text:
Danke Schoen è una canzone del 1962 registrata per la prima volta da Bert Kaempfert; comunque, divenne famosa nel 1963 quando il cantante statunitense Wayne Newton ne registrò una propria versione. La musica è di Bert Kaempfert e le parole di Kurt Schwaback e Milt Gabler.

Versione di Newton
La prima versione di Wayne Newton venne registrata quando il cantante aveva 21 anni. La canzone era stata originariamente scritta per il cantante Bobby Darin come seguito al suo singolo di successo Mack the Knife , ma dopo aver visto Newton esibirsi al Copacabana, decisero di affidargli la canzone cambiando l'arrangiamento per adattarlo alle caratteristiche vocali di Newton. La voce acuta di Newton è a volte scambiata per quella di una cantante, da chi non conosce la canzone. Essa è stata utilizzata in molti spettacoli televisivi e film, come Ferris Bueller's Day Off, Meet the Parents , Il genio della truffa, Vegas Vacation e Fools Rush In. La versione di Newton ha raggiunto il #13 nella classifica delle canzoni pop ed il #3 nell'easy listening.

Altre versioni

Nello stesso anno di Newton, Laila Kinnunen ne fece una versione in finlandese.

Brenda Lee registrò "Danke Schön" per il suo album del 1964, By Request, prodotto da Owen Bradley.

Nel 2004, Deluxe (un gruppo spagnolo indie-rock) registrò una versione rock per l'album If things were to go wrong.

Dettagli linguistici
In lingua tedesca Danke Schoen (ortografia alternativa alla più corretta "Danke schön") è equivalente all'italiano "molte grazie"; la risposta corrispondente è "bitte schön", ovvero "di nulla".

Collegamenti esterni

Singoli del 1962

redpajama_set_name: RedPajamaWikipedia


text:
humedica helps monsoon victims in India
by Sebastian Zausch, 2019/07/16
The humanitarian organization humedica in Kaufbeuren supports the monsoon victims in Asia with short-term emergency relief aid. Its local partner Emmanuel Hospital Association will assist humedica to provide especially affected people in the North Indian state of Bihar with food and water.
Currently, the monsoon brings heavy rainfall to wide parts of Asia. Nepal, Bangladesh and the North of India have been hit especially hard. Rivers overflowed, complete villages were flooded and houses were destroyed. More than100 people have lost their lives till date, thousands were injured, numerous lost their homes. In the Northern federal states alone live more than 4.5 million people, who suffer from these water masses.
In Bihar, one of the poorest Indian states, people had to flee from the downpour, too. Many of them now live on the streets. To relieve the worst misery humedica distributes food packages via its partner organization Emmanuel Hospital Association. The rations consist mainly of rice, pulses and other calorific nutrition as well as water purification tablets.
"In a first step we provide approximately 1,000 people with emergency assistance rations", reports humedica general manager Johannes Peter. "We are monitoring the situation closely in order to be able to assist the people with other relief measures if necessary. Please support our help with donations."
Many houses in the Indian federal state of Bihar are submerged. Photo: humedica
Your support makes our work possible
Stay a part of our work and support us with a donation.

redpajama_set_name: RedPajamaCommonCrawl


Chris Wilder wants to see his side end the 2017/18 season on a real high at Bristol City on Sunday afternoon.
Speaking ahead of the clash at Ashton Gate, Wilder remarked: "I want us to play in the same positive way that we have done for much of the season.
"I want the players to leave everything out there and reward the travelling supporters who are making the long trip down for the game.
"We want to leave them with a positive final memory of the season and hopefully they have a good day and a safe trip home and are filled with confidence for next season."
The Blades boss added: "It's been an outstanding season for both clubs and it shows what can be done.
"I think there are a lot of similarities between the two clubs, both have been in really good positions and both perhaps thought there would be more riding on this game.
"Their attitude is similar to ours, so it isn't for the want of trying, they want to win and have a togetherness like we do.
"Like us they've also not got any big egos, they've not got overpaid players and both of us play in a positive manner, so it'll be two teams going all out for a victory."


It's a bit strange to me how developers behind these Mahjong Solitaire games came up with different names for the adaptations; I remember one version for the PC calling it Taipei. Strangely, I still managed to catch on the game's real name as a kid. Have you ever played the competitive Mahjong? It's supposed to be quite complex.
Competitive Mahjong is nigh indecipherable until you learn all the lingo. I've never managed it, despite Yakuza 3 attempting to train me. They recently added it to Final Fantasy XIV, so it will be interesting to see how that does.
Yes, I remember there being a couple of games called Taipei, one was mahjong solitaire and the other was a weird (and not very good) strategy game about becoming a merchant sailor and/or pirate in China.
Apparently, Go is supposed to be the opposite; easy to learn and nigh-impossible to master.
Do you remember what that strategy game was called?
I beg your pardon, it was called Taipan, not Taipei. Blame the Friday afternoon blues for that one. Pretty sure there were a number of games called that too, however!


Grofer is a well known online store which offers extensive variety of grocery products. Headquartered in Gurgaon this online grocery store operates in more than 26 cities. Grofer offers its customers grocery, bakery, fresh food items, fruits, vegetables, cake, flowers, baby care, personal care and other gift items which may include your gadgets, make up items and more. There is no such product you don't get here in short words we can say grofer is all in one roof which gives you chance to enjoy comfortable shopping sitting at your home, now you don't have to stand anymore in the long queues for buy your grocery. Grofer which started few years is already a big name in market. From grocery items to makeup it offers large discounts and make you save big. Grofers mobile application will notify you about the daily deals and will let you grab a chance to save on your items.
Enjoy extra Rs.150 super cash when payment is made through Mobikwik Wallet. To grab this offer apply given coupon code at the time of final payment. This offer cannot be combined or clubbed with any other offer. Enjoy the offer before it ends. This offer is available for limited period only. Hurry!!
Save up to 37% off on pooja need products which includes all pooja products like agarbati, dhoop, kalash, diya and more without any coupon or promo code. This offer cannot be combined or clubbed with any other offer. Enjoy the offer before it ends. Hurry to grab the offer.
Enjoy 19% off on Aashirvaad Shudh Chakki Whole Wheat Atta 10kg pack without any coupon code. Save money by getting it at just Rs. 268 instead of Rs. 330. This offer cannot be combined or clubbed with any other offer. Enjoy the offer before it ends.
Enjoy up to 60% discount on order of different Grocery and Staples products like olive oil, ghee, salt, sugar etc. To enjoy this offer no coupon code is required at the time of checkout. Enjoy the offer before it ends and save money.
Put an order now of dish wash products like dish wash bar, dish wash gel, steel scrubber etc and enjoy up to of 20% discount on it. To avail this offer no coupon code is required. Check out the landing page for more information. Get the offer before it expires.
Now get 5 kg sugar free on your minimum purchase of Rs.999. Use the Grofers coupon code at the checkout page to avail the offer. Offer is valid for purchase from Grofers online store only. Explore offer page for more deals and grab them fast.
Shop online now and save up to 83% off on different beverages products tea, coffee, juices, cold drinks and more without any coupon code. The discount available on beverages may differ from product to product. Enjoy the offer before it ends and save money.
Put an order now of Fruits and vegetables like apples, kiwi, pomegranate, cabbage, green capsicum, beans etc and enjoy up to 23% discount on them. To avail this offer no coupon code is required. Check out the landing page for more information. Get the offer before it expires.
Shop grocery and more from Grofers and get 20% cashback in your wallets. Use the given code at checkout page to avail the discount. Visit promo page for exclusive deals and buy items at best discounted prices.
Now get up to 80% off on summer essentials and save more with Grofers online store. Shop for items such as Glasses, Bowls, Bath Towels, Hand Towels, Jugs, Ice Trays, Bottles, Sprout Maker, Buckets, Mug Sets and lot more to discover. Grab these online products without any coupon code and enjoy!
Shop online and save up to 70% off on different home and kitchen appliances without any coupon code. The discount available on appliances may differ from product to product. Enjoy the offer before it ends and save money. Limited period offer.
Save more with exclusive membership. To be a Smart Bachat Club member and enjoy shopping at wholesale prices, just add a membership plan to your cart. There is no limit to the number of order that you can place on the Grofers platform. Smart Bachat Club membership can be bought for a period of 1 month, 6 months, and 12 months. Membership expires at midnight on the last day of your membership period.
Order online and get 47% off when you buy Dinewall Pailsy Round Printed Melanium 18 pcs dinner set. No coupon code required. This box contents 4 pcs dinner plate, 4 pcs small plate, 4 pcs veg bowl, 2 pcs donga, 2 pcs donga lid, and 2 pcs serving spoon. Grab the deal to redeem this offer.
Put an order now of personal care products like face wash, Sunscreen lotion, Shower gel, Shampoo etc and enjoy a minimum of 20% discount on it. To avail this offer no coupon code is required. Check out the landing page for more information. Get the offer before it expires.
Save up to 47% off on cookware which includes induction kadai, pan, multi deluxe tawa, steamer and more without any coupon or promo code. This offer cannot be combined or clubbed with any other offer. Enjoy the offer before it ends. Hurry to grab the offer.
Shop with grofers and get all food items at best prices for all users. Grab up to 25% off on chocolates, namkeens, snacks, biscuits and lot more. Apply coupon code and get 20% cashback .The offer is applicable for all the new users. Enjoy the yummy treat!
Enjoy up to 74% discount on order of different storage & containers products like Salt Sprinkler, Lunch boxes, Vacuum flask, Container set etc. To enjoy this offer no coupon code is required at the time of checkout. Enjoy the offer before it ends and save money.
Get flat 15% off paying through axis credits and debits cards on Grocery, Household products, Personal care range, beverages, biscuits, snacks and more.
The offer is applicable on every Wednesdays.
You can avail the maximum discount is Rs.300.
The minimum order value is Rs.1500.
Spend minimum Rs.1500 and get flat Rs.75 cashback on mid-month sale. Use the given coupon code at the time of checkout. Offer is valid on 15th to 18th of every month.
Order online and get Rs.250 discount when you transact minimum Rs.1500. To avail this offer use the given coupon code at final payment. Enjoy the deal before it ends.
Pay via Paytm wallet and get up to Rs.200 cashback. You may get Rs.100 cashback each on two transactions. Cashback will be credited to Paytm wallet within 24 hours.
Grofers is giving you House Full Sal. Buy 2 products and get one free. Choose from the categories men's Deo, Women's Deo, and Perfumes shown on the offer page. Enjoy the deal before it ends.
Now buy home needs and furnishings online under Rs.599. You may choose from the categories bedsheets, curtains, hand towels, face towels, pillow fillers, bean bags, wall stickers, and many more shown on the deal page. Don't miss out.
Order from Big Brands Fest and avail up to Rs.300 cashback. Minimum Order of Rs.1200 is required. Grab the given promo code to redeem this offer. Offer is valid for a limited period.
Buy now and get flat Rs.100 on online order. Minimum order of Rs.1500 is required to avail this offer. Coupon code is available to enjoy the deal. Don't miss this deal.
Shop for Rs.2500 or more and get 5% direct discount. Maximum discount of Rs.150 can be availed. Coupon code is also available to avail this offer. Check out the promo page for more details.
My Vishal is giving a special offer for SBI Card users. Get an additional 10% off on your next purchase. Use the given coupon code at the time of checkout. Free shipping is also available. Offer is valid on payment done via SBI Debit card or credit card.
Order stationery items online and enjoy up to 21% discount on them which includes pen, notebooks, watercolor, pencils, erasers, lunch boxes etc. To enjoy this offer no coupon code is needed. This offer cannot be combined or clubbed with any other offer. Enjoy the offer.
Enjoy flat 50% off on kids' fashion. For more exciting deals and offers have a look on promo page. No coupon code required.
Online store for all your household needs : Based out of Gurgaon, this online concept was founded in 2013 by Albinder Dhindsa and Saurabh Kumar. The online app based grocery brand is owned and managed by Grofers India Private Limited and serves across several cities in the country. It is the one-stop shop for every household requirement right from fresh fruits and vegetables, groceries, bakery, cosmetics, personal care, etc. You can download this app on your phone if you are in Delhi, Gurgaon, Mumbai, Bangalore, Kolkata, Noida, Pune, Ahmedabad, Chennai, Hyderabad, Jaipur, Surat, Chandigarh, Agra, Indore, Nagpur, Ludhiana, Vadodara, etc.
With this brand, you need not go to any store for any of your household needs. You can pick from a wide assortment of brands and buy what you love from more than 5000 productsand this is what makes it the one stop shopping destination for you along with online grocery delivery. Here is a quick list of all that you can buy from here.
Fresh fruits and vegetables, sprouts, herbs, organic products, etc.
Grocery and staples, spices, edible oils, dry fruits and nuts, etc.
Beverages that include cold drinks, juices, health and energy drinks, tea and coffee, etc.
Home and kitchen tools, accessories, dining table requirements, etc.
Personal care includes bath and body, skin care, oral care, deodorant, perfumes, hair care, etc.
Breakfast and dairy, helps you with milk and milk products, dairy, breads, eggs, etc.
Sauces, jams, conserves, condiments, spreads, etc.
Household needs like detergent, cleaners, cleaning tools and equipment, etc.
Shopping for all that you need from this platform also helps you save money. Apart from competitively priced products, you also get many offers that lead to monthly savings. Every user can get discounts up to 20% through the Grofers app offer. If you have just downloaded the app you can also get up to Rs. 100 of on your first app order. Paying with digital wallets like Mobikwik or Paytm also lets you earn cashbacks up to 10% on your total bill. Look for discount coupons on Savio Plus and use these codes at the time of checking out to save on your final bill.
Ordering all your household essentials on this online app has many more advantages than simply saving time and money. It also helps you to save on your monthly grocery bills with Grofers cashback offers. This is how you do it.
Grofers cash – You have this special wallet that you can load and use it to buy whatever you want from this store. It is a free service plus all your cashbacks are conveniently credited to this account that you can use for future purchases.
Track your order – The app has a user-friendly order tracking option that updates you on your order status. You can find out how your order is being processed and when you can expect it at your doorstep.
Numerous payment methods – You can pay through various modes when you shop here. Net banking, mobile wallets, credit and debit cards, Grofers cash and even cash on delivery are your choices for paying even if you use Grofers coupons.
Uncomplicated return policy – You can easily return a product you are not happy with within 24 hours of delivery for all perishable items and 48 hours for non-perishable products.
Easy refunds – If you return a product you can get easy refunds directly to the account you have used to pay within 7-10 working days if the amount is more than Rs. 500 and to the Grofers cash account if it is less than that.
Online cancellation – You can also cancel your order online through the app or from the website before it has been dispatched. You can also manage other aspects of your order from the 'My Order' section.
Efficient customer care – You can refer to skilled and efficient customer care executives from the 'Contact Us' section for all your problems and expect them to be resolved in minimum time.
You can run your household in a stress-free and hassle free manner by ordering everything you need from here. This unique app not only helps you save time and money but also gets you the high-quality products of different kinds so that you get your money's worth. Don't forget to check out every Grofers offer that comes your way today for maximum savings.


From Paris to Tokyo, via Los Angeles, the Maison Kitsuné x Oliver Peoples Tokyo Clip Sunglasses take inspiration from the classic style of the 1950s. Hand crafted in Japan from durable acetate in a unique brown marble, this timeless style features a keyhole bridge alongside an antique gold plaque and comes with detachable and adaptable clip on Polarized lenses. Available now at End.
This entry was posted in Sunglasses and tagged Acetate, Clip On, Handmade, Made in Japan, Maison Kitsune, Oliver Peoples, Sunglasses, Tokyo. Bookmark the permalink.


text:
Home > Articles > Operating Systems, Server > Solaris
Sun ONE Portal Server 3.0 Rewriter Configuration and Management Guide
By Sun Microsystems
Deployment Assumptions
How the Gateway Works
Concepts of the Rewriter
Adding and Removing Rewriter Rules
Methodology for Rule Extraction
Out-Of-Box Rule Set
Rewriting HTML Attributes
Rewriting FORM Tag Input
Rewriting JavaScript Content
Rewriting Applet Parameters
Rewriting Cascading Style Sheets
Rewriting XML
Order Importance
CASE Studies: How to Configure the Gateway to Rewrite a Web-Based JavaScript Navigation Bar
Third Party Application Cookbooks
How to Get Hot Patches
< Back Page 4 of 21 Next >
Capacity Planning for Internet Services
The flexibility of the netlet and the uniqueness of the rewriter is what differentiates the Sun ONE Portal Server from most, if not all, other Portal Server offerings. Understanding how the rewriter works and what necessitates rule configuration is essential to a successful and secure Portal Server deployment. Experimenting with the rewriter before the Portal Server is moved into production will also reduce last minute problems that could be avoided.
Rewriter Verses Browser
Because the rewriter is one of the most highly used and sought after features in the Portal Server, it is constantly undergoing modifications and enhancements. Many Portal Server administrators found out that this content that worked in the SP2, no longer worked in SP3, and newer, versions. One major reason for this difference in behavior was the administrator's reliance (knowingly or not) on the browser to handle the resolution of relative URLs by using the location field as a BASE tag equivalent when the page was rendered.
This was more evident where the gateway component had been deployed as employee-facing secure remote access to an existing Intranet portal. In this particular case, an employee would log in to the gateway and be redirected, not to the Portal Server Desktop, but to their own home page or corporate Intranet portal. The location field in the URL would still have the gateway address prepended to it, and the Portal Server session would remain active, as long as requests continued to be made through the gateway. Relative URLs in the redirected page would be resolved by the location field as long as there was not a BASE tag present in the document.
Where this browser relative path resolution took place actually represented inadequacies in the rewriter itself. It meant that there was content that the rewriter was missing or not interpreting correctly. This was usually acceptable in cases where the browser would be able to help out, but prior to SP3, there were large gaps in rewritten content, such as in the case of imported JavaScript or imported CSS. For instance, in SP2, the SRC attribute in the SCRIPT tag would be rewritten so that the browser would be able to correctly retrieve the JavaScript content, but the JavaScript content itself was not rewritten according to the rules specified in the gateway profile. While some people were seeing favorable results where the browser would handle relative URLs, other people had problems where variables in imported JavaScript content were not being rewritten correctly.
Administrators who deployed the gateway in front of the Sun ONE Portal Server desktop in SP2 found that in SP3, with the new rewriter functionalities, the browser location field no longer could be used for resolution of relative URLs. The reason is that the URLs on the Portal Server desktop are derived from scraped channels or custom providers and cannot be resolved using the document location that contains the gateway URL, server URL, and DesktopServlet in the path.
For instance, consider the following URL:
https://ips-gateway/http://ips-server:8080/DesktopServlet
This URL would not work for a relative URL of ../ for a page scraped from an internal site, other than ips-server because the incorrect server would be referenced by the relative path resolution of the browser.
Relative URLs, which are not rewritten to absolute URLs, should be avoided for the following reasons:
The Portal Server wants to be sure that requests to get internal content will always come back to the gateway component.
Absolute URLs are used to determine if the URLs need to be rewritten based on their domain and/or subdomain value.
Absolute URLs are compared to the profile of the user to see whether or not they have permission to retrieve the specified content.
Absolute URLs avoid situations where the browser may resolve a relative path to the incorrect fully qualified path.
Gateway Profile
The gateway profile is a component stored in LDAP with attributes and attribute values used by the gateway for initialization and runtime purposes. Contained in the gateway profile are attributes that are used specifically by the rewriter to determine what content, if any, should be rewritten. To look at the contents of the gateway profile, you can use the ipsadmin command to dump the component into an XML file to view it. Otherwise, you can access the Administration Console, select Gateway Management and Manage Gateway Profile to view the gateway profile. Both of these methods are explained in detail in "Adding and Removing Rewriter Rules" on page 8.
While the gateway profile contains entries for a variety of aspects related to the gateway operation, only those fields and/or attributes directly related to the rewriter will be discussed. Two settings to be aware of that control the overall behavior of the rewriter are the Rewrite All URLs Enabled checkbox and the DNS Domains and SubDomains list. These settings are not mutually exclusive as the checkbox will override any entries for Domains and SubDomains if checked. The remainder of the document assumes that Rewrite All URLs Enabled is checked.
It is worth noting that if Rewrite All URLs Enabled is not checked, any content you wish to have rewritten must have its server domain and subdomain (if one exists) entered in the DNS Domains and SubDomains list. If there is not a subdomain associated with the domain, be sure to put a vertical bar after the domain name. For instance, if you wanted to rewrite every URL that contains iplanet.com, you would add an iplanet.com| entry to the DNS Domains and SubDomains list. If you want to rewrite only certain subdomains within that domain, you would add an iplanet.com|internal entry (internal, in this case, signifies a fictitious subdomain name).
Rule Interpretation by the Gateway
Rules are a means of informing the gateway how to determine if content that passes through it contains a URL that needs to be rewritten. The rules are either strings, or, in some cases, strings containing wildcards, that are used as regular expressions. Each rewriter attribute and/or field in the gateway profile has an associated environment where the rule will apply, and a top down order in which rules will be compared one by one to content within that document or document section to see if there are any URLs which require translation.
One way an environment can be determined is by an HTML tag such as the SCRIPT tag for JavaScript code or the STYLE tag in the case of CSS. Within each environment, there are different data constructs that may require differing syntactical interpretation by the gateway. The JavaScript language, for instance, contains functions that can take function parameters. If one of these function parameters happened to be a URL, a rule would have to be added to the gateway Profile under the Rewrite JavaScript Function Parameters section that would determine the function name and parameter that requires rewriting.
Environments can also be determined by MIME types so that when the content is retrieved by the gateway, it is compared to the appropriate subset of rules and rule values. Imported JavaScript code would contain a MIME type of application/x-javascript extracted from the browser GET request so that when the gateway retrieves the content, it knows what the environment used to rewrite it.
Network Distributed Computing: Fitscapes and Fallacies
By Max K. Goff
J2EE Platform Web Services
By Ray Lai
Secure Shell in the Enterprise
By Jason Reid


text:
NFL docks Ravens' final two OTAs over infraction
The NFL has fined Baltimore Ravens coach John Harbaugh and owner Steve Bisciotti, along with canceling the team's final two days of OTAs, for an undisclosed infraction on Wednesday.
Harbaugh must pay $50,000 and Bisciotti owes $100,000, the league ruled.
While the violation was not revealed, the Ravens released a statement shortly after the decision.
"We are vigilant about practicing within the Collective Bargaining Rules," general manager Ozzie Newsome wrote. "I am. John (Harbaugh) and his assistants are. I attend every practice and then watch the practices again on video. I see how the coaching staff teaches, corrects and addresses issues immediately on the field. In meetings, I have watched John's presentation to his players and assistants regarding how to properly practice and the pace of these sessions. We have players competing, including rookies and those fighting to make our team. Sometimes, breaking old practice habits of these players, especially rookies, takes more repetitions. We'll continue to be vigilant about this."
%InlineRelated-url="https://www.aol.com/article/news/2018/06/05/giants-gm-gettleman-reveals-lymphoma-diagnosis/23451908/" CTA="SEE ALSO" title="Giants GM Gettleman reveals lymphoma diagnosis"%
Harbaugh also released a statement, inferring that the penalty was over contact made during passing drills.
"We take very seriously reading. understanding, abiding by and playing by the rules," Harbaugh's statement began. "Our coaches, staff and players have worked extremely hard to run the offseason program according to all the Collective Bargaining Agreement rules. Our team has been singled out for pass coverage contact during the early part of OTAs. We have heavily emphasized these CBA pass coverage rules in meetings, and coached them diligently on the practice field. It has also been our priority to include our veteran players, along with new Ravens who have practiced and played for other teams, in the process and use their input and ideas. Even with consistent and repeated teaching, these rules pose considerable adjustments for the young players. We have tried very hard to eliminate contact in pass coverage during OTAs, even so far as to pull players out of practice who struggle with these adjustments. I am confident we have done everything within our power and ability to practice within the rules, and we will continue to focus on preparing, teaching and practicing the right way."
Related: NFL players who changed teams this offseason:
The Ravens and Harbaugh were fined approximately half a million total for a similar infraction in 2016.
While they'll lose scheduled practices on Thursday and Friday, mandatory minicamp begins for the Ravens next week.
More from Aol.com:
Eagles' Malcolm Jenkins has message for media after Trump controversy
Colts DE McCain denies battery charges
Dennis Rodman will be in town when Donald Trump, Kim Jong Un meet: report


I am an intern in a busy internal medicine program. I try to pump several times a day. At first, it was very challenging for me to balance pumping and being an intern. I hope I can shed some light on how it can be done and let other moms know that that I once struggled with it too. It is part of who I am now, but it took a lot of commitment and preservence. I know not all mothers choose to pump and not all mothers can pump, and that's great too! This is how I do it. I will first say that I have an incredibly supportive residency program. I hope that is the case for all mommas wanting to pump.
1. Make it known that you have to pump. Be upfront about it with the chief residents, senior residents and your co-interns. This way, people don't wonder where you are. You'd be surprised how many people are supportive of your need to pump. And impressed!
2. Plan your day accordingly. I would make sure to get a session in before rounds, during lunch conference and once or twice in the pm depending on the length of the work day. It requires a lot of planning but think ahead! There have been times when rounds starts earlier than expected, but some time pumping is better than no time!
3. Have a system. Efficiency is key. A handsfree clip on bra helps! A tote bag with a cooler and ice pack helps! Find what works best for you.
4. Have a safe space. A designated pumping room with an outlet, sink, chair, table is what you need. Find a way to get the environment you need. If your facility does not have a lactation or expression room, they really should! It is required by law. Check out mamava.com if you want to help your hospital get a pumping pod.
5. Support at home. My husband helps out so much with washing my pumping bottles and preparing our baby's bottles for daycare every night. I couldn't do it without him.
6. Prioritize pumping. There will be times you think you're too busy to pump. Do it anyways. Figure out a way. You'd be surprised how you can squeeze it in the workday. You'll be so glad you did it.
7. Try your best not to skip sessions because it can mess up your supply, cause engorgement and even mastitis. This may not be true for everyone, but it was true for me. After I got mastitis from missing pumping sessions, I knew I had to be more diligent about pumping every 3-4 hours.
8. Massage/squeeze during pumping! This helps prevent clogged ducts and really increases the flow.
9. Drink lots of water and carry snacks. You have to be well hydrated and well fed for a good milk supply. Also rest is key! Good rest is hard for an intern but the more rested you are the better the milk supply!
10. Be so proud of yourself. It is a huge accomplishment to be able to pump and be an intern! Some days you'll have a bigger supply than other days but keep going! You're a rockstar for doing this and your healthy baby will thank you!
11. Nights can be particularly hard but doable. When I was working nights, I was so exhausted, mainly because I was unable to sleep more than a few hours during the days because I was still pumping every 3 hours. It was very hard, no other way to say it. I even got mastitis then. I was fortunately allowed 2 sick days so I could heal from my mastitis. In addition to taking antibiotics, my trusted lactation consultant advised me to just keep on pumping even if the output is low and as soon as I recover, the milk supply will pick back up. And she was right!
If you're also a pumping resident, please comment and let me know your experience!
I should also mention only about half of his milk is breast milk. We supplement with formula! There is no way I can keep up with his needs through just pumping. Our breast milk and formula combination works for us and it's always encouraging to hear how whatever a mamma and baby do works for them!
I'm just a M3 but in my surgery rotation and pumping. I've struggled with asking to pump. I have ended up pumping once in the car on the way to the hospital (4a) and then usually get to pump one more time around 1p. One of my chiefs has been good at getting me 15min to pump before we started any case that was going to be longer than 6hrs but otherwise people seemed to think that one time should be plenty (no other med student or any of the female surgical residents have kids). I usually pumped one side on my way home since I'd be so full, it'd be enough for baby on the other side. I tell all my friends, thank goodness this is baby #2, I struggled so much with my milk supply with baby #1 but this time, my supply seems more resistant to poor nutrition/hydration and lack of opportunity to pump. Baby is 7months and we're thrilled to still be going strong! It is a lot of work and I hate pumping so very much but with the long hours I'm gone, its a way I can assuage some of my mommy guilt and have some "insta-bonding" time with baby when I'm home. But I am so happy to hear of other mothers in medicine pumping and the support you have received in your program, I hope the trend and the acceptance continues because sometimes I feel a little disheartened about that lack of acceptance at times.
Wow! I can't even tell you how impressed I am that you are able to pump as a medical student on a surgery rotation. Not only does being in surgery cases make it intrinsically difficult to pump, but being a student must be so hard too since you're often at the mercy of your residents. I'm so proud of you for speaking up- I know I would have struggled with that as a student. Keep up the AMAZING work!
I love how you were committed to pumping and not giving up! AWESOMENESS!


text:
Times of resistance
When All Else Fails: THE ETHICS OF RESISTANCE TO STATE INJUSTICE
The economist Albert O. Hirschman famously argued that citizens of democracies have only three possible responses to injustice or wrongdoing by their governments: we may leave, complain, or comply. But in When All Else Fails, Jason Brennan argues that there is a fourth option. When governments violate our rights, we may resist. We may even have a moral duty to do so.
For centuries, almost everyone has believed that we must allow the government and its representatives to act without interference, no matter how they behave. We may complain, protest, sue, or vote officials out, but we can't fight back. But Brennan makes the case that we have no duty to allow the state or its agents to commit injustice. We have every right to react with acts of "uncivil disobedience." We may resist arrest for violation of unjust laws. We may disobey orders, sabotage government property, or reveal classified information. We may deceive ignorant, irrational, or malicious voters. We may even use force in self-defense or to defend others.
The result is a provocative challenge to long-held beliefs about how citizens may respond when government officials behave unjustly or abuse their power.
Docuncert Txarango
Welfare State apocalypsis
WILL POPULATION AGEING SPELL THE END OF THE WELFARE STATE?
Too many people argue over the end of the welfare state. There are reasons for concern, but apocalyptic views are unnecessary. A new book reviews the ageing process and the implications for the welfare state. The message is a balanced perspective:
Upon closer inspection, available evidence suggests that caring for a growing older population may not be so costly to finance and that older people provide significant economic and societal benefits, especially when healthy and active:
– Population ageing has a modest and very gradual effect on health expenditure forecasts, compared
to traditional cost drivers such as price growth and technological innovation.
– Demand for long-term care is expected to increase substantially due to population ageing but it is coming from a low baseline currently. However, projected increases in long-term care spending do not account for the economic cost of informal long-term care, as this is not captured in international statistics (nor fully understood).
– Many older people continue to provide paid or unpaid work beyond official retirement age and continue to make a positive economic and societal contribution. The value of unpaid work provided by older people is considerable but not regularly quantified.
– While in Europe older people's consumption is mainly financed by public transfers, many older people pay for (part of) their consumption from private sources, including from incomes from their own continued work or from accumulated assets.
– Accumulation of asset wealth also benefits the economy indirectly through its contribution to productivity growth; health is a key predictor of asset accumulation.
– Older people, even if not in paid employment, continue to pay consumption and other non-labour-related taxes, and thus contribute to public-sector revenues.
Mostly, I agree with this view. The retirement funding issue is the largest challenge for the welfare state and our politicians are playing with fire.
Health at a Glance: Europe 2018
Every two years OECD publishes this report for the European Union on the state of health. The new one has an interesting thematic chapter on mental health. It says:
According to the latest IHME estimates, more than one in six people across EU countries (17.3%) had a mental health problem in 2016 – that is, nearly 84 million people.
The most common mental disorder across EU countries is anxiety disorder, with an estimated 25 million people (or 5.4% of the population) living with anxiety disorders, followed by depressive disorders, which affect over 21 million people (or 4.5% of the
population).An estimated 11 million people across EU countries (2.4%) have drug and alcohol use disorders. Severe mental illnesses such as bipolar disorders affect almost 5 million people (1.0% of the population), while schizophrenic disorders affect another estimated 1.5 million people (0.3%).
And the second thematic chapter is about health expenditure: Strategies to reduce wasteful spending: Turning the lens to hospitals and pharmaceuticals. It says:
For hospitals, reducing or eliminating unnecessary investigations and procedures, many of which expose patients to unnecessary risks without the prospect of clinical benefit, is an obvious target for direct intervention. Expanding the use of day surgery can also be instigated at hospital level. However minimising avoidable admissions, particularly for ambulatory care-sensitive conditions, reducing unnecessary length of stay, and improving discharge processes require broader perspectives. Enhanced primary care services, expanded postacute care facilities, post-discharge care coordination, and in home care services all require health system reforms that cannot be initiated by hospitals alone.
For pharmaceuticals, creating and supporting competitive markets and promoting the uptake of generics and biosimilars can generate substantial savings. That said, reducing waste does not necessarily mean spending less; it may equally be achieved by gaining better value for money from existing expenditure. Both supply and demand side levers offer scope for better value. Using health technology assessment to inform selection, pricing and procurement of new medicines facilitates an understanding of the true opportunity costs of therapies and helps avoid the displacement of high value interventions with ones of lesser value.
This is not new. We have already heard the same for years. Therefore, current inertia is supported by strong incentives that prevent change (either in policy or management). This is the key challenge.
Broken markets create broken politics
THE MYTH OF CAPITALISM
Monopolies and the Death of Competition
These are some selected key messages from the book:
Capitalism without competition is not capitalism.
Competition matters because it prevents unjust inequality, rather than the transfer of wealth from consumer or supplier to the monopolist. If there is no competition, consumers and workers have less freedom to choose. Competition creates clear price signals in markets, driving supply and demand. It promotes efficiency. Competition creates more choices, more innovation, economic development and growth, and a stronger democracy by dispersing economic power. It promotes individual initiative and freedom. Competition is the essence of capitalism, yet it is dying.
Competition is the basis for evolution. An absence of competition means an absence of evolution, a failure to adapt to new conditions. It threatens our survival. There are fewer winners and many losers when there is less competition. Rising market power by dominant firms has created less competition, lower investment in the real economy, lower productivity, less economic dynamism with fewer startups, higher prices for dominant firms, lower wages and more wealth inequality. The evidence from economic studies is pouring in like a flood.
As you may imagine, what the authors do is precisely to show the evidence of the monopolist and oligopolist activities in the US markets. Our close markets are in the same situation and antitrust authorities are failing to preserve competition. Unfortunately, recent legislation has not helped to reverse the trend. Higly recommendable book.
The author 6 years ago at TV3:
Ill-prepared for the arrival of new medicines
Pharmaceutical Innovation and Access to Medicines
While in the last years the number of new drugs in the market has been limited, this trend has changed and countries may expect larger bills in the next future. The OECD report explains the main challenges of pharmaceutical innovation and says:
Despite a slowdown in growth in the 2000s, pharmaceutical spending has nevertheless increased sharply in some therapeutic areas, such as oncology and certain rare diseases where many new medicines target small population groups and command high prices. While these may well address unmet needs, they often have prices that may not be justified by the health benefits they confer.
Countries may be ill-prepared for the arrival of novel medicines targeting wide population groups. In 2013, the first of a new class of very effective but expensive
drugs known as direct-acting anti-virals (DAAs) for hepatitis C created a shock due to the potential budget impact of treating all infected people. Many countries initially restricted access to the most severely affected patients, creating frustration among patients and clinicians alike. Although subsequent entries of alternative products have created competition on prices and allowed payers to expand eligibility to treatment, the initial shock highlighted the lack of readiness of payers for such events.
In some countries, sudden, large price increases for off-patent medicines have made important treatments unaffordable for patients.
Finally, innovation is lacking in certain areas of high-unmet need, such as new antimicrobials, non-vascular dementia, and some rare diseases.
The report summarises different proposals and measures that would be helpful for a government that cares about citizens' welfare. Unfortunately, this is not our case.
Exhibition at Foto Collectanea
The charade of doing well by doing good
Winners Take All
THE ELITE CHARADE OF CHANGING THE WORLD
Anand Ghiridhas has done a great job with his new book. He has set up the context for understanding the duality government elites. I've picked only several key statements. The whole book is well written and gives a lot of examples (US-based of course).
Many millions of Americans, on the left and right, feel one thing in common: that the game is rigged against people like them. Perhaps this is why we hear constant condemnation of "the system," for it is the system that people expect to turn fortuitous developments into societal progress. Instead, the system—in America and around the world—has been organized to siphon the gains from innovation upward, such that the fortunes of the world's billionaires now grow at more than double the pace of everyone else's, and the top 10 percent of humanity have come to hold 90 percent of the planet's wealth.
Some elites faced with this kind of gathering anger have hidden behind walls and gates and on landed estates, emerging only to try to seize even greater political power to protect themselves against the mob. But in recent years a great many fortunate people have also tried something else, something both laudable and self-serving: They have tried to help by taking ownership of the problem.
What is at stake is whether the reform of our common life is led by governments elected by and accountable to the people, or rather by wealthy elites claiming to know our best interests. We must decide whether, in the name of ascendant values such as efficiency and scale, we are willing to allow democratic purpose to be usurped by private actors who often genuinely aspire to improve things but, first things first, seek to protect themselves. Yes, government is dysfunctional at present. But that is all the more reason to treat its repair as our foremost national priority.
Claiming for global regulation of genome editing
Genome editing and human reproduction
The Nuffield Council of Bioethics release last July a key document on Bioethics of Genetics. Now that a chinese "scientist" claims to have edited the genomes of twin baby girls is the right moment to read it. And the key principles are:
Principle 1: The welfare of the future person
Gametes or embryos that have been subject to genome editing procedures (or that are derived from cells that have been subject to such procedures) should be used only where the procedure is carried out in a manner and for a purpose that is intended to secure the welfare of and is consistent with the welfare of a person who may be born as a consequence of treatment using those cells.
Principle 2: Social justice and solidarity
The use of gametes or embryos that have been subject to genome editing procedures (or that are derived from cells that have been subject to such procedures) should be permitted only in circumstances in which it cannot reasonably be expected to produce or exacerbate social division or the unmitigated marginalisation or disadvantage of groups within society.
New concerns are arising from CRISPR application and international regulations would be necessary to cope with them. The Association for responsible research and innovation in genome editing is precisely requesting this effort. The only precedents are the Declaration of Human Rights and it seems that it will not be an easy task to fulfill.
PS. Check the former post on Nuffield reports on this topic
Ageing policies, a long way ahead
A new book by WHO provides some insights about the impact of ageing. The frame of the message is built around these questions:
1. What are the implications of population ageing for health and long-term care needs and costs?
2. What are the implications of population ageing for paid and unpaid work?
3. What are the implications of population ageing for the acceptability, equity and
effectiveness of financing care and consumption?
4. The policy options: How can decision-makers respond to population ageing?
5. Building on what we know and improving the evidence base for policy-making.
And these are the policies they suggest:
I. Policies to promote healthy and active ageing
II. Policies to promote cost-effective health and long-term care interventions
III. Policies that support paid and unpaid work
IV. Policies to support acceptable, equitable and efficient funding and income transfers
This is just a start. Since ageing is a multidimensional issue, governmental policies should embrace a wider multisector strategy (that the book forgets). There is a long way ahead.
Doctor Prats - Caminem junts
Driving evidence-based health policy
Driving Better Health Policy: "It's the Evidence, Stupid"
Baicker and Chandra are backing an evidence-based health policy. I reviewed it in a previous post. Now the Uwe Reinhardt Memorial Lecture insists on it.
Speaking in favor of evidence-based health policy can be more controversial than one might think. Health policy analysts, health services researchers, and economists in particular often get in trouble by trying to quantify what many hold as unquantifiable and trying to put a price tag on what many think should be priceless.
This is the ouline of the lecture:
WHAT IS AND IS NOT A POLICY
Slogans are Not Policies
Differentiating Between Goals and Policies
EVIDENCE IS INHERENTLY EMPIRICAL
Evidence is Rarely Straightforward
Fact Patterns Alone Do Not Reveal Policy Effects
WORKING TO BASE POLICY ON EVIDENCE
Separating Evidence from Preferences
Using Evidence to Inform Policy
And these are the take-away messages:
Serious policy assessment requires a detailed description of the policy—slogans are not policies.
Clearly articulating and differentiating between goals and policies is crucial to evaluating the most effective way to achieve policy goals.
Evidence is often mixed or ambiguous. Researchers should not let their own policy preferences bias their interpretation or synthesis of the evidence.
Evidence does not speak for itself. Researchers need to dedicate effort to timely, accessible, reliable translation.
Agreed. Unfortunately, our close politicians are not interested in evidence if it goes against their ideological criteria. Therefore, claiming evidence for health policy is useless, unless the premise of "politicians will take into account evidence" is really credible. The lecture forgot this "minor" issue, the cognitive biases of health policy.
Josep Segú
On free genetic sequencing, opioids and the Hockney portrait
FROM GENE EDITING TO A.I., HOW WILL TECHNOLOGY TRANSFORM HUMANITY?
FIVE BIG THINKERS — REGINA BARZILAY, GEORGE CHURCH, JENNIFER EGAN, CATHERINE MOHR AND SIDDHARTHA MUKHERJEE — PUZZLE OVER THE FUTURE OF THE FUTURE.
Mortality risk, insurance, and the value of life
Opioid nation by Marcia Angell
Genetics Start-Up Wants to Sequence People's Genomes for Free
THESE DNA STARTUPS WANT TO PUT ALL OF YOU ON THE BLOCKCHAIN
In favour of positive discrimination for troublemakers
IN DEFENSE OF TROUBLEMAKERS: The Power of Dissent in Life and Business
L'Illusion du consensus
Charlan Nemeth has done a great job explaining the role of dissent in life and organizations. Her last book shows exactly what happens when we emphasize excessively the consensus.
Rather than worry about appeasing others or making sure we do not offend by disagreeing with them, the message of this book is that there is importance and value in authentic debate. The idea that dissent causes irritation and conflict is only partially accurate. Dissent and debate also bring joy and invigorate discussion. Best of all, genuine dissent and debate not only make us think but make us think well. We become free to "know what we know." We make better decisions, find more creative solutions, and are better able to render justice.
The topic has strong connections with political correctness and hate. The book by Chantal Mouffe addresses this issue with precision.
Afin d'éviter toute confusion, je devrais peut-être préciser que, contrairement à certains penseurs postmodernes qui envisagent un pluralisme sans aucune frontière, je ne crois pas qu'une politique démocratique doive considérer comme légitimes toutes les revendications formulées dans un société donnée. Le pluralisme que je défends exige de discriminer parmi ces demandes celles que l'on peut accepter comme faisant partie du débat démocratique et celles qui doivent en être exclues. Une société démocratique ne peut pas traiter comme des adversaires légitimes ceux qui remettent en question ses institutions de base. L'approche agonistique ne prétend pas englober toutes les différences ni abolir toutes formes d'exclusion. Mais les exclusions sont envisagées en termes politiques et non pas en termes moraux. Certaines revendications se trouvent exclues de fait, non parce qu'elles sont « mauvaises », mais parce qu'elles défient les institutions constitutives de l'association politique démocratique. Entendons-nous bien, la nature des institutions fait aussi partie du débat agonistique, mais pour qu'un tel débat puisse avoir lieu, l'existence d'un espace symbolique partagé est nécessaire. C'est cette idée que j'ai voulu exprimer quand j'ai soutenu, dans le chapitre 1, que la démocratie nécessitait un « consensus conflictuel » : consensus sur les valeurs éthico-politiques de liberté et d'égalité pour tous mais dissensus sur leur interprétation. Il faut par conséquent tracer une ligne de démarcation entre ceux qui rejettent complètement ces valeurs et ceux qui, tout en les acceptant, en défendent des interprétations opposées.
Troublemakers as dissenters in politics are welcome. Though, if they want to undermine democracy, then forget any positive discrimination. This is not their place.
PS. Bad blood wins the Business book of the year contest.
Oriol Romaní
"Going Dutch" in regulating the mandatory coverage
Can universal access be achieved in a voluntary private health insurance market? Dutch private insurers caught between competing logics
Healthcare in The Netherlands is widely seen as a benchmark for many scholars. Though it is expensive, it combines mandatory coverage with the choice of private insurance coverage. Sounds of interest, though the devil is in the details.
This article explains the main issues surrounding such model:
The Dutch history of voluntary private health insurance shows both the strengths and weaknesses of public–private health insurance systems, especially in the context of a rising demand for (universal) access to health care. As we have explained, social and private health insurance are based on two divergent logics of different institutional orders (the market and the state).
The Dutch case strongly suggests that universal access can only be achieved in a competitive individual private health insurance market if this market is effectively regulated. The tension between adverse selection and universal access that had vexed the Dutch private health insurance industry throughout its existence was resolved by combining elements from both the insurance logic and the welfare state logic: i.e. an individual mandate, guaranteed issue, community-rated premiums, income-related subsidies and a sophisticated risk equalization scheme .
Achieving universal access in a competitive private health insurance market is institutionally complex and requires broad political and societal support.
Therefore, unless there is a smart regulator, forget it...
PS. Spanish embroglio at Marginal revolution.
PS. How is Obamacare doing?
From Lisa Eckdahl latest album
Provider payment strategies to improve health
Value-based provider payment: towards a theoretically preferred design
The case for improving health is related, among many things, with the incentive structure of the whole system (people, professionals and providers). If we focus our aim towards providers, then we need to reassess current flaws in the system, and ask what do we have to do. A new article tries to address these issues.
In order to tackle the problems related to current payment methods, worldwide, policymakers and purchasers of care are exploring alternative payment strategies to help steering health care systems towards value . A well-known endeavour in this regard is pay-for-performance (P4P), in which providers are explicitly rewarded for 'doing a better job'. Although P4P is an appealing idea, explicit financial incentives for value should in principle be used only modestly in provider payment methods because of the multitasking problem. Therefore, it is not surprising that in practice, the majority of provider revenues (typically referred to as the base payment) is not explicitly linked to value. This base payment, however, does create implicit (dis)incentives for value, because each payment method influences providers' behaviour through incentives.
The article reflects a conceptual framework of key components and design features of a theoretically preferred Value Based Payment method. And the key message is:
We conclude that value is ideally conceptualised as a multifaceted concept, comprising not only high quality of care at the lowest possible costs but also efficient cooperation, innovation and health promotion. Second, starting from these value dimensions, we derived various design features of a theoretically preferred VBP model. We conclude that in order to stimulate value in a broad sense, the payment should consist of two main components that must be carefully designed. The first component is a risk-adjusted global base payment with risk-sharing elements paid to a multidisciplinary provider group for the provision of (virtually) the full continuum of care to a certain population. The second component is a relatively low-powered variable payment that explicitly rewards aspects of value that can be adequately measured.
I fully agree with what they say. Close politicians and officials should take this message into consideration regarding the next primary care physicians' strike, and forget the current confusing approach.
TIRED SALESGIRL ON CHRISTMAS EVE
Estimate $5,000,000 — 7,000,000
(It may be yours, upcoming auction at Sotheby's)
Care Needed. Improving the lives of people with dementia
Across the OECD, nearly 19 million people are living with dementia. Millions of family members and friends provide care and support to loved ones with dementia throughout their lives. Until a cure or disease-modifying treatment for dementia is developed, the progress of the disease cannot be stopped.
We all know cases of close relatives with dementia, and we understand the suffering that surrounds the disease. OECD has made a good job coping with this difficult topic.
These are the three key chapters:
Identifying people with dementia
Helping people with dementia live well in the community
Health and long-term care services for advanced dementia are poor
As people live at home longer, communities need to be better equipped to meet the needs
of people living with dementia. Post-diagnostic care pathways can help connect people with dementia and their families with available services. But communities themselves must also adapt: community-friendly initiatives that train local populations and businesses to respond more effectively to people with dementia can help to reduce stigma around dementia while making the environment safer and more welcoming. Aging at home also means that informal carers will play an important role in supporting people with dementia. Informal carers should receive the support they need, and governments should assess whether existing services for carers are also adequate for carers of people with dementia, who may have unique needs.
Definitely, every country needs to develop a strategy for this disease. Catalonia has already defined its strategy, though resources are not enough.
Jaume Plensa at Madison Square Park
Next generation sequencing is knocking at the door (and the door is open)
Genetic testing: Opportunities to unlock value in precision medicine
Next-Generation Sequencing to Diagnose Suspected Genetic Disorders
Documento de consenso sobre la implementación de la secuenciación masiva de nueva generación en el diagnóstico genético de la predisposición hereditaria al cáncer
This week I've been reading three pieces on the same topic. First, a McKinsey insight on genetic testing, second a NEJM basic article that reviews the whole state of the issue, and third a consensus by three societies on how to implement next generation sequencing .
All of them are required reading for anyone interested in the topic. You'll notice that technology is knocking at the door and we do need to understand how to manage it. Otherwise it will enter anyway (without knocking) and then it will be more value extraction (by others) than value creation (for patients).
Unfortunately, what you'll not find in these articles is how to manage the introduction of the technology with organizational patterns, allocation and coordination of tasks and decisions. If you want some clues on this, read my previous post on Geisinger, they are applying what it seems to me the most appropriate perspective.
Sense Sal-Fins que surti el sol
The Cost of End-of-Life Care
The Myth Regarding the High Cost of End-of-Life Care
Systematic review of high-cost patients' characteristics and healthcare utilisation
The size of the healthcare costs at the end of life is properly reflected in this article (forget exaggerations):
We estimated that in 2011, among those with the highest costs, only 11% were in their last year of life, and approximately 13% of the $1.6 trillion spent on personal healthcare costs in the United States was devoted to care of individuals in their last year of life.
Longitudinal analyses of spending show that the population with the highest annual health care costs can be divided into 3 broad illness trajectories:
individuals who have high health care costs because it is their last year of life (population at the end of life),
individuals who experience a significant health event during a given year but who return to stable health (population with a discrete high-cost event and,
individuals who persistently generate high annual health care costs owing to chronic conditions, functional limitations, or other conditions but who are not in their last year of life and live for several years generating high health care expenses (population with persistent high costs).
Understanding individual costs is a required step for the analysis and improvement of healthcare delivery. Unfortunately it is a marginal practice. For a systematic review, check this article.
'Windrush: A Celebration', Barbican,
London, November 17, barbican.org .uk
Pharmarketing impact on prescribing behaviour
Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia
Gifts from pharmaceutical companies are believed to influence prescribing behavior, but few studies have addressed the association between industry gifts to physicians and drug costs, prescription volume, or preference for generic drugs
Governments in USA and EU have enacted laws for greater transparency of the relationship between pharma firms and physicians. Unfortunately evidence is limited about the concrete impact of gifts on physicians prescribing decisions.
This article sheds light on the issue and its conclusions say:
In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. In six specialties (General Internal Medicine, Family Medicine, Obstetrics/Gynecology, Urology, Ophthalmology, and Dermatology), gifts were associated with a significantly increased average cost of claims. For Internal Medicine, Family Medicine, and Ophthalmology, gifts were associated with more branded claims. Gift acceptance was associated with increased average cost per claim for PAs and NPs. Gift acceptance was also associated with higher proportion of branded claims for PAs but not NPs. Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups.
If gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions, then all of us as patients have to be concerned. And my impression is that regulation is not enough. Maybe one day the doors of physician offices will reflect current pharma payments to the patients. Right now they have to look at the web.
Beyond this, I suggest you check this news and you'll see the current flaws between pharma and research.
Museu Picasso. Barcelona
The "secret sauce" of Kaiser Permanente
Financing and Payment Strategies to Support High-Quality
Care for People with Serious Illness: Proceedings of a
A recent report by NASEM explains in one paragraph what is the key factor of succesful Kaiser Permanente model:
The "secret sauce" that enables Kaiser Permanente to deliver high quality care, explained Annet Arakelian, executive director of Medicare strategy and care delivery at Kaiser, is the way it has aligned its revenues and expenses. Kaiser's revenue comes from the Kaiser Foundation health plan that collects premiums from groups, individual members, and some prospective contracts with government payers. Expenses go through a hospital
service agreement with Kaiser Foundation hospitals and a capitated medical service agreement with the Permanente Medical Groups that employ the physicians who work at Kaiser hospitals and clinics. The hospitals and foundation are nonprofit organizations, while the medical groups are for profit agencies with their own board of directors and governance processes. Incentives are aligned across the hospitals, health plan, and medical groups on quality metrics, as well as financial and regulatory initiatives.
Great definition. This is the ingredient for success. And you'll understand why it is so difficult to replicate in a private world with vested interests between different stakeholders: insurers and providers. The nonprofit element of the foundation and hospitals is crucial.
Second statement. Regarding the report on how to pay for serious illness:
Susan Wang, regional lead for shared decision making at the Southern
California Permanente Medical Group, explained that Kaiser's approach to
comprehensive financing of serious illness care begins with a population
health perspective, which stems from the capitated arrangement that features
a fixed payment per person enrolled in its medical groups. "Because
we are capitated, we are accountable for our entire membership, it behooves
us to touch our patients at every opportunity," said Wang
Summary: Kaiser has a patient centered strategy. Finance follows the patient not the specific illness. Great. Agree.
The media and the Theranos incredible deception
On Theranos failure, highly recommended for journalists.
From CBSNEWS, a basic piece to understand the power of the media in creating and destroying (false) value:
Was the media duped by Elizabeth Holmes?
A conversation with 60 Minutes about media coverage of the rise and fall of Elizabeth Holmes and her hot startup, Theranos
The biggest financial heist in history
BILLION DOLLAR WHALE
The Man Who Fooled Wall Street, Hollywood, and the World
In 2009, with the dust yet to settle on the financial crisis, a baby-faced, seemingly mild-mannered Wharton grad began setting in motion a fraud of unprecedented gall and magnitude – one that would come to symbolize the next great threat to the global financial system. His name is Jho Low, a man whose behavior was so preposterous he might seem made up.
An epic true-tale of hubris and greed from two Pulitzer-finalist Wall Street Journal reporters, Billion Dollar Whale reveals how a young social climber pulled off one of the biggest financial heists in history–right under the nose of the global financial industry–exposing the shocking secret nexus of elite wealth, banking, Hollywood, and politics
This book is specially helpful to understand our times. There are value creators and at the same time value extractors. Beyond them there is the greatest fraudster, Jho Low, a guy that stole $3.5 billion from Malaysian sovereign fund 1MDB, and helped former Malaysia president to get $700m.The total amount of the heist could be $6.5 billion, 2.5% of Malaysian GDP. If you want to know the details, just read the book.
It is strongly recommended to understand the corruption of the global financial system and audit firms (Goldman Sachs, Deloitte et al.). This guy would not have been able to commit any theft without their help.
Once you have started the book it will be difficult to stop. Right now, there are others following Jho Low's path and value extractors are among us. Our institutions are extremely fragile tackling these issues. Just take this week cum/ex fraud:.
The German finance ministry said it was aware of 418 different cases of cum-ex tax fraud with a combined value of €5.7bn, adding that any guess about the total damage caused was "speculation" as the investigations were still ongoing.
An investigation published on Thursday by Correctiv, a German non-profit investigative journalism group, and 19 news organisations, cited leaked spreadsheets that show "an organised theft from the tax coffers of at least ten European states, besides Germany" that it claimed had cost taxpayers about €55.2bn.
Forecasting global life expectancy and morbidity
Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for 195 countries and territories
Key messages from The Lancet article:
Global life expectancy was projected to increase by 4·4 years (95% UI 2·2–6·4) for men and 4·4 years (2·1–6·4) for women by 2040, to 74·3 years (72·1–76·4) and 79·7 years (77·4–81·8), respectively.
Compared with the past, global progress in extending life expectancy was forecasted to be slower from 2016–40. This trend resulted from forecasts of slowed advances on key drivers such as SDI; worsening of several risks, particularly high BMI; and stagnated gains on cardiovascular diseases, which was a major factor in historical improvements in life expectancy.
Genome sequencing, what's it worth?
Evaluating the Outcomes Associated with Genomic Sequencing: A Roadmap for Future Research
The health economic evidence base for WES -whole exome sequencing- and WGS -whole genome sequencing- is very limited . A recent literature review identified just eight economic evaluations of either WGS or WES, six of which were cost-effectiveness analyses using diagnostic yield as the outcome measure. Only two publications presented cost-utility analyses using quality-adjusted life-years (QALYs) as the measure of health outcomes, as recommended by most health technology assessment (HTA) agencies. However, neither of these cost-utility analyses provides information on health outcomes that HTA agencies can use to inform the translation of NGS technologies into clinical practice for specific disorders.
Last May I wrote a post on this topic. Now James Buchanan and Sarah Wordsworth provide a roadmap for future research with three steps.
First, it is crucial that health economists generate evidence on the clinical utility of genomic sequencing using the methods and metrics that are recommended by HTA agencies. Here, we are primarily referring to the use of preference-based HRQoL instruments such as EQ-5D questionnaires to generate utility weights that can be used to calculate QALYs
If there is reason to believe that patient wellbeing will change after undergoing genomic sequencing (for example, supportive qualitative evidence), but commonly used HRQoL instruments show no effect, a second step would be to explore the use of alternative health-state valuation techniques to generate utility weights within the QALY framework. The time-trade-off (TTO) technique is one such approach
A third step would be to make full use of existing evidence on the diagnostic yield of WGS and WES. Studies that link this evidence to patient survival and quality of life (for example, trials or observational studies with long-term follow-up), could inform decision making regarding the translation of these technologies into clinical practice.
Unfortunately, it is easier said than done. I'm dubious regarding the potential of QALYs on assessing value of such technology, despite I have no alternative solutions right now.
Exhibition at Saatchi gallery
Geisinger (it is not any fiord)
A suggestion for weekend reading: excellent interview by Eric Topol with the Geisinger Health System CEO, in Medscape.
Regarding genetics in clinical practice:
Our approach is based on asking, "What if we did whole-exome sequencing on our entire population?" We started this to see whether we could find medically actionable genetic conditions that we could do something about. We are 200,000 patients into it—or I should say, research subjects, because we started with research—and we have found that 3.5%-4% of those people have something actionable: BRCA, malignant hyperthermia, Lynch syndrome, genes associated with cardiac arrhythmia.
They are unique.
And this is what happens at Sotheby's after the purchase for$1.4m
Banksy is a genius
The order of time
I've just finished the book I started this summer: The order of time. It's quite difficult to enter in physicists territories, and time is the last frontier and a mystery. But Carlo Rovelli does a great job explaining in easy terms such complicated things.
This is the disconcerting conclusion that emerges from Boltzmann's work: the difference between the past and the future refers only to our own blurred vision of the world. It's a conclusion that leaves us flabbergasted: is it really possible that a perception so vivid, basic, existential—my perception of the passage of time—depends on the fact that I cannot apprehend the world in all of its minute detail? On a kind of distortion that's produced by myopia? Is it true that, if I could see exactly and take into consideration the actual dance of millions of molecules, then the future would be "just like" the past? Is it possible that I have as much knowledge of the past—or ignorance of it—as I do of the future? Even allowing for the fact that our perceptions of the world are frequently wrong, can the world really be so profoundly different from our perception of it as this?
All this undermines the very basis of our usual way of understanding time. It provokes incredulity, just as much as the discovery of the movement of the Earth did. But just as with the movement of the Earth, the evidence is overwhelming: all the phenomena that characterize the flowing of time are reduced to a "particular" state in the world's past, the "particularity" of which may be attributed to the blurring of our perspective.
As The Guardian review says, the book is "an expression of the scientific desire to know and understand the world". Rovelli's message: time doesn't go by, time doesn't really exist as we imagine, it is only our construct.
La rumba del temps by Joan Miquel Oliver
Insuring biomarkers coverage
From the Past to the Present:Insurer Coverage Frameworks for Next-Generation Tumor Sequencing
Technology is one step ahead regulation and coverage. Sounds normal. However, the size of this step may be bigger than you think if we refer to next generation sequencing biomarkers. A new article in Value in Health journal covers this topic in detail.
One of the challenges of insurance coverage for next-generation sequencing is that it pushes the very boundaries of the underlined framework used by insurers in coverage decisions. For example,to receive insurance coverage, a medical technology must be determined "medically necessary" and not "experimental/investigational." Next-generation sequencing blurs the boundaries between these two concepts, making coverage decisions difficult.
Therefore some trade-offs are unavoidable. Inside the article you'll find them.
Anoro, Barnadas gallery
Healthcare services governance
The Firm Divided
Manager-Shareholder Conflict and the Fight for Control of the Modern Corporation
There is a unique feature of health services,- where public or non-profit organizations play a major role- it requires a deep understanding of the governance of the firms and its conflicts.
A new book provides a summary for private firms. In my opinion, most of the recommendations are applicable to public and not-for-profit organizations.
There are many partial solutions to manager–shareholder conflict, but none of them
work perfectly. In fact, even when they are all combined, the outcome is far from perfect. In some solutions, shareholders and directors play a hands-on role, taking responsibility themselves for keeping managers in line. In short, they monitor. Shareholders do some monitoring themselves; the rest they leave to a board of directors, which they elect—but everyone is involved in managing the managers. Directors play more of a hands-off role in the next set of solutions.
They set a few ground rules that executives must follow, create few incentives, and then step back and allow events to unfold. That is, they motivate.
However, directors cannot do everything themselves, so in the third set of solutions they enlist outside parties to do some of the monitoring and motivating on their behalf. They delegate. These outsiders have their own selfish reasons for getting involved, but their presence can still benefit shareholders.
As a last resort, and the last time that shareholders are even indirectly involved in the game, shareholders can sell, or threaten to sell, their shares to another firm. Selling is the ultimate hands-off policy.
All of these approaches to corporate governance occur in a world of rules and regulations. That is why there is a final solution to manager–shareholder conflict, of which shareholders are entirely passive beneficiaries: the fight to change the rules of the game. These are the key steps to effective corporate governance: monitor, motivate, delegate, sell. The rules of the game matter as well.
Definitely, the last resort doesn't apply to publicly owned and nonprofit organizations. For private managers, this is a real threat, not replicable elsewhere. It is precisely for this reason that governance matters and an additional effort should be devoted.
Economics of ownership in healthcare
Private Provision of Publicly Funded Health Care: The Economics of Ownership
You'll find an interesting review of public private provision by Martin Chalkley in this brief. It says:
Viewed through the lens of economics, concern over ownership arises from the impossibility of complete contracts between purchasers of health care and providers of health care. Were complete contracts feasible they would render the question of ownership redundant. But contracts will always be incomplete: it is not possible to specify in advance all of the relevant circumstances around the care of every patient who is to be served, so as to ensure that they receive appropriate quality of care at a cost that reflects complete efficiency and does not leave the provider either with unsustainable losses or supernormal profits.
But the existence of the collective purchaser(s) for health care means that purchasers have power that individual consumers in other sectors do not have. NHS purchasing arrangements have the potential to ensure that private ownership does not lead either to a 'race to the bottom' – sacrificing quality in order to cut costs – or to supernormal profits being earned – which would siphon off NHS funds that could otherwise be used to deliver more health care.
And the final statement:
We conclude overall that when considering the ownership of health care providers in a publicly funded health care system, statements such as "public good, private bad", or the other way about, are misplaced. All health care providers require regulation. All health care providers require carefully thought out contractual arrangements that recognise the incentives and constraints they operate with – and these do differ between ownership types. The collective nature of health care purchasing provides the means for achieving this.
That's it. A clear message for any open-mind politician.
Are we paying too much for pharmaceutical innovation?
Economics of the Pharmaceutical Industry
The question of whether innovation is too high or too low is a first-order—perhaps the first- order—policy question in the economics of the pharmaceutical industry. Yet, economists have not produced a definitive answer. At best, we have suggestive analyses that point to the low rate of surplus capture by innovators, and modeled estimates suggesting that the social return to innovation is positive on the margin. While helpful, these findings each require a speculative leap in order to draw an inference about the social efficiency of innovation. Much rides on the answer to this question. If innovation is indeed excessive, then public and private payers are wasting money paying excessively high rewards to firms producing innovations. In contrast, if innovation is too low, lives are being lost prematurely due to a lack of medical progress.
This is the "answer" that Lackdawalla gives in an interesting article in Journal of Economic Literature (more details inside). If you want a review in 50 pages of the main issues surrounding the industry, this is the article you have to read.
Courtauld Impressionists exhibition at the National Gallery
Lamarck returns
Lamarck's Revenge: How Epigenetics Is Revolutionizing Our Understanding of Evolution's Past and Present
I've just started to read this amazing book. Chapter 1 says:
Charles Darwin espoused evolution as driven by natural selection. However, an earlier theory, proposed more than a half century before the first publication of Darwin's greatest work, came from a naturalist whose life and work were limned by the flames of the French Revolution.
Lamarck arrived at a three-step process in what was to be the first really rational explanation for what we now call "organic evolution." First, an animal experienced a radical change of the environment around it. Second, the initial response to the environmental change was some new kind of behavior by that animal (or whole species). Third, the behavioral change was followed by morphological changes that were heritable in subsequent generations. This proposed process came to be named after its author. Today, a variant on what Lamarck proposed is sometimes called "neo-Lamarckism," but more often "epigenetics," or "heritable epigenetics."
Jean-Baptiste-Pierre-Antoine de Monet, Chevalier de Lamarck, had a different view about heredity and why animals changed through time. His scientific beliefs were that things that happen to us during our lives can change what we pass on to our next generation, and perhaps into even further generations. Darwin knew well what Lamarck theorized. Darwin believed that his own theories about evolution could not coexist with any aspect of what Lamarck postulated. We now know this is no longer the case.
Lamarck's Revenge looks anew at what are, perhaps, humanity's most basic questions: the "where," "when," and "why" of getting to the present-day biota on this planet. But the vehicle to do this is by asking specifically about the "how." What were the evolutionary mechanisms, the balance between Darwinian and neo-Lamarckian (aka heritable epigenetics), that produced not only our physical biology but some aspects of our heritable behavior as well?
Here are some possibilities. First, that the process known as epigenetics combined with periods of extraordinary environmental change has played a far greater role in what is called the "history of life" than is accepted by all but a small cadre of revolutionary biologists. This is perhaps most decisively shown through the epigenetic process of "lateral gene transfer," where on a given day, in a given minute, some organism is invaded by another and a product of that invasion is the incorporation of vast numbers of new genes, making the invaded creature something else again, neither the invader nor the invaded. This is known.
Second, new evidence points to a probable role of epigenetics in producing rapid species transitions by mechanisms other than lateral gene transfer. Science has discovered that major evolutionary change of a species can happen a thousand times faster by epigenetics than by the process demanded by the Darwinian theory of single, random mutations along a creature's genome or DNA (or, in some cases, RNA). This is most likely to occur during and immediately after rare, major environmental perturbations (such as mass extinctions and their aftermath).
Commercial determinants of health
Systems Thinking as a Framework for Analyzing Commercial Determinants of Health
Unhealthy commodity industries (UCIs) are defined as industries in which a significant share of their product portfolio comprises unhealthy products including tobacco, alcohol, energy‐dense and low‐nutrient foods and beverages, and gambling services.
Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.
Reviewing health systems
Spain Health system review
The series Health systems in transition by WHO is a helful source to understand the current state of healthcare. Now you can red the updated version for Spain. Check p.68 and you'll have to reduce the number of members with private insurance by 1.5m, because income protection products have been added,, and they don't reflect health insurance, they are "income insurance". Anyway, in p.61 you'll find the size of administrative costs, 3%. This is one of the reasons why the spanish health system is so cheap. But if you split between private and public you get the following: private insurance premiums are 10% approx of public expenditure, and represent half of administrative costs.I know that the estimation is quite difficult, but anyway, this is what the table says.
A big effort and a very helpful text for anyone interested in understanding the health system.
Khan el-Khalili based drug pricing
When is it too expensive? Cost-effectiveness thresholds and health care decision-making
In one week of difference, the same technology: CAR T-cells has had two different options for drug pricing. Last week, under NICE review the answer was no to Gilead, and yesterday was yes to Novartis. The first paradigm applied to Yescarta is well known: marginal effectiveness should be acceptable at an affordable cost (NICE). The second one applied to Kymriah is based on preferences and willingness to pay under confidential prices. It is also a well known system specially at bazaars like Khan el-Khalili in Cairo.
This is an example of how two systems are applied in practice and nobody cares about it. I'm concerned about transparency, and that's why I can't understand why with public money the expenditure is confidential. I would agree if somebody explain the budget impact that have been agreed, otherwise with public money Kahn el-Khalili system is not acceptable. After more than four decades, Torrance would ask himself if all this effort on cost-effectiveness analysis has had any sense to arrive at this point.
Anyway, the remaining question is: when is too expensive? This is precisely what this editorial asks. And the and the answer (?) is:
For deciding whether something is too expensive, thresholds are crucial. Depending on which perspective is taken, the word 'threshold' may either refer to the consumption value of health or the marginal cost-effectiveness of current spending.
This is a standard health economics perspective that no health politician nowadays will buy. Right now they are not buying the idea, and I think that they prefer confidential prices. It allows to reflect power, discretionality, or even worse arbitrariness. Khan el-Khalili system has won.
A controversial view of epigenetic inheritance
A critical view on transgenerational epigenetic inheritance in humans
A new article in Nature suggest that more evidence is needed to ascertain the role of epigenetic inheritance.
Even if the molecular mechanisms exist to transmit epigenetic information across generations in humans, it is very likely that the transgenerational transmission of culture by communication, imitation, teaching and learning surpasses the effects of epigenetic inheritance and our ability to detect this phenomenon. Cultural inheritance has certainly had an adaptive role in the evolution of our species, but the evidence for transgenerational epigenetic inheritance, as laid out above, is not (yet) conclusive.
Let's wait for new evidence...
Overturning conventional wisdom
Randomistas: How Radical Researchers Are Changing Our World
Clinical trials are the standard way to produce new evidence. A new book reminds us that this is quite new. It starts explaining the scurby case and how it took 50 years to apply its results (lemon) to avoid death among sailors. There is aplenty of details and experiments among medicine, social and policy domains. You'll find a reference to the Rand Health Insurance Experiment and nudge examples.
If you want a good review of the book, check this one or Diane Coyle.
The more we ask the question 'What's your evidence?', the more likely we are to find out what works – and what does not. Scepticism isn't the enemy of optimism: it's the channel through which our desire to solve big problems translates into real results. If we let our curiosity roam free, we might be surprised how much we can learn about the world, one coin toss at a time.
Is there a room for autonomous medical diagnosis?
Pivotal trial of an autonomous AI-based diagnostic system for detection of diabetic retinopathy inprimary care offices
With an eye to AI and autonomous diagnosis
In Digital medicine you'll find the article on an artificial intelligence-based diagnostic of diabetic retinopathy. It's the first AI system approved by FDA last April, and represents the begining of new aids for medical decision making. Therefore, there is a room for supporting decision making with AI, but maybe one day autonomous diagnosis could be the issue, who knows.
The prespecified sensitivity end point agreed with the FDA was 85.0% and this was met with a point estimate of primary sensitivity of 87.2%. However, the confidence intervals of this estimate were 81.8–91.2% (that is, spanned the superiority end point). The study also employed an intention-to-screen protocol; however, 40 participants successfully enrolled in the study were excluded from analysis as their images were subsequently found to be insufficient quality to be graded by the image reading center. The authors attempt to address this by considering a worst-case scenario where all such images are incorrectly graded and repeating the analysis. In this approach the sensitivity would
be 80.7% (76.7–84.2%).
Although deep learning will not be a panacea, it has huge potential in many clinical areas where high dimensional data is mapped to a simple classification and for which datasets are potentially stable over extended periods. As such, it will be incumbent on healthcare professionals to become more familiar with this and other AI technologies in the coming years to ensure that they are used appropriately.
Alice Francis - Coco Baca Bum Bum
The uselessness of current hospital rankings
Personalized Hospital Ratings — Transparency for the Internet Age
Eric Topol said in a tweet: It's high time to transcend hospital ratings and move to indvidualized ratings of hospitals. He refers to an NEJM article that supports personalized hospital ratings like the Rand ones.
As currently constructed, the weighting systems that underlie overall hospital performance ratings are expressions of the values, preferences, and tastes of their creators. Why not ask patients what's important to them instead?
It makes sense.
PS. FT life of a song
The paucity of public information about medical devices
The need for transparency of clinical evidence for medical devices in Europe
Last year EU approved a new law for assessing safety and efficacy of medical devices. Unfortunately, it comes late and it is not enough to solve current situation of lack of information on evidence. An article in Lancet explains precisely what should be done to increase the transparency of information on medical devices.All the details in this list:
A small task force of regulators and invited stakeholders has recommended what information should be included in the summaries of safety and clinical performance and which components of the Eudamed database need to be open to public access. Those recommendations are now under revision. The European Commission has been delegated authority to translate them into further legislation, but it has indicated that it does not consider that to be a priority. Any member of the public or any organisation with an interest in these issues should therefore make representations now to the European Commission. The medical device regulations will take effect from 2020.
On free genetic sequencing, opioids and the Hockne...
In favour of positive discrimination for troublema...
"Going Dutch" in regulating the mandatory coverage...
Next generation sequencing is knocking at the door...
Are we paying too much for pharmaceutical innovati...
The paucity of public information about medical de...


text:
Q: The account "username1" is still being used by these components: SharePoint Server Search similar to the question,i have found here
Error deleting Managed Account

am using SharePoint 2010 Server and when I try and delete this account I get this error.

The account DOMAIN\muser1 is still being used by these components:
  SharePoint Server Search.

What am i doing wrong ?
i tried to delete this using powershell, but that also thrown into error.
$account = Get-SPManagedAccount -identity "domain\muser1"
Remove-SPManagedAccount $account

 and when i tried to select the newly created special id account for the sp search in "configure service accounts link in central admin" , after selecting the search dropdown item and clicking ok, am getting the below error

'mapAccountPicker' has a SelectedValue which is invalid because it does not exist in the list of items.
  Parameter name: value

Troubleshoot issues with Microsoft SharePoint Foundation.
Correlation ID: 642976cd-5cbe-4f66-8d3f-be5aa76d6853
Date and Time: 10/16/2017 5:24:51 P

A: You are unable to delete a managed account which is used in a service.
To solve this issue, create a new user and register a managed account using this new user, then go to Configure Service accounts, configure all services which is used the old managed account to use the new managed account.

redpajama_set_name: RedPajamaStackExchange


text:
namespace Pixator.Api.Areas.HelpPage.ModelDescriptions
{
    public class DictionaryModelDescription : KeyValuePairModelDescription
    {
    }
}

redpajama_set_name: RedPajamaGithub


text:
More than 100 people rescued from overloaded sailboat before it hit sandbar in Florida Keys, Coast Guard says
More than 100 people were rescued from an overloaded sailboat before it hit a shoal in the Florida Keys on Monday, the US Coast Guard said.
A good Samaritan reported the vessel to Key West watchmen around 5 am local time, Coast Guard District 7. tweeted.
Crews responded to the incident off Rodriguez Key after receiving "reports of people in the water," the tweet said.
They encountered "6 to 10 foot seas, 25 mph winds to get people off the boat safely," the Coast Guard said.
The rescue effort appeared to be an hour-long effort, with officials saying the weather and rough seas presented "a challenge."
Initially, the Coast Guard said 22 people were rescued from the overloaded sailboat.
He later revised that number to more than 100 people, saying dozens had been rescued before the boat hit a sandbar off Whale Harbor. The nationalities of the people aboard the ship were not immediately clear until early Tuesday morning.
A US Coast Guard officer carries two children, rescued off the south Florida coast after a boat struck a sandbar near Whale Harbor on Monday. @USCGSureste / Twitter
The rescue comes as the Southeast Coast Guard said it would call off the search for possible survivors after a homemade boat carrying migrants from Cuba capsized off the Florida coast over the weekend.
A total of 19 people are believed to be on the boat and survivors reported four people drowning immediately after it capsized Saturday, Coast Guard District 7 said.
The crew of the Coast Guard Pablo Valent rescued nine people and recovered one body, while on Sunday and Monday, crews recovered five bodies, Coast Guard District 7 said in a statement. Press release.
"Our condolences go out to the family and friends of those presumed lost at sea," Cmdr. Richard Armstrong, Deputy Sector Commander for Coast Guard Sector Key West, in a statement Monday night announcing the suspension of the search for survivors.
Armstrong said the life jackets worn by some of those on the ship "certainly saved their lives in treacherous sea conditions."
Chantal Da Silva is a breaking news editor for NBC News Digital based in London.
Marlene Lenthang contributed.
Previous: English soccer league stars resign after 'heated discussion' over schedule shoot: report
Next: 'The Umbrella Academy' Season 4 Eyes February 2023 Filming Start