Digital music is here to stay, and these days, when it comes to music, specialty toy store owners are focusing on instruments and toys rather than CDs. From guitars to harmonicas, there's an instrument for every store on the list below. Take a closer look and see which one will be the bandleader at your store this year.
Pop! Pop! Piano™ by PATCH PRODUCTS INC.
When children press a key on the piano, they not only hear a sound, they see stars pop up! The clear arch guides the popped stars onto a different pipe so when another note is played, they'll pop some more! Adults can remove the arch to allow the stars to land on the floor, encouraging children to crawl after them. Pop! Pop! Piano measures 9" x 11" x 5.34" with clear arch attached. For ages 12 months and up.
— Dean Smith, owner of JaZams in Princeton, N.J., told TDmonthly in a January 2015 survey that Pop Pop Piano is their store's best-selling musical toy. They sell around 10 each month.
— Dean Smith, owner of JaZams Toys in Princeton, N.J., told TDmonthly in an April 2015 survey that the Pop-Pop Piano is their store's best-selling infant & toddler toy. They sell around 12 each month.
— In a January 2015 survey, two out of 10 retailers told TDmonthly that Schylling Harmonicas were their store's best-selling music toys.
This high-quality wooden xylophone is designed with lifestyle colors, has a handle for easy toting and storage for two sticks. The baltic birch frame and maple keys and two sticks offer fun, safe early melodies. Robin Lehnert, Hape Marketing Manager, told TDmonthly, "A 10-month old begins with a rap and a tap. Who knows what could happen next on the very beginner xylophone." Launch date: February 2010.
— In a January 2014 survey, Cariad Owens Fichtner, manager of Out of the Blue, Ltd in Albuquerque, N.M., told TDmonthly that Hape Xylophones were one of the top-2 best-selling musical toys at her store.
— In a January 2015 survey, two out of 10 retailers told TDmonthly that Xylophones were their store's best-selling music toys.
This 10-piece set of musical instruments (heavy on the percussion with maracas, a tambourine and a triangle) lets a child explore the wonders of sound, music, anthropology or just the fun of making some noise.
― Richard Gibson, owner of Learning Express of Newton, Mass., says his store sells about 6 or 7 of these sets per month.
— Three of 45 retailers cited Band in a Box when asked about best-selling musical toys in mid 2007, citing sales of between three and 10 units per month. Seven of 48 retailers named it as a musical best seller in January 2010.
Tuned to a C Major scale, the Chimalong is an 8-note metallophone that can be played by number, color or notes. The youngest children will use the included 15-song songbook to play by color; older children can play by number. As they progress, they'll learn to read the music and play by note. Additional songs are available on the Woodstock Chimes website. Packaged in a 4-color window box. Comes with 2-mallets, 15-song songbook and an extra #7 tube, which changes the B (for key of C) to B flat (for key of G), giving greater musical flexibility. Chimalong is "recommended for its educational value by many professional musicians, including John Sebastian, Marilyn Horne, André Watts, Peter Schickele and the late Jim Henson," Peggy Daniel, Web Development Director of Woodstock Chimes, told TDmonthly. The Chimalong has received the following awards: 2003 Parent's Choice Top 25 Toys in 25 Years; 1995 Oppenheim Toy Portfolio Classic Toy, Blue Chip Award; 1995 Oppenheim Toy Portfolio Best Toy Award, Platinum; 1995 Oppenheim Toy Portfolio Best Toy Award, Gold Seal; and 1987 Parent's Choice Gold Award. Launch date: 1986.
― Karen Park, owner of Zaks Gifts in Manchester-by-the-Sea, Mass., only recently began selling Chimalongs, she told TDmonthly in 4Q 2010; she sells about four per month.
— Patti Tepper-Rasmussen, owner of Learning Tree Toys, Games & Books, Inc. in Oklahoma City, Ok., told TDmonthly in a January 2015 survey that the Woodstock Chimalong is their store's best-selling musical toy.
— Taka Andrews, owner of Miller's in Mamoroneck, N.Y., told TDmonthly in a January 2015 survey that they sell a handful of Janod Guitars each month, making them the store's best-selling musical toy.
Build a musical instrument with this 24-piece set. Includes 2 mouthpieces, 2 trumpet ends and twisting tubes. All components are made of unbreakable ABS plastic. Compatible with Tubation.
— David Stelzer, owner of Shananigans Toy Store in Baltimore, Md., told TDmonthly in a January 2015 survey that the Saxoflute is one of their store's best-selling musical toys.


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Don't Explore These 5 Haunted Minnesota Trails Alone
Carly Ross Updated: August 10, 2022
JM_Image_Factory
It's almost one of my favorite times of the year! No, not State Fair Season. No, not the Holiday Season. I'm talking about Spooky Season! Halloween is going to be here before we know it, hands down one of my favorite holidays, but it's never too soon to talk about haunted places around Minnesota.
I wanted to look into some spooky trails/outdoor locations around Minnesota. Spots that you can explore that are allegedly haunted and you probably shouldn't explore alone.
Before we get into those though, I need to throw out this disclaimer:
Do not trespass on any private property if you do explore these places and please be safe. Use your brain.
Ok, now we can get into the fun!
Dead Man's Trail
Dead Man's Trail is in Theif River Falls and there are two stories that go along with this one. The first is this man who was wanted for murder. According to Only in Your State he fled to a cave along to river by Dead Man's Trail. There's no cave there now but people like to say that he's the one who haunts the trail.
The other story is of a Native American woman who was running away with her baby from people chasing her. She put the baby in the river to be able to travel faster. When she returned to get her baby the river had carried him away. People say that they can see and hear the woman searching for her baby.
Hamlet Park
Mimadeo
Hamlet Park is home to Dead Man's Pond and is located in Cottage Grove. According to Minnesota Haunted Houses, Dead Man's Pond took a victim long ago. It's described as a "swampy, algae-covered pond" and that it's waiting for its next unassuming victim to come along.
Quarry Hill
joachimbago
Yep, as in our Quarry Hill in Rochester! The land was originally part of the Rochester State Hospital farm and cemetery where patients of the hospital were buried so if that doesn't tell you it's spooky... The cemetery and the caves are said to be haunted, according to Minnesota Haunted Houses. However, I've been to Quarry Hill a few times and I've never experienced anything so who knows!
Holbrook Park
daniilphotos
Holbrook Park in Long Lake and according to locals it's haunted by a little girl. Minnesota Haunted Houses says that the little girl will appear on Sundays at about 2 AM but if you get too close she'll vanish. Sometimes she returns with her dad and apples in her apron. But when the dad appears, look out, apparently, if you get too close he'll attack.
Milford Mine
Zeferli
The Milford Mine is in Crosby and was a manganese mine until it was flooded in 1924. The flood killed 41 miners, according to Minnesota Haunted Houses. People say that the area is haunted by those miners today.
So how much of this do you believe? I'm very open-minded when it comes to this kind of thing however I've never personally experienced anything.
SCARY: 10 of The Most Haunted Places In Minnesota
Minnesota may not be the most frightening place on earth, BUT there are some scary places that you may want to visit if you are ever looking for that "haunted" experience. Check out the list of some of the most haunted places in Minnesota below!
Source: Don't Explore These 5 Haunted Minnesota Trails Alone
Filed Under: Haunted, hiking, minnesota
Categories: Featured, Minnesota News, Weird News
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redpajama_set_name: RedPajamaCommonCrawl


Fitbits are so helpful in providing motivation to be more active! I've been using one for more than two years now and discovered some interesting Fitbit facts you may not know.
Love using a Fitbit — and have had one on my arm day and night for more than two years. The only problem is — it looks pretty plain and functional (even the wrist-slimming, ever-popular black).


text:
Marionetas de la sombra (Shadow Puppets) es una novela de ciencia ficción escrita por Orson Scott Card en 2002, continuación de La sombra del Hegemón, la tercera de la Saga de la Sombra de Ender, también conocida como El cuarteto de Bean. Originalmente la novela se llamaba La Sombra de la Muerte.

Argumento

Poco tiempo ha pasado desde que Bean entregó a Aquiles a los chinos. Durante esta temporada ha estado trabajando junto a Peter, el Hegemón, con la ayuda de Petra y Suriyawong en el puesto de Estrategos. Pero todo cambia el día que Peter decide alterar el curso de una misión y Bean decide dimitir de su puesto y marcharse junto a Petra.

Bean y Peter lucharán en dos frentes diferentes esta vez. Bean se enfrentará al deseo irrefrenable de Petra de casarse y tener hijos con ella. Y Peter, al único enemigo capaz de hacerle sombra en la hegemonía sin la ayuda de Bean, donde deberá aprender a confiar en gente que no es lo que parece y no es estúpida, tal y como él mismo piensa: sus padres.

John Paul y Theresa Wiggin deberán enseñarle a su hijo a abrir los ojos y le demostrarán que no es el único miembro listo de su familia aparte de sus hermanos en la lucha frente al más temible enemigo que Peter jamás tendrá, Aquiles de Flandes.

Peter, el hermano de Ender, es ahora  Hegemon de la Tierra. Aceptando ayuda desde China, donde Aquiles de Flandes está prisionero, Peter planea con Bean la misión, pero en el último minuto (porque duda que Bean coopere) se la asigna a Suriyawong, alumno de la escuela de batalla de Tailandia, para rescatar a Aquiles, creyendo que podría espiarle y darle acceso a su sistema,  y volver hacia su lado a algún país que le apoya (en ese momento, Aquiles ha traicionado a Rusia, Pakistán, y la India).

Aquiles es conocido por matar a cualquiera que le vea vulnerable. Bean y su amiga Petra, quienes también sirvieron con Ender ven lo que se avecina, así que inmediatamente pasan a la clandestinidad, y comienzan la preparación para una futura confrontación. Bean cree que Peter ha sobrestimado a Aquiles seriamente. Durante sus viajes, Petra le convence para casarse con él y tener hijos, a pesar de que puedan heredar la Clave de Anton, aunque Bean sea reluctante de trasmitir su defecto. Bean encuentra al doctor Volescu, el que activó originalmente la clave en sus genes, y les prepara nueve embriones para inseminación artificial. Uno es implantado en petra y el resto se guardan.

Al mismo tiempo, recibe un mensaje de Han Tzu, un camarada de la Escuela de Batalla, quien más tarde informa a Peter sobre Aquiles.  Al darse cuenta de que todo había sido un montaje, Bean manda un mensaje para los padres de Peter, y huye con Peter del complejo del Hegemón, logra escapar de un intento de asesinato y se refugia en Damasco, donde se encuentra a otro camarada de la escuela, Alai, el nuevo Califa no confirmado del mundo unificado del islam. Mientras tanto, sus embriones son robados y Bean cree que Aquiles los usará para amenazarle.

Peter y sus padres escapan a la plataforma de colonización en el espacio (la antigua escuela de Batalla), bajo la protección del Coronel Graff, su antiguo comandante, y ahora Ministro de Colonización. Poco después de llegar un mensaje delata su presencia. Fingiendo su salida de la estación espacial, Peter y sus padres descubren al traidor. El servicio de transporte no tripulado enviado como señuelo es derribado sobre Brasil (la ubicación del primer complejo del Hegemón, ahora ocupado por Aquiles).

En la novela anterior, China ha conquistado la India e Indochina.  Alai planea liberarlos invadiendo primero China (en una finta) y luego la India (una vez que China haya retirado sus tropas para defender su patria). Su invasión es exitosa, y dándose cuenta de la situación de peligro, el gobierno chino relega a Aquiles, al demostrarse que robó el lanzador de misil que destruyó el transbordador espacial que actuó como señuelo. Sin nadie a quien acudir, Aquiles contacta con Bean y le ofrece los embriones a cambio de un salvoconducto.

Bean y Peter retornan al complejo del Hegemon.  Aquiles espera que Bean esté tan obsesionado con la idea de recuperar a sus hijos que pueda ser asesinado con una bomba en el maletín de transporte que los lleva. Cuando Bean descubre la trampa, Aquiles ofrece hasta embriones falsos en un plato de petri, con la esperanza de atraer a Bean a una posición vulnerable, donde Bean pueda ser asesinado. Sin embargo, Bean ya ha decidido que Aquiles estaba fingiendo y se niega a caer en cualquiera de sus trampas.  Por último, Bean saca una pistola, y con Aquiles suplicando por su vida, le dispara en el ojo. Por lo tanto, Aquiles muere de una manera similar a su primera víctima, Poke, a quien mató con un cuchillo en el ojo.

La novela termina con Peter restaurado como Hegemón, Petra se reúne con Bean, Ali como califa al mando de los musulmanes del mundo, una China muy reducida en territorio y obligados a aceptar condiciones humillantes, pero los ocho embriones siguen perdidos.

Referencias

Véase también

 Saga de Ender
 Anexo:Organizaciones de la Saga de Ender

Enlaces externos

 Sinopsis de la novela en la página oficial del autor

Novelas de la Saga de Ender
Libros de 2002

redpajama_set_name: RedPajamaWikipedia


text:
Getting back to work after injury: the UK Burden of Injury multicentre longitudinal study
Denise Kendrick1,5,
Yana Vinogradova1,
Carol Coupland1,
Nicola Christie2,
Ronan A Lyons3 &
Elizabeth L Towner4
Injuries to working age adults are common and place a considerable burden on health services accounting for more than 10% of GP sick notes and 14% of those claiming benefits because they are unable to work in the UK. General practitioners (GPs) currently assess fitness to work and provide care and referral to other services to facilitate return to work (RTW). Recent UK recommendations suggest replacing GP sickness certification with independent assessments of fitness to work after four weeks sick leave. The impact of a wide range of injuries on RTW and subsequent need for independent fitness to work assessments has not been well studied in the UK. The aim of this study was to quantify RTW and factors predicting RTW following a wide range of injuries.
We used a multicentre longitudinal study, set in four acute NHS Trusts in the UK which recruited emergency department (ED) attenders and hospital admissions for injury and included those aged 16–65years that were employed or self-employed before the injury. Participants were followed up by postal questionnaire at 1, 4 and 12 months post injury to measure health status (EQ-5D), recovery, use of health and social services, time off work in the preceding month and work problems amongst those who had RTW. Multivariable Poisson regression with a robust variance estimator was used to estimate relative risks for factors associated with RTW.
One month after injury 35% of ED attenders had fully RTW. The self employed were more likely (RR 1.70, 95% CI 1.17 to 2.47 compared with employed) and the moderate/severely injured less likely to RTW (RR 0.48, 95% CI 0.32 to 0.72 compared with minor injuries). At four months, 83% of ED attenders had RTW and self employment and injury severity remained significant predictors of RTW (self employment RR 1.15, 95% CI 1.03 to 1.30; moderate/severe injury RR 0.79, 95% CI 0.68 to 0.92). At four months 57% of hospital admissions had RTW. Men were more likely than women to RTW (RR 1.94, 95% CI 1.34 to 2.82), whilst those injured at work (RR 0.49, 95% CI 0.27 to 0.87 compared with at home) and those living in deprived areas (most deprived tertile RR 0.59, 95% CI 0.40 to 0.85 and middle tertile RR 0.61, 95% CI 0.40 to 0.93) were less likely to RTW. Health status was significantly poorer at one and four months after injury than before the injury and was significantly poorer amongst those that had not RTW compared to those that had. Problems with pain control, undertaking usual activities, mobility and anxiety and depression were common and persisted in a considerable proportion of participants up to four months post injury.
Injuries have a large impact on time off work, including amongst those whose injuries did not warrant hospital admission. The majority of injured people would require an in-depth fitness for work assessment if recent UK recommendations are implemented. Many people will have on-going pain, mobility problems, anxiety and depression at the point of assessment and it is important that patients are encouraged to use primary care services to address these problems. A range of factors may be useful for identifying those at risk of a slower recovery and a delayed RTW so that appropriate interventions can be provided to this group.
Injuries to working age adults are a major public health problem, resulting in more than 400,000 hospital admissions in England [1] and approximately 2.8 million emergency department (ED) attendances in the UK [2] annually. There is also evidence that those who have suffered injury have greater health service use in the years following their injury than the general population, and in some cases this can continue for many years following the injury [3].
Injuries also have a major impact on work absence in the UK. More than 10% of all general practitioner (GP) sick notes are issued for injuries [4] and they are the second most common reason for Employment Support Allowance (the benefit paid in the UK for incapacity) accounting for 14% of all claimants [5].
As there is evidence that work has a positive impact on health, [5] helping people return to work (RTW) following illness or injury is central to the UK Governments strategy for the health and well being of working age adults [6]. Sickness certification in the UK is currently provided by GPs and a new "fit-note" was recently introduced to enable GPs to make recommendations to employers to facilitate RTW, accompanied by a national training programme for GPs [7]. A more recent independent review now recommends major changes to the certification of sickness absence in the UK, removing the GP from this task once sickness absence has lasted four weeks. It proposes an independent service to provide an in-depth assessment of physical and mental function and to advise about supporting people in RTW [5]. This is likely to have major implications for those suffering injuries and for GPs who provide continuing care, on-going support and co-ordination of other services for people after injury.
Although there is a body of literature exploring the impact of injuries on work in other countries, this may not be generalisable to the UK because the types of occupations, compensation systems, health care and welfare systems vary between countries. Little research to date has examined the factors associated with RTW following a wide range of injuries in the UK. A recent systematic review of prognostic factors for RTW after orthopaedic trauma found 15 longitudinal studies, only two of which were from the UK [8]. The first showed that RTW was more strongly associated with the amount of time a person had been off work, psychological problems and age than with clinical characteristics of the injury [9]. The second found that perceived blame, litigation and disrupted social activities were more important than injury severity in predicting RTW at six months and that post traumatic stress disorder avoidance symptoms and disrupted usual physical activities were the only factors associated with RTW 18 months post injury [10]. The analyses in this paper have been undertaken to quantify the impact of a wide range of injuries on RTW, health care use and health status in the UK and explore factors associated with RTW via a secondary analysis of data from the UK Burden of Injury Study (UKBOI) [11].
The UKBOI study was a prospective longitudinal study set in four acute NHS Trusts in the UK. The analyses presented in this paper use a subset of participants from the UKBOI study.
The four study centres participating in the UKBOI study were Swansea, Nottingham, Bristol and Guildford. These cities and towns had populations in 2006 ranging from 132,000 in Guildford to 414,000 in Bristol, with working age adults comprising between 63% (Swansea) and 69% (Nottingham) of the population [12]. Employment rates in 2006 ranged from 64% in Nottingham to 82% in Guildford [13]. The 2001 census found the percentage of the population in higher and intermediate managerial, administrative or professional occupations ranged from 16% in Nottingham to 34% in Guildford and the percentage on state benefits, unemployed or in the lowest grade occupations ranged from 12% in Guildford to 21% in Nottingham [14]. Age standardized mortality rates from unintentional injuries between 2008 and 2010 varied between the study centres, being significantly higher in Nottingham and lower in Guildford than those for England [15]. Directly comparable rates are not available for Swansea, but the age standardised unintentional injury mortality rate in 2003 was significantly higher in Wales than in England, and similar to that for the East Midlands region which contains Nottingham [16].
Participants for the UKBOI study were people aged 5 years and over attending EDs or admitted to hospital in one of the four study centres with a wide range of injuries, including fractures/dislocations, lacerations, bruises/abrasions, sprains, burns/scalds, and head, eye, thorax and abdominal injuries [11]. In the UK, trauma cases usually attend EDs, with those that are assessed in the ED as needing admission being admitted to hospital. ED attenders were therefore defined as those attending ED who were not admitted to hospital. Hospital admissions were defined as those admitted to hospital, whether or not they attended ED immediately prior to their admission. Injuries had to have occurred within 2 weeks of attendance for ED treated patients and four weeks for hospital admitted patients. Patients had to be able to give consent and complete questionnaires or to have a suitable proxy who could assent to their inclusion and agree to complete future questionnaires. Those without permanent UK addresses were excluded. Participants were recruited face-to-face during their hospital admission or attendance between September 2005 and April 2007. The analyses presented in this paper were restricted to those aged 16–65 years inclusive that were employed or self-employed before the injury.
Participants self-completed questionnaires at recruitment and by post at 1, 4 and 12 months post injury. Once participants reported complete recovery (defined as the injury no longer affecting them in any way), no further questionnaires were sent. Questionnaires were designed specifically for this study. They included an open question about how the injury happened, plus closed questions asking about activity at time of injury, place of injury, whether a motor vehicle was involved and injury intent. Socio-demographic data included closed questions, taken from the 2001 UK Census on accommodation type, number of rooms in household, number of people living in household, number of cars or vans by use of household members and ethnic group [17]. The participant's postcode was obtained from direct enquiry at recruitment, and from this, the Townsend deprivation score was obtained. The Townsend deprivation score is a composite deprivation index comprising four indicators: unemployment, housing tenure, car ownership and overcrowding [18]. Information on whether the participant had any disability or long term health problems prior to the injury which limited usual activity was ascertained using a dichotomous question. General health prior to injury was measured using the EQ5D index and Visual Analogue Scale (VAS) [19]. Employment status prior to injury was ascertained by asking if participants were employed, self-employed or not working. Self-completed follow-up questionnaires collected data on general health (EQ-5D and VAS) and recovery using a dichotomous question (defined as whether the injury still affected them in any way on the day of completing the questionnaire). Data on RTW was collected by asking the number of days that participants did not attend work due to their injury in the preceding four weeks. Data on use of health and social services was collected by asking participants to specify the number of days on which they used a range of pre-specified services in the preceding four weeks because of their injury. Work problems for those who had RTW were measured using the Work Limitations Questionnaire [20]. Data on the body part injured and injury severity was ascertained from medical records and injury severity was scored using the Abbreviated Injury Scale (AIS) [21].
We defined full RTW as not being prevented from working for any days in the last four weeks. Where participants did not answer this question but reported they had returned to normal activities on other questions, we assumed full RTW. Those reporting they had fully recovered from their injury at one month (100 participants) were not sent a four month questionnaire; hence we assumed they had fully RTW at four months.
Twelve month data were not analysed as only 20 participants had not RTW at this point. We ran separate analyses for ED attenders and hospital admissions, as previous studies suggest RTW may vary by admission status [22]. Only 10 participants who had been admitted to hospital had RTW one month following injury, so prognostic factors for RTW were only explored for those admitted to hospital using the four month data. Outcomes were commonly reported, hence Poisson regression, with a robust variance estimator [23, 24] was used to estimate the relative risk of RTW at one and four months post injury. Age and deprivation were categorised as each had a non-linear relationship with RTW. Injury type was categorised into upper limb, lower limb and other injuries as numbers were small for some injury types and previous studies suggest prognostic factors may differ between upper and lower limb injuries [8]. Injury severity was categorised into minor (AIS=1) and moderate/severe (AIS=2 or 3). We present two multivariable models for each analysis. The first includes all baseline variables (study centre, age, sex, deprivation, employment status, long-term illness, place of injury, type of injury, severity and injury intent) and the second uses backward stepwise regression, forcing study centre into the model, and retaining other variables if the Wald test for their removal was significant (p<0.05). Observations with missing data were excluded, model assumptions were checked and sensitivity analyses undertaken excluding observations with standardised residual values >2 or<−2 and highly influential observations.
Health status (EQ5D index and VAS scores) was compared between pre-injury and post injury at one and four months post injury using the Wilcoxon matched pairs test. Health status was compared between those who had and who had not RTW at one and four months post injury using the Mann–Whitney U test.
Ethical approval was provided by Dyfed Powys Local Ethics Committee (Number: 05/WMW01/23).
At baseline 664 participants were included, of these 83% were employed (n=554) and 17% were self employed (n=110). Fifty eight percent (n=385) were ED attenders and 41% (n=271) were hospital admissions. At one month, 62% of both ED attenders and hospital admissions returned questionnaires. Four month data were available on 51% (197/385) of ED attenders and 48% (130/271) of admissions. These figures include those fully recovered at one month who were not sent a four month questionnaire and who were assumed to be fully RTW at 4 months. Data from 51% of ED attenders (195/385) was included in the multivariable analysis at one month and from 44% (171/385) of ED attenders and 42% (114/271) of admissions at four months. (Figures 1 and 2).
Responders and non-responders to one month follow up questionnaire and return to work (RTW). *6 who had RTW and 16 who had not RTW excluded from multivariable analysisdue to missing data on returned questionnaire.
Responders and non-responders to 4 month follow up questionnaire and RTW. 19 A&E attenders who had RTW and 1 who had not RTW excluded from multivariable analysis due to missing data on returned questionnaire. *6 hospital admissions who had RTW and 3 who had not RTW excluded from multivariable analysis due to missing data on returned questionnaire.
At one month, responders were older than non-responders (median 41 years vs. 32 years, p<0.001), more likely to be female (44% vs. 28%, p<0.001), less likely to live in deprived areas (27% in most deprived tertile vs. 39%, 31% vs. 32% in middle tertile and 37% vs. 23% in least deprived tertile, p<0.001), had more severe injuries (60% had moderate or severe injuries vs. 46%, p<0.001) and were less likely to have had their injury at work, on the road or at a sports ground (home 24% vs 23%, work 18% vs. 20%, road 21% vs. 24%, sports ground 13% vs. 18% and other location 25% vs. 12%, p=0.002). At four months, responders were older than non-responders (median 45 years vs. 33 years, p<0.001), more likely to be female (48% vs. 29%, p<0.0001), less likely to live in deprived areas (28% in most deprived tertile vs. 37%, 32% vs. 32% in middle tertile and 37% vs. 26% in least deprived tertile, p=0.02), had more severe injuries (73% had moderate or severe injuries vs. 51%, p<0.001), were more likely to have upper or lower limb injuries and less likely to have other injuries than non-responders (upper limb injuries 25% vs. 22%, lower limb injuries 45% vs. 38%, other injuries 30% vs. 41%, p=0.03) and had a similar pattern in terms of injury location as at one month (home 22% vs. 22%, work 16% vs. 19%, road 22% vs. 25%, sports ground 14% vs. 17%, other location 26% vs. 15%, p=0.045).
Baseline characteristics
Table 1 shows that at baseline just over half (56%) of ED attenders were male, and almost half (48%) were aged 16–35 years. Most injuries in ED attenders occurred at home (25%), at work (20%) or on the road (19%). Superficial injuries (24%), upper limb fractures (18%) and other lower limb injuries (17%) were the most common injuries. Two fifths (41%) were moderate or severe injuries.
Table 1 Baseline characteristics of study participants and their injuries (column percentage)
More than two thirds of those admitted to hospital were male (71%), and most were aged 16–35 or 36–55 years (42% each). Most injuries occurred on the road (27%) and at home (22%). Fractures were the most common injury (38% lower and 14% upper limb). Three quarters (75%) were moderate or severe injuries.
Use of health services and time off work
Table 2 shows that at one month one third of ED attenders (33%) had consulted their GP and 19% had consulted the practice nurse because of their injury. Two thirds (65%) had taken time off work in the previous month, with one third (31%) taking 11 or more days off. Almost half (47%) had taken time off for health care visits and 27% had relatives or friends who had taken time off to care for them. Injuries needing hospital admission had a greater impact on health care use and on work. More than half (58%) had consulted their GP, 81% took 11 or more days off work, 59% took time off for health care visits and 58% had others taking time off to care for them.
Table 2 Use of health care services and impact of injury on work in the preceding 28 days at 1 month and 4 months post injury (column percentage)
At four months 21% of ED attenders had consulted their GP because of their injury in the last month, 31% had taken time off work, with 19% taking 11 or more days off, 21% had taken time off for health care visits and 7% had others who had taken time off to care for them. For hospital admissions, 36% had consulted their GP, and 41% took 11 or more days off work, 29% took time off for health care visits and 21% had others taking time off to care for them.
ED attenders and work status following injury
One month after injury only 35% (77/217) of ED attenders had fully RTW (Figure 1). Table 3 shows that the self-employed were 70% more likely to RTW at one month than employed participants (RR 1.70, 95% CI 1.17 to 2.47) and those with a moderate or severe injury were 52% less likely to RTW than those with a minor injury (RR 0.48, 95% CI 0.32 to 0.72).
Table 3 Factors associated with full RTW at 1 month post injury for emergency department attenders, frequencies (row percentage) and unadjusted and adjusted relative risks
At four months, 83% (159/191) of ED attenders had fully RTW (Figure 1). Table 4 shows that injury severity was significantly associated with RTW, with those with a moderate or severe injury being 21% less likely to RTW than those with a minor injury (RR 0.79, 95%CI 0.68 to 0.92). The self-employed were 15% more likely to RTW than employed participants (RR 1.15, 95%CI 1.03 to 1.30). Analyses were robust to the sensitivity analyses described above.
Table 4 Factors associated with full RTW at 4 months post injury for emergency department attenders, frequencies (row percentage) and unadjusted and adjusted relative risks
Hospital admissions and work status following injury
One month after injury only 7% (10/146) of hospital admissions had fully RTW (Figure 1). At four months 57% (70/123) had fully RTW. Table 5 shows that men were almost twice as likely to have RTW at four months than women (RR 1.94, 95% CI 1.34 to 2.82) and those injured at work were 51% less likely to have RTW (RR 0.49, 95% CI 0.27 to 0.87) than those injured at home. Participants from more deprived areas were about 40% less likely to have RTW than those from the most affluent areas (participants from the most deprived tertile RR 0.59, 95% CI 0.40 to 0.85 and from the middle tertile RR 0.61, 95% CI 0.40 to 0.93 compared with the least deprived tertile). Analyses were robust to the sensitivity analyses described above.
Table 5 Factors associated with full RTW at 4 months post injury for hospital admissions, frequencies (row percentage) and unadjusted and adjusted relative risks
Table 6 shows median EQ5D index and VAS scores at baseline, one and four months for ED attenders and for hospital admissions. The EQ5D index and VAS scores were significantly lower than baseline values for ED attenders and hospital admissions at both one and four months (all p values <0.001).
Table 6 Health status at baseline, one and four months post injury for ED attenders and hospital admissions, comparing one and four month values with baseline values
Table 7 shows that the EQ5D index was significantly lower at one and four months post injury amongst ED attenders that had not fully RTW (1 month post injury p<0.001; 4 months post injury p=0.039) and hospital admissions (1 month post injury p=0.022; 4 months post injury p=0.003). The VAS score was only significantly lower amongst ED attenders that had not RTW at one month post injury (p=0.002).
Table 7 Health status at baseline, one and four months post injury for ED attenders and hospital admissions comparing those who had and had not fully RTW
Pain was the most common problem at all time points (Figure 3). Of those who had not fully RTW, 71% of ED attenders and 84% of hospital admissions had problematic pain four months after injury. Problems with usual activities and mobility were the second and third most commonly reported problems at all time points. At one month ED attenders who had not RTW reported significantly more problems in each domain than those who had (all p values <0.05). At four months, ED attenders who had not RTW reported significantly more problems with mobility and usual activities than those who had (both p values <0.05). At four months hospital admissions who had not RTW reported significantly more problems with usual activities, mobility and self care than those who had (all p values <0.05). One fifth of ED attenders reported anxiety or depression at 1 month and 7% at 4 months, whilst 27% of hospital admissions reported anxiety or depression at four months.
Health status (EQ5D index) for emergency department attenders at one month and four months and for hospital admissions at four months by full RTW.
Summary of main findings
Injuries have a large impact on health care use and time off work in the UK. This applies at both one and four months post injury, and even injuries that "only" required ED attendance have considerable impact four months post injury. Prognostic factors for RTW vary over time and between those attending ED and those admitted to hospital. Amongst ED attenders, injury severity and employment type (self employed or employed) predict RTW in the short term and medium term (four months). Amongst those admitted, gender, deprivation and place of injury predict RTW in the medium term. Health status was significantly poorer at one and four months after injury than before the injury and was significantly poorer amongst those that had not RTW compared to those that had. Many people experienced problems with pain, undertaking usual activities and mobility in the short and medium term, with a smaller proportion experiencing problems with anxiety and depression. Those who had not RTW experienced more problems than those who had, particularly with mobility and usual care activities in the medium term. A high proportion of injured people experienced problems with pain at all time points whether they had RTW or not.
Strengths and limitations of the study
This is the largest UK study quantifying health care use and work impact resulting from a wide range of injuries. Our response rates are similar to one comparable UK study, [10] but lower than those from a UK study focussing on road traffic injury in ED attenders [25]. The differences we observed in characteristics between responders and non-responders may influence our estimates of rates of RTW in either direction. Firstly women and those with more severe injuries were more likely to respond at one and four months, and both these factors have been found to be associated with lower rates of RTW [8] suggesting our RTW rates may be underestimated. Secondly those with workplace injuries, [10] blue collar workers and those with lower educational levels have been found to have lower rates of RTW, [8] and our finding of lower response rates amongst those with workplace injuries and the more disadvantaged may indicate our RTW rates are overestimated. The same review found conflicting evidence about the relationship between age and RTW, [8] making it difficult to estimate the likely effect of differential response rate by age in this study. As we did not collect detailed occupational data, we could not explore how specific injuries affect RTW in different occupations. Previous studies demonstrate RTW may be less likely in more physically demanding jobs, [26] which may at least partly explain the lower rates of RTW with increasing deprivation in this study.
We did not send further questionnaires to those who reported being fully recovered at the previous follow up time point. We assumed that these people remained fully RTW at subsequent time points. This is likely to overestimate our RTW rates as some people will have further time off work because of their injury. Our study did not collect data on psychological or social functioning which may play an important role in RTW post injury [27, 28]. Such factors may confound the relationship between prognostic factors and RTW that we found, or act as effect modifiers or mediators. Despite this being the largest UK study of the longer term effects of a range of injuries, small numbers, particularly in the four month analysis for hospital admissions may mean some negative findings may result from insufficient power. In addition, small numbers within injury categories prevented us from exploring the impact of specific injuries on RTW.
The study did not collect data on benefits received by participants, hence the relationship between the benefits received and other factors associated with RTW could not be explored. The UK benefit system for those unable to work due to injury or illness is complex. Occupational sick pay entitlement schemes vary between companies with a minimum amount of statutory sick pay being paid to those whose companies do not provide their own sick pay schemes. At the time of the study, incapacity benefit was available to those unable to claim statutory sick pay (e.g. the self employed or unemployed). Those injured at work may have been eligible for Industrial Injuries disablement Benefit which is claimable 90 days or more following an accident at work and the sum payable is based on the degree of disability [29].
Comparisons with existing literature
There are no directly comparable prospective UK studies with which to compare our findings. One study of employed men admitted to hospital in Sheffield in 1996 found 26% of participants had RTW 6 weeks post injury and 54% by six months post injury [10]. A study of consecutive road traffic injured ED attenders in Oxford found 69% were working by 3 months and 74% by one year [25]. We found only 7% of hospital admissions had RTW at 1 month and 57% at four months post injury. Despite differences in study populations and data collection time frames, our findings are broadly similar to these studies.
Our findings are consistent with others who found that factors predicting RTW vary over time [10, 27, 30, 31] and that non-clinical factors (e.g. gender, deprivation, place of injury) are often more important than clinical factors (e.g. injury type or severity) in predicting RTW [8–10, 22, 26, 27, 31, 32]. Potential explanations for gender and deprivation differences in RTW may include differences in the nature of work undertaken, in rates of psychological morbidity post injury and in physical and psychosocial outcomes post injury [8, 22, 26, 27, 32–38]. Our findings are also consistent with research suggesting that those who had not RTW in the short or medium term post injury had poorer mental health, increased physical disability, pain and greater problems with social functioning [10]. Several studies suggest those experiencing a greater degree of pain are less likely to RTW [26, 36]. Recent work suggests attitudes towards pain may also be important, with those believing they should not work with their current level of pain being significantly less likely to RTW [27].
Implications for practice and research
If the recommendations of the recent review of sickness absence are implemented, the majority of those suffering injuries will require an in-depth assessment of their fitness to work, as most will have more than 4 weeks sickness absence. Fitness for work assessors can use the risk factors we found to identify those at risk of a later RTW and use this information to provide evidence-based interventions to help this group make a successful RTW.
Consultations with patients requesting "fit-notes" are valuable opportunities to identify and address on-going problems. Removing the need for GPs to provide "fit-notes" may discourage people from consulting and opportunities to maximise recovery may be missed. Whilst in-depth assessments of fitness to work may help people RTW more quickly, recovery is a broader concept than just RTW. It is therefore important that, as part of the assessment process, people are encouraged to consult GPs with any on-going physical and psychological problems. Such consultations are likely to need to focus on improving pain control, exploring attitudes towards pain, addressing mobility problems, and identifying and managing anxiety and depression.
Further research is needed to provide a more comprehensive assessment of the complex relationships between physical, psychological, social and occupational outcomes for a wide range of injuries of varying mechanisms and severities in the UK. This includes exploring the determinants of persistent pain, mobility problems and psychological problems following injury. In order to investigate the impact of specific injury types on RTW considerably larger studies will be required. Such research is needed to inform the design and evaluation of potential interventions for maximising recovery and ensuring successful RTW. In addition, if the recent review of sickness absence is implemented, it will be important to measure the impact of this on patient outcomes post injury. Assessing access to primary care services will be a key question, as primary care is ideally placed to address the most common physical and psychological problems after injury.
This work is based on independent research commissioned and funded by the Policy Research Programme in the department of Health (reference number 0010009). The views expressed are not necessarily those of the department.
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The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/584/prepub
The authors would like to thank all patients who participated in the study and staff at the 4 participating hospitals for facilitating the conduct of the study.
UK Burden of Injuries Study Group:
S Brophy, A Evans, RA Lyons, S Macey, I Pallister: School of Medicine, Swansea University, United Kingdom.
B Carter, EL Towner: Centre for Child and Adolescent Health, University of the West of England – Bristol, United Kingdom.
N Christie, J Sleney: Postgraduate Medical School, University of Surrey, United Kingdom.
C Coupland, L Groom, D Kendrick, C Mulvaney, S Smith: Division of Primary Care, University of Nottingham, Nottingham, United Kingdom.
F Coffey: Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
Division of Primary Care, University Park, Floor 13 Tower Building, Nottingham, NG7 2RD, UK
Denise Kendrick
, Yana Vinogradova
& Carol Coupland
Centre for Transport Studies, Department of Civil, Environmental and Geomatic Engineering, UCL Gower Street, London, WC1E 6BT, UK
College of Medicine, Swansea University, Grove Building, Singleton Park, SA2 8PP, Swansea
Ronan A Lyons
Centre for Child & Adolescent Health, University of the West of England, Oakfield House, Oakfield Grove, Clifton, Bristo, l BS8 2BN, UK
Elizabeth L Towner
the UK Burden of Injuries Study Group, UK
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Correspondence to Denise Kendrick.
Authors' contribution
DK was the PI for the Nottingham site, contributed to study design, statistical analysis plan, and interpretation of results and drafting of the paper. YV contributed to the analysis plan, undertook the analysis and contributed to the interpretation of the results and drafting of the paper. CC contributed to the study design, statistical analysis plan, and interpretation of the results and drafting of the paper. NC was the PI for the Surrey site and contributed to study design, interpretation of results, and drafting of the paper. RL was the CI for the UK Burden of Injuries Study and PI for the Swansea site, contributed to study design, interpretation of results, and drafting of the paper. ET was the PI for the Bristol site and contributed to study design, interpretation of results, and drafting of the paper. All authors read and approved the final manuscript.
Kendrick, D., Vinogradova, Y., Coupland, C. et al. Getting back to work after injury: the UK Burden of Injury multicentre longitudinal study. BMC Public Health 12, 584 (2012) doi:10.1186/1471-2458-12-584
Received: 16 December 2011
DOI: https://doi.org/10.1186/1471-2458-12-584
Visual Analogue Scale Score
EQ5D Index
Abbreviate Injury Scale
Post Injury


text:
AARON CHALMERS TO COMPETE AT BELLATOR 200
BAMMA Press Office - Official Statement
[London 14.03.18] One of BAMMA's most exciting and controversial stars is set to make headlines once more as he competes on the main card of Bellator's landmark 'Bellator 200' show, taking place at the SSE Arena, Wembley, London on May 25th.
BAMMA, the UK's premier MMA promotion, has given Aaron 'The Joker' Chalmers a conditional one fight release to appear on their promotional partner's momentous event.
BAMMA will return to Dublin once more on Saturday May 12th for the hotly anticipated BAMMA 35. For more information BAMMA.com
Please Do Not Remove the ticket links from articles as this helps us better understand what traction each site is getting on releases.
In any articles from this point, please refer to the promotion only as 'BAMMA'. British Association of Martial Arts is NOT to be used
Press Information:
For further enquiries please contact mattb@bamma.com
High res photos and post-fight interview videos available on request
Do NOT Crop or reproduce the attached artwork in any way without prior written permission.
Interviews available on request
BAMMA, Europe's Leading Mixed Martial Arts Entertainment Brand, is the home for elite fighters from around the world. Launched in 2009 and drawing unrivalled domestic viewing figures, the UK based promotion continues to showcase the most exciting and entertaining fights, between the toughest and most skilled competitors the sport has to offer.
RDX SPORTS
RDX Sports is a British combat sports and fitness brand, Established in Bury, Manchester in 1999. Every resource and our endless energy is put into research and development keeping us at the forefront of the market. We never settle or compromise, and our aim is to always improve, an ethos any athlete or fitness fanatic can appreciate. By 2004, Backed up by our "fighter centric" model that believes in "Athlete Safety over Everything Else". RDX expanded their UK base of operations. Today, we stand as a global sporting brand exporting from the UK to 57 countries around the world.
UNILAD is the number one content publisher on social media and – with just under a billion engagements and over 25 billion video views in 2016 alone – has matured into the most engaged and viewed channel in the world. Established in 2014, UNILAD has grown from a single Facebook page and website for the social generation to a highly-engaged suite of channels catering for passions and interests such as food, tech and gaming. Initially only licensing viral content, UNILAD has now evolved into a leading original content producer, blending the best viral videos with home-grown content built for social and becoming one of the fastest growing media properties in the world.
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SAFE MMA is a voluntary medical advisory body established to improve the safety of MMA fighters in the UK and is housed at 76 Harley Street in London. Under the Safe MMA banner, the medical centre provides a secure, centralised and confidential database for fighter medical records; and coordinates affordable, standardised blood and medical tests for all registered fighters. Member promotions commit to only using professional fighters that have been medically cleared by Safe MMA doctors. Additionally, member promotions provide pre and post-fight medical examinations for fighters at events. All medical data is submitted along with advisory suspensions to Safe MMA. For more information visit www.safemma.co.uk


Like his rap career, Bun B's sneaker game is no joke. Whether it's getting exclusive Jordans and Air Force 1s early, designing his own sneakers for brands like Greedy Genius and PRO-Keds, or being a member of the exclusive ATF crew, Bun's name is always in the mix of celebs who rock heat. Did we mention he's designed one of the best Nike Bespokes to come out of 21 Mercer? Recently, we sifted through pictures on the Internet to compile Bun's Greatest Footwear Moments, but this time around we sat down with the Houston legend to get his mega-list of his 50 Favorite Sneakers direct from the source. What took top billing? You're going to have to click for that. Start the countdown below, and then save the date for Bun's new album, Trill O.G., which hit stores August 3.


Want help from a designer like omarguerreroc?
I'm Omar Guerrero. I'm a civil engineer and CAD drafter. I have 7 years working with AutoCAD designing floor plans, structural plans, land surveying plans and architectural plans. Also, I know how to use Arcgis and Sketchup softwares. I've worked with companies related to civil engineering in Venezuela, Ecuador and Panama and I've participated in projects of urban planning. I can speak English and Spanish.


text:
Study in Canada as an international student
Designated Learning Institutions in Canada
Volunteer work conducted by foreign students: When is a work permit and an ESDC confirmation required?
What is work?
"Work" is defined in the Regulations as an activity for which wages are paid or commission is earned, or that competes directly with activities of Canadian citizens or permanent residents in the Canadian labour market.
Foreign students engaging in "work" are required to have a work permit. Exceptions:
on-campus employment, for which a work permit is not required.
Health care students doing an internship or practicum. The primary purpose of the practicum must be to acquire training; therefore these positions may be unpaid and should not be of more than 4 months' duration.
Volunteer activities that are not "work" and do not require a work permit
Volunteer work for which a person would not normally be remunerated, such as a foreign student being a 'big brother', or 'big sister' to a child; being on the line at a rape crisis centre. Normally this activity would be part time and incidental to the main reason that the person is in Canada (in this case, to study).
Unremunerated observation of the functioning of a given work environment or occupation (i.e. following a geologist on their sample-gathering trips). In some cases, minor tasks may be performed by the foreign student (such as clerical chores), however there should not a significant contribution to the productivity of the enterprise.
Unremunerated helping of a friend or family member during a visit.
There may be other types of unpaid short-term work where the work is really incidental to the main reason that the foreign student is in Canada and is not a competitive activity, even though non-monetary valuable consideration is received. For instance, if a foreign student wishes to stay on a family farm and work part time just for room and board for a short period (i.e., 1-4 weeks), this would not be considered an activity which requires a work permit.
Volunteer activities which do require a work permit, but remain ESDC confirmation exempt:
With respect to volunteer work, the following conditions apply in order to be eligible for confirmation exemption:
The individual will not receive remuneration, other than a small living expense; and
The organization or institution which is sponsoring the foreign worker will not, itself, receive direct remuneration from any source on behalf of, or for, the services rendered by the foreign worker; and
The work goes above and beyond normal work in the labour market, whether remunerated in some manner or not. Examples of this might be constructing a house for 'habitat for humanity', living in and supporting a L'Arche group home.
It's envisioned that normally, this kind of work would be full-time and so not applicable to full-time students during the school term.
Work permit and ESDC confirmation required:
Work (remunerated or not) in situations that do not fulfil the conditions above.
Any activity which might be considered 'competitive' within the Canadian labour market, even if unpaid. For example, if the work might be a valuable work experience for a Canadian student (for example, an internship with a television station or with a high-profile NGO, even if unpaid). For cases which don't conform to the guidelines allowing for confirmation exemption (above) ESDC is prepared to offer a labour market opinion.
The work is "normal" work in the labour market: i.e. it competes with other jobs in the Canadian labour market. For example, if a foreign student is doing an internship that is not a requirement for the completion of the academic course of study, whether paid or unpaid, that fulfils the definition of "work," an ESDC confirmation is required.
The designated learning institution portal
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Advisory Committee on International Students and Immigration (ACISI)
Study, work and stay in Canada – promotional material for schools


I have a remote "agent" that returns "yes" or "no" when handed a string. Communicating with this agent is expensive, so I'm hoping to find a library that will allow me to iteratively build a regular expression given positive and negative feedback, while being intelligent about its construction. This would allow me to cache answers on the sending side.
For example, suppose we query the agent with "good" and receive a "yes". The initial derived regular expression ought to be "good".
Suppose I query then with "goop" and receive a "yes". I would expect the derived regular expression to be "goo[dp]", not "good|goop".
I do not need backtracking or any other fancy non-linear time operations in my derived regex. Presumably the generated regex would be a DFA under the hood. Is anyone aware of any c/c++ regular expression libraries capable of doing this? Alternatively, reasons why this is a dumb idea and better solutions to my real problem would also be useful.
Rather than a regular expression, you could use a Trie.
Then for each new string you walk the trie one node for each character. I suspect that you would also want a marker character for end of string - once you reach this character, if the node exists, it holds the yes/no answer.
Well, unless I'm missing something in your situation, I think that memory is cheap enough to just straight up implement a dumb cache - say, an unordered_map of <std::string, bool>. Not only will this be much easier to build, it will probably be faster too, since you're building a hash map. The only downside to this is if you were going to query the remote service with a bazillion different keys, then this might not be the best approach.
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text:
Adrin Mammen and Jeffrey B. Short Meet Patients Where They Are
Adrin Mammen and Jeffrey B. Short usher Montefiore Health System into the golden era of healthcare's digital transformation with innovative, accessible care options
By Billy Yost
Every initiative, every measure, and every proactive move Adrin Mammen and Jeffrey B. Short have enacted is summed up by Mammen in one perfect quote: "Our stance has always been to meet people where they are."
Mammen, who serves as Montefiore Health System's associate vice president and patient access transformation officer, and Short who serves as its vice president, transformation officer, chief of staff, and leader of the faculty practice physician group have cultivated an enduring partnership that has created staggering results in just a short timeline.
Prior to the COVID-19 pandemic, Mammen and Short had embarked on an extensive digital transformation journey on behalf of the health organization. "We had started putting a road map together to expand patient access, improve productivity, and drive patient satisfaction," Mammen explains. "Once we established our priorities, we started mapping out sequentially what, why, and how it was that we wanted to accomplish. Then the pandemic happened."
The Silver Lining of Pandemic Transformation
For most healthcare organizations, the pandemic meant the grinding halt of any projects or initiatives not explicitly related to fighting COVID-19. It might be because of Mammen's Baldrige National Examiner training, her Lean Six Sigma Black Belt, or her Six Sigma Master Black Belt, but she and Short saw the situation differently.
Adrin Mammen, AVP and Patient Access Transformation Officer, Montefiore Health SystemPhoto by Karla Esqueche Altamirano
"The pandemic accelerated innovation in many different sectors by as much as ten years. Healthcare was no different," Short says. "Regulators quickly removed reimbursement and regulatory barriers, and our clinicians and patients were willing to try telemedicine out of necessity. Suddenly thousands of patients and clinicians were using telemedicine. This rapid adoption transformed healthcare from a face-to-face business to one that was now a mixed model that includes a large virtual or online segment."
"The pandemic allowed us to leverage a lot of the great work that we had done, and to do it quickly," Mammen says. Working nimbly, they were able to transform their already existing plan and, essentially, put it into overdrive.
A telehealth program often requires one-to-two years to properly stand up in most healthcare settings. At Montefiore, the organization went from five telehealth visits in 2019 to 637,000 from March to December of 2020 alone.
"Key to the progress that was made is the leadership structure employed during the pandemic," Short notes. "A central command structure was set up that simplified decision making and allowed us to quickly make decisions and allocate resources to key initiatives."
The transformation begs an in-depth study of its own, but Mammen pauses. "That was just telehealth," she says.
The success and blowup of the telehealth program got the transformation team thinking about the health system's scheduling process. "We were trying to get more and more appointments scheduled online because we were setting up COVID-19 vaccinations and our phone lines were being flooded," Mammen explains.
Defied Expectations
Mammen says embracing online scheduling meant deconstructing some long-held beliefs about Montefiore's patient population. "Our patients are located in the Bronx in New York; they're a very socioeconomically diverse population, and a lot of our patients don't speak English as their primary language," Mammen says. Right or wrong, the AVP says expectations suggested that Montefiore's patients may not have internet access in their homes due to economic instability, and that a lack of digital literacy may keep its patients from engaging online.
"We needed to take the chance and try to meet people wherever they are," Mammen says. "If they want to engage with us digitally, we'll be there for them. If they want to engage with us over the phone, we can meet them there as well."
Mammen, Short, and the transformation team quickly found that questioning long-held beliefs was the right move. Montefiore discovered not only were its patients engaging digitally, but it had patients engaging via mobile devices in huge swaths of the area. "We're able to engage with our patients via SMS and mobile apps," Mammen explains. "The first month we rolled out our telehealth mobile app, it was in the Top 100 of the Apple App Store's healthcare section."
"The acceleration of online visits allowed us to engage patients and clinicians and create rapid learning cycles. We quickly gained insights on how to improve the experience and the process," Short adds. "We learned about the importance of the ability to launch a visit without the need to download an app first. We also learned how vital in-visit translation was for our diverse patient base. The learnings came quickly, and we were able to react quickly."
Jeffrey B. Short, VP, Transformation Officer, Chief of Staff, and Leader of the Faculty Practice Physician Group, Montefiore Health SystemPhoto courtesy of Montefiore Health System
So, the transformation team went further. A chatbot was installed on the Montefiore website that uses artificial intelligence to help patients find the information they need quicker. Specifically, conversational AI enables the chatbot to update in real time with new information about the pandemic, vaccinations, or more common queries.
"We didn't have to go in and change code every time we needed to update information, because the AI was doing it for us," Mammen explains.
With that, the transformation team returned to its goal to help patients not only find information about their doctors or treatment on its website but also schedule appointments without picking up the phone. In August of 2021, Montefiore rolled out an interactive online directory that will allow patients to identify the appropriate physician based on their condition or specialty.
"We will use clinical focus terms to match patients with providers based upon their clinical need, using layman's language," Mammen says. "You can search for 'diabetes' or 'back pain' and will find who you're looking for."
"We are thrilled that Montefiore Health is advancing their digital front door using symplr Directory," says Tom White, CEO and founder of Phynd and now general manager of symplr, which acquired Phynd in February 2021. "Adrin is a visionary patient access and transformation leader and is driving Montefiore to deploy a modern digital patient experience using the symplr provider data platform. Our partnership will help Montefiore Health fulfill their mission and bring operational efficiencies to their entire enterprise, strengthening Montefiore's position as a healthcare leader in the New York City area."
That's only phase one. Phase two will include the ability to self-schedule an appointment online. By the end of the year, Mammen hopes 5 to 10 percent of Montefiore's appointments will be scheduled online.
"I believe we are currently in the 'golden age' of healthcare," Short says. "The present healthcare marketplace, due to the COVID-19 pandemic and other contemporary factors, is hungry for change in terms of digital transformation.
"Patients simply demand what the banking and travel industries have given them: self-service, on-demand access," he continues. "Now we must deliver the ability to schedule medical appointments just as easily as people can check their bank balance or book a flight. These are things we at Montefiore are already actively working on."
Mammen says Montefiore's goal is to reduce the demands on patients while simultaneously improving their health outcomes. If an economically struggling patient can receive the care they need via telehealth visit—that will not require them to take a half or whole day off work—Mammen and Short want to make it happen. If the health system can find ways to engage with patients proactively to receive automatic communications to schedule their next appointments or refill a prescription, Mammen and Short want to make that happen, too.
And for the transformation team at Montefiore, it's about far more than wanting. The team is already down the path.
"There are so many ways that I think we can be more proactive about managing our patients' care," Mammen says. "It's something I'm thinking about all the time. And I really think we're going to do it."
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text:
Home Load & Haul Turning Pain Into Profit
Load & Haul
Turning Pain Into Profit
Sitting amidst the hardest rock in Southern Africa, Vedanta Zinc International's Black Mountain base metals mine in the Northern Cape is reaping the rewards from optimising its mining fleet with record production levels and ever-improving profitability.
With 65% of production from cut & fill mining and 35% from open-stoping, the mine operates around the clock. Black Mountain Mining (BMM) is heavily dependent on its load-haul-dump (LHD) fleet to haul ore in continuous round-the-clock tramming cycles. The mine requires extreme reliability from the equipment to meet production requirements.
Machinery breakdowns can restrict operations in the decline or access to production levels and have severe consequences for production and profitability.
For several years, this had been the case with several of the machines in the mine's 18-strong LHD fleet. Their comparatively low availability had hamstrung the operation and given rise to considerable frustration and lower than expected production rates on the mine. However, the tipping point came when management reviewed statistics of machines in the fleet and approached Sandvik Mining and Rock Technology, the OEM with the best performing LHDs on the mine, to replenish and optimise the rest of its fleet in line with the mine's expectations.
Fleet replenishment
According to Praveen Pinisetti, Sandvik Mining Key Account Manager, the mine has subsequently begun a programme to standardise its fleet on the ever reliable and durable Sandvik LH517 (17 tonne LHD) machines and has begun systematically replacing other non-performing utility LHDs. New equipment usage strategies have also been implemented in partnership with Sandvik and are rapidly improving production.
Since the inception of the programme the mine has changed the composition of its fleet from just seven Sandvik LHDs to 13 out of the 18 machines on site. Others will be replaced in due course.
"This is an exceptionally tough mine with hard rock and long tramming distances that can reach up to 5.5km (round trip). The remote location of the mine and long tramming distances to surface through an old small decline make 'swop-outs' of faulty machines difficult and time consuming. But those are the challenges of the mine and the only solution is to have machines that are more reliable," says Praveen.
He points out that the relationship between Sandvik and the mine has developed into a close partnership. "Beginning with the company's CEO, Deshnee Naidoo, and General Manager, Andre Trytsman, and extending to the men on the ground, the relationship is sterling. This is because they realise that for us it's not just sales talk. We actually do deliver on our promises regarding machines, management services and around-the-clock support.
"Wherever possible we have also assisted the mine with focused training of operators as well as undertaken other initiatives to improve overall fleet availability and help boost production. We have also improved the skills of workshop staff to better analyse and service machines. These interventions have contributed to improved fleet utilisation and availability with significantly reduced mean time to repair (MTTR) and improved mean time before failure (MTBF)."
Building on the success of the LHD fleet upgrade, the mine has recently chosen to further expand its fleet with the acquisition of 16 Sandvik units. These are working at strategic points where the production units continue to produce above average tonnages at a fast, steady and reliable pace.
"We are particularly encouraged by the General Manager, who recently stated that based on the introduction of the longhole drill rigs, BMM's future has been secured," Praveen concludes.
Sandvik Mining, Alice Ward
Tel: (011) 929-5300, Email alice.ward@sandvik.com
www.mining.sandvik.com
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In Memoriam: Rev. George R. Spee
News, In Memoriam
Louis M. Tamminga
Rev. George R. Spee, passionate about missions and devout friend of new believers, passed away in Twin Falls, Idaho.
Spee was born in Grand Rapids, Mich., where he graduated from Grand Rapids Christian High School in 1946 and from Calvin College in 1950. He studied the next two years at the Free University of Amsterdam, followed by three years at Westminster Seminary in Philadelphia, and another year at the Columbia School of Missions in Columbia, S.C. Only then did he enroll at Calvin Theological Seminary, graduating in 1956.
For the next 27 years, Spee and his wife, Jean, served as missionaries in Nigeria, West Africa, among the Tiv people. They loved the Tiv, and that feeling was mutual.
Spee felt a deep burden for unreached people. He would trek for days into remote mountainous areas to share the Good News with isolated people. It was said of him that he never met a stranger. Humble and selfless, he lived for helping others. Where Spee's life was at times a bit spread out it, Jean's patient practicality brought it all together. The love of Jesus motivated this lovely couple.
Their years in Nigeria, however, took a toll on Rev. Spee's health. In 1983 the Spees returned to the United States. However, God graciously provided another mission challenge.
In 1984 Spee agreed to be "loaned" to the Gospel Missionary Union of the Bahamas. Though the Spees retired officially in 1992, they remained active in the Bahamas till 2010.
Spee is survived by his wife, Jean; by their children, Rachel and Dale Frazier, Ana and Al Carter, Elizabeth and Paul Braselton, Martha and Russ De Kruyf; and by eight grandchildren.
Louis Tamminga is the Banner's writer of In Memoriams for pastors.
See comments (2)
Alan Reberg replied on Fri, 08/26/2011 - 3:18pm
Hey Louis,
Please don't publish this....
Nice Memoriam for George. Thank you.
Could you email us a mailing address for Jean Spee? We lived with George and Jean and the girls at Kunav for a term (1968-1970). Would like to send Jean our condolences.
Alan Reberg
MICHELE MORGAN replied on Wed, 12/14/2011 - 12:00am
I'D LIKE TO GIVE MY CONDOLENCES ON THIS FAMILY'S LOSS. ELIZABETH AND I WERE VERY GOOD FRIENDS AT ONE TIME. I'D LOVE TO BE ABLE TO GET BACK IN TOUCH WITH HER AS I HAVE TRIED MANY TIMES SEARCHING FOR HER. PLEASE FORWARD MY EMAIL ADDRESS TO HER. SHE HAS ALWAYS BEEN IN MY HEART AND I MISS HER TERRIBLY. THANKS.
MICHELE LIGON MORGAN
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