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How Do I Determine if My Patient has Decision-Making Capacity?
The Hospitalist. 2011 August;2011(8)
Joyeeta G. Dastidar, MD
Andy Odden, MD
Competency is a global assessment and legal determination made by a judge in court. Capacity is a functional assessment and a clinical determination about a specific decision that can be made by any clinician familiar with a patient's case.
Hospitalists frequently encounter situations in which a patient's capacity is called into question; in most cases, this is a determination a hospitalist can make independent of consultants.
The four key components to address in a capacity evaluation include: 1) communicating a choice, 2) understanding, 3) appreciation, and 4) rationalization/reasoning.
Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med. 1988;319(25):1635-1638.
Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decisionmaking capacity. J Am Med Dir Assoc. 2004;5(4):263-267.
Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.
A 79-year-old male with coronary artery disease, hypertension, non-insulin-dependent mellitus, moderate dementia, and chronic renal insufficiency is admitted after a fall evaluation. He is widowed and lives in an assisted living facility. He's accompanied by his niece, is alert, and oriented to person. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. His labs are notable for potassium of 6.3 mmol/L, BUN of 78 mg/dL, and Cr of 3.7 mg/dL. The niece reports that the patient is not fond of medical care, thus the most recent labs are from two years ago (and indicate a BUN of 39 and Cr of 2.8, with an upward trend over the past decade). You discuss possible long-term need for dialysis with the patient and niece, and the patient clearly states "no." However, he also states that it is 1988. How do you determine if he has the capacity to make decisions?
Hospitalists are familiar with the doctrine of informed consent—describing a disease, treatment options, associated risks and benefits, potential for complications, and alternatives, including no treatment. Not only must the patient be informed, and the decision free from any coercion, but the patient also must have capacity to make the decision.
Hospitalists often care for patients in whom decision-making capacity comes into question. This includes populations with depression, psychosis, dementia, stroke, severe personality disorders, developmental delay, comatose patients, as well as those with impaired attentional capacity (e.g. acute pain) or general debility (e.g. metastatic cancer).1,2
ave for the comatose patient, whether the patient has capacity might not be obvious. However, addressing the components of capacity (communication, understanding, appreciation, and rationalization) by using a validated clinical tool, such as the MacCAT-T, or more simply by systematically applying those four components to the clinical scenario under consideration, hospitalists can make this determination.
Table 1. Ten Myths About Capacity
Decision-making capacity = competency.
Against medical advice = lack of decision-making capacity.
There's no need to assess decision-making capacity unless a patient goes against medical advice.
Decision-making capacity is all or nothing.
Cognitive impairment = no decision- making capacity.
Lack of decision-making capacity is permanent.
Patients who have not been given relevant information about their condition can lack decision-making capacity.
All patients with certain psychiatric disorders lack decision-making capacity.
All institutionalized patients lack decision-making capacity.
Only psychiatrists and psychologists can assess decision-making capacity.
Source: Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decisionmaking capacity. J Am Med Dir Assoc. 2004;5(4):263-267.
Review of the Literature
It is important to differentiate capacity from competency. Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. A hospitalist often is well positioned to make a capacity determination given established rapport with the patient and familiarity with the details of the case.
To make this determination, a hospitalist needs to know how to assess capacity. Although capacity usually is defined by state law and varies by jurisdiction, clinicians generally can assume it includes one or more of the four key components:
Communication. The patient needs to be able to express a treatment choice, and this decision needs to be stable enough for the treatment to be implemented. Changing one's decision in itself would not bring a patient's capacity into question, so long as the patient was able to explain the rationale behind the switch. Frequent changes back and forth in the decision-making, however, could be indicative of an underlying psychiatric disorder or extreme indecision, which could bring capacity into question.
Understanding. The patient needs to recall conversations about treatment, to make the link between causal relationships, and to process probabilities for outcomes. Problems with memory, attention span, and intelligence can affect one's understanding.
Appreciation. The patient should be able to identify the illness, treatment options, and likely outcomes as things that will affect him or her directly. A lack of appreciation usually stems from a denial based on intelligence (lack of a capability to understand) or emotion, or a delusion that the patient is not affected by this situation the same way and will have a different outcome.
Rationalization or reasoning. The patient needs to be able to weigh the risks and benefits of the treatment options presented to come to a conclusion in keeping with their goals and best interests, as defined by their personal set of values. This often is affected in psychosis, depression, anxiety, phobias, delirium, and dementia.3
Several clinical capacity tools have been developed to assess these components:
Clinical tools.
The Mini-Mental Status Examination (MMSE) is a bedside test of a patient's cognitive function, with scores ranging from 0 to 30.4 Although it wasn't developed for assessing decision-making capacity, it has been compared with expert evaluation for assessment of capacity; the test performs reasonably well, particularly with high and low scores. Specifically, a MMSE >24 has a negative likelihood ratio (LR) of 0.05 for lack of capacity, while a MMSE <16 has a positive LR of 15.5 Scores from 17 to 23 do not correlate well with capacity, and further testing would be necessary. It is easy to administer, requires no formal training, and is familiar to most hospitalists. However, it does not address any specific aspects of informed consent, such as understanding or choice, and has not been validated in patients with mental illness.
The MacArthur Competence Assessment Tools for Treatment (MacCAT-T) is regarded as the gold standard for capacity assessment aids. It utilizes hospital chart review followed by a semi-structured interview to address clinical issues relevant to the patient being assessed; it takes 15 to 20 minutes to complete.6 The test provides scores in each of the four domains (choice, understanding, appreciation, and reasoning) of capacity. It has been validated in patients with dementia, schizophrenia, and depression. Limiting its clinical applicability is the fact that the MacCAT-T requires training to administer and interpret the results, though this is a relatively brief process.
The Capacity to Consent to Treatment Instrument (CCTI) uses hypothetical clinical vignettes in a structured interview to assess capacity across all four domains. The tool was developed and validated in patients with dementia and Parkinson's disease, and takes 20 to 25 minutes to complete.7 A potential limitation is the CCTI's use of vignettes as opposed to a patient-specific discussion, which could lead to different patient answers and a false assessment of the patient's capacity.
The Hopemont Capacity Assessment Interview (HCAI) utilizes hypothetical vignettes in a semi-structured interview format to assess understanding, appreciation, choice, and likely reasoning.8,9 Similar to CCTI, HCAI is not modified for individual patients. Rather, it uses clinical vignettes to gauge a patient's ability to make decisions. The test takes 30 to 60 minutes to administer and performs less well in assessing appreciation and reasoning than the MacCAT-T and CCTI.10
It is not necessary to perform a formal assessment of capacity on every inpatient. For most, there is no reasonable concern for impaired capacity, obviating the need for formal testing. Likewise, in patients who clearly lack capacity, such as those with end-stage dementia or established guardians, formal reassessment usually is not required. Formal testing is most useful in situations in which capacity is unclear, disagreement amongst surrogate decision-makers exists, or judicial involvement is anticipated.
The MacCAT-T has been validated in the broadest population and is probably the most clinically useful tool currently available. The MMSE is an attractive alternative because of its widespread use and familiarity; however, it is imprecise with scores from 17 to 23, limiting its applicability.
click for large version
Table 2. Components of Capacity Assessments
At a minimum, familiarity with the core legal standards of capacity (communication of choice, understanding, appreciation, and reasoning) will improve a hospitalist's ability to identify patients who lack capacity. Understanding and applying the defined markers most often provides a sufficient capacity evaluation in itself. As capacity is not static, the decision usually requires more than one assessment.
Equally, deciding that a patient lacks capacity is not an end in itself, and the underlying cause should be addressed. Certain factors, such as infection, medication, time of day, and relationship with the clinician doing the assessment, can affect a patient's capacity. These should be addressed through treatment, education, and social support whenever possible in order to optimize a patient's performance during the capacity evaluation. If the decision can be delayed until a time when the patient can regain capacity, this should be done in order to maximize the patient's autonomy.11
Risk-related standards of capacity.
Although some question the notion, given our desire to facilitate management beneficial to the patient, the general consensus is that we have a lower threshold for capacity for consent to treatments that are low-risk and high-benefit.12,13 We would then have a somewhat higher threshold for capacity to refuse that same treatment. Stemming from a desire to protect patients from harm, we have a relatively higher threshold for capacity to make decisions regarding high-risk, low-benefit treatments. For the remainder of cases (low risk/low benefit; high risk/high benefit), as well as treatments that significantly impact a patient's lifestyle (e.g. dialysis, amputation), we have a low capacity to let patients decide for themselves.11,14
Other considerations.
Clinicians should be thorough in documenting details in coming to a capacity determination, both as a means to formalize the thought process running through the four determinants of capacity, and in order to document for future reference. Cases in which it could be reasonable to call a consultant for those familiar with the assessment basics include:
Cases in which a determination of lack of capacity could adversely affect the hospitalist's relationship with the patient;
Cases in which the hospitalist lacks the time to properly perform the evaluation;
Particularly difficult or high-stakes cases (e.g. cases that might involve legal proceedings); and
Cases in which significant mental illness affects a patient's capacity.11
Early involvement of potential surrogate decision-makers is wise for patients in whom capacity is questioned, both for obtaining collateral history as well as initiating dialogue as to the patient's wishes. When a patient is found to lack capacity, resources to utilize to help make a treatment decision include existing advance directives and substitute decision-makers, such as durable power of attorneys (DPOAs) and family members. In those rare cases in which clinicians are unable to reach a consensus about a patient's capacity, an ethics consult should be considered.
Table 3. Comparison of Competency Evaluation Tools1,2,3,4
Back to the Case.
Following the patient's declaration that dialysis is not something he is interested in, his niece reports that he is a minimalist when it comes to interventions, and that he had similarly refused a cardiac catheterization in the 1990s. You review with the patient and niece that dialysis would be a procedure to replace his failing kidney function, and that failure to pursue this would ultimately be life-threatening and likely result in death, especially in regard to electrolyte abnormalities and his lack of any other terminal illness.
The consulting nephrologist reviews their recommendations with the patient and niece as well, and the patient consistently refuses. Having clearly communicated his choice, you ask the patient if he understands the situation. He says, "My kidneys are failing. That's how I got the high potassium." You ask him what that means. "They aren't going to function on their own much longer," he says. "I could die from it."
You confirm his ideas, and ask him why he doesn't want dialysis. "I don't want dialysis because I don't want to spend my life hooked up to machines three times a week," the patient explains. "I just want to let things run their natural course." The niece says her uncle wouldn't have wanted dialysis even if it were 10 years ago, so she's not surprised he is refusing now.
Following this discussion, you feel comfortable that the patient has capacity to make this decision. Having documented this discussion, you discharge him to a subacute rehabilitation facility.
Bottom Line.
In cases in which capacity is in question, a hospitalist's case-by-case review of the four components of capacity—communicating a choice, understanding, appreciation, and rationalization and reasoning—is warranted to help determine whether a patient has capacity. In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized.
Drs. Dastidar and Odden are hospitalists at the University of Michigan in Ann Arbor.
Buchanan A, Brock DW. Deciding for others. Milbank Q. 1986;64(Suppl. 2):17-94.
Guidelines for assessing the decision-making capacities of potential research subjects with cognitive impairment. American Psychiatric Association. Am J Psychiatry. 1998;155(11):1649-50.
Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
Etchells E, Darzins P, Silberfeld M, et al. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999;14:27-34.
Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatr Serv. 1997;48:1415- 1419.
Marson DC, Ingram KK, Cody HA, Harrell LE. Assessing the competency of patients with Alzheimer's disease under different legal standards. A prototype instrument. Arch Neurol. 1995;52:949-954.
Edelstein B. Hopemont Capacity Assessment Interview Manual and Scoring Guide. 1999: Morgantown, W.V.: West Virginia University.
Pruchno RA, Smyer MA, Rose MS, Hartman-Stein PE, Henderson-Laribee DL. Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. Gerontologist. 1995;35:622-629.
Moye J, Karel M, Azar AR, Gurrera R. Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia. Gerontologist. 2004;44:166-175.
Grisso T, Appelbaum PS. Assessing competence to consent to treatment: a guide for physicians and other health professionals. 1998; New York: Oxford University Press, 211.
Cale GS. Risk-related standards of competence: continuing the debate over risk-related standards of competence. Bioethics. 1999;13(2):131-148.
Checkland D. On risk and decisional capacity. J Med Philos. 2001;26(1):35-59.
Wilks I. The debate over risk-related standards of competence. Bioethics. 1997;11(5):413-426.
Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2004;5(4):263-267.
Acknowledgements:The authors would like to thank Dr. Jeff Rohde for reviewing a copy of the manuscript, and Dr. Amy Rosinski for providing direction from the psychiatry standpoint
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Asher Bilu (born 1936) is an Australian artist who creates paintings, sculptures and installations. He has also contributed to several films by Director Paul Cox as production designer. He was born in Israel, and began his career as an artist soon after arriving in Australia in 1956. From the start, his art has been abstract, with particular emphasis on technological experimentation. His technique changes as he investigates the use of new media, but his work always reflects his fascination with light, and his love of music and science, especially cosmology.

Early life
Bilu was born in Tel Aviv on 16 December 1936. At the age of fourteen he was sent to Kibbutz Mizra in the Jezreel Valley where he lived and studied until his mandatory army service began in 1954. From the age of eight he studied classical violin. The art teacher at the kibbutz, Rafael Lohat, developed a love of painting in the young musician, and eventually, during his term of army service, the instrument was abandoned and painting became his preferred mode of artistic expression. Early in 1956 he was excited by an exhibition in Tel Aviv of abstract work in the style of Vieira da Silva and was lucky enough to meet and befriend the artist Efraim Modzelevich whose encouragement for his early paintings was pivotal in forming his career.  Asher Bilu has not had any other formal art training. However he has continued his musical expression through study of classical Hindustani music on the Indian instrument, the sarod, learning with Pandit Ashok Roy and Dr. Adrian McNeil.

Art career
Bilu arrived in Melbourne, Australia, in December 1956, after completing his Israeli army service. He came to join his parents and sister who had migrated two years earlier. He quickly settled into a studio in St. Kilda Road, completing work for his first solo exhibition at Allan David's Dalgety Street Gallery in 1959. The exhibition was opened by the acclaimed architect Ernest Fooks and was attended by artworld personalities John & Sunday Reed and Georges Mora, the artist Don Laycock and the Brazilian dancer and sculptor Antonio Rodrigues, who all became close friends. This exhibition was followed by two solo exhibitions at John Reed's renowned Museum of Modern Art of Australia and exhibitions in Sydney and Adelaide soon established his reputation. In 1963 Asher Bilu moved to London, where he lived for two years, exhibiting at the Rowan Gallery in London and Kunst Kring in Rotterdam, the Netherlands. Shortly after his return to Melbourne in 1965, he won the prestigious Blake Prize for Religious Art for a work entitled I form Light and Create Darkness – Isiah 45:7 which is dominated by a large meteor shape suggesting a dramatic moment in the birth of life out of chaos. In 1967 Sculptron was exhibited at George Mora's Tolarno Galleries Melbourne. Sculptron was the first electronic sculpture in Australia (Patrick McCaughey, "The Age" 11 July 1967) and was designed with engineering assistance by Tim Berriman. In 1970 he won the First Leasing Prize which was an invitational non-acquisition exhibition mounted at the National Gallery of Victoria, with a first prize of $7,000 the largest prize to date. Second prize winner was Brett Whiteley and third prize winners (shared) Jan Senbergs and Alun Leach-Jones.

Art materials
Early paintings used raw pigments combined with resins sourced from industrial applications and acetone. Textures were achieved by the use of water and fire. 1974 saw the first painting to break the two-dimensional surface (Zone 1) with cut out sections of the painting extending into space. Later dimensional paintings were formed with plywood, then cut out and mounted on wooden blocks, set on a variety of levels. His discovery of a self-supporting paint – a polyvinyl alcohol resin that can be applied on nonporous surfaces, then peeled off when dry – opened up further possibilities. The first major use of this medium was [Amaze (1982)], a walk through painting suspended from the ceiling 42 metres long and 3 metres high and which used 1 ton of paint, exhibited first at United Artists Gallery in Melbourne.  Other installations using this medium are [Heavens (2006)] and [In-Visible (2007)]. Found objects and other unconventional materials have also formed the basis of installations and sculpture. [Escape (1992)] utilized 16 tons of paper offcuts from machinery for envelope manufacture, [Explanandum (2002)] utilized industrial wire mesh and [Mysterium (2003)] utilized wooden match splints.

Installations
Bilu transformed Realities Gallery, Melbourne for his exhibition Infinities in 1979, working with lighting designer John Comeadow to install theatre spotlights to light the paintings edge-to-edge, and speakers for music which he had composed and recorded on the Fairlight Synthesiser with the assistance of musician Duncan McGuire. In 1982 Amaze was first exhibited at United Artists Gallery in Melbourne, later touring to Mount Gambier, Sydney and Armidale. Escape (1992) was commissioned by the Melbourne International Festival as an interactive experience for the seven thousand people who visited in ten days.  Sanctum (1993) was included in the art component of the Melbourne International Festival. Explanandum (2002), was shown to an invited audience in Melbourne and Adelaide. Mysterium (2003) was commissioned as a non-competitive work for the inaugural sculpture prize at the McClelland Gallery. Heavens (2006) was commissioned by the [Jewish Museum of Australia] and was travelled by [NETS (National Exhibition Touring Support)] to regional galleries in Mornington, Latrobe Valley and Benalla.  In-Visible (2007), with lighting designer John Comeadow, was commissioned by Wilson Street Gallery, Sydney. M –Theory(2010), Plexus (2011), Cosmotif (2012) and resurrection (2016) are installations exhibited in the artist's studio.

Exhibitions and collections
Bilu has had 50 solo exhibitions in Australia, and in London, Rotterdam and Los Angeles. His work has been represented in group exhibitions which include Australian Art Today, touring exhibition to SE Asia (1969), McCaughey Prize, National Gallery of Victoria (1979), I Had a Dream – Australian Art in the 1960s (1997), National Gallery of Victoria, Melbourne, O Soul O Spirit O Fire, Queensland University of Technology Art Museum, Brisbane & touring (2001), After Van Gogh: Australian Artists in homage to Vincent, Mornington Peninsular Regional Gallery (2005), Earthly reflections of heavenly things, 3 person exhibition with Leonard Brown & Emily Kame Kngwarreye, The Ian Potter Museum of Art, Melbourne (2007–08), Volume One: MCA Collection, Museum of Contemporary Art, Sydney (2012). He is represented in the collections of The National Gallery of Australia, National Gallery of Victoria, Art Gallery of NSW, Museum of Contemporary Art, Sydney, Museum of Modern Art at Heide, Melbourne, and many regional galleries and corporations. He was commissioned in 1982 to produce four paintings for the Concert Hall of the Victorian Arts Centre.

Awards
 1965	C.H. Richards Memorial Prize, Brisbane.
 1965	Blake Prize, Sydney.
 1970	First Leasing Prize, Melbourne.
 1973	Grant, Visual Arts Board, Australia Council

United Artists Gallery
Bilu and Ivan Durrant were the initiators of United Artists Gallery, an artist cooperative situated in the room vacated by Georges Mora's Tolarno Gallery in Fitzroy Street St Kilda. The cooperative flourished from 1982 till 1985, run by a group of mainly mid career artists who wanted to reach the public with innovative work exhibited accessibly. Members included Mike Brown, Joel Elenberg (estate), Dale Hickey, Don Laycock, Peter D. Cole and David Larwill. Asher Bilu painted Amaze to celebrate the spirit of United Artists Gallery which was to provide an art experience that reached viewers across the whole range from the art uneducated to the cognoscenti and to demonstrate that "art" and "the public" were not mutually exclusive.

Film
Bilu has contributed to several films by Director Paul Cox as production designer, Man of Flowers (1983), My First Wife (1983), Cactus (1984), Human Touch (2003) which also features the two installations Explanandum and Amaze and Force of Destiny (2015) in which he created a room using several of his paintings and a sculpture "Time Piece".  For the film Vincent: The life and Death of Vincent van Gogh (1987), he designed the scenes to illustrate the paintings of the bedroom and the potato eaters, and painted eleven copies of original Van Gogh paintings to be used for filming.

Bibliography
Examples of Bilu's works are included in the following books on Australian art:
 The Art Collection of the Victorian Arts Centre, Victorian Arts Centre, Melbourne, Australia 1992
 Bonython, Kym, Modern Australian Painting 1970–1975, Rigby Limited, Australia 1976
 Bonython, Kym, Modern Australian Painting 1975–1980, Rigby Limited, Australia 1980
 Crumlin, Rosemary, Images of Religion in Australian Painting, Bay Books, Kensington, NSW, Australia 1988
 Crumlin, Rosemary, The Blake Book/Art, Religion and Spirituality in Australia, MacMillan Art Publishing, Australia 2011
 Drury, Neville (Ed) New Art Five, Craftsman House BVI Ltd, Tortola, BVI 1991
 Drury, Neville, Images in Contemporary Australian Painting, Craftsman House BVI Ltd, Tortola, BVI 1992
 Gleeson, James, Masterpieces of Australian Painting, Landsdowne Press Pty Ltd, 1969 - Maha Yuga, 1967
 Gleeson, James, Modern Painters 1931 1970, Lansdowne Press, Dee Why West, Australia 1971
 Heathcote, Christopher, A Quiet Revolution: The Rise of Australian Art 1946–1968, The Text Publishing Company, Melbourne, Victoria 1995
 Jones, Stephen, Synthetics/Aspects of Art & Technology in Australia 1956–1975, MIT Press, 2011
 Lindsay, Robert (Ed.), The Seventies: Australian Paintings and Tapestries – from the Collection of the National Bank of Australia, National Bank of Australasia, Melbourne, Australia, 1982
 Manton, Neil, Cultural Relations: The Other Side of the Diplomatic Coin, Homosapien Books, 2003
 McCulloch, Alan & Susan, The Encyclopaedia of Australian Art, Allen & Unwin
 Reed, John, New Painting 1952 62, Longmans, Australia 1963
 Smith, Bernard, Australian Painting 1788–2000, Oxford University Press 2001
 Space Place Space Time/Asher Bilu Paintings and Installations, New Street Publishing, Australia 2010
 Reid, Barrett & Underhill, Nancy, Letters of John Reed, Viking 2001
 Thomas, Daniel, Outlines of Australian Art: The Joseph Brown Collection, The MacMillan Company, Australia 1973
 Thomas, Laurie, The Most Noble Art of Them All, University of Queensland Press, St. Lucia, Queensland, Australia 1976
 Wilson, Ashleigh, Brett Whitelely/Art, Life and the Other Thing, Text Publishing, 2016

References

External links
 Official Asher Bilu website

 Asher Bilu Videos

1936 births
Artists from Melbourne
Australian Jews
Living people
Israeli emigrants to Australia
Jewish Israeli artists
Jews in Mandatory Palestine
People from Tel Aviv
20th-century Australian painters
21st-century Australian painters
20th-century Australian sculptors
21st-century Australian sculptors
Blake Prize for Religious Art winners

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JTA launches Hebrew-language website, syndication service
(JTA) – The Jewish Telegraphic Agency (JTA) has launched a Hebrew-language website and syndication service aimed at the Israeli public. The service features original Hebrew articles and videos with Hebrew translations of items published in English by JTA and adapted for Israeli audiences. JTA's new Hebrew news site is www.jtahebrew.com.
The goal is to inform the Israeli public about Diaspora Jews and Jewish issues, and to use news items, feature stories and videos to increase Israelis' understanding of Diaspora Jewry. Jewish communal leaders and some Israeli officials have voiced growing concern for years over what they describe as the widening gap between Israeli Jews and Jews in North America and the rest of the world.
"We hope that by telling the stories of Diaspora Jews in Hebrew, and having those stories syndicated in widely read Israeli news outlets, Israelis of all stripes will better appreciate the issues affecting Jews in America and around the world," said Ami Eden, the CEO and executive editor of JTA's parent organization, 70 Faces Media. "And hopefully Israelis will better understand what Jewish identity means in the Diaspora."
JTA was founded in 1917 with the mission of spreading news around the world about what was happening in persecuted and impoverished Jewish communities in Russia and Europe. Today, about 70 newspapers, magazines and websites subscribe to JTA's English-language syndication service, including news outlets on five continents. JTA is part of 70 Faces Media, a nonprofit organization that runs a variety of Jewish content brands, including the Jewish information and living website My Jewish Learning, the parenting site Kveller, the Jewish food brand The Nosher, and Alma, a site for millennial-age Jews.
The project is being supported in part by the Israeli Diaspora Ministry as one of its initiatives to enhance Israelis' connections to Diaspora Jewry. Under the project terms, JTA maintains complete editorial independence. In addition to revenue from its syndication service and advertising business, 70 Faces Media receives funding from an array of sources, including foundations, Jewish federations and individual donors.
Several of Israel's leading news outlets already subscribe to the new JTA Hebrew service, and the agency is seeking to expand its syndication partnerships in Israel.
Controversial antisemitism bill dies in House
Conversation with Prof. Erich Gruen
Aerosmith's Steven Tyler met Ambassador David Friedman at the Kotel

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Do the Newest Batch of Weiner Photos Seal the Congressman's Fate?
News 12:00 PM PDT, June 13, 2011 - Inside Edition
12:00 PM PDT, June 13, 2011 - Inside Edition
If embattled congressman Anthony Weiner thought taking a leave of absence to deal with his sexting scandal would save his House seat, he appears to be sorely mistaken.
Yet another batch of raunchy pictures has gone public, featuring Weiner clutching his private parts in the official Congressional gym.
Weiner, who took the pictures in a mirror with his Blackberry, reportedly sent them to a young woman. In one, he appears to be completely naked.
CBS News Chief Washington Correspondent Bob Shieffer could barely contain his contempt. "This is beyond just a sex scandal here. I mean, this is sort of an electronic version of a flasher. These latest pictures are disgusting," he said.
The photos were taken at the Capitol Hill gym, a lavishly-appointed, members-only facility. Members of Congress can swipe in, or be buzzed in using a phone.
The fact that the photos were taken on government property could doom Weiner's defense that he didn't use taxpayer resources to execute his sexting activities.
Bob Cusack, managing editor of congressional newspaper The Hill, commented: "This could be the final nail in the coffin for him." Another Capitol Hill insider was quoted saying that the new photos of Weiner "could very well seal his fate."
The scandal seems to be taking its toll on Weiner's pregnant wife. Huma Abedin, who was photographed with her boss Hillary Clinton in Tanzania on Sunday, looked both anxious and grim.
Weiner's friends describe the congressman's present state as "distraught and fragile," and say he is "falling apart."
Over the weekend, Weiner was spotted taking out, of all things, his dirty laundry. Later that day, he announced he was entering a rehab facility to treat his psychological issues.
"It really told me that this is someone who was totally out of control, who gave in completely to his impulses, and this was extremely destructive," psychologist Jeff Gardere said of the photos.
With key Democratic Party leaders now urging Weiner to resign, one can't help but wonder: is the Congressman's career over?


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A holistic approach to digital learning
CGI supplied thousands of computing devices to teachers and students during the first wave of the pandemic
Thanks to their early adoption of innovative teaching tools, some Scottish schools were already well prepared for the digital revolution, writes Nan Spowart.
THE value of using digital tools to access learning has been brought to the fore due to the current pandemic, but in certain parts of Scotland the advantages had already been understood and innovative programmes were already being adopted.
Global tech company CGI has been rolling out devices which have proved invaluable in delivering continuity of learning during this time.
The pandemic has accelerated this strategy and, while it is hoped pupils will soon be able to return to their physical classrooms, it seems certain that some form of digital learning will remain in place, as it has a plethora of benefits for pupils, teachers, parents and carers.
Two areas that had started ground-breaking work before the pandemic were the Scottish Borders and Glasgow which, with CGI's help, were deploying their Empowered Learning solution as part of the Inspire Learning and Connected Learning projects
Originally seen as a way of removing the issue of inequality of access to digital learning, improving attainment and increasing efficiency, the importance of the projects has been highlighted by the closure of schools and the need for pupils to learn from home.
In both areas, iPads are being supplied to all pupils from Primary 4 (Borders) and Primary 7 (Glasgow) upwards with devices used by the younger children in class.
In Glasgow in particular, the roll-out is vast and specifically targeted at equity so that every child has access to the same tools for learning. When the initial lockdown hit, CGI made a huge effort to continue to supply devices to teachers and students. In the Borders this involved developing a home delivery approach where pupils and parents were helped to build and operate the devices with the aid of videos and phone support.
"It has been an effective partnership with our customers in both Glasgow and Scottish Borders to make sure that they can continue the delivery of education and we are very proud of that," said Richard Sadler, Director Consulting Expert for education at CGI.
With over 65,000 managed devices across both projects, the second lockdown has meant schooling has been easier this time round for those supplied with iPads and the knowledge of how to use them properly.
"Parents are talking positively about it – access to the device is a massive help – there has been a big difference between the first and second lockdowns," said Sadler. "Educators also speak highly about having one solution across the board, with everyone having the same devices. Having a uniform approach really helps."
In Glasgow the expedited deployment phase for primary and secondary is now complete – ahead of the original end date of August 2021. An additional 6,940 iPads have been deployed for vulnerable children and all teachers and pupils from P7 to S6 now have their own tablets. Shared devices are being deployed across users in P1 to P6 and teachers in early year establishments.
"In Glasgow remote learning has been heavily reliant on tablets as part of the connected Empowered Learning solution," said Sadler. "We have seen a threefold increase in usage and active connections since schools adopted remote learning. This solution is allowing secondary schools to follow existing timetables and utilise digital learning for lessons."
There is also the opportunity for parents to receive a personalised code to access uploaded digital learning content for their children and over 4,000 new Apple TVs and projectors have been installed within classrooms as part of a huge upgrade to classroom AV infrastructure.
"Making sure there is a good quality, secure, safeguarded solution that everyone can use whether they are in school or not is really important to us," said Sadler.
An added benefit has been seen around mental health during an incredibly difficult year for young people. The iPads from Empowered Learning mean teachers can keep in regular contact with students and how they are feeling.
"Meaningful contact is very important for both students and their teachers during this period. Teachers are being supported and we are also trying to help parents wherever we can," Sadler said.
However, when the pupils are back in school full time and the pandemic is behind us, digital learning will continue because of the benefits it offers, including reducing the equality gap and helping to raise levels of attainment.
Whether at home or in a busy classroom, pupils can be given speedy feedback from teachers.
Using the devices in this way can save teacher time and increase engagement from pupils as they feel better supported and can be more creative as a result of all the ways the devices can be used.
"Personalised feedback and timeliness are really important in raising attainment and teachers are able to do that through apps, video clips and sound clips on pieces of work," said Sadler.
"Also, via our Monitoring & Tracking web service we can capture key education attainment data and reduce the time it takes to do school reports. We try to take away the resource heavy activities in order to allow teachers to focus on teaching. Working with the Empowered Learning solution day to day gets the best outcomes for everyone."
This includes making sure the devices are safe and secure.
"We manage all the tablets and make sure the security updates are reviewed and updated at the right times so they don't affect the school day," explained Sadler.
"We also apply content filtering both at school and at home to safeguard the pupils. We work closely with customers on the apps they use to make sure all apps are assessed and secure for use. The app store is agreed with customers so schools can access the appropriate apps but not anything else. Empowered Learning is a fully managed but flexible solution."
Sadler is convinced the effect of the pandemic will make digital learning more widespread in future.
"In Glasgow and the Borders key large education transformation programmes had already started before Covid focussed on learning and teaching, equity of access to learning, raising attainment, creativity, mobility – the pandemic has just highlighted their importance."
Digital learning for all is here to stay.
cgi.com/uk
This article appears as part of The Herald's The Future Of Education campaign, in association with CGI.


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Home People Community Loews Hotels CEO Contributes $10,000 to AH&LEF
Loews Hotels CEO Contributes $10,000 to AH&LEF
WASHINGTON, D.C.—Kirk Kinsell, president and CEO of Loews Hotels & Resorts, contributed $10,000 to the American Hotel & Lodging Educational Foundation 2016 Annual Giving Campaign, marking his fourth consecutive personal gift in the last four years at the six-diamond level or higher, and his first at the leadership level.
The Annual Giving Campaign is the Foundation's yearly fundraiser that raises unrestricted funds to support its core missions, including providing scholarships to hospitality management students and hotel employees; funding important research in areas such as room tax, economic impact studies, and ADA requirements; and workforce development initiatives that promote hospitality as a career of choice.
Additionally, Kinsell has recently made a personal pledge of $100,000 to a special AH&LEF major fundraising effort which he is chairing and will be publically announced in the coming months. Vice Chair of AH&LEF's board of trustees and a long-time, active member of the American Hotel & Lodging Association, Kinsell is a fourth generation hotelier and has worked in the hospitality industry for more than 30 years.
"The talent agenda has to be a number one priority for all of us in the hotel industry, and supporting research and exceptional students as future leaders is all of our responsibility," said Kinsell. "In my own career, I have seen how crucial industry support is and giving back is a responsibility we all have. It's my honor to participate in this industry I love so much and support our future—and current— professionals."
"Kirk has been such an instrumental figure in our industry and at the Foundation. His incredible gestures of support are a testament to the value in our programs. We are thrilled that Kirk, who is at the helm of one of the biggest and most influential brands in our industry, is supporting the Annual Giving Campaign at such a high level," said Joori Jeon, AH&LEF president and COO. "Kirk leads by example. His personal philanthropic leadership should encourage all to be so generous in their giving."
AH&LEF is the not-for-profit affiliate of AH&LA and is funded solely by charitable donations from progressive hospitality leaders and companies within the industry. In 2016, AH&LEF anticipates disbursing more than $1.5 million to prepare promising college students for a career in hospitality, to attract and retain talented industry professionals, and to fund valuable research for the industry. Since the Foundation's inception, $20 million has been distributed through its scholarship, education, outreach, and research programs.
Loews Hotels & Resorts
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The projected upper bound is: 1.62.
The projected lower bound is: 1.39.
The projected closing price is: 1.50.
STARHUB LTD closed up 0.010 at 1.510. Volume was 23% below average (neutral) and Bollinger Bands were 57% narrower than normal.
STARHUB LTD is currently 13.2% below its 200-period moving average and is in an upward trend. Volatility is extremely low when compared to the average volatility over the last 10 periods. There is a good possibility that there will be an increase in volatility along with sharp price fluctuations in the near future. Our volume indicators reflect moderate flows of volume out of STAR.SI (mildly bearish). Our trend forecasting oscillators are currently bullish on STAR.SI and have had this outlook for the last 4 periods.
One method of interpreting the Stochastic Oscillator is looking for overbought areas (above 80) and oversold areas (below 20). The Stochastic Oscillator is 9.0909. This is an oversold reading. However, a signal is not generated until the Oscillator crosses above 20 The last signal was a buy 7 period(s) ago.
The RSI shows overbought (above 70) and oversold (below 30) areas. The current value of the RSI is 39.85. This is not a topping or bottoming area. A buy or sell signal is generated when the RSI moves out of an overbought/oversold area. The last signal was a buy 8 period(s) ago.
The CCI shows overbought (above 100) and oversold (below -100) areas. The current value of the CCI is 38. This is not a topping or bottoming area. The last signal was a buy 8 period(s) ago.
During the past 10 bars, there have been 1 white candles and 3 black candles for a net of 2 black candles. During the past 50 bars, there have been 10 white candles and 22 black candles for a net of 12 black candles.


A classic! Rolleiflex were always notable for their exceptional build quality, compact size, modest weight, superior optics, durable, simple, reliable mechanics and bright viewfinders.
Oh, you're the one that I want!
Also, the exceptional street photographer Vivian Maier shot with Rolleiflex. Check her work here, and a documentary made about her intriguing story here.


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Poseidon ist ein Seekabel für die Offshore-Öl- und Gasindustrie im östlichen Mittelmeerraum. Es wurde 2012 in Kooperation der Cyprus Telecommunications Authority (Cyta), dem staatlichen Kommunikationsanbieter der Republik Zypern, mit der Radius Oceanic Communications (Radius), ein auf Fieberglasanbindungen von Offshore-Plattformen spezialisiertes Unternehmen, ausgelegt.

System
Das 800 km lange System bildet einen Ring um Zypern und erstreckt sich in dessen ausschließlicher Wirtschaftszone. Die Cyta-Seekabel-Landstationen Pentaskhinos und Yeroskipos werden von Poseidon als LAN-Anbindungen genutzt. Radius will für bestehende und künftige Öl- und Gasbohrplattformen ein gesamtes Kommunikationspaket anbieten.

Einzelnachweise

Telekommunikations-Seekabel
Wirtschaft (Republik Zypern)
Offshorebauwerk (Mittelmeer)


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The Air Force Academy's Sexual Assault Prevention Office Is A Total Disaster
Mismanagement of the Air Force Academy's Sexual Assault Prevention and Response Office has put the school out of compliance with...
By Tom Roeder, The Gazette (Colorado Springs, Colo.) | Published Feb 9, 2018 3:27 PM
Mismanagement of the Air Force Academy's Sexual Assault Prevention and Response Office has put the school out of compliance with Defense Department policies, a Pentagon report released Wednesday said.
The problems, revealed late last year in a 560-page report released to The Gazette under the Freedom of Information Act, included infighting, mishandled cases, questionable record keeping and alleged office romances.
"A commander-directed investigation disclosed significant evidence of mismanagement and unprofessionalism that negatively impacted victim advocacy and assistance rendered to a number of cadets," the Pentagon said in its latest report, which compares sexual assault programs across the military's three major service academies.
The academy was the only program found to be operating outside Defense Department guidelines, but for the first time in a decade saw its sexual assault numbers fall below its peers.
Air Force had 33 reported sexual assaults, with Army tallying 50 – nearly doubling its numbers in a year. Navy had 29 reported sexual assaults.
"We are absolutely committed to making the academies safe," said Robert Wilkie, the Defense Department's undersecretary for personnel and readiness. "It is imperative that these future officers understand how eliminating sexual harassment and assault advances our ability to protect the nation."
The report found that programs at the Naval Academy in Maryland and the U.S. Military Academy in New York complied with Pentagon policies, with Air Force falling short because of chaos in its prevention office.
Overall, reported sexual assaults at the three academy showed a sharp increase, to 112 for the year from 86 in the prior year.
The Defense Department attributed the increase to changes at West Point.
"Most of the reporting increase occurred at the U.S. Military Academy following a change in reporting policy and the relocation of its victim assistance office," the report said.
Investigators praised Air Force sexual assault prevention programs in the report, but found the school hadn't properly cared for victims.
Problems arose last summer in the Air Force sexual assault response office after leaders suspended its director Theresa Beasley and other workers. Last fall, the academy released its report that found the office had been "derelict" in victim care, with some victims ignored.
The new report acknowledged the problems, but found the academy had taken appropriate steps to address its woes.
"The department saw substantive evidence that the superintendent and the leadership team were fully engaged in making sexual assault prevention and response a priority for the academy," the report said.
The academy on Wednesday said it is in the final stages of hiring new workers in its sexual assault office.
"This includes a new program manager, two sexual assault response coordinators, three victim advocates and two violence prevention integrators," the academy said in an emailed statement.
The hirings, the academy said, are the last step in addressing the troubles of 2017.
"We are confident that we have addressed the issues in the … office at the academy and will continue to scrutinize our efforts and remain transparent as we strive to develop a culture of dignity and respect at the academy," the statement said.
©2018 The Gazette (Colorado Springs, Colo.). Distributed by Tribune Content Agency, LLC.
Military Sexual Assault


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Causes of World War 1
Submitted By: alexanderhook
Although there were many reasons the European Nations first broke out in war, the fighting of Austria-Hungary and Serbia contributed to the expansion of the war. This war was resulted by the aggression of European countries that strived to be the best. These country's nationalism, militarism, imperialism and alliances escalated into the spreading of war. (The Great War 1)
Imperialism was at the hands of Germany during the outbreak of war. Germany was not far-gone when it came to taking over territories in Africa. They had to compete against France and Great Britain to gain control of this territory. This competition spelled out war between these European countries. Germany's intent here was to better their own country, and prove that their country was better than all the rest. The extreme nationalism led European nations to compete for the largest army and navy, or for the greatest industrial development. This proves that not only does Germany use imperialism, but they use nationalism as well. Territorial disputes were an ongoing problem for many European countries. The leaders of these countries always wanted more land to make them better than all the rest, but the leaders did not know who owned this land because it was always being taken. As we know, Germany declares war on France on August 3rd, 1914 claiming that France came upon their territory. Once this happened, many other countries got involved. Once Germany declared war on France, they moved into Belgium where they took over. Great Britain sent an ultimatum to Germany stating if they didn't withdraw from Belgium, they would have to enter the war. (Germany during World War One 3)
In 1879, Germany and Austria-Hungary formed a Dual Alliance. In 1882 this became the Triple Alliance when Italy joined in. Each country established that they would assist one another if attacked by either France or Russia. Accepting Italy was because they did not want Italy choosing sides with Russia....
Major Causes of World War 1
Causes of the First World War
Causes of the Great World War
Causes of World War Ii
cause of world war 2
Long Term Causes of the First World War
The Cause of the Break Out of World War I
World War 1&2


One can, without any doubt say that the employees of an organization work chiefly for the benefits and compensation, in the first place. As such creating an efficient benefits and compensation program is profoundly imperative from a management standpoint. The magnitude of effectively managing various compensation and benefits program is stressed further by the fact that its mismanagement can negatively affect the contentment of the employees which can lead to dwindling levels of efficiency, productivity, effectiveness and overall profitability of the organization. As such, it is really central that all businesses have human resource professionals adequately outfitted with all the required skills to make, implement and control a choice of benefits and compensation programs.
Upon taking the compensation and benefits training program offered by us, the aspirants can gain outstanding knowledge in the below given areas of the process of compensation management.
· Become proficient in a variety of compensation and benefits programs and understand total rewards at the same time.
· Be able to establish the management objectives of the business and incorporate the same seamlessly into a mixture of compensation strategies.
· The aspirant wills also acquire the natural aptitude to appraise the techniques used for job pricing and assess if it can help the business improve the morale and satisfaction levels of the employees adequately.
· Successfully employ a range of data analytical and statistical techniques and methods to carry out exceptional compensation research and activities.
· It also will help the candidate assess the compensation requirements of the employees from time to time and devise effective programs to meet the changing requirements of the employees.
The training program is conceived with the intent of not only helping the professionals to become certified but also provide various businesses with the ability to enhance the skills of their HR executives and payroll professionals carrying out various compensation activities.


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Nut Browned Ale for Christmas 2005 - a review
Peter Scholey, ex lead brewer of Brakspear and soon-to-be brewer for the resuscitated same, has a line of Christmas beers he contract brews under the name Ridgeway. I believe he uses the Brakspear yeast strain which he rescued from oblivian. Anyway, the line includes Bad Elf, Very Bad Elf, Lump of Coal, and more. My favorite of the bunch is new this year - Warm Welcome Nut Browned Ale.
The label has a picture of Santa descending down the chimney, his lower extremeties about to be scorched on a roaring fire - hence the name of the beer. What a wonderful brown ale - nutty, light caramel, hints of low-toned fruit. Except for its higher alcohol - 6% - I could believe this to be what Newcastle Brown may have once been.
Banned in Connecticut due to the drawing of Santa Claus on the label!
From the importer's website:
It's a sad tale, the closing of the venerable Brakspear brewery in Henley-on-Thames, where the most famous and surely the best Bitter in England has been made for centuries. The brewery, in operation since 1779, was sold off in 2002 in parts to make room for an upscale hotel, and everyone who worked there was let go, without so much as a by-your-leave. But for beer lovers, the closing was not a complete disaster. Thankfully, the master brewer at Brakspear, Peter Scholey, determined to strike out on his own. Peter has set up shop as Ridgeway Brewing, not so far from Henley, and already he's putting out beers so good they could almost make you forget Brakspear altogether.
The Ridgeway Brewery is named for the ancient road – passable now only on foot – that meanders along a low escarpment across the high, rolling pastoral plain that is the southwest of England. The now patchy stone surface of the Ridgeway was laid by Britain's oldest inhabitants – Druids and the like – thousands of years before the Romans turned up to build their own roadways. It is the oldest road in the British Isles and Europe, running nearly 100 miles, past that other ancient landmark, Stonehenge, as well as Peter Scholey's relatively modern home, along the way.


text:
Shaivism
Shaktism
Vaishnavism
Pancaratra
Ganapatya
Theravada
Mahayana
Dhanurveda
Dharmashastra
Jyotisha
Natyashastra
Rasa-shastra
Shilpa-shastra
Vastu-shastra
Kosha
Subhashita
Various traditions
All glossaries
Animal Kingdom (Tiryak) in Epics
by Saranya P.S | 2019 | 51,616 words | ISBN-10: 8190396315 | ISBN-13: 9788190396318
Hinduism Purana
An English study the Animal Kingdom (Tiryak) in Epics.—The present thesis is based entirely on Ramayana and Mahabharata although an attempt is made to analytically compare the Animal kingdom with Mriga-pakshi-shastra—'The ancient Indian science of of Animals and Birds'....
Chapter 1.11 - Interpretation of myths
(index)
Different European scholars used various theories for interpreting myths. Some of them considered myths as allegories. Some others insisted that they are symbolic or primitive rationalism.10Here some of the more important theories which interpret myths are discussed.
The allegorical theory:
According to the allegorical theory, myths are nothing but allegories. They contain deep and edifying meanings. They are the creations of primeval sages with intentional obscurity. The wisdom of the ancient sages is hidden in allegories because of the following reasons:
i. They might have wished to prevent great truths passing into the hands of persons too ignorant to deal with them.
ii. Their intention might have been to attract people by stories since a dry and formal discussion fails to do it. This theory treats the story as a garment under which a hidden meaning should be sought.
For example, the mediaeval Christian mythologists read "Pilgrim's Progress" as demonstrating the life of a wise Christian, patiently suffering many hardships finally returning to the abode of his God. Homer's Iliad and Odyssey can also be read as some kind of allegorical tales.
The euhemeristic theory:
Euhemerus was a writer who lived in Greece after Alexander in BC 300. According t him gods of popular tradition were historical personalities. People who were benefited by these great men made them gods. Thus gods of popular traditions were simple men deified by those who benefited from them. Euhemerism is an approach to the interpretation of mythology in which mythological accounts are presumed to have originated from real historical events or personages. Euhemerism supposes that historical accounts become myths as they are exaggerated in the retelling, accumulating elaborations and alterations that reflect cultural mores. In the more recent literature of myth, such as Bulfinch's Mythology, euhemerism is termed the "historical theory" of mythology.
Euhemerus was not the first to attempt to rationalize mythology in historical terms, as euhemeristic views are found in earlier writings including those of Xenophanes, Herodotus, Hecataeus of Abdera and Ephorus. However, the enduring influence of Euhemerus upon later thinkers such as Ennius and Antoine Banier identified him as the traditional founder of this school of thought. Euhemerus asserts that the great god Zeus as originally a human hero who was deified by the community in return for his victory over the oppressive tyrants. Thus, myths often explain historical happenings.
Last Updated: 12 August, 2021
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text:
Axios Review – a different route to peer review
BioMed Central formalizes its partnership with Axios Review, an external peer review service that aims to improve the efficiency of the peer review system.
Elizabeth Moylan 27 May 2015
Energy efficient peer review
Flickr/Michael Smith
Just last week at BioMed Central's London Roadshow, authors, peer reviewers and Editors were discussing some of the current challenges with peer review. We heard about the struggles researchers faced with a system which can be slow, inefficient, political and prone to bias. Because of this, BioMed Central always welcomes initiatives which work to improve the peer review process and Axios Review aims to achieve just that.
The premise, according to its founder Tim Vines, is to improve the efficiency of peer review and make it less arduous for researchers.
I spoke to Tim Vines about why he set up Axios Review, and in this short podcast he explains his motivation for starting the service.
https://blogs.biomedcentral.com/bmcblog/wp-content/uploads/sites/7/2015/05/Tim-Vines-on-Axios-Review.mp3
Vines discusses the inefficiencies in peer review that come with rejecting a manuscript that is sound but just doesn't 'fit' a given journal, only to see the process repeated (and end with rejection) at another journal. His proposed solution is to position peer review 'upstream' of submission to a given journal.
To do this, Axios has set up a process which runs as follows:
Authors submit a manuscript for peer review to Axios, suggesting four journals where they'd like to see their work published.
Axios manages the peer review process and peer reviewers advise on the suitability of the manuscript for publication in selected journals.
Axios then contacts the recommended journal(s), with the reviewer reports to see if the Editor would be willing to consider the manuscript.
If the Editor agrees, Axios lets the authors know and it's up to authors whether they take up the journal's offer.
Axios charge authors a fee of $250 for their services, once a decision has been made on their manuscript. (A charge we subtract from our article processing charge, for authors who use the service, in acknowledgement of the fact that the peer review process has been managed externally.)
We announced a trial partnership with Axios Review in May 2014, and since then we've published a number of manuscripts from authors via this route. BioMed Central editors are also excited by innovations which can facilitate the peer review process and benefit authors, reviewers and editors a like.
In this interview, two of our Editorial Board Members who are also on the Editorial Board of Axios Review explain why they chose to engage with Axios. Certainly, based on the feedback we've received (see below) and how smoothly the process has worked we're delighted to formalize our partnership.
Why would an author submit to Axios Review?
There are various reasons why an author might find Axios Review helpful, but we've found it's been particularly useful when authors are unsure about where to send their manuscript.
Bert Van Bocxlaer explained that he submitted his manuscript to two journals before going to Axios Review and receiving an offer via this route from BMC Evolutionary Biology:
"Although the manuscript received invariably positive comments from the reviewers, it was rejected both times because 'our paper didn't fit the journal scope', which makes one wonder why it was sent for review in the first place, and once because the editors did not consider it sufficiently innovative for their journal in the end.
"We felt that our paper was becoming a moving target – decisions were not substantiated with scientific arguments, but rather with subjective judgments – which is why we submitted to Axios Review."
What was the experience like?
The reviewers as well as the editor helped me to decide on the most appropriate journal. When I made the necessary corrections and submitted my manuscript to the chosen journal, it was accepted within 24 hours!
Stephanie Dowell
We found that authors were generally satisfied with the turnaround times and reviewer comments when they submitted to Axios.
Author Liliana Davalos found the experience to be: "Overall positive, we were able to get feedback promptly and to rewrite the manuscript with a clearer target the second time."
Stephanie Dowell, who also used the service, echoed this saying, "The reviewers as well as the editor helped me to decide on the most appropriate journal. When I made the necessary corrections and submitted my manuscript to the chosen journal, it was accepted within 24 hours!"
Do you think peer review services like this will become more common?
Bert Van Bocxlaer felt that the competition to publish research in biology is increasing:
"Most [of my colleagues] indicate that they regularly need to submit manuscripts multiple times before they find them accepted."
Stephanie Dowell said, "I absolutely think reviewing services will become more common. I hope that a greater number of journals will be willing to cooperate with reviewing services in the near future."
Liliana Davalos added, "There is a real sense of explosion in biology. We need services like this because there simply are too many potential target journals and this makes the process arduous, especially for beginners. Having the ability to get the peer reviews without worrying as to the journal fit is a bonus."
So did this 'route' increase the efficiency of peer review?
On the whole, the feeling of everyone I spoke to was that it did…
Bert Van Bocxlaer said, "Our paper was handled in a timely way by Axios, the reviews were overall constructive, and the editors handled the referral process to potential journals very well. Overall, we were satisfied with the handling by Axios Review, and we would recommend it, certainly to colleagues who have trouble deciding on the submission strategy for a particular paper."
Another author, Bjorn Stelbrink added, "Not only do you receive suggestions from the reviewers about which target journal is most suitable, you also save time compared to submitting a manuscript to four journals in succession."
With the caveat that reviewing services are able to provide quality feedback in a timely manner Stephanie Dowell could also see the potential for them to be "extremely beneficial".
To conclude, Eric Pante noted that, "Peer review in itself is the same whether you go through Axios or another journal; what's very efficient with Axios is the fact that experienced editors then help you better target a journal to submit to. I would say that a service like Axios increases the efficiency of science communication – getting published faster than through traditional routes."
So after feedback like that, hopefully you can see why we think our partnership with Axios Review could bring great benefits to researchers looking for a place to publish.
Admin in research: the good, the bad and the ugly
Publish or perish: is there an alternative?
View the latest posts on the Research in progress blog homepage
Elizabeth Moylan
Senior Editor (Research Integrity) at BioMed Central
Elizabeth has a PhD and post-doc from the University of Oxford, UK. In 2004, she moved into publishing as an in-house Editor handling peer review on the BMC-series journals. In her present role as Senior Editor (Research Integrity), Elizabeth has oversight of editorial policies and peer review processes and is particularly interested in models of peer review.
Latest posts by Elizabeth Moylan (see all)
Advancing peer review at BMC - 24th November 2017
What does transparency in peer review mean to you? - 21st September 2017
Peer Review Week – it's back! - 18th July 2016
Popular BioMed Central blog tags
Tweets by @BioMedCentral


Where can i find some anime episodes (RAW)!!!
Hun, it depends on what Anime you're looking to get. Cuz I can get all the Raw Soul Eater episodes from youtube, I can get some footage from other animes from other sites like Veoh. I also just google the specific episode I'm looking for and SOMETIMES it'll have a link that works.


text:
Police Discover More Than 350,000 Images Of Child Porn Found On Church Worker's Computer [VIDEO]
A former music director at a Florida church has been charged with multiple child sex charges after a coworker trying to prank him stumbled upon more than 350,000 images of child pornography on the man's laptop, police said.
Chad Everett Robison, 36, of Hernando, is charged with three counts of video voyeurism, three counts of lewd and lascivious exhibition and one count of promoting the sexual performance of a child, according to the Citrus County Sheriff's Office. He remained in the Citrus County Jail on Monday in lieu of $26,000 bond.
"I want to emphasize that this is a textbook case of an online sexual predator," Sheriff Mike Prendergast said during a Thursday afternoon news conference, which was streamed live on Facebook. "It will not be tolerated in Citrus County, and we're going to vigorously pursue people who commit crimes like this."
Prendergast detailed some of what investigators found on Robison's laptop.
"We have videos of Robison having virtual sex with an underage female who is not local, as well as trying to coerce young girls to show him their breasts while he masturbated on camera with them," Prendergast said. "In addition, the defendant was secretly videoing and recording females in his restroom at his home over the course of the time that he gathered up these digital images and videos. We have yet to identify those victims, so additional charges may be forthcoming as we continue to press through the evidence that we've gathered."
Prendergast said in a news release last week that the investigation thus far has "just scratched the surface," and that investigators anticipated finding additional suspects as the probe continues.
Capt. Brian Spiddle, with the Sheriff's Office's Major Crimes Unit, said some of Robison's victims could be local, but that others have already been identified out-of-state and in Canada. Investigators have contacted the law enforcement agencies in those jurisdictions.
"It's going to be a very difficult and long process to find those who have been victimized by this man," Spiddle said in the news release.
German Teen Who Fled To Join ISIS Is Having Second Thoughts….
[VIDEO] New Kennedy Assassination Information Released


The Democratic Party has become the target of a take-over bid mounted by a heterogeneous coalition of anticapitalists, feminists and supporters of allegedly downtrodden ethnic minorities.
Something very strange is happening in US politics. By making full use of his many histrionic talents, Donald Trump keeps driving the Democrats further and further towards the left-hand side of the ideological spectrum. While in Europe and elsewhere leftist parties are getting wiped out in places they once dominated, in the US, the people who currently call the shots in their transatlantic counterpart are staging a gleeful onslaught against the established order and are advocating policies of the kind that strongly appeal to student radicals but have traditionally been rejected by the wider population.
Ever since he began his rise to high office, Trump has sought to knock his opponents off balance and make them behave in a manner that would cost them support. As he well knows, what soon got dubbed "the Trump derangement syndrome" has let him play the role of a circus ringmaster; whenever he cracks his whip, the entire world starts dancing. By behaving the way he does, he goads his many foes into assuming bellicose postures, hence the leftward lurch of a party that, from a European perspective, used to be stodgily conservative on almost all issues.
This is why Trump continues to go on about the need to build his famous wall. He may lose some battles in the Lower House which the Democrats control, but he evidently thinks he will win the war because most North Americans remain unconvinced that they, or their country, would be better off were border controls to be abolished as some of the more enthusiastic Democrats would like. Most may want the laws to be made more flexible and feel sympathy for those who arrived when they were children, but are unable to see the advantages of admitting unchecked large numbers of semi-literates liable to end up on welfare, let alone the gang-members or Jihadists who would be sure to accompany them.
Like Labour in the United Kingdom, the Democratic Party has become the target of a take-over bid mounted by a heterogeneous coalition of anti-capitalists, feminists, supporters of allegedly downtrodden ethnic minorities and Islamist militants whose loathing for "Zionism" is hard to distinguish from feverish antiSemitism. On a roll, some such rebels against the established order seem to think they have the party in the bag and the White House is there for the taking.
The Starbucks billionaire, Howard Schulz, disagrees: convinced that Donald Trump would thrash any far-out candidate, or that if he failed to do so, the winner would then go on to wreck the US economy and while about it, set off an explosion of violence, Schulz says he will enter the lists, a decision that has greatly alarmed his fellow-Democrats who fear that by splitting the progressive vote, he could hand the hated incumbent an easy victory.
For months, would-be Democrat presidential candidates, of whom there are many, have been doing their best to outbid one another in an effort to show they are more radical than any of their rivals. Back in 2015, Bernie Sanders was regarded as too much of a socialist to have any chance of winning in a country that has always been averse to anything smacking of that particular creed, which was one reason why Hillary Clinton found it easy to get the party bosses to thwart him, but by today's standards, old Bernie was a moderate. As for Barack Obama, activists will remember him fondly as a grizzled old patriarch whose quaint ideas seemed advanced in the dark ages from which, thanks to them, the US is now emerging.
One Democrat front-runner, Senator Kamala Harris, who is said to be "black" though, on television at any rate, she is no more so than most Europeans or Latin Americans, wants to phase out all unrenewable energy sources within 10 years, an idea she picked up from Alexandria Ocasio-Cortez, the scatterbrained young congresswoman who is happy to admit that she is no expert on the issues she talks about. Her frankness in this respect has not harmed her; many see in the chirpy 29-year-old the future leader of US progressivism.
In his State of the Union address, Trump defiantly told the assembled legislators that "America will never be a socialist country," a pronouncement that echoed the words of Brazil's new President Jair Bolsonaro when talking about his country's future. However, by riling his opponents so much that many adopt postures that, before he arrived on the scene, would have struck most voters as outlandish, Trump is playing a dangerous game. Psephologists agree he has a good chance of getting re-elected, but if he loses he could be replaced by a man or woman committed not only to a series of drastic social reforms but also to spending far more money than even the US economy is capable of generating.
There can be little doubt that going "green" almost overnight in order to fight climate change would have a devastating impact on manufacturing, which would be bad news for tens of millions of working-class people of many ethnic origins who are getting left behind by the technological revolution. Even more harmful would be the boost given to "identity politics" by politicians who are exploiting the many existing grievances for all they are worth. Waging war against "whitey" and his disgraceful proclivities may play well in inner city districts and in prosperous places where allegedly progressive thoughts are in fashion, but it would not help overcome the divisions that, pessimists warn, are Balkanising US society.


text:
<?xml version="1.0" encoding="ISO-8859-1"?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">

<title>guid must be a full URL, unless isPermaLink attribute is false</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />

<link rel="start" href="http://feedvalidator.org/docs/" title="Home" />

FEED Validator

Documentation

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Message

guid must be a full URL, unless isPermaLink attribute is false

Explanation

By default, the guid element specifies a permanent link for an item, the value must be a full URL (starting with ""http://"").

Solution

If you are using the guid element as a permanent link, make sure the value is a full URL, including the "http://" at the beginning.

If you are using the guid element simply as a unique identifier (and not a link to the item), then the value can be whatever you want, but you must include the attribute isPermaLink="false" in the guid tag.

Both of these are valid guids:

<samp><guid>http://www.example.com/archives/000054.html</guid></samp>

<samp><guid isPermaLink="false">article 54 at example.com</guid></samp>

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<address>Copyright © 2002-4 Mark Pilgrim and Sam Ruby</address>

redpajama_set_name: RedPajamaGithub


Enjoy downloading the Valentine Party Flyer Template created by Saltshaker911!
Valentines Party Flyer is unique and colorful party flyer. It is perfect for any kind of your parties, the main file include .psd file (Photoshop file) It is very easy to edit all the text colors images etc. A Fresh design for your valentines event, with a unique top-down perspective, and realistic light effects. you can easily change Texts, Colors, Add/Remove objects to this layered PSD , To get new versions of the design. What you see is what you get… all elements shown are included in the PSD.
The Valentine Party Flyer Template was designed to promote your next Valentines Day Party and Club Event. This print ready premium flyer template includes a 300 dpi print ready CMYK file. All main elements are editable and customizable. You can edit the main text via text tool, the model image you can replace via smart object, right click edit smart object in your layer menu. The flyer is fully layered and organized to keep customization very simple!


text:
[![Build Status](https://travis-ci.org/Prowect/Routing.svg)](https://travis-ci.org/Prowect/Routing)
[![Code Climate](https://codeclimate.com/github/Prowect/Routing/badges/gpa.svg)](https://codeclimate.com/github/Prowect/Routing)
[![Test Coverage](https://codeclimate.com/github/Prowect/Routing/badges/coverage.svg)](https://codeclimate.com/github/Prowect/Routing/coverage)
[![Latest Release](https://img.shields.io/packagist/v/drips/Routing.svg)](https://packagist.org/packages/drips/routing)

## Beschreibung

Das Routing ist zuständig für die Auslösung der URLs zu PHP-Funktionen. Somit können (schöne) URLs manuell festgelegt werden.

## Installation

### Apache 2

Einfach eine `.htaccess` Datei im entsprechenden Verzeichnis hinzufügen:

```apacheconf
<IfModule mod_rewrite.c>
    RewriteEngine On
    RewriteCond %{REQUEST_FILENAME} !-d
    RewriteCond %{REQUEST_FILENAME} !-f
    RewriteRule ^(.*)$ index.php [QSA]
</IfModule>
```

> Hierfür muss das Rewrite-Modul (`mod_rewrite`) des Webservers aktiviert sein.

### NGINX

Grundsätzlich müssen alle Anfragen an die `index.php` weitergeleitet werden. Hierfür kann folgende Konfiguration verwendet werden:

```nginx
location / {
    if (!-e $request_filename) {
        rewrite ^(.*)$ /index.php;
    }
}
```

## Verwendung

### Anlegen eines Routers

Zuerst muss der Router geladen und angelegt werden.

```php
<?php
use Drips\Routing\Router;

$router = Router::getInstance();
```

### Hinzufügen von Routen

Nachdem ein entsprechender Router angelegt wurde, können für diesen Routen registriert werden.

```php
<?php
$router->add("name_der_route", "/my/url", function(){
    echo "Hello World!";
});
```

> Wird die URL `/my/url` aufgerufen, so wird die festgelegte Funktion ausgeführt und es wird `Hello World!` angezeigt.

> **Achtung:** der Name der Route muss eindeutig sein. Ist der Name bereits vergeben, kann die Route nicht hinzugefügt werden.

#### MVC-Unterstützung

Das Routing-System unterstützt zusätzlich die Verwendung des [Drips-MVC](https://github.com/Prowect/MVC) Systems. Dementsprechend kann beim Hinzufügen von Routen nicht nur eine Funktion sondern auch ein Controller übergeben werden:

```php
$router->add("name_der_route", "/my/url", MyController::class);
```

#### Routen mit Platzhaltern

Oftmals sind Routen dynamisch. Deshalb können die Routen auch mit Platzhaltern versehen werden. Ein Platzhalter verwendet folgende Schreibweise: `{name_des_platzhalters}`.
Alle Parameter entsprechen den jeweiligen Platzhaltern. (Die Reihenfolge der Parameter ist zwingend einzuhalten!)

```php
<?php
$router->add("name_der_route", "/my/url/{name}", function($name){
    echo "Hello $name!";
});
```

Außerdem können die Platzhalter mithilfe von regulären Ausdrücken eingeschränkt werden.

```php
<?php
$router->add("name_der_route", "/my/url/{name}", function($name){
    echo "Hello $name!";
}, array(
    "pattern" => array(
        "name" => "([A-Za-z]+)"
    );
));
```

#### Routen einschränken

Die Routen können mehrfach eingeschränkt werden:

 - auf bestimmte Domains
 - nur für HTTPS-Verbindungen
 - auf bestimmte Verbs (Request-Methoden) ... GET, POST, DELETE, PUT

Um eine Einschränkung festlegen zu können wird beim Hinzufügen einer Route ein weiterer Parameter angegeben. Dieser ist ein Array und beinhaltet alle gewünschten Einschränkungen.

```php
<?php
$router->add("name_der_route", "/my/url", function(){
    echo "Hello World!";
}, array(
    "https" => true,
    "verb" => ["POST", "GET"],
    "domain" => ["example.com", "example.at"]
));
```

### Routing starten

Wenn der Router angelegt ist und alle Routen registriert sind, dann kann mit dem Routing-Prozess begonnen werden. Dies funktioniert vollkommen automatisch - es muss lediglich die Funktion, die das Routen übernimmt, aufgerufen werden.

```php
<?php
$router->route();
```

### Routen abfragen

Die Methode `getRoutes()` liefert alle registrieren Routen zurück. Mithilfe der Funktion `hasRoutes()` kann überprüft werden, ob bereits Routen registriert wurden, oder nicht.

```php
<?php
if($router->hasRoutes()){
	// Es sind bereits Routen registriert
} else {
	// Es sind noch keine Routen registriert
}
```

```php
<?php
$routes = $router->getRoutes(); // returns array
```

### Seite nicht gefunden - Error 404

Wird keine entsprechende Route gefunden, wird eine `Error404Exception` geworfen.

```php
<?php
try {
    $router->route();
} catch(Error404Exception $e) {
    echo "Error 404 - Die Seite wurde nicht gefunden!";
}
```

### Links generieren

Damit sich die URLs jederzeit ändern können und auch von unterschiedlichen Verzeichnissen aus aufgerufen werden können, werden die Verlinkungen mit Hilfe der `route` Funktion erzeugt.

Ein Link kann wie folgt generiert werden:

```php
<?php
$url = route("testRoute");
```

Übergeben wird der Name der Route. Des Weiteren können bei Routen mit Platzhaltern die Links auch entsprechend erzeugt werden, indem einfach die Parameter als Array übergeben werden.

Angenommen es gibt eine Route `/users/{username}`:

```php
<?php
$url = route("users", array("username" => "admin"));
```

### Assets

Das Link-System funktioniert auch für "Dateien", die nicht im Router registriert sind. Gibt es beispielsweise eine CSS-Datei, welche auf einer bestimmten Seite angezeigt werden soll, kann für diese ebenfalls ein absoluter Pfad generiert werden.

```php
<?php
$url = asset("css/style.css");
```

### Umleitungen

Oftmals ist es notwendig auf eine andere Seite weiterzuleiten. Dies erfolgt über die `redirect`-Funktion. Diese funktioniert im Prinzip genau gleich, wie die `routelink`-Methode, mit dem einzigen Unterschied, dass kein Link zurückgeliefert wird, sondern direkt auf diese Seite weitergeleitet wird.

```php
<?php
redirect("home");
```

### Automatisches Routing

Die Route wird wie folgt definiert: `/my/url/[auto]`. Somit werden alle Informationen die nach `/my/url/` folgen als Parameter übergeben.


text:
1-818-424-2220 Justin@prisonprofessors.com
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Another federal judge uses compassionate release as a second look resentencing provision
by Shon Hopwood | Jun 25, 2019 | Bureau of Prisons, Early Release from Federal Prison, First Step Act, Sentencing, Shon Hopwood
Another federal judge has found that the criteria for compassionate release, contained in the U.S. Sentencing Guidelines, is inconsistent with the statutory changes made by the First Step Act. Yesterday, Federal Judge Sim Lake reduced Arturo Cantu-Rivera's prior...
Federal District Court Judge uses compassionate release as a second look resentencing provision
by Shon Hopwood | Jun 24, 2019 | Bureau of Prisons, Early Release from Federal Prison, First Step Act, Reforms, Sentencing, Sentencing Guidelines, Shon Hopwood
I recently posted about my new law review article called Second Looks & Second Chances, and the argument that federal district court judges may use the compassionate release, as amended by the First Step Act, to give second looks in individual cases and then...
A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
by Shon Hopwood | Jun 18, 2019 | Bureau of Prisons, Early Release from Federal Prison, First Step Act, Reforms, Shon Hopwood
There is a viable argument for why federal district court judges can use the compassionate release statute, as amended by the First Step Act, as a second look provision to reduce a sentence for people in federal prison if "extraordinary and compelling reasons" are...
Why Prison Professors?
by Shon Hopwood | Mar 20, 2019 | Early Release from Federal Prison, Justin Paperny, Prison Consultant, Shon Hopwood
Why Prison Professors? I'm often asked why I co-founded a company called Prison Professors L.L.C. and further asked what the company does. I intend to answer both those questions in this post. I started Prison Professors with Michael Santos and Justin Paperny in the...
The Fight for the First Step Act
by Shon Hopwood | Feb 26, 2019 | First Step Act, Shon Hopwood
By the time this post is published, the Yale Law Journal Online will have published a series of essays from the formerly incarcerated, including mine on The Effort to Reform the Federal Criminal Justice System. In the essay, I explain how the First Step Act came to...
President Trump Congratulates Shon Hopwood
Preparing for Early Release
Good day for thinking hard about sentencing second looks and second chances – Jehtro Lewis – Blog on A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
Julie Harding on A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
Good day for thinking hard about sentencing second looks and second chances – Douglas Cogan on A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
Chad Marks on A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
Bette Davis on A Second Look at a Second Chance: Seeking a Sentence Reduction under the Compassionate Release Statute, 18 U.S.C. § 3582(c)(1)(A), as Amended by the First Step Act
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text:
Radical chik: Chikungunya fever presenting as a toxic epidermal necrolysis-like eruption
By Warren R. Heymann, MD
Chikungunya fever: morbilliform rash with islands of sparing. Photograph courtesy of Zawar Vijay, MD, Nashik, India.
Credit: JAAD
I have seen only one documented case of Chikungunya fever (CF), in a young woman who returned from Puerto Rico, presenting with high fever, joint pains, and a morbilliform rash (see image). Unfortunately, she will not be the last.
CF is caused by the Chikungunya virus, an RNA Flavivirus (which is related to the viruses responsible for Zika, dengue, yellow fever, and West Nile infections). Aedes aegypti and A. albopictus mosquitos are the main vectors. The emergence of CF is due to a multiplicity of factors, including climate change, urbanization, extensive agriculture, and global air transport. (1)
Riyaz reviewed 162 cases of CF (all but 5 confirmed by a positive IgM titer to the virus). Patients presented with either a single lesion or a combination of lesions. The most common presentation was an erythematous rash in 94 (58%) patients. Most of the skin lesions developed during the acute phase of the disease, 2 to 3 days after the onset of fever (74.16%). Localized erythema and swelling of the pinnae mimicking erysipelas was observed in 7 patients. Similarly, erythema and edema of BCG scar and pre-existing post traumatic scars and striae resembling the 'scar phenomenon' of sarcoidosis were seen in 4 patients. Other lesions were vesicles and bullae over the extremities in 21 (12.96%). Seven infants (4.32%), had an entirely different presentation with charring, vesicles and bullae, followed by peeling, clinically mimicking toxic epidermal necrolysis (TEN), but without mucosal involvement. Oral mucosal involvement was found in 22 (13.64%) patients in the form of multiple aphthae, erosions, and cheilitis. Bilateral involvement of conjunctiva was present in 14 (8.64%). Nasal erosions were seen in 8 (4.94%) patients. Two patients (1.24%) had scrotal ulcers. Mucosal lesions lasted for 7-10 days and subsided completely without any sequelae. The peculiar nail findings noted in our study were black lunulae, diffuse and longitudinal melanonychia, transverse pigmented bands in two patients each and a single case each of leukonychia and onychomadesis. Skin lesions subsided without any sequelae in the majority, except pigmentation in 62 patients (38.27%). Various types of pigmentation were observed, the most common site being the nose. (2) This is known as the "Chik sign", which may endure for months (see DI&I April 24th, 2016).
Garg et al reported 21 children with CF (13 boys, 8 girls) presenting with vesico-bullous and necrotic lesions; purpura and necrosis was seen in 16 (76%) patients. Skin lesions resolved in 5-7 days, leaving behind hyperpigmentation in 7 (33.3%) patients and hypopigmentation in 3 (14.2%). Minor oral erosions were observed in 3 (14.2%) patients, and palmoplantar erythema was seen in 4 (19.04%). Importantly, most children were active, playful, and eating well through their illness (compared to patients with TEN). The authors concluded: "It is essential for dermatologists to understand the Stevens-Johnson syndrome and toxic epidermal necrolysis-like presentation of chikungunya and not to misinterpret it as true Stevens-Johnson syndrome and toxic epidermal necrolysis, which will lead to unnecessary intervention and management." (3)
Although the pathomechanism for the epidermal necrosis is unknown, the presumption is that due to immunologic factors combined with a direct cytopathic effect of the virus. (2)
CF is usually self-limited, with the majority of symptoms resolving in 7 to 10 days. Rheumatologic, neurologic, cardiac, respiratory, renal, and ocular complications may ensue, lasting for months. Elderly patients are at risk for more severe disease. Hypertension, diabetes and cardiac comorbidities may contribute to a severe outcome of CF. (4)
Chikungunya means "that which bends up" in Bantu language of the Makonde people, due to the potentially devastating painful arthralgias accompanying CF. (5) Vector control is currently the only comprehensive solution for decreasing the number of CF cases. (1). Vaccines for CF are being developed, 2 of which have successfully completed phase I clinical trials. (6)
The late, iconic author Tom Wolfe coined the phrase "radical chic." Hopefully a new vaccine will allow for a radical change in the incidence of this devastating disease.
Point to remember: CF may present mimic Stevens-Johnson and TEN, especially in children.
1. Paixão ES, et al. Zika, chikungunya and dengue: The causes and threats of new and re-emerging arboviral diseases. BMJ Glob Health 2017; 3: e000530.
2. Riyaz N, et al. Cutaneous manifestations of chikungunya during a recent epidemic in Calicut, north Kerala, south India. Indian J Dermatol Venereol Leprol 2010; 76: 671-6.
3. Garg T, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis-like cutaneous presentation of chikungunya fever: A case series. Pediatr Dermatol 2018; 35: 392-6.
4. Badawi A, et al. Prevalence of chronic comorbidities in Chikungunya: A systematic review and meta-analysis. Int J Infect Dis 67; 2018: 107-113.
5. Bautista-Reyes E, et al. Chikungunya: Molecular aspects, clinical outcomes and pathogenesis. Rev Invest Clin 2017; 69: 299-307
6. Tharmarajah K, et al. Chikungunya: Vaccines and therapeutics. F1000Res 2017; 6: 2114.