}
delete :: Int -> Run ignored -> IMap a -> IMap a
delete k r m
    | len r < 1 = m
    | otherwise = m { _runs = IM.union (_runs lt) (_runs gt) }
    where
    (lt, ge) = splitLE (k-1) m
    (_ , gt) = splitLE (k+len r-1) ge

-- | Given a range of keys (as specified by a starting key and a length for
-- consistency with other functions in this module), restrict the map to keys
-- in that range. @restrict k r m@ is equivalent to @intersectionWith const m
-- (insert k r empty)@ but potentially more efficient.
restrict :: Int -> Run ignored -> IMap a -> IMap a
restrict k r = id
    . snd
    . splitLE (k-1)
    . fst
    . splitLE (k+len r-1)

lookup :: Int -> IMap a -> Maybe a
lookup k m = case IM.lookupLE k (_runs m) of
    Just (k', Run n a) | k < k'+n -> Just a
    _ -> Nothing

-- | @splitLE n m@ produces a tuple @(le, gt)@ where @le@ has all the
-- associations of @m@ where the keys are @<= n@ and @gt@ has all the
-- associations of @m@ where the keys are @> n@.
splitLE :: Int -> IMap a -> (IMap a, IMap a)
splitLE k m = case IM.lookupLE k (_runs m) of
    Nothing -> (empty, m)
    Just (k', r@(Run n _)) -> case (k' + n - 1 <= k, k' == k) of
        (True , False) -> (m { _runs = lt }, m { _runs = gt })
        (True , True ) -> (m { _runs = IM.insert k r lt }, m { _runs = gt })
        (False, _    ) -> ( m { _runs = IM.insert k'    r { len =     1 + k - k' } lt' }
                          , m { _runs = IM.insert (k+1) r { len = n - 1 - k + k' } gt' }
                          )
        where
        (lt', gt') = IM.split k' (_runs m)
    where
    (lt, gt) = IM.split k (_runs m)

-- | Increment all keys by the given amount. This is like
-- 'IM.mapKeysMonotonic', but restricted to partially-applied addition.
addToKeys :: Int -> IMap a -> IMap a
addToKeys n m = m { _runs = IM.mapKeysMonotonic (n+) (_runs m) }

-- TODO: This is pretty inefficient. IntMap offers some splitting functions
-- that should make it possible to be more efficient here (though the
-- implementation would be significantly messier).
intersectionWith :: (a -> b -> c) -> IMap a -> IMap b -> IMap c
intersectionWith f (IMap runsa) (IMap runsb)
    = IMap . IM.fromDistinctAscList $ merge (IM.toAscList runsa) (IM.toAscList runsb)
    where
    merge as@((ka, ra):at) bs@((kb, rb):bt)
        | ka' < kb = merge at bs
        | kb' < ka = merge as bt
        | otherwise = (kc, Run (kc' - kc + 1) vc) : case compare ka' kb' of
            LT -> merge at bs
            EQ -> merge at bt
            GT -> merge as bt
        where
        ka' = ka + len ra - 1
        kb' = kb + len rb - 1
        kc  = max ka  kb
        kc' = min ka' kb'
        vc  = f (val ra) (val rb)
    merge _ _ = []

mapMaybe :: (a -> Maybe b) -> IMap a -> IMap b
mapMaybe f (IMap runs) = IMap (IM.mapMaybe (traverse f) runs)

fromList :: [(Int, Run a)] -> IMap a
fromList = foldl' (\m (k, r) -> insert k r m) empty

-- | This function is unsafe because 'IMap's that compare equal may split their
-- runs into different chunks; consumers must promise that they do not treat
-- run boundaries specially.
unsafeToAscList :: IMap a -> [(Int, Run a)]
unsafeToAscList = IM.toAscList . _runs

-- | This function is unsafe because it assumes there is no overlap between its
-- arguments. That is, in the call @unsafeUnion a b@, the caller must guarantee
-- that if @lookup k a = Just v@ then @lookup k b = Nothing@ and vice versa.
unsafeUnion :: IMap a -> IMap a -> IMap a
unsafeUnion a b = IMap { _runs = _runs a `IM.union` _runs b }

redpajama_set_name: RedPajamaGithub