text:
package com.balance.life.model;

import java.util.ArrayList;
import java.util.Calendar;
import java.util.Date;
import java.util.List;

import javax.persistence.CascadeType;
import javax.persistence.Entity;
import javax.persistence.FetchType;
import javax.persistence.GeneratedValue;
import javax.persistence.GenerationType;
import javax.persistence.Id;
import javax.persistence.JoinColumn;
import javax.persistence.ManyToMany;
import javax.persistence.ManyToOne;

import com.fasterxml.jackson.annotation.JsonManagedReference;

@Entity
public class Item {

	@Id
	@GeneratedValue(strategy=GenerationType.AUTO)
	private long itemId;

	private String name = "";

	private Date creationDate = Calendar.getInstance().getTime();

	@ManyToOne(fetch = FetchType.EAGER, cascade = CascadeType.PERSIST)
	private Status currentStatus;

	@ManyToMany
	private List<ItemStatusLog> statusHistory = new ArrayList<ItemStatusLog>();

	@ManyToMany
	private List<Tag> tags = new ArrayList<Tag>();

	@ManyToMany
	@JsonManagedReference
	private List<Association> associations = new ArrayList<Association>();

	protected Item() {
	}

	public Item(String name) {
		this.name= name;
		this.currentStatus = new Status();
	}

    public long getItemId() {
        return itemId;
    }

    public String getName() {
	        return name;
	}

    public List<Tag> getTags() {
		return tags;
	}

    public List<Association> getAssociations() {
		return associations;
	}

	public void setId(long itemId) {
		this.itemId = itemId;
	}

	public Date getCreationDate() {
		return creationDate;
	}

	public Status getCurrentStatus() {
		return currentStatus;
	}

	public void setCurrentStatus(Status currentStatus) {
		this.currentStatus = currentStatus;

	}

	public List<ItemStatusLog> getStatusHistory() {
		return statusHistory;
	}

}


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text:
Recovering from Cystectomy: Patient Perspectives
Authors: McMullen, Carmit K.a; * | Kwan, Marilyn L.b | Colwell, Janice C.c | Munneke, Julie R.b | Davis, James V.a | Firemark, Alisona | Brooks, Neona | Grant, Marciad | Gilbert, Scott M.e | Altschuler, Andreab
Affiliations: [a] Center for Health Research, Kaiser Permanente, Portland, OR, USA | [b] Division of Research, Kaiser Permanente, Oakland, CA, USA | [c] University of Chicago Medicine, Chicago, IL, USA | [d] City of Hope, Duarte, CA, USA | [e] Moffitt Cancer Center and Research Institute, Tampa, FL, USA
Correspondence: [*] Correspondence to: Carmit K. McMullen, Kaiser Permanente Center for Health Research, 3800N. Interstate Avenue, Portland, OR 97217, USA. Tel.: +1 503 335 6381; Fax: +1 503 335 6311; E-mail: [email protected].
Keywords: Patient-reported outcomes, bladder cancer, cystectomy, qualitative methods, focus groups
Journal: Bladder Cancer, vol. 5, no. 1, pp. 51-61, 2019
Received 19 October 2018
Accepted 10 January 2019
Bladder cancer patients who undergo cystectomy and urinary diversion face functional and quality-of-life challenges. Little is known about these patients' experiences during decision-making, surgery, and recovery, or how they vary by treatment setting.
To learn about patients' experiences with treatment choice, surgical care, and recovery across health settings. Understanding patient experiences is essential to closing care gaps and developing patient-reported measures.
We conducted focus groups with cystectomy patients and family caregivers at a large comprehensive health care system (N = 32 patients) and an NCI-designated comprehensive cancer center (N = 25 patients and 5 caregivers). Using standard qualitative methods, we identified themes that are not well-represented in existing research.
Across both systems, patients described variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by information; others felt poorly informed. Many found self-care equipment challenging; many felt they knew little about what to expect regarding chemotherapy, recovery, and transitioning home. At times, health care personnel could not help manage patients' ostomies or catheterization equipment. Our study also contributes a grounded theoretical framework for describing meaningful domains of patient experience with cystectomy and urinary diversion. We identified a common trajectory that includes decision-making, surgery and post-operative recovery, mastery of self-care, and reintegration.
Patients with radical cystectomy and urinary diversion report a wide variety of experiences not captured by quantitative measures. These findings demonstrate that many cystectomy patients could benefit from additional post-operative support. We offer a framework to measure patient-centered domains in future research.
Bladder cancer patients who undergo cystectomy and urinary diversion face persistent functional impairments and poor health-related quality-of-life [1–11]. A recent stakeholder-driven research prioritization study involving bladder cancer patients and caregivers identified the need for more information about urinary diversion choice, cystectomy education, expectations about recovery, and impacts of cystectomy and urinary diversion [12]. Qualitative research using grounded theory approaches can provide these needed insights into common experiences, trajectories and transitions in illness experience [13] for bladder cancer patients undergoing cystectomy.
The few existing qualitative studies of patients who have undergone cystectomy and urinary diversion explored their decision-making processes and unmet needs over the course of treatment, but only in the context of academic medical centers [14–16]. Understanding the full range of patient experiences and concerns, and how they might vary across treatment contexts, is an essential precursor to identifying ways that health systems can effectively support patients throughout their treatment journey and developing objective measures that compare patient outcomes across choice of urinary diversion.
In this study, we conducted focus groups and in-depth interviews with bladder cancer patients treated with radical cystectomy and urinary diversions in both (1) a large integrated health care delivery system, and (2) a comprehensive cancer center. We sought to identify patients' needs and challenges from pretreatment to approximately two years after surgery, and to identify how these needs were addressed across two different delivery systems.
Theoretical approach and design rationale
We conducted focus groups in two health center contexts in order to develop a framework for research and practice improvement derived from patients' and caregivers' experiences with cystectomy and urinary diversion. Our study design, data collection, and analysis were based on modified grounded theory [17, 18].
In the first phase of data collection, we conducted focus groups with patients who had undergone urinary diversions at Kaiser Permanente Northern California (KPNC). We used a purposeful sampling strategy [19, 20] which we have employed previously in the colorectal cancer context [21] and assigned patients into focus groups by diversion type and gender, since both these variables were likely sources of variability in experience.
In the second phase, we conducted focus groups at Moffit Cancer Center. To more fully capture the family/caregiver experience, we included both patients and caregivers in these focus groups. We also decided to shift our attention to areas of common experience across diversion types. Therefore, those focus groups included patients and caregivers of mixed gender and urinary diversion type. The main source of variability of interest in this analysis, the health system context, was accounted for by collecting and analyzing data using similar methods from patients in two health systems. Exploring differences in experience by urinary diversion type and gender was not the focus of this analysis, but we did obtain data from each of these perspectives to ensure that our framework included experiences of male and female patients with different diversion types.
Integrated health care system: Kaiser Permanente Northern California (KPNC)
KPNC is a comprehensive medical system serving over 4.2 million members throughout Northern California. Patients were eligible for study participation if they were at least 21 years old at the time of surgery, resided in the greater San Francisco Bay Area, and received a cystectomy with urinary diversion (ileal conduit, neobladder, or continent pouch) for treatment of bladder cancer at KPNC between January 2007 and August 2012. Patients were not required to be Kaiser Permanente health plan members at the time of the study. We identified 303 eligible patients using electronic research databases derived from health plan data. We confirmed each patient's type of urinary diversion through chart review.
We emailed each eligible patient's urologist to ask permission to contact their patient(s). If the physician did not deny permission within two weeks, we mailed the patient an invitation letter and a postcard that interested patients could return. A study coordinator called patients who returned the postcard to schedule focus groups. We sent a reminder letter with the date, time, and location of the focus group to all patients who agreed to participate. Recruitment efforts continued until at least ten patients signed up for each focus group. We aimed to recruit at least two members of minority racial/ethnic groups in each focus group. Several recruited participants did not come to the focus groups, and we were not able to recruit ten women with neobladder or continent pouch diversions. Ultimately, we collected data from 32 enrolled patients: nine men with an ileal conduit, nine men with a neobladder, nine women with an ileal conduit, and five women with a neobladder or continent pouch. Focus groups were scheduled for all groups except women with neobladder diversions: Because of the small number of patients in this group, we interviewed each participant individually by telephone. All data collection occurred in the spring of 2013.
Comprehensive cancer center: Moffitt cancer center
Moffitt Cancer Center is an NCI-designated comprehensive cancer center based in Tampa, Florida that serves the Southeastern United States. Moffitt's primary service area covers over 5 million individuals. Patients from Moffitt were eligible for recruitment if they were at least age 21 at the time of surgery and received a cystectomy and urinary diversion (ileal conduit, neobladder, or colon pouch) for treatment of bladder cancer between January 2011 and April 2016. We identified 484 eligible participants treated with cystectomy within this timeframe. A subgroup of patients who lived within 60 miles of the center were then prioritized for recruitment and contacted by a study coordinator who introduced the study and screened for eligibility. A total of 76 patients were reached, and 35 agreed to participate. They were scheduled to attend one of four focus groups based on what time was most convenient for them, and they were invited to bring a caregiver along to participate. Twenty-five patients and five caregivers arrived for the focus groups and all were consented and enrolled in the study during the day of the focus group. This resulted in the recruitment of 15 men with an ileal conduit, six men with a neobladder, three women with an ileal conduit, and one woman with a neobladder or continent pouch. Five caregivers participated in the focus groups, including one adult child and four spouses of participating patients.
The Institutional Review Boards at KPNC and KP Northwest reviewed and approved the study involving focus groups at KPNC. Moffitt Cancer Center approved of the study involving focus groups at Moffit Cancer Center. All procedures performed were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Focus groups and interviews
We used an interview guide for the focus groups and individual interviews that was developed based on previous literature as well as input from consulting urologists and ostomy nurses. Interviews began by eliciting general comments about diagnosis and treatment decision-making, and then asked about more specific experiences with surgery and recovery, as well as challenges and adaptations (see Fig. 1 for specific discussion prompts). At Moffit Cancer Center, we also asked questions about whether an online informational intervention would be useful for supporting patients and families before and after cystectomy (subsequent discussions about the informational intervention were not the focus of this report), An experienced, PhD-level qualitative researcher (either AA or CM) led each of the focus group discussions, and AA conducted the telephone interviews at KPNC. Either an ostomy nurse (JC) or urologic oncologist (SG) was present at the focus groups to address any clinical questions. All interviews were audio recorded and transcribed.
Discussion prompts for focus groups and individual interviews.
The goal of the analysis was to describe a general framework for understanding diverse experiences. To accomplish this, we analyzed transcripts to identify commonalities and differences by: 1) urinary diversion type; and 2) health system. We used a modified grounded theory approach for analysis [22] to identify themes across the dataset, complemented by analytic memos and comparative analysis.
Theme identification
Starting with the KPNC dataset, the lead author reviewed all transcripts, and created a list of topics that were then consolidated into a set of unique themes and domains that were discussed with the research team. The lead author, a PhD-level anthropologist and qualitative researcher (CM), and a research associate (JD) then returned to the transcripts and the interviews and coded segments of KPNC focus groups associated with those themes and domains. For the Moffitt dataset, the lead author and another research associate (AF) slightly revised that list of themes and domains, and AF returned to the transcripts to code them accordingly. MG, a PhD-level nurse researcher, reviewed the Moffit dataset and confirmed that the revised themes and domains were appropriate and correctly applied to the data.
Analytic memos
Analytic memos provided another approach to summarize key insights from each focus group, as well as the set of individual interviews. AA, a PhD-level sociologist who collected the KPNC data, wrote analytic memos about the KPNC data. SG, a urologic oncologist experienced in qualitative methods and who was present at the Moffitt focus groups, wrote analytic memos about the Moffitt data. MG, who had independently read all the data, also reviewed and commented on the analytic memos.
To write this manuscript, which focused on cross-site comparisons, take-aways from analytic memos (which were written by site) and summaries of the coded data from each site were reviewed by the lead author (CM) and a research associate (NB).
On average, participants at the integrated system were 70 years old (range: 47–87 years). Their surgeries took place an average of 2.6 years before their study participation (range: 1–6 years). Each focus group included two racial/ethnic minority participants; four of the women we interviewed by telephone were non-Hispanic white and one was of unknown racial/ethnic background.
The average age of the comprehensive cancer center patient participants was 68 years (range: 38–93 years). Their surgeries took place an average of 2.1 years before study participation (range: 0–5 years). One patient participant self-identified as a racial or ethnic minority, all others identified as non-Hispanic white.
Domains of patient experience
We identified 12 themes from the interviews that we grouped into four domains of post-operative experience: (1) decision-making about and preparation for urinary diversion; (2) surgery and post-operative recovery; (3) mastery of self-care for the urinary diversion; and (4) reintegration of identity and participation in major life activities (Fig. 2). These domains correspond to major phases in the clinical course for patients undergoing cystectomy with urinary diversion and also conformed to how patients described their experiences. Specific quotes related to each theme are found in Table 1.
Domains and themes of patient experience.
Selected patient quotes illustrating phases of urinary diversion experience
DECISION-MAKING "I had the situation where he explained – like I said, he explained everything to me. He explained the positives and negatives of either way. And I selected not (to have) the neo-bladder. Because one of the things that I was concerned about was the leakage." (integrated health system)
"But I just didn't feel as I had enough information. I changed my mind within 8 hours of the operation." (cancer center)
SURGERY &POST-OPERATIVE RECOVERY
Transition to home "We had really awesome home health care and people came for us every day and they changed out the wafers periodically so I got to kind of learn from somebody who actually knew what to do what they do how to avoid problems and I think we've all had a few screw ups over the last couple years and for whatever reason never figured it out but basically it's been good." (cancer center)
Patient 1: "Well, we had home care for a week or two."
Patient 2: "Well, I didn't have that… they said, if I'm not able to get to the hospital, then they would do that, but I had to send an affidavit that I was, you know, bedridden and couldn't get there."
Patient 1: I had three, four weeks of it.
Patient 3: I did too.
Patient 4: They asked me and I said no. (integrated health system)
Coordination of care "I went to BCG and all the other multiple cystos up to that point, but one day I was in there for a cysto and a doctor came in and said, "oh I guess we'll put the stoma right here." And I said, "What?" It was like out of the blue, and then he said, "… we're going to take your bladder." It was like a total shock." (cancer center patient talking about experiences before coming to the cancer center)
"Inside the urology community, they know about neobladders, but the minute you get outside, they haven't a clue." (integrated health system)
Managing adjuvant chemotherapy "I wish that my urologist would have talked to my oncologist more. Because when I found out I had bladder cancer, they just said, "you know, you got to have the R.C., blah blah blah blah." And then…after the surgery, I went to see my Oncologist…and he said that, if he would have known, if they were talking to each other, I would have had some chemo before the surgery, then I wouldn't have had to have as much chemo at the back end." (integrated health system)
"The thing that kind of threw me a little bit off was the chemo part of it seem[ed] to be harder than the surgery part of it…I was just thinking I'll be back at work in two weeks and it didn't work out that way obviously it was probably closer to 2 months before I got back to…working." (cancer center)
Managing complications "I'd like to have had more information on edema… and hernias. I had a hernia that started about 2 months after surgery and I'd deal with it with a hernia belt and my leg started swelling maybe 3 months after. I didn't know that was going to happen." (cancer center)
"I had a lot of issues after surgery because I developed a fistula after surgery, and they did not want to go in and do surgery again. So I was on TPN for two months… it's a way to feed yourself through an IV because some people think fistulas heal better if you don't put any food in your mouth." (integrated health system)
Issues with UD equipment "I wound up with like a rash around my stoma… And it was weeping, and so pouches would fall off… so each time I'd get in the shower and wash everything off, try patting all dry and everything and try it again... I'd put on a pouch. It would fall off because of the weeping. I'd be a mess, and a lot of it was about 3:00 in the morning. I had one pouch left." (integrated health system)
"The nurse at the hospital would show me but what I should have had was like a mirror to see what she was doing. I couldn't see over her fingers." (cancer center)
Difficulty sleeping I did the night bag…and it was just so restrictive…you can't really move around. So you're not really sleeping well, and then a couple times [the night bag] dislodged. So then I found I had to tape it to stay on, and so finally I said I'm just not going to do this. I'm just going to use my kitchen timer, and I'm going to set it for two hours. I'm going to get two hours sleep, and then I'll just wake up when it goes off and I'll go to the bathroom. (integrated health system)
"I found it helpful when I got home I slept in a recliner for like 2 months [others agree]. It's hard for me to sleep anywhere else." (cancer center)
Support from caregivers "My wife said, "No." "I love you, but I'm not doing that. [Flushing tubes and changing bandages]." (integrated health system)
"I have never changed my bag since I came out of the hospital. She [wife] does it all the time. I know it may be a problem for her but it's a godsend for me." (cancer center)
MASTERY OF SELF-CARE
Peer support "I go do BCAN every day (Bladder Cancer Advocacy Network). You can talk to others. I saw a YouTube video of this man changing his bag, and what he did... He said your stoma should be dry before you put on your bag." (integrated health system)
"I went to one (support group). I hated it. I enjoyed talking to people and learning about their situation, but at the end of it, there was the word of the day, like compassion – people sort of speak on the word and then we held hands." (cancer center)
Lack of familiarity with UD care among health care personnel "The nurses, even the stoma nurses, really don't know about day to day. We had to work our way through it. I (used a movie) on YouTube." (integrated health system)
"I mean, I was in there and I didn't have anybody to come over to check this bag and when I had a vac and that's supposed to be changed and they never…they never, they were supposed to send somebody up here to change it and they never changed, I just sat there for a week with that thing leaking all over." (cancer center)
Preparedness for self-care "When it comes to the neobladder in particular, they did a good job in the hospital or showing me how to use … the syringe and the catheters and all that stuff, but when you get home (laughs)…And now you've got all this stuff you're trying to figure out how am I going to do this and that whatever, I think videos probably would have been very helpful." (cancer center)
"Nice people. Knew what they were talking about. Of course, it's still a learning curve. I mean, they never told you that whenever you put stuff on, take your hair dryer out and make sure everything's dry…" (integrated health system)
REINTEGRATION "If you're tough, you can manage it. If you're not, I don't know... I would say it's not as bad as what you think. Because the ordeal that I went through was really a lifetime challenge for me. I had no experience, no real expectations, and everything hit me right in the moment. Recovery was difficult. Changing my lifestyle, my clothing. It is hard. Having gone through that gave me some different expectations... I can perform at a much higher level that I thought I could." (integrated health system)
"We spent the first year of healing and regaining in general and then this past year we started trying to alter the life as needed and um several aspects that we're still struggling with in our daily life." (cancer center)
Across both health systems, participants described highly variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by the amount of information they were given, while others felt that their doctors did not inform them adequately about their options. Some recalled that their urologist expressed a strong preference for one type of diversion; others were presented with more neutral information. Perceptions about the benefits and disadvantages of different diversion types were also not consistent. For example, ileal conduits and neobladder diversions were each described as simpler to live with by different urologists.
Participants also varied in whether they preferred to follow a clear recommendation from their provider or whether they wanted a more active role in the decision. Some patients sought second opinions from other urologists, sought additional information online, or reported consulting with others. While patients at both health systems reported some similar experiences, integrated system patients described their diagnosis and decision-making processes as relatively straightforward. By contrast, patients who were treated at the cancer center often had initial unsatisfying experiences in other health systems before seeking a second opinion at the cancer center; others saw different providers within the cancer center for treatment before their diversion surgery. Some described poor communication or follow-up between these previous providers.
Surgery and post-operative recovery
With few exceptions, the immediate postoperative recovery period was a challenging time for patients. Patients and caregivers struggled to learn self-care skills at the hospital that would prepare them for a smooth transition to home. Patients were often unaware of potential issues they might have with bowel function or other complications that can arise after surgery—infection, hernia, and urinary tract infection (UTI). Patients in both systems reported wanting more information and supplies when being discharged from the hospital. However, some participants described being overwhelmed by supply samples and unsure how to choose and order the right supplies for themselves.
A primary challenge for many patients was learning to use self-care equipment during the recovery period both in the hospital and once they had returned home. Some patients at the integrated system reported having issues with nurses and other staff who were unfamiliar with their diversion or the related equipment or felt that they were expected to learn self-care after just a few demonstrations. Patients at both systems reported that they were often unsure if they were doing self-care correctly, especially after returning home, and weren't sure what problems required medical attention and what was a normal part of their body adapting to the change. In addition, patients struggled to learn how to sleep with their new equipment while dealing with nighttime leakage.
One area where patient experience differed notably between systems was coordination of care. Patients in the integrated system reported a variety of experiences with care coordination after surgery. While some felt they received excellent care, others faced challenges: in some cases, no stoma nurse was available in a patient's city; in other cases, providers treating surgical complications appeared unfamiliar with urinary diversions. In general, patients in the integrated system did not always know who to contact to get their needs met after leaving the hospital. Patients at the cancer center did not mention as many care coordination or follow-up care challenges and tended to have a clear understanding about who they should reach out to with problems and concerns.
After returning home, some patients began adjuvant chemotherapy shortly after the surgery, further complicating their recovery. Participants reported a wide variety of information needs that they wished had been met before surgery: many did not feel that they had been given adequate information about what to expect from chemotherapy, recovery, and transitioning to home, or that they weren't given enough information about self-care. These struggles were common for patients in both health care systems.
Family caregivers often took charge of changing ostomy equipment, managing medication regimens, and providing other support after patients returned home. These caregivers frequently learned by observing nurses in the hospital, but they were not typically given any formal training or resources during the postoperative period.
After the initial recovery period, patients gradually became experts who were comfortable and skilled with self-care. The pathway to becoming an expert was highly variable but was a uniform goal.
Some patients had home care nurse visits a for a month or two after surgery, and gradually assumed more and more of their self-care; many found these visits very helpful. Participants sought out additional information related to their urinary diversion through Internet searches, blogs, and YouTube videos. Some of the most valuable help came from conversations with others who had gone through a similar surgery, whether those people were friends and relatives, support group members, or contacts given by a provider. Participants commented that even the focus group discussions yielded additional information and tips on self-care.
Patients at both health care systems shared experiences in which hospital staff or home health care nurses did not know enough about a patient's urinary diversion to help manage their ostomy or catheterization equipment.
Participants talked about making choices about the type of equipment that worked best, becoming comfortable with catheterization, and learning to treat and prevent skin problems. Several patients noted that there was an inevitable "learning curve" to becoming an expert at self-care regardless of the quality of support one receives from their providers, in part because every patient faces different challenges.
Participants talked about the challenges involved with the changes to their body and daily routine, as well as difficulties coping with their cancer diagnosis. For some, life after cystectomy entailed enduring the loss of valued physical activities, employment, and independence; others found that they didn't have to make major changes to their lifestyle. Some expressed difficulties with traveling, a lack of spontaneity in everyday activities since immediate access to toilet facilities may be essential, loss of stamina and endurance, sexual inability, and lost friends. Participants stated that adjusting to these challenges was part of regaining self-confidence and self-acceptance. Several also noted positive changes in their outlook and personality that they attributed to the experience of surviving a major illness.
Through focus groups and interviews with total cystectomy patients in two very different types of health care systems, we identified substantial variability within and across settings in the experiences and challenges patients faced. However, we found that participants consistently described a transformative process with four domains of experience: pre-operative decision-making, surgery and post-operative recovery, mastery of self-care, and eventual reintegration into the activities of daily life. Across a wide range of experiences, these domains reflect a consistent pathway that was salient to the men and women we interviewed regardless of health system or urinary diversion type (see Fig. 2). These four domains and the themes within each domain provide insight into critical patient experiences and outcomes beyond straightforward measures of functioning and quality of life. These include decision making and decision appraisal, satisfaction with care, ostomy or neobladder-related self-care, informal caregiving, self-efficacy, and personal meaning in illness experience. These aspects of patient experience are often overlooked in comparative studies about different urinary diversions, which have focused more on health-related quality of life measures and clinical outcomes [23, 24].
While patients in both health systems reported similar treatment and recovery journeys and highlighted the same needs for information and support throughout the process, a few key differences emerged between the two health systems. First, the diagnosis and decision-making journey tended to be more consistent for patients in the integrated system (KPNC) than for cancer center (Moffitt) patients. Second, patients in the two systems reported different experiences of follow-up care: cancer center patients had a more straightforward process for getting post-operative problems addressed and were less likely to experience challenges with hospital staff care coordination or treatment for complications. These differences likely reflect realities of receiving care at a cancer center and an integrated health system. Because many patients turn to cancer centers for a second opinion or through referral, they are not typically being treated by their primary urologist, and represent a somewhat different population of individuals than those treated in an integrated system, where patients are often treated by the same urologist throughout the course of their bladder cancer. In an integrated system, the number of patients receiving cystectomies is much lower than in a comprehensive cancer center, and there are many possible entry points to care after surgery; depending on the need, patients might contact or be routed to a general advice nurse, a primary care provider, or a provider in the urology department. By contrast, patients at the cancer center rely on a designated urologic oncology team for all follow-up care. These differences nonetheless highlight the importance of care coordination to patients in both systems throughout the treatment journey. More research is needed to examine how health systems can encourage patient-centered care for treatment decisions, peri-operative and post-operative care, and longer-term survivorship.
Because many patients facing cystectomy are candidates for more than one type of urinary diversion, more research on decision making about diversion types is needed. A recent study of cystectomy patients who received care at a major academic medical center found that these patients' highest priorities in treatment decision-making were receiving treatment from experts and making decisions based on personal preferences [16]. These priorities differed sharply from those expressed by integrated system patients in our study, who infrequently sought second opinions or additional consultations to help decide between cystectomy options. This contrast illustrates the importance of collecting diverse patient perspectives on cystectomy and urinary diversion.
This study had the strength of comparing patient outcomes across two very different health systems while demonstrating numerous common themes in the treatment and recovery experiences of patients, suggesting wide generalizability of our findings. However, we did not directly assess patients treated in other settings (such as fee-for-service private practice), and more research is necessary to determine how our findings generalize to these patients. Another potential limitation of our study is that participants were as much as 6 years removed from their surgery and may have experienced some recall bias. These limitations should be addressed by future research.
Our study, which elicited patient perspectives on the process of urinary diversion surgery and recovery across two health care settings, highlighted several care gaps. In decision-making, for example, across both health systems, participants described highly variable experiences. Before making this major decision, some patients said they received too little information; some said they received too much. Some patients were told an ileal conduit was "simpler to live with"; others were told the opposite—that a neobladder would be simpler. In the recovery phase, many patients found learning to use self-care equipment a challenge. Patients at both health systems felt unprepared for the transition to home and often weren't sure what problems required medical attention and what was normal. Our study underscores that cystectomy patients often do not receive adequate information, preparation, or training in how to care for themselves post-surgery [14, 15, 25].
This study also contributes a grounded theoretical framework for describing the treatment and recovery experience of patients undergoing cystectomy and urinary diversion (see Fig. 2). Our results highlight that while patient experiences are variable, they can be understood as part of a process encompassing decision-making, recovery, developing self-care expertise, and reintegration. This general framework suggests patient-centered domains for research and care improvement efforts that transcend urinary diversion type, gender and health system contexts.
The authors have no conflicts of interest to report.
This project was funded by the National Institutes of Health, Grant Number: 1R01CA164128.
We would like to thank David Aaronson, Assistant Chief of the Department of Urology at Kaiser Permanente East Bay, for his support in conducting this research.
Stein JP , Lieskovsky G , Cote R , Groshen S , Feng AC , Boyd S , et al. Radical cystectomy in the treatment of invasive bladder cancer: Long-term results in 1,054 patients. J Clin Oncol. 2001;19(3):666–75.
Gerharz EW , Mansson A , Hunt S , Skinner EC , Mansson W . Quality of life after cystectomy and urinary diversion: An evidence based analysis. J Urol. 2005;174(5):1729–36.
Porter MP , Penson DF . Health related quality of life after radical cystectomy and urinary diversion for bladder cancer: A systematic review and critical analysis of the literature. J Urol. 2005;173(4):1318–22.
Porter MP , Wei JT , Penson DF . Quality of life issues in bladder cancer patients following cystectomy and urinary diversion. UrolClin North Am. 2005;32(2):207–16.
Nabi G , Yong SM , Ong E , McPherson G , Grant A , N'Dow J . Is orthotopic bladder replacement the new gold standard? Evidence from a systematic review. J Urol. 2005;174(1):21–8.
Hardt J , Filipas D , Hohenfellner R , Egle UT . Quality of life in patients with bladder carcinoma after cystectomy: First results of a prospective study. Qual Life Res. 2000;9(1):1–12.
Henningsohn L , Wijkstrom H , Dickman PW , Bergmark K , Steineck G . Distressful symptoms after radical cystectomy with urinary diversion for urinary bladder cancer: A Swedish population-based study. Eur Urol. 2001;40(2):151–62.
Hautmann RE , Volkmer BG , Schumacher MC , Gschwend JE , Studer UE . Long-term results of standard procedures in urology: The ileal neobladder. World J Urol. 2006;24(3):305–14.
Botteman MF , Pashos CL , Hauser RS , Laskin BL , Redaelli A . Quality of life aspects of bladder cancer: A review of the literature. Qual Life Res. 2003;12(6):675–88.
Dutta SC , Chang SS , Coffey CS , Smith JAJ , Jack G , Cookson MS . Health related quality of life assessment after radical cystectomy: Comparison of ileal conduit with continent orthotopic neobladder. Journal of Urology. 2002;168:164.
Hobisch A , Tosun K , Kinzl J , Kemmler G , Bartsch G , Holtl L , et al. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. SeminUrolOncol. 2001;19(1):18–23.
Smith AB , Chisolm S , Deal A , Spangler A , Quale DZ , Bangs R , et al. Patient-centered prioritization of bladder cancer research. Cancer. 2018. doi: 10.1002/cncr.31530
Strauss A , Corbin JM . Grounded Theory in Practice. Thousand Oaks, CA: SAGE Publications; 1997.
Mohamed NE , Chaoprang Herrera P , Hudson S , Revenson TA , Lee CT , Quale DZ , et al. Muscle invasive bladder cancer: Examining survivor burden and unmet needs. J Urol. 2014;191(1):48–53. doi: 10.1016/j.juro.2013.07.062
Mohamed NE , Pisipati S , Lee CT , Goltz HH , Latini DM , Gilbert FS , et al. Unmet informational and supportive care needs of patients following cystectomy for bladder cancer based on age, sex, and treatment choices. Urol Oncol. 2016;34(12):531.e7–e14. doi: 10.1016/j.urolonc.2016.06.010
Berry DL , Nayak M , Halpenny B , Harrington S , Loughlin KR , Chang P , et al. Treatment Decision Making in Patients with Bladder Cancer. Bladder Cancer. 2015;1(2):151–8. doi: 10.3233/blc-150029
Foley G , Timonen V . Using grounded theory method to capture and analyze health care experiences. Health Serv Res. 2015;50(4):1195–210. doi: 10.1111/1475-6773.12275
Strauss A , Corbin J . Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications; 1990.
Luborsky MR , Rubinstein RL . Sampling in qualitative research: Rationale, issues, and methods. Res Aging. 1995;17(1):89–113. doi: 10.1177/0164027595171005
Patton M . Qualitative Evaluation and Research Methods. Thousand Oaks, CA: SAGE Publications; 2002.
Grant M , McMullen CK , Altschuler A , Mohler MJ , Hornbrook MC , Herrinton LJ , et al. Gender differences in quality of life among long-term colorectal cancer survivors with ostomies. Oncol Nurs Forum.. 2011;38(5):587–96. doi:10.1188/11.onf.587-596
Schreier M . Qualitative content analysis. In Flick U. ed. London: Sage; 2014, pp. 170–83.
Ghosh A , Somani BK . Recent trends in postcystectomy health-related quality of life (QoL) favors neobladder diversion: Systematic review of the literature. Urology. 2016;93:22–6. doi: 10.1016/j.urology.2015.12.079
Tyson MD 2nd , Barocas DA . Quality of life after radical cystectomy. Urol Clin North Am. 2018;45(2):249–56. doi: 10.1016/j.ucl.2017.12.008
McMullen CK , Hornbrook MC , Herrinton LJ , Altschuler A , Grant M , Wendel C , et al., editors. Kaiser Permanente Northern California improving survivorship care for long-term colorectal cancer survivors: Key findings of a 5-years study, 2009.

redpajama_set_name: RedPajamaCommonCrawl


text:
Innovation & Investment
Early-stage diet innovator secures Aqua-Spark investment
Monday, 15 April 2019 Lauren Kramer
Norway-based Molofeed's microcapsules deliver slow-release larval feed
These flatfish larvae have just hatched. Their yolk sac provides their nutrition for a couple of days, and when larvae switch from endogenous to exogenous feed, it is essential for proper growth and development that the larvae receive feed with all the nutrients they would have gotten from their yolk sac. Photo by Dr. Bernd Ueberschär.
Early-stage marine finfish and shrimp have a finicky diet, often requiring live feeds like the brine shrimp artemia. Limited supplies of live feeds has led to a race for replacements, with investors taking a keener interest in the aquafeed sector.
Aqua-Spark, the Netherlands-based investment fund for sustainable aquaculture, is now backing Molofeed, a company that has developed a proprietary micro-encapsulation technology that provides a slow release of feed to early stage fish and shrimp.
Norway-based Molofeed will receive close to €2 million from Aqua-Spark: the first infusion in the coming weeks and the second later this year.
"We're at a stage where we're building a more robust organization to be ready for further scaling up," Arve Fresvik, chairman of Molofeed's board, told the Advocate. "But we don't have any big investment needs now, which is why we didn't need the full amount immediately."
Ingmar Hogoy founded the company in 2015, at which time it consisted of technology and intellectual property rights representing previous research. As he sought funding, Hogoy partnered with Fresvik, who created a consortium of investors by fall 2016. Over the past three years, Molofeed has been gradually building its production capacity in Norway and completing a series of formulations for its feed capsules for tropical shrimp, sea bream and sea bass.
While the capsules are still being tested, the feed for tropical shrimp will be ready by summer 2019. Once the production line-up is running at full capacity the company will manufacture 50 metric tons of capsules a year.
The microcapsules were created as a solution to live feed availability, and to ultimately replace it.
"Live feed is a limited resource, there are quotas for it and there are often quality issues and fluctuating prices," Fresvik said. "Our aim is to gradually replace live feed. For farmers it means they will have more controlled feeding procedures, stable prices and less fear of illness and biohazards, as this is a formulated feed that we control all the way. We believe that in time, farmers will be able to significantly reduce their operational costs by using our feed, while achieving the same or better growth and survival rates and level of deformities."
Most marine fish larvae start life with a very simple digestive tract. They have no stomach yet and have to rely mainly on Trypsin as the major proteolytic digestive enzyme to deal with the ingested proteins. Thus, it is difficult to develop a first feed that meets their nutritional needs and is easy to digest. The picture demonstrates this and provides a closer look at the gut and a Trypsin molecule. Photo diagram by Dr. Bernd Ueberschär.
Each capsule is one-tenth of a millimeter in size, and its contents will vary according to the species being targeted.
"That's the fantastic part about this technology," he said. "Some species need feed that has a specific smell while another needs feed that doesn't smell at all. We're able to design the feed according to the species we're targeting."
Pilot customers in Europe for sea bream and sea bass, and in Brazil and Ecuador for tropical shrimp, will begin redesigning their feeding protocols to include the capsules this year. By Q3, Fresvik said commercial sales should be ramping up.
Molofeed uses salmon oil and other types of marine protein sources in its capsules, and anticipates probiotics and immune-stimulants may be part of the formula, too. Farmers will deliver the capsules via specialized feeding devices that open into hatchery tanks.
For now the company is focused on early stage feeding when the needs of the fish and shrimp are at their greatest.
"This is where we really create value for hatcheries," Fresvik said. "But it is possible to use the capsules in later stage feeding too, with small adjustments in the manufacturing process. So there's quite a sizable market for us."
Prices for the capsules have not been established yet but Fresvik said that given the many benefits the capsules have compared to current feeding protocols, it will be a good deal.
Having Aqua-Spark's support is a significant boost for Molofeed, he acknowledged.
"While we could have received that same funding elsewhere, Aqua-Spark's backing is important because of their global network and presence. Becoming one of their portfolio companies will open doors to market segments that interest us," he said. "In addition other companies in their portfolio, such as those farming insect protein, could be really useful to us as we move forward. That was absolutely the most important reason for teaming up with Aqua-Spark."
Tom Prins, dealflow manager at Aqua-Spark, said that demand for formulated diets will strengthen because of limited availability and high prices of live feeds like artemia.
"Molofeed products have the potential to decrease and replace the need for live feeds in the hatchery phase of marine fish and shrimp. By doing so it allows for reducing costs and the issues related to the use of live feeds," he said. "Furthermore, it decreases the risk on disease transmitted through live feeds, decreases labor, energy and enrichment costs related to live feeds, and it simplifies hatchery management as a whole."
Follow the Advocate on Twitter @GAA_Advocate
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… we hope you'll consider supporting our mission to document the evolution of the global aquaculture industry and share our vast network of contributors' expansive knowledge every week.
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Lauren Kramer
Lauren Kramer, a Vancouver-based correspondent for the Global Aquaculture Advocate, has written about the seafood industry for the past 15 years.
Aqua-Spark Artemia Lauren Kramer live feed microcapsule Molofeed
A new nutrient for aquaculture, from microbes that consume carbon waste
A push for rapeseed as a viable aquafeed ingredient
Algae innovators aim to freeze out early-stage shrimp losses
Artemia, the 'magic powder' fueling a multi-billion-dollar industry


text:
Sigle
 X-ray Photoelectron Spectroscopy – spettroscopia fotoelettronica a raggi X

Chimica
 XPS – polistirene espanso estruso

Codici
 xps – codice ISO 639-3 della lingua pisidica

Informatica
 XML Paper Specification – formato di file di Microsoft
 Dell XPS – computer della Dell

Altro
 Peugeot XPS – motocicletta della Peugeot

redpajama_set_name: RedPajamaWikipedia


Visitors to Wadham's C Day-Lewis Room will have admired the new photographic portrait of journalist Amelia Gentleman (Russian and History, 1991).
One of a series of newly commissioned photographic portraits, which are going up around College, the sitters have been chosen following nominations from staff, students and alumni, as inspirational members of the Wadham community.
Photographer Sophia Spring was commissioned to capture the first nine sitters who will be featured individually on the website over the coming weeks.
Guardian journalist Amelia Gentleman is the subject of the wonderful portrait located in the C Day-Lewis room.
Novelist Hari Kunzru (English, 1988) is the new face in Wadham's Okinaga Room following the unveiling of his portrait.


While everyone is busy with the Hustle Bustle of the Auto Expo 2018, Volkswagen India organized a rather interesting experiential event on the morning of 9th Feb 2018. We attended the same and bring you our first-hand experience of the same. But before that, let me give a little background.
We (around 30 people including myself) gathered at a meeting point at 9th Feb 2018 at around 9 AM. Volkswagen has arranged a fleet of 30 cars ranging from the Volkswagen Polo, Vento, Tiguan, Passat etc. So the 30 of us included some fellow automobile bloggers, some media friends, some customers of Volkswagen and some social media influencers and celebrities. It was a nicely managed location in Noida and all the cars were ready, we did the registrations and shared some of the reactions on camera before we hit the road. The drive was from near Sector 18 in Noida to the India Expo Mart in Greater Noida experiencing a bit of city traffic (5 KM) and a large stretch of Noida-Greater Noida Expressway (25 Km). Here we share our experience behind the wheel of a Volkswagen Tiguan.
We started from the Sector 18 in a convoy of 30 cars lined one behind the other and soon in about 10 minutes, we hit the expressway. The car we drive was a Volkswagen Tiguan 2.0 TDI with an automatic transmission gearbox. Se we have already posted a detailed Volkswagen Tiguan Review here, I will not go all in-depth but restrict it to my 30 to 40 minutes experience I had with this car.
The car is extremely well insulated from any outside noise. The engine is super refined and the gadgetry is also elaborate. There is a drive or a sports mode in the transmission. The Drive mode keep the car accelerate gently while the sports mode unleashes more punch by delaying the gear shifting and makes the car even more agile. For most drivers, D mode will suffice, but if you want to have some fun, you can do that in the sports mode.
The car is very pliant on the road and overtaking is a breeze with just a tap on the accelerator and the transmission gives you a surge to do the needful. The driving dynamics, cornering, ride comfort and stability of the car on the highway is exceptionally good. I am especially impressed by the ride quality of the car. It soaks in most of the irregularities of the road effortlessly.
Overall, the car is smooth, powerful, silent inside, super fun to drive and spacious at the same time. This drive left me wanting for more of it. I leave you with a video and some beautiful pictures below to admire.
So what do you think? Share your views in the comments section below.


Based in the UK, Witchingseason are a dark alt-rock trio who certainly know how to write music that makes an impression. Not for the faint of heart, their music is a cacophony of heavy guitar riffs, riotous drums and coarse, melodic vocals that are tailor made for rock audiences to shout right back at the band.
Building a reputation for being real hard workers, the single drops soon having only released their debut EP in November. You can hear the track below, including backing vocals from none other than Tommy Smith of Leogun.
It's not hard to see how this sound can make an impact, its immediacy speaks for itself and is the reason why not too long ago the band were able to play a huge live show at the prestigious 100 Club in London. And 2015 is set to keep up that momentum, with the single out on April 27th plus an exciting gig coming up at Camden Barfly on July 10th, with more dates to follow when work is completed on the summer album they have planned.


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text:
The Resource Guide
Porsches for Sale
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By Law: Daytona Prototype driver's journey through 24-hour race
By Darren Law on Sun, Feb 13, 2011 2:13 AM PST
Darren Law (left) talks to engineer Iain Watt. Photo by Bob Chapman/AutosportImage.com
The #5 Action Express DP, the car Darren is driving this season, finished ninth. THe #9 finished third. Photo by Bob Chapman/AutosportImage.com
Drivers from background to foreground: Darren Law, Buddy Rice, Christian Fittipaldi. Photo by Bob Chapman/AutosportImage.com
The #5 DP ran up front until problems with the car forced a ninth place finish. Photo by Bob Chapman/AutosportImage.com
Photo by Bob Chapman/AutosportImage.com
I kept a log during my race week to give you an idea of what a driver goes through during the Rolex 24 At Daytona. Our #5 Action Express Porsche-Riley Daytona Prototype was really strong and I had great co-drivers in David Donohue, Burt Frisselle, and Buddy Rice. We led a lot of the race and stayed in the top three for the first 18 hours, but some issues dropped us back to finish ninth. Here's the story.
The Action Express drivers were part of Grand-Am Day at Camp Boggy Creek, a special camp for children with serious or life-threatening illnesses about 40 minutes from Daytona Beach. There were no children at camp while we were there — it's a summer camp — so we participated in camp activities instead.
We had a terrific time! It's a great time to get together with several of the other drivers for a fun day before all of the chaos starts at the race track. We did a fun charity golf event and then we built and raced soapbox derby cars. Everyone thought they could out-engineer each other, but I am happy to say the #5 Action Express car won that race! We thought, 'Alright, here's the first trophy for the weekend…'
Then David and I went to the track. After we checked in with the team and finalized our plans for Thursday, we set up our personal items for the weekend. For a 24-hour race, the team brings in motorhomes for the drivers so we have somewhere to rest at night and between driving stints. David and I moved all of our stuff over to our motorhome and made sure we had what we needed for hydration and meals. Fortunately, it was right across from the infield fitness center. Not that we were planning to work out; this is where we showered and it is also where our team doctors and masseuse were set up.
My day ended with a team dinner. Everyone was there — crew, drivers, owners, and sponsors. It is really the only time we can all get together before the event starts. Once Thursday morning comes around, everyone is very busy.
Thursday was packed with two daylight practice sessions, qualifying, and then night practice. Qualifying didn't go exactly how we wanted it, but both of the Action Express cars qualified within a tenth of a second of each other. We qualified 13th, right behind our teammates in the #9 car. We were starting a little further back than we would have liked, but realistically, qualifying is not too significant in a 24-hour race — it's more about bragging rights. Last year, our team won the race from eighth starting position. Our cars are good this year and they were handling well, so we were all pretty confident going into the race.
Friday was a short day on track for us. We had two short sessions before lunch. Most of the morning was spent installing the race engine, gearbox, and all of the race components. Most teams didn't run many sessions. Our main goal was to make sure everything was working properly on our virtually brand-new race car and confirm that we were ready to race. After the morning sessions were done, I went to the hotel to relax, had an early dinner, and got some sleep before race day.
Saturday 12:00 PM
Race day! This was a very busy time for us, even though our race didn't start until 3:30 PM. We were up early and there was a lot going on. We had a team meeting when we first got to the track, then immediately following we had the official driver meeting. I don't always enjoy driver meetings, but I like going to this one. So many drivers from so many different disciplines show up, from Formula One to NASCAR, IndyCar to ALMS, and, of course, Grand-Am. It's one of the few times a year when we all get to see each other and get together.
After the meeting, we went straight to the autograph session, followed by driver introductions. There was very little time for breaks, other than to run back, grab some food, and get ready before the race. Since I was the starting driver, it was even busier for me. The other guys didn't drive until a couple of hours into the race, so they had a little more time to relax and set up.
We had beautiful weather — not too hot, which was nice. It was great for the fans, it was great for us.
Since I was the starting driver, my first stint stretched from 3:30 PM to almost 5:15 PM. It was a good one. I started 13th and moved up to fifth and I was happy with how the car was running. We made minor adjustments to help the handling as we went. Our plan was to run a steady pace and try to stay out of trouble through the night as it got pretty hectic with all the GT cars out there; some people just weren't thinking! For my two-hour stint — a double — I just played it safe. If a move was questionable, I didn't make it.
After pitting for a driver change, I dried my helmet and suit, changed into dry clothes, made sure I was hydrated, and ate some food. My next stint would start at around 12:25 AM.
Sunday 3:15 AM
By 3:15 AM I was finally finished with my second drive in the car — almost a triple stint! I drove for approximately two and a half hours.
I was really tired at the end of the stint, as you can see in this video:
Things tend to settle down on track in the early morning hours of a 24-hour race. We're all trying to get through with a good car for the daylight hours, when we will need to push hard to the finish. To this point, we had been really trouble-free and running at a good pace up front. Things were going well. We had some minor problems and a few setbacks, but no worse than anyone else. We consistently kept the car in the top four and out of trouble. It was definitely tiring and I was pleased with our run that far, but we were only halfway through the race!
In addition to eating, hydrating, and getting massages between stints, we also slept in a hyperbaric chamber. It's actually a pressurized tube that gets pure oxygen pumped into it. It blocked out most of the noise from the race cars and we had a pillow in there to make it easier for us to fall asleep. We didn't use them much longer than 30 to 45 minutes, however. I napped for a bit, ate some food, and cleaned up.
My family went back to the hotel to sleep. It's no fun for them to sit there all night long when we're just coming in and out of the pits. It would be distracting for the drivers, too, so it was a win-win situation for everybody. I'm usually ornery when I get out of the car, anyway. But I love having them at races and I'm glad they were back to watch the finish.
I was pretty tired after my last stint, but I felt a lot better after eating and resting. Our team's drivers all did double-stints through the whole race, which made for long drives, but also long rest periods.
I was scheduled to close out the race with a double-stint, and was really looking forward to pushing hard. Our team's two race cars were running in third and fourth place all the way up until about 10:00 AM. I'm not exactly sure what happened to our #5 car on track, but it was towed in. Shortly after, I learned that it lost its clutch sometime during the night. We lost three laps and went from fourth place to 10th before we were back on track. Once moving, the car didn't need the clutch, but it was impossible to drive out of pit lane without being pushed! This cost us several seconds at every pit stop.
Despite our problems, I went out there for my last stint around 1:40 PM and pushed hard to see if we could make up another position or two. It was the final stint and our last chance to try and get some points out of the race.
The race ended at 3:30 PM, and the final portion of the race was really tough. We just had a lot of little problems that got us in the end. Without a clutch, we had to come into pit lane, pop the transmission into neutral, and then shut the motor off while the crew completed the pit stop. To get out of the pits, we had to put it in gear and give the race car a push-start while hitting the starter button… It was a pain in the butt and we lost a lot of time because of it. The car also had a fueling issue during the last hour. The plunger in the receiving end of the car's fuel system got stuck open and fuel was sprayed onto the left sidepod and caught fire. I had to jump out of the car, so we lost more laps there.
Besides those issues, the car was running great and it was quick. Our lap times matched the race leaders', but we fell behind once the problems started. I finished the race and we received points for our ninth-place finish.
It was a tough and disappointing race because we had a fast car — at least as fast as our teammates' #9 car, which finished on the podium. Barring problems, I think we could have made the podium in our car. But, as hard as it is to swallow, that's racing.
Both Action Express cars ran in the top three positions for 75 percent of the race. We had a great run and it's really a testament to the team and what it has put together. Our performance displayed the caliber of the team and we're pretty happy about what we've got coming for the season.
In the meantime, we celebrated my wife's birthday the evening after the race ended, before I headed to Sebring for the week to coach several guys who are competing in the IMSA GT3 Cup Challenge. Their event preceded the Sebring winter test for the American Le Mans Series. I was there with Flying Lizard Motorsports, testing and getting ready for the 12 Hours of Sebring in March. Basically, I didn't get a break until the 11th of February … and I wouldn't want it any other way.
A racer reflects on competing concurrently in Grand-Am and ALMS
By Law: Concrete Jungle - Taking Racing to the Streets
By Law: In the driver's seat, along for the ride
By Law: Pre-race season performance development and tire testing
By Law: Testing tires and off-season antics
By Law: Pre-race procedure at Petit Le Mans 2010
By Law: Darren Law reflects on his 2010 season, comments on next
No. 266 | On Sale Now! See what's inside…
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text:
from asciimatics.widgets import Frame, TextBox, Layout, Label, Divider, Text, \
    CheckBox, RadioButtons, Button, PopUpDialog, TimePicker, DatePicker, DropdownList, PopupMenu
from asciimatics.effects import Background
from asciimatics.event import MouseEvent
from asciimatics.scene import Scene
from asciimatics.screen import Screen
from asciimatics.exceptions import ResizeScreenError, NextScene, StopApplication, \
    InvalidFields
from asciimatics.parsers import AsciimaticsParser
import sys
import re
import datetime
import logging

# Test data
tree = r"""
       ${3,1}*
${2}      / \
${2}     /${1}o${2}  \
${2}    /_   _\
${2}     /   \${4}b
${2}    /     \
${2}   /   ${1}o${2}   \
${2}  /__     __\
  ${1}d${2} / ${4}o${2}   \
${2}   /       \
${2}  / ${4}o     ${1}o${2}.\
${2} /___________\
      ${3}|||
      ${3}|||
""".split("\n")

# Initial data for the form
form_data = {
    "TA": tree,
    "TB": "alphabet",
    "TC": "123",
    "TD": "a@b.com",
    "RO": "You can't touch this",
    "Things": 2,
    "CA": False,
    "CB": True,
    "CC": False,
    "DATE": datetime.datetime.now().date(),
    "TIME": datetime.datetime.now().time(),
    "PWD": "",
    "DD": 1
}

logging.basicConfig(filename="forms.log", level=logging.DEBUG)

class DemoFrame(Frame):
    def __init__(self, screen):
        super(DemoFrame, self).__init__(screen,
                                        int(screen.height * 2 // 3),
                                        int(screen.width * 2 // 3),
                                        data=form_data,
                                        has_shadow=True,
                                        name="My Form")
        layout = Layout([1, 18, 1])
        self.add_layout(layout)
        self._reset_button = Button("Reset", self._reset)
        layout.add_widget(Label("Group 1:"), 1)
        layout.add_widget(TextBox(5,
                                  label="My First Box:",
                                  name="TA",
                                  parser=AsciimaticsParser(),
                                  line_wrap=True,
                                  on_change=self._on_change), 1)
        layout.add_widget(
            Text(label="Alpha:",
                 name="TB",
                 on_change=self._on_change,
                 validator="^[a-zA-Z]*$"), 1)
        layout.add_widget(
            Text(label="Number:",
                 name="TC",
                 on_change=self._on_change,
                 validator="^[0-9]*$",
                 max_length=4), 1)
        layout.add_widget(
            Text(label="Email:",
                 name="TD",
                 on_change=self._on_change,
                 validator=self._check_email), 1)
        layout.add_widget(Text(label="Readonly:", name="RO", readonly=True), 1)
        layout.add_widget(Divider(height=2), 1)
        layout.add_widget(Label("Group 2:"), 1)
        layout.add_widget(RadioButtons([("Option 1", 1),
                                        ("Option 2", 2),
                                        ("Option 3", 3)],
                                       label="A Longer Selection:",
                                       name="Things",
                                       on_change=self._on_change), 1)
        layout.add_widget(CheckBox("Field 1",
                                   label="A very silly long name for fields:",
                                   name="CA",
                                   on_change=self._on_change), 1)
        layout.add_widget(
            CheckBox("Field 2", name="CB", on_change=self._on_change), 1)
        layout.add_widget(
            CheckBox("Field 3", name="CC", on_change=self._on_change), 1)
        layout.add_widget(DatePicker("Date",
                                     name="DATE",
                                     year_range=range(1999, 2100),
                                     on_change=self._on_change), 1)
        layout.add_widget(
            TimePicker("Time", name="TIME", on_change=self._on_change, seconds=True), 1)
        layout.add_widget(Text("Password", name="PWD", on_change=self._on_change, hide_char="*"), 1)
        layout.add_widget(DropdownList(
            [("Item 1", 1),
             ("Item 2", 2),
             ("Item 3", 3),
             ("Item 3", 4),
             ("Item 3", 5),
             ("Item 3", 6),
             ("Item 3", 7),
             ("Item 3", 8),
             ("Item 3", 9),
             ("Item 3", 10),
             ("Item 3", 11),
             ("Item 3", 12),
             ("Item 3", 13),
             ("Item 3", 14),
             ("Item 3", 15),
             ("Item 3", 16),
             ("Item 4", 17),
             ("Item 5", 18), ],
            label="Dropdown", name="DD", on_change=self._on_change), 1)
        layout.add_widget(Divider(height=3), 1)
        layout2 = Layout([1, 1, 1])
        self.add_layout(layout2)
        layout2.add_widget(self._reset_button, 0)
        layout2.add_widget(Button("View Data", self._view), 1)
        layout2.add_widget(Button("Quit", self._quit), 2)
        self.fix()

    def process_event(self, event):
        # Handle dynamic pop-ups now.
        if (event is not None and isinstance(event, MouseEvent) and
                event.buttons == MouseEvent.DOUBLE_CLICK):
            # By processing the double-click before Frame handling, we have absolute coordinates.
            options = [
                ("Default", self._set_default),
                ("Green", self._set_green),
                ("Monochrome", self._set_mono),
                ("Bright", self._set_bright),
            ]
            if self.screen.colours >= 256:
                options.append(("Red/white", self._set_tlj))
            self._scene.add_effect(PopupMenu(self.screen, options, event.x, event.y))
            event = None

        # Pass any other event on to the Frame and contained widgets.
        return super(DemoFrame, self).process_event(event)

    def _set_default(self):
        self.set_theme("default")

    def _set_green(self):
        self.set_theme("green")

    def _set_mono(self):
        self.set_theme("monochrome")

    def _set_bright(self):
        self.set_theme("bright")

    def _set_tlj(self):
        self.set_theme("tlj256")

    def _on_change(self):
        changed = False
        self.save()
        for key, value in self.data.items():
            if key not in form_data or form_data[key] != value:
                changed = True
                break
        self._reset_button.disabled = not changed

    def _reset(self):
        self.reset()
        raise NextScene()

    def _view(self):
        # Build result of this form and display it.
        try:
            self.save(validate=True)
            message = "Values entered are:\n\n"
            for key, value in self.data.items():
                message += "- {}: {}\n".format(key, value)
        except InvalidFields as exc:
            message = "The following fields are invalid:\n\n"
            for field in exc.fields:
                message += "- {}\n".format(field)
        self._scene.add_effect(
            PopUpDialog(self._screen, message, ["OK"]))

    def _quit(self):
        self._scene.add_effect(
            PopUpDialog(self._screen,
                        "Are you sure?",
                        ["Yes", "No"],
                        has_shadow=True,
                        on_close=self._quit_on_yes))

    @staticmethod
    def _check_email(value):
        m = re.match(r"^[a-zA-Z0-9_\-.]+@[a-zA-Z0-9_\-.]+\.[a-zA-Z0-9_\-.]+$",
                     value)
        return len(value) == 0 or m is not None

    @staticmethod
    def _quit_on_yes(selected):
        # Yes is the first button
        if selected == 0:
            raise StopApplication("User requested exit")

def demo(screen, scene):
    screen.play([Scene([
        Background(screen),
        DemoFrame(screen)
    ], -1)], stop_on_resize=True, start_scene=scene, allow_int=True)

last_scene = None
while True:
    try:
        Screen.wrapper(demo, catch_interrupt=False, arguments=[last_scene])
        sys.exit(0)
    except ResizeScreenError as e:
        last_scene = e.scene

redpajama_set_name: RedPajamaGithub


Although I've had quite a few milestones over the last year I've hit another quite unexpectedly today. It's not a 'scale' or a 'non scale' victory but instead an experience that's caused me to pause and reflect on what might come next.
But I'll rewind a little.
When I started writing today's post I was sitting in the reception of a school. I was quietly looking at my visitor's pass and the really nice light brown stair carpet nearby. I'd had a sudden realisation that there wasn't a single carpet in any of my schools as a child -but here there was one – and it looked pristine.
However – instead of being here under the pretext of evaluating the rugs – I was waiting for a teacher to come and chaperone me to her classroom. She had kindly invited me to come and speak to her sixth form 'A level' group about the psychology of weight loss.
Her class was apparently interested in discussing the supposition that diets don't work and that any weight lost on such plans will inevitably be regained.
Regular readers will know that this is a topic close to my heart and from time to time is something that I still worry about. Not only have I been in this 'yo-yo'ing' no-man's land several times but I have the (stretched) tee-shirts and the photos to prove it. Despite the fact that standing in front of a class of people I didn't know seemed a bit daunting (and might possibly dredge up some bad memories) it also sounded like something that would be pretty cool to do and push me out of my comfort zone – so I said yes!
When I awoke was hungry. I don't normally want breakfast – so I'm pretty certain that this was related to a minor case of stage fright. However – instead of going down the (seldom successful) denial route I instead prepared for the journey with some virtuous nibbles.
I've learned the hard way that it's better to have a banana and some carrots nearby and to stuff your face with cucumber and tomatoes than to end up eating crap in a service station.
When I arrived (very early) I parked up nearby and set off for a stroll around the area with an objective that I should fill my watch's exercise ring before I started. Thankfully nearby there were a couple of little hills to walk briskly up and down for a while – and I rattled off my cardio for the day pretty quickly.
Consequently when I finally presented myself at the school gate an hour later I felt pretty good – and when my host arrived shortly after she found me in reception all warm and cosy from my stroll quietly considering the soft furnishings.
The class that she introduced me to were a friendly, engaging and bright bunch. Each one of them (some even attending in their free period!) came with insightful and thought provoking questions about how my upbringing, family life, the media, genetics and even mindfulness had played a part in my personal process.
Oddly – as the Q&A went on I realised that before I arrived I had envisaged myself standing in front of these students and touting myself as an example of what NOT TO BE, and a cautionary tale of where one might go wrong in life.
Then I was asked by one of the students whether I'd inspired change in anyone I knew because of what I'd accomplished.
I couldn't get this question out of my head as I drove home. I've been asked this before – but I've dodged the answer most of the time and felt embarrassed. However, the truth of it is I have seen such changes in others occasionally – and I like feeling like I can help other people.
However I still believe that you can't just rock up and make someone successful or change them for the better with a neatly written list of self help tips or a glossy book. You never know what someone will latch on to, what will be personal, or what will mean something to them.
There's no one answer for everyone.
People don't change their habits spontaneously in my experience unless deep down a part of them wants to. Because of this I'm not sure that you consciously 'inspire' anyone – it just happens when you least expect it. They are often just waiting (whether they know it or not) for a catalyst to provoke a change that they already know deep down they have to make.
Some will find it – some won't.
But you can try to give a good example to other people and present the best possible version of yourself to everyone you meet.
In my previous life I know I wasn't very good at doing this. I suspect if many people I know were really honest with me they would tell me that I could very often be accused of not practicing what I preached. I knew deep down (particularly related to my job – but also at times in my personal life) that I didn't always lead by example – and that used to irk me. I definitely hid from the reality of this for a long time – but now I think things may be different.
Maybe for the first time today I began to realise that trying to be a good example to anyone that may be watching is something I really really strive to do. However it's more fundamental than that.
It's actually become something that motivates me now and makes me genuinely happy. Without realising it I think I've felt like this for a while. Standing in front of this class of fresh faces today I felt I learned as much about myself as I imparted to them (maybe more) and I definitely left feeling both energised and alive.
Thanks for visiting us today Dave. My students were so impressed with your warm & candid account of your slimming 'journey'. As I mentioned to you I really think you should explore career opportunities which would utilise your excellent communication skills perhaps in the field of nutrition/obesity counselling.
Thanks Jackie 😄👍🏽 my visit to your school left me with a lot to think about! I really appreciate your feedback! Hopefully I'll see you (and your lovely colleagues) soon!


text:
package com.primeton.devops.test.util;

/**
 * Constants.
 *
 * @author ZhongWen Li (mailto:lizw@primeton.com)
 */
public interface Constants {

	String DEVOPS_URL = "http://localhost:8080/default";

	String DEVOPS_USER = "sysadmin";

	String DEVOPS_PASS = "000000";

	String DEVOPS_ORIGINAL_URL = "/coframe/auth/login/login.jsp";

}


Eid mubarak, friends! Sorry I took a long break without a precaution. I'm really bad at managing my online and real life. Turned out Ramadan this year was more exhausting that I thought it would be; with me having to cook for sahur early in the morning, it felt like the day was way shorter than 24 hours. I felt so burned out, especially when Eid was coming closer and Eid shopping had to start. It was all so crazy!
I still think it's funny that both Afief and I call Lampung our hometown. He was born and raised in the border region between Pesawaran and Pringsewu, while I go to North Lampung every year for Eid because my Granny lives there. I always imagined going 'mudik' (=back to one's hometown for the holiday) to my (then future) husband's hometown somewhere in eastern Java and no longer going mudik to Lampung. But no; I still went to Lampung for Eid this year. And I'm going to Lampung for all the Eids to come. It's amazing. Haha!
Also, we took Miss Jess to her very first car ride which was really a long road trip. She didn't see that coming and became kinda stressed during the trip. But as soon as she arrived in Negararatu, she found her freedom in the form of trees. She climbed trees, the roof of Granny's house, and all the furniture inside the house. She had so much fun.
That poor thing wanted to chew on the birds, but the humans wouldn't let her. She was seriously mad.
We stayed in Lampung for 10 days and went back to Bandung last Wednesday. It was the longest holiday I have ever had (or so I think), since we usually stay for only about 7 days. We didn't do much but it was fun anyway.
Do you celebrate Eid? How was your Eid this year?


text:
Is Fair Use Fair? Analyzing the Defense of Fair Use in a Copyright Infringement Case
Home | Case | Business and Management | Is Fair Use Fair? Analyzing the Defense of Fair Use in a Copyright Infringement Case
Amy Smith
copyright, copyright infringement, defenses, fair use, critical incident
"Fair use" is a defense to a claim of copyright infringement codified in 17 U.S.C. § 107. Courts have struggled to create uniform interpretations of the law of fair use, and because of this, claims of fair use being unfair abound. Even though interpretations vary, it is important for students to understand and be able to analyze the fair use defense. This critical incident, based upon the case of Authors Guild v. Google, Inc. (804 F.3d 202 [2nd Cir. 2015]), provides an example of its use. A dispute arose when Google, Inc. digitally scanned more than 20 million books under agreements with several major libraries, but without the permissions of the associated copyright holders. Google then established a publicly available search engine making "snippets" (a horizontal segment usually containing about an eighth of a page highlighting the searched term) from the digitized, copyrighted copies available without charge to users. A copyright infringement lawsuit was filed against Google. Google asserted fair use in its defense. In this critical incident, students are asked to draw on the facts and arguments asserted in the suit against Google to both critique the rationales for copyright law and analyze and assess the elements of copyright infringement and the fair use defense.
Explain and debate the rationale for the protection of intellectual property, specifically copyrights
Analyze and summarize the elements necessary for copyright, as well as copyright infringement
Critique the rationale of the fair use defense, and explain the factors used in determining whether the use is fair
Analyze the four factors that courts use in determining whether a defendant's use is considered fair or considered infringement under the law


AU students enjoying their time in Brussels, Belgium.
The Kogod School of Business and AU Abroad are thrilled to launch the Brussels Business Internship Program, adding to the University's 100+ study abroad program offerings.
The Internship Program gives Kogod students, preferably rising juniors or seniors, the opportunity to study and work in Brussels, Belgium for a semester. Participants take courses at the KU Leuven – Brussels Campus, intern with an organization in the city, and are actively integrated into Brussel's culture through various clubs and social functions at KU Leuven.
Students collaborate with an Internship Coordinator at the AU Brussels Center, the program's site in the city that houses faculty and staff office space, meeting rooms, and study areas. They are matched with organizations in Brussels and the surrounding region, and are expected to work at least two days a week.
Perhaps the greatest cultural immersion students receive, however, is through their homestay. Program participants reside with families throughout the city, giving them the chance to experience Belgium culture in its entirety. Homestay families provide breakfast daily and three evening meals weekly; students receive an additional stipend for meals outside of the home.
AU Abroad offers a number of scholarship awards each semester ranging from $250 to $2,500. Students interested in receiving aid must fill out a separate awards application.
Applications for Spring 2017 are due by September 15, 2016. Learn more about the program and submit your application today!


text:
October 18Pride of the Lions
September 30Carterville School District
Laughing Lions
The Student News Site of Carterville High School
Emir Sensini Comes to Carterville!
Teresa Pender, Staff Writer
Emir Sensini is a Latin Contemporary Christian song artist from Argentina. Some of his hit songs include "Solo Tú Sacias Mi Vida", "Eres Tú", and his most known song "Soy Feliz". Emir visited Carterville High School on Friday, March 9th, 2018. It was his second time here in Carterville and he put on an amazing show! But sadly, it was the last time for a while, that Emir will have stopped in Carterville as he is going to stop touring. He will be taking a break from music to focus on his family and faith.
Spanish students from Carterville and Southern Illinois had a phenomenal time singing and dancing along with Emir. Sophomore, Toby Farrar, says, "It was a great experience!" Emir put on a show to remember. He even pulled a few students from the crowd to participate in the show. His concerts and music help to bring those listening together. Sophomore Megan Barton said of the concert, "It was a really good time and I made lots of memories." Emir has brought so much joy to Carterville when visiting; he will be missed next year. We love you Emir!
As a junior, Tersea likes to watch Rick and Morty, eat pasta, and sing. Memes are one of the best things to look at. Sleeping is also something she loves.
A Disaster to Remember
On April 15, a tragedy happened in the capital of France. The Notre Dame Cathedral caught fire. The church...
A Very Special Event: SIU Hosts Special Olympics
Each year SIU hosts a Special Olympics for those who have a special need. This will be the 51st Anniversary...
A Different Kind of Competition: Academic Challenge
A select few of students around Carterville High School participate in a group called ACES. This group...
Dear Future Seniors,
AP Test Taking Tips
Taking a Step in to Prep: the SAT and ACT
The Struggle: SAT Prep
The Most Anticipated Night in Hollywood
Almost Show Time
An Annual Tradition
CHS Couples and Valentine's Day
¿Donde es Sophia?


text:
Nominations for the 2021 Provost's Teaching Innovation Prize will be accepted through Feb. 1 from students, faculty, graduate student instructors, department chairs, directors, deans and staff members.
U-M's 2020 United Way employee giving campaign has surpassed its stated goal and raised more than $1.2 million thanks to the generosity of faculty, staff and retirees.
During U-M's 2021 Rev. Dr. Martin Luther King Jr. Symposium keynote lecture, Gloria House and Malik Yakini praised King's fearlessness and perseverance, and said his message continues to resonate today.
Biden's inauguration speech to set the tone for new leadership
In his inaugural address Jan. 20, a newly sworn-in President Joe Biden seeks to unite the country in the backdrop of a global pandemic, racial tensions and the second impeachment of his predecessor.
The sixth cohort of U-M's Interprofessional Leadership Fellows program will undertake team projects that center predominantly on interprofessional education in experiential settings.
Assistant professor recalls 'Jeopardy!' experience
Ian Shin, assistant professor of history and American culture in LSA, appeared on "Jeopardy!" in 2017 and finished second. Shin fondly recalls his time with longtime "Jeopardy!" host Alex Trebek, who died of pancreatic cancer Nov. 8, 2020.
This Week in U-M History — Jan. 18-24
On Jan. 20, 1967, the university kicked off its yearlong sesquicentennial celebration with a luncheon, speeches and historic photos. Read about some of the other things that happened in U-M history during the week of Jan. 18-24.
Obituary — James Renick
Former UM-Dearborn chancellor James Renick was a leader who noticed when people went above and beyond. Renick, who served as chancellor from January 1993 through July 1999, died Jan. 3 at the age of 72.
Police Beat — Jan. 18, 2021
Roundup of crimes reported on and around the University of Michigan campus.
Short news items from around the University of Michigan.


text:
Woodfibre LNG Gets BC OGC Permit
Map: BC Oil & Gas Commission
Woodfibre LNG, a liquefied natural gas (LNG) export facility planned for Howe Sound on the southern B.C. coast, has received its facility permit from the British Columbia (BC) Oil and Gas Commission (OGC).
"Following a rigorous process, Woodfibre LNG has received our Facility Permit issued from the BC OGC, one of the key permits required for construction and operation of the project. This is a positive step forward as we work to build the cleanest LNG export facility in the world," said Woodfibre LNG president David Keane.
"This permit specifies requirements the project must comply with for design, construction and operation of the Woodfibre LNG Project, with a focus on public and environmental safet," he added.
The permit contains 35 conditions for Woodfibre to meet, in addition to standard regulatory requirements.
"As we move towards construction, we will strive to exceed the high standards of public and environmental safety that are expected of us by the Canadian, B.C., and Squamish Nation governments, and the Squamish community. This permit is a large piece of our puzzle, and with it in place, we are working towards a final decision to proceed with this project this summer," Keane said.
Santos Posts Record Production in Q2
Australia's No 2 independent gas producer Santos Ltd said on Thursday it had clocked record gas production in the second…
LNG Project Sanctions Set Records in 2019
Rystad Energy expects LNG greenfield investment in 2019 to reach almost $103 billion, which will be the biggest investment…
LNG Bunkering Market to Reach $12bn by 2024
The global LNG bunkering market was valued at approximately USD 397.70 million in 2017 and is expected to generate revenue…
McDermott-Chiyoda Sign Cameron LNG Deal
American multinational company McDermott International and its joint venture member Chiyoda have reached an agreement with…
Corpus Christi Train 2 Delivers 1st LNG Cargo
Bechtel Corporation and Cheniere Energy have completed the first liquefied natural gas (LNG) commissioning cargo from Train…
USA to Dominate in LNG Capacity
The US and India are expected to lead capacity growth in the global LNG liquefaction and regasification industries from planned…
Total Launches New Supercomputer
Energy major Total said its new supercomputer - which has propelled it to a world ranking as the most powerful computer in…
Floating Production Units
Maritime Magazine


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