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Feb 15, 2001 Issue
Disability Prevention Principles in the Primary Care Office
MICHAEL P. McGRAIL, JR., M.D., M.P.H., HealthPartners Medical Group and Clinics, Minneapolis, Minnesota
WILLIAM LOHMAN, M.D., University of Minnesota School of Public Health, Minneapolis, Minnesota
ROBERT GORMAN, M.D., M.P.H., Occupational HealthSystem Minnesota, Park Nicollet Clinic
Am Fam Physician. 2001 Feb 15;63(4):679-685.
Impairment vs. Disability
Strategies to Assist in Returning to Work
Importance of the Physician-Patient Relationship
Assessing the Patient's Capacity for Activity
Factors That May Delay Recovery
Principles of Good Physician Interaction
The simple request for a sick note can disguise important medical, psychologic or social issues. Disability may be influenced by social and cultural factors as well as by patient expectations. Assessment of impairment and subsequent disability is best made on the basis of objective data by use of a biopsychosocial model to ensure that the expression of disability does not mask other unaddressed psychologic or social issues. Enabling prolonged disability in such a situation can be a dysfunctional physician response to a maladaptive process. The physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources and to provide education about the therapeutic benefits of returning to optimal function. This factual, medical-based approach offers an effective preventive strategy that will save many patients from unnecessary disability and morbidity.
Although busy family physicians may be frustrated when the sole purpose of a patient's visit is to obtain a sick note for the workplace, this simple but sometimes annoying request can disguise more complicated issues. For example, the patient may more urgently need treatment for community-acquired pneumonia than an excuse to give to his or her employer; however, regardless of whether medical attention or only a sick note is required, important disability issues can be identified and favorably dealt with by the astute physician.
Prolonged absence from usual roles, including work, is detrimental to physical, mental and social well-being.1 It is important for family physicians to recognize the financial impact of disability on our patients. The total lost income for the U.S. work force in 1994 during the first six months of disability was $81.1 billion. A disproportionate $55.2 billion was lost from nonoccupational conditions, $36.2 billion of which was unrecoverable from wage protection programs.2
Under current economic conditions, including a shrinking labor force and the passage of the Americans with Disabilities Act, employers have been required to make work-site accommodations and are seeking to extend these for general medical as well as work-related conditions. These trends require physicians to recognize the impact of a health condition on functional and social status. We are challenged to address the interaction between the disabled individual, the work-place and society, and to link medical interventions with strategies to reduce vocational and avocational disability.3
Unfortunately, most physicians have not received sufficient training regarding disability prevention practices as a method of secondary prevention—that is, the reduction of disease-associated disability4 or the therapeutic benefit of optimal activity, including early return to work when appropriate.5 Although unnecessary disability can be generated by inappropriate prescriptions for bed rest and inactivity,6 current reimbursement does not recognize the importance of, or adequately compensate, disability prevention practices.
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To carry out disability prevention principles, a physician must be able to discriminate between impairment and disability. Physical examination and ancillary testing establish impairment, an objective anatomic or physiologic deficit. Disability, on the other hand, is an impairment-associated curtailment of activities. Impairment alone does not determine the disability. Other factors—age, general health, education, motivation, satisfaction with job or supervisor7 and social support—are important effect modifiers.8 Individuals with the same objective degree of impairment can have different disability outcomes. Disability has a subjective component, determined by the patient's testimony and demonstration as well as by the observations of family, friends, co-workers and employers.
In turn, sick leave (temporary disability) is not limited to impairment but may also relate to factors such as job stress and burnout or the care of a sick child.9,10 Sick leave is frequently generated by the patient, with the individual seeking documentation for his or her perceived disability from the physician.11 Rates of sick leave vary widely between societies. In Poland, the 1994 rate of sickness-related absences averaged 25.1 days for female employees,12 compared with 7.9 days for employees of the state of Minnesota in the United States (unpublished data from the State of Minnesota Department of Employee Relations). A small segment of the population accounts for a disproportionate amount of disability. Ten percent of one working population in an Israeli study13 was found to be on nonaccident sick leave for more than 20 days. This group averaged 11 episodes of sick leave per employee, 4.9 days per episode, and 54 days per individual per year. Such marked variations suggest that disability has important social determinants.5
Although prolonged absence may create a "point of no return," with less than one half the disabled workers in one study14 returning to work after an absence of eight weeks, early efforts to help the patient regain function appear to be effective. For example, the risk of developing chronic pain in patients with an initial acute musculoskeletal condition was eight times lower for an "early activation" group compared with usual care.15 Early return to activity helps patients avoid illness reinforcers, such as disability income, family and community sympathy, reduced responsibility and assumption of disability, as a method to resolve conflicts.16–18
Another important component of disability prevention relates to the biopsychosocial paradigm.19 Biologic health has long been a recognized physician domain, with increased attention focused on mental health issues in the past 30 years. Similarly, we are now increasingly aware of the impact of lifestyle and social factors, such as employment, on health status.20 We now appreciate the potential for unfavorable interaction between biologic deconditioning, psychologic depression and the social isolation and lost opportunities that result from prolonged separation from usual activities.18
The effective implementation of disability prevention practices relies on a successful physician-patient relationship. It is essential to make a positive connection and demonstrate a sincere interest by listening closely to patients' concerns, including their perspectives on how the condition may influence their activities and lifestyles. Discussing the illness or injury in light of its natural history and prognosis can alleviate anxiety and further facilitates discussion regarding lifestyle and activity. An activity prescription or plan can help patients remember the details and anticipate changes in activity level.
It is also important to recognize that patients may be physically, psychologically or socially unable to return to work. Most patients with febrile pneumonia or who have lost a family member, for example, will do better if they are away from vocational activities for a short while. Prescriptions for bed rest should only be used with recognition of the risks, including muscle atrophy, cardiopulmonary deconditioning, bone mineral loss, risk of thromboembolism and perception of severe illness, as well as the economic consequences of time away from work.21 In these situations, it is advisable to schedule a return visit in the near future to follow up on the patient's condition and to continue the discussion of appropriate activity after the period of incapacitation.
In the absence of complete disability, the next consideration is the capacity of the patient for activity. While firefighting with a healing fracture of the radius would be inadvisable, desk work may be appropriate. Reduced endurance and effort arising from a medical condition can also be accommodated, if necessary. Occasionally, the employer will not have accommodations available, preventing the patient from returning to work until completely able to perform his or her usual tasks. The return-to-work process ideally relies on patient and employer negotiation. If accommodations are required, the physician can provide appropriate activity recommendations once patient permission has been obtained.
The discussion of appropriate activity relies heavily on the physician's understanding of the pathophysiology and natural history of the impairment, as well as on the level of disability that may be reasonably expected. For example, most patients with the impairment of a mild to moderate ankle sprain can expect some difficulty with bearing weight for seven to 10 days but can expect significant improvement thereafter. Avoiding excessive weight bearing for the first week, followed by gradual resumption of activity with follow-up if the anticipated course of recovery is not realized, would therefore be reasonable advice on the basis of what we know about this condition.
Factors that may delay recovery should also be considered. For example, an obese patient with type 1 diabetes (formerly known as insulin-dependent diabetes) may benefit from an early referral to physical therapy to help with early mobilization and to avoid other complications, such as thrombophlebitis. Similarly, a patient with a history of significant disability in the past can be evaluated early for economic, legal, psychologic or other factors that may need to be addressed to avoid a repeat episode of delayed recovery.
Physical limitations out of proportion to the diagnosis could signal misdiagnosis or complicating psychosocial factors. A related consideration is the determination of appropriate recovery periods. Even allowing for individual variability, physicians have a wealth of information about the usual natural history of most conditions. Just as unexpected types of limitations should be measured against pathophysiology, so should prolonged recovery periods be compared with the typical prognosis.
Prolonged disability should prompt diagnostic review and a search for unrecognized psychologic or social factors. Attention to the course of activity recovery has the advantage of being a patient-centered approach based on the patient's best interests. If risk factors for delayed recovery (Table 1) are recognized early, intervention strategies, including appropriate referrals, can be formulated. Discussing these concerns with the patient may also lead to insight regarding specific issues, which may diffuse potential problems. This approach enables physicians to determine appropriate activity and to assess patient reports with respect to their biologic, psychologic and social significance.
View/Print Table
Risk Factors for Delayed Recovery
Personal or family history of prolonged disability
Symptoms or disability out of proportion to diagnosis
Perceived exaggerated pain behavior
Dysfunctional family dynamics
History of physical or other abuse
Job dissatisfaction
Workplace friction
Economic or legal factors
Underlying medical conditions
If the diagnosis is correct, perpetuation of physical limitations past the time of biologic necessity produces iatrogenic harm through deconditioning while not providing treatment to psychologic or social factors, which may contribute to undesirable outcomes. Enabling prolonged disability is a dysfunctional physician response that risks iatrogenic injury within an already maladaptive process.
Useful principles outlining an optimal physician interaction with the patient and employer when dealing with return-to-work issues have been articulated by the Canadian Medical Association; these are summarized in Table 2.1
The Physician's Role in Helping Patients Return to the Workplace After an Illness or Injury
Encourage early communication between the patient and employer.
Be familiar with the patient's family and community support systems.
Engage in early patient discussion of expected healing and recovery times and the role of early, graduated activity increase on physical and psychologic healing.
Be knowledgeable about, and use appropriately, the services of a multidisciplinary team of health care professionals.
Recognize that ultimately the employer determines the type of work that is available and the feasibility of accommodating the physician's recommendations.
Obtain, when appropriate, information regarding workplace policies, in-house resources, essential job demands and possible workplace health and safety hazards.
Be as specific as possible when describing the patient's capabilities to work.
Consider task limitations in light of the job demands, schedule modification, environmental restrictions, medical aids or personal protective equipment.
Be aware of the risks to the patient, co-workers or the public that could arise from the patient condition or drug therapy and put public interest before that of the patient.
Respect the patient's right to confidentiality.
Consider referral to an occupational medicine physician if conflict between employer and employee or other complication arises.
Obtain all relevant medical records when seeing a patient with a longstanding condition for the first time before offering advice regarding safe, timely return to work.
Clearly inform the patient when the physician believes that the patient has recovered sufficiently to return to work safely.
Provide a copy of the return-to-work documentation prepared by the attending physician to the patient.
Counsel the patient on preventive strategies whenever possible.
Reprinted with permission from Canadian Medical Association Position Paper: The physician's role in helping patients return to work after an illness or injury. Can Med Assoc J 1997;156:680A–C.
Application of these principals can assist the family physician with effective disability prevention practices to help their patients achieve optimal physical and vocational recovery and avoid unwarranted disability and resulting morbidity.
Ultimately, the physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources, and to provide education on the therapeutic benefit of returning to optimal function with the knowledge that such factual, medical-based opinions present an effective preventive strategy. Referral to other health care professionals, such as physical therapists, mental health professionals and social workers, can also provide invaluable help in specific situations.
It is essential, however, that in order to implement these strategies effectively, the family physician should recognize that the most effective tools, as outlined by Welter,22 must be compassion and understanding combined with firm therapeutic goals.
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MICHAEL P. MCGRAIL JR., M.D., M.P.H., is the head of the Department of Occupational and Environmental Medicine and director of the Occupational Medicine Residency, HealthPartners Medical Group and Clinic, Minneapolis, Minn. Dr. McGrail received his medical degree from the University of Minnesota Medical School, Minneapolis, and completed a family practice residency at Malcolm Grow U.S.A.F. Medical Center, Andrews Air Force Base, Maryland. He also completed a fellowship in occupational medicine at Johns Hopkins University Hospital and School of Public Health, Baltimore....
WILLIAM LOHMANN, M.D., is an adjunct assistant professor at the University of Minnesota School of Public Health, Minneapolis, and directs the University of Minnesota Medical School's M.D., M.P.H. program. He also serves as medical director to the State of Minnesota Department of Labor and Industry, St. Paul. Dr. Lohmann obtained his medical degree from McGill University School of Medicine, Montreal, Canada, and completed his internal medicine residency at the University of Minnesota Hospitals, Minneapolis, and his occupational medicine fellowship at Ramsey Hospital, St. Paul.
ROBERT GORMAN, M.D., M.P.H., is the assistant medical director of Occupational HealthSystem Minnesota, Park Nicollet Clinic, St. Louis Park, Minn. He received his medical degree from the University of Minnesota Medical School and completed an internal medicine and occupational medicine residency through a joint program with the University of Minnesota Hospitals and Ramsey Hospital.
Address correspondence to Michael P. McGrail, Jr., M.D., M.P.H., Occupational Medicine Residency, Department of Occupational Medicine, Regions Hospital, 640 Jackson St., St. Paul, MN 55101 (e-mail:Michael.P.McGrail@HealthPartners.com). Reprints are not available from the authors.
The article was supported in part by the Worker's Compensation Health Initiative, a program sponsored by the Robert Wood Johnson Foundation.
1. Canadian Medical Association Position Paper. The physician's role in helping patients return to work after an illness or injury. Can Med Assoc J. 1997;156:680A–C....
2. Kerns WL. Cash benefits for short-term sickness, 1970–94. Soc Secur Bull. 1997;60:49–53.
3. Richardson M. The impact of the Americans with Disabilities Act on employment opportunity for people with disabilities. Annu Rev Public Health. 1994;15:91–105.
4. Last J. Scope and methods of prevention, In: Last J, Wallace R, eds. Maxy-Rosenau-Last public health and preventive medicine. 13th ed. Norwalk, Conn.: Appleton Lange, 1992:3–10.
5. Cassidy S. Principles and practices of disability management in industry [Book review]. J Occup Environ Med. 1996;38:1277.
6. Loeser J, Sullivan M. Doctors, diagnosis and disability: a disastrous diversion. Clin Orthop. 1997;336:61–6.
7. Bigos SJ, Battie MC, Spengler DM, Fisher LD, Fordyce WE, Hansson TH, et al. A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine. 1991;16:1–6.
8. Rael EG, Stansfeld SA, Shipley M, Head J, Feeney A, Maemot M. Sickness absence in the Whitehall II study, London: the role of social support and material problems. J Epidemiol Community Health. 1995;49:474–81.
9. Parker PA, Kulik JA. Burnout, self-and supervisor-rated job performance, and absenteeism among nurses. J Behav Med. 1995;18:581–99.
10. Hermann SJ, Earle A, Egleston B. Parental availability for the care of sick children. Pediatrics. 1996;98(2 pt):226–30.
11. Larsen BA, Forde OH, Tellness G. Physicians role in certifying sick leave. Tidsskr Nor Laegeforen. 1994;114:1442–4.
12. Indulski JA, Szubert Z. Female sickness absenteeism in Poland. Int J Occup Med Environ Health. 1996;9:219–25.
13. Eyal A, Carel RS, Goldsmith JR. Factors affecting long term sick leave in an industrial population. Int Arch Occup Environ Health. 1994;66:279–82.
14. Bjorndal A. Follow-up of persons on long-term sick leave. A cohort study in the city of Moss. Tidsskr Nor Laegeforen. 1994;114:2857–62.
15. Linton SJ, Hellsing AL, Andersson D. A controlled study of the effects of early intervention on acute musculoskeletal pain problems. Pain. 1993;54:353–9.
16. Derebry VJ, Tullis WH. Delayed recovery in the patient with a work compensable injury. J Occup Med. 1983;25:829–35.
17. Crook J, Moldofsky H. The probability of recovery and return to work from work disability as a function of time. Qual Life Res. 1994;3(suppl 1):S97–109.
18. Salcedo-Wasicek MC, Thirlby RC. Postoperative course after inguinal herniorrhaphy. A case-controlled comparison of patients receiving workers' compensation vs. patients with commercial insurance. Arch Surg. 1995;130:29–32.
19. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535–44.
20. Lohmann W. Resources for disability prevention. Occupational medicine update: selected topics in occupational medicine. St. Paul, Minn.: 72–84.
21. Bigos SJ, et al. Acute low back problems in adults. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Clinical practice guidelines no. 14. Rockville, Md.: Government Printing Office; AHCPR publication no. 95–0642:53.
22. Welter ES. The role of the primary care physician in occupational medicine. In: Zenz C, Dickerson OB, Horvath EP, eds. Occupational medicine. 3d ed. St. Louis, Mo.: Mosby Year-Book, 1994:13–27.
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Bronchiolitis News and Research
Researchers uncover the role of protein in identifying common cold virus
The role of a protein in detecting the common cold virus and kickstarting an immune response to fight infection has been uncovered by a team of scientists from Nanyang Technological University, Singapore (NTU Singapore), the Agency for Science, Technology and Research (A*STAR) and the National University of Singapore.
Early interferon therapy may mitigate COVID-19 severity
A recent review of COVID-19 therapies explores the utility of interferons in the battle against severe COVID-19, and concludes that they deserve further development.
Strategizing pediatric healthcare preparedness for the second wave of the COVID-19 pandemic
The paper, put together by a team of scientists based in the United Kingdom and Italy, also underscored the need for healthcare policies to account for the very real possibility of inadequate protective personal equipment (PPE), staff and hospital capacity, aggravated by the increased number of pediatric infections.
Channel 7 grants fund new projects focusing on care for homeless children
Nurse practitioners working with social service agencies is one way to help the estimated 22% of Australian children living in temporary or precarious conditions, with families hit hard by unemployment and other problems created by the pandemic.
Hamsters and ferrets clear low dose SARS-CoV-2 infection in 14 days
A recent study by French researchers has demonstrated that experimental exposure to severe acute respiratory coronavirus 2 (SARS-CoV-2) is capable of inducing mild infection in hamsters and ferrets within 7 – 10 days of exposure. However, the infection completely resolves within 14 days. The study is currently available on the bioRxiv preprint server.
Study presents early data on SARS‐CoV ‐2 testing, outcomes at Australian children's hospital
In the first 30 days since seeing their first patient, the number of children testing positive to COVID-19 at an Australian tertiary pediatric hospital has been low and none who contracted the virus required in-hospital treatment, according to a new study.
Spanish study shows infections in children occur early in COVID-19 epidemics
With the spread of COVID-19, scientists are finding out more about the disease. One major aspect that is being studied is how the virus affects children. A new report from Spain, published in the journal JAMA Pediatrics in April 2020, shows that pediatric populations are infected early in the epidemic and that about 10% of those with symptoms suggestive of infection test positive. Severe infection can also occur among children, requiring hospitalization and intensive care.
Reducing albuterol use in children with bronchiolitis without compromising care
Bronchiolitis, a lung infection that is one of the most common reasons for hospitalizations in young children, is most prevalent during the winter months and is usually treated with albuterol delivered via inhalers, despite evidence showing no benefit in most patients.
NTU scientists find potential route to disabling viruses causing severe respiratory diseases
A team of molecular and structural biologists from Nanyang Technological University, Singapore have found a potential new route to disabling respiratory syncytial virus and human metapneumovirus after elucidating the structure of one of its key components.
New technology developed for treatment of children suffering from respiratory diseases
A new technology to unblock and remove secretions from the respiratory tract of children has been developed as part of a collaboration between researchers at Ben-Gurion University of the Negev and its affiliated Soroka University Medical Center, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati.
New research case report describes lung injury related to e-cigarette use
A research case report describing lung injury related to e-cigarette use in a 17-year-old Canadian may be the first documented case of a new form of damage from vaping products.
Inhaled immunosuppressant could improve prognosis of lung transplant patients
University of Maryland School of Medicine researchers found that lung transplant recipients who had early signs of organ rejection could increase their chances of survival by using an inhaled form of the immunosuppression drug cyclosporine.
Penn researcher-led study aims to improve long-term outcomes of lung transplants
Lung transplantation can be a life-extending option, but severe postoperative complications-including reduced lung function caused by organ rejection-often affect a recipients' quality of life and limit long-term survival.
AACN grants support nurse-driven research designed to improve critical care nursing practice
The American Association of Critical-Care Nurses announces the recipients of its annual research grants. Clinicians and researchers are invited to submit projects by Nov. 1, 2019, for the next application cycle, with total available funding of $160,000.
Avoiding overtesting in the emergency department could create significant health care savings
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Nicotine concentration in JUUL e-cigarette products is dangerously high, finds study
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Study offers new insights for vaccine development to prevent RSV disease
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Infants with bronchiolitis are at increased risk of hospitalization for asthma in preschool years
Infants who are admitted to hospital with the common infection bronchiolitis are at increased risk of further emergency hospital admissions for asthma, wheezing and respiratory illness in the first five years of their life.
E-cigarette flavorings shown to be harmful to the human lungs
Scientists have discovered that two chemicals that are commonly used to flavor e-cigarettes can cause harm to the human lungs.
Chemicals used to flavor e-cigs may impair lung function
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Posted in: Business News
January 13, 2020 4:58 PM UTC
Mark Hamill Deletes Facebook, But Will He Turn Off His TV?
Mark Hamill bashed Mark Zuckerberg for the Facebook refusal to fact check political ads, but television has done this by law since 1934.
Author: W. E. Messamore @thehuli
Star Wars legend Mark Hamill quits Facebook - and has some choice words for Zuckerberg's company, too. | Image: AP Photo/Chris Pizzello
Star Wars legend Mark Hamill announced he's deleting Facebook, and slammed Mark Zuckerberg for valuing "profit more than truthfulness."
Hamill joins a bevy of celebrities and politicians who have condemned Facebook for its role in U.S. elections and its 2020 campaign ad policy.
But Facebook is following the exact political ad policy television stations have for nearly a century. So may the farce be with you.
Mark Hamill tweeted Sunday that he's going to delete his Facebook. The announcement drew cheers from his fans. The Star Wars actor lashed out at Mark Zuckerberg, saying Facebook's CEO "values profit more than truthfulness."
He also tweeted a Malaysian flag emoji, an "is greater than sign," and a money bag emoji. He corrected it to an "America is greater than money" emoji message in a reply tweet.
Celebrities Bash Zuckerberg, #DeleteFacebook
Hamill joins a number of notable politicians and entertainment celebrities in condemning or outright deleting Facebook. Hillary Clinton bashed Facebook in October for refusing to fact check political ads and censor those deemed false.
2020 presidential candidate Sen. Elizabeth Warren has been on an absolute war path against Zuckerberg over Facebook's hands-off policy.
Even before the policy became a publicity scandal for the social media giant, a number of celebrities had deleted Facebook for its role in the 2016 election.
That includes Cher, Will Ferrell, Rosie O'Donnell, Jim Carrey, and even Elon Musk, who said Tesla's Facebook page, "Looks lame anyway."
But Facebook Is Doing Nothing New
The media and anti-Facebook activists have spoken of Facebook's ad policy like it's something radical. Many, like Mark Hammil, have painted it as an existential threat to American democracy itself. But television stations have done this for decades.
A television news veteran with 30 years as a TV news director explains why:
If TV stations were allowed to censor political ads, it still would be extremely tough to determine what makes a political ad false. Without some guidelines, every political candidate would claim that every one of their opponents' ads was filled with falsehoods while their own ads were beacons of truth.
In fact television stations aren't allowed to fact check and remove political ads they deem false, by law. The Federal Communications Commission (FCC) would yank their licenses if they did. The Communications Act of 1934 doesn't give television broadcasters any leeway to censor paid statements by political candidates.
So when FEC Commissioner Ellen Weintraub said last week that Facebook, "has no idea how seriously it is hurting democracy," she appeared to have no idea how democracy's been working under FCC regulation by an act of Congress for nearly a century.
At least Hamill has the excuse that he's just an actor, not an authority on U.S. policy. And can't even tell the difference between the Malaysian and American flag in emoji form. It's very odd that the media has completely overlooked how conventional Facebook's political ad policy is. May the farce be with you.
W. E. Messamore @thehuli
Markets Contributor for CCN living in Nashville, Tennessee. Bachelor of Business Administration from Belmont University in 2009 (majored in Entrepreneurship). Organized Senator Rand Paul's first and second online fundraisers in 2009. Correctly predicted the bitcoin bull market of 2019. Roving editor for the Independent Voter Network since 2013. Email me | Follow Me on Twitter (followed by: fmr Rep. Ron Paul (R-TX), Sen. Rand Paul (R-KY), fmr NM Gov. Gary Johnson, and Rep. Thomas Massie (R-KY))
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Special Guests: Lead Actor & Producer of THE HUSBAND, May 1st
Lead Actor of THE HUSBAND, Max McCabe-Loko, and producer, David Miller, to appear Opening Night, May 1st, for introductions and Q&A!
THE HUSBAND is the latest film from legendary Canadian director, Bruce McDonald (Roadkill, Highway 61). Winner of Best Canadian Feature Film at the Whistler Film Festival. McCabe-Lobos was nominated for an ACTRA for Outstanding Male Performance for this role.
Maxwell McCabe-Lokos is a Canadian actor, screenwriter and musician. Formerly a keyboardist for the garage-rock band The Deadly Snakes, in which he was known by the stage name Age of Danger, his roles as an actor have included the films Land of the Dead, Lars and the Real Girl, The Incredible Hulk, Toronto Stories and The Husband (playing Canada Film Days 2014). Television roles include Happy Town, Being Erica, The Listener, Copper and Lucky 7.
David Miller is an internationally established producer, who has overseen independent productions both within Canada and abroad. He originally hails from Kitchener-Waterloo.
Miller has garnered numerous international awards and received a 2009 Genie nomination for Best Motion Picture for the multi-award winning feature film Amal (by Richie Mehta). Miller's film Blackbird (Jason Buxton), which played Canada Film Days 2013, was awarded Best First Feature film at the 2012 TIFF, Best Canadian Film at VIFF and the Canadian Screen Award's prestigious Claude Jutra Award. Miller has completed Siddharth (Richie Mehta), It Was You Charlie (Emmanuel Shirinian). His latest release is Algonquin, directed by Jonathan Hayes, playing Canada Film Days 2014 (May 7-8), and The Husband, playing Canada Film Days 2014 (May 1-3).


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We're just about into single digits to the due date around here, though I know from past experience that those things are merely suggestions (Freddie was 4 days late, and those 4 days felt as long as the entire pregnancy, I swear).
That hasn't stopped me from keeping my eye on the calendar like a high school senior with graduation day fast approaching. And boy have I been busy. I cooked a metric ton of food to put in the freezer, which is notable because I usually loathe cooking (I also baked lemon cookies with lemon buttercream frosting for a potluck and made hummus from scratch, because hey, why not?).
In case you want the recipes … the first is Mediterranean Tuna Noodle Casserole (I added a bunch of garlic powder, salt, and pepper to the sauce to keep it from being too bland). The second is Vegetable Enchiladas (I subbed my fave taco seasoning for the plain cumin, and I added about double what the recipe called for). And finally, I made Salisbury Steak with Onion Gravy and a carrot and potato mash … basically homemade tv dinners!.
I've got the carseat installed, I've got the baby room set up, I've cleaned everything in sight … what I'm saying is YOU CAN GO AHEAD AND SHOW UP ANYTIME, KID.
And so now I've got just under two weeks left, two weeks which have the possibility of feeling like an eternity and a half. So what have I been doing? Well, turning to books, of course!
I finally pulled ILLUMINAE by Jay Kristoff and Meagan Spooner off my shelf (where it's been sitting since the day it released) and burned through it. Holy wow, was that a wild ride. I grabbed GEMINA, the sequel, this weekend and plan to get that read, since those are definitely not good e-book reads and e-book reads are all I'll be able to do once I've got an infant in my arms and a toddler running away from me. I also reread Audrey, Wait! by Robin Benway, which I've been meaning to do for years. Let me tell you, that book holds up. If you've never read it, I highly recommend you get on that. And I just started a galley of Katie Cotugno's October release (yes, she has TWO books coming out this year), called TOP TEN. I'm about a third of the way through, and holy crap you guys, it's amazing. I think it's going to be my favorite of her books.
All this reading has meant that for the first time in weeks, I can sort of forget that I'm enormous and hot and achy and uncomfortable. We'll see how many of them I get through, or if I have to add to my list if I burn through these. I'm definitely going to try and keep myself busy so that I don't go bananas trying to wish myself into labor (which is definitely not the most far-fetched labor-inducing tip I've ever heard).
Make sure to follow along on Instagram stories to see what I'm reading … and Instagram is probably where I'll go first when this kiddo decides to make his debut! So make sure you're following me, mmmkay?


Over eight hours of (aQ) hits!
It featured a whole bunch of crucial faves we'd hailed on the aQ list between 1995 and 2010, everything from Os Mutantes to Philip Jeck to Uz Jsme Doma to Neutral Milk Hotel to Kathy McGinty to Beyond Dawn to Hatebeak to Boards Of Canada to The Bee Gees, and (of course!!) quite a few selections from The Conet Project, as well as choice cuts from The Ghost Orchid, Sounds Of North American Frogs, and Sounds Of American Doomsday Cults.
We mixed in some one-hit wonders at the shop like The Jones Machine and Jud Jud, as well as highlighting tracks by longtime staples of the aQ catalog like the mighty Circle, the Thai Elephant Orchestra, Village Of Savoonga, and the Ethiopiques series. And you'll find not just one but two f'ed up cover versions of Iron Maiden songs. So many obscure faves and favorite obscurities. While not totally comprehensive (it'd have to be another 8, or 10, or 20, or 100 hours long) it's still a pretty spot-on 'greatest hits' of a lot what we were listening to and raving about at aQ back in the day. Needless to say, our eventually forthcoming 'big book of aQ reviews' will include our write-ups about ALL of these, without a doubt.
"aQ40: To commemorate the 40th anniversary of aQuarius recOrds, we've gathered up some of our all time favorite tracks from throughout the store's long and storied history, songs and sounds that defined the store, and helped make aQuarius one of the most idiosyncratic sources for far our sounds in the world. Many of these gems were aQ Records Of The Week, most of them are long out of print, and all of them are amazing! A sprawling sonic mix tape for our beloved friends and customers around the world. aQ would be nothing without all of you. Thank you from the bottom of our hearts for your years of love, loyalty and support. And of course for loving music as much as we do!"
When we reviewed this Belgian unit's previous disc, Sowberry Hagan, on the aQuarius list four or five years ago, for some reason we omitted to discuss their (ironically?) hyper-masculine name. That could have been the only review of them ever not to talk about how they chose to be called Ultraphallus. Well, gonna mention it now, if only to let you know that if you were to assume on account of their moniker that their music was especially aggro, ugly and crude, that would be an ultra-fallacy (sorry). While they are quite heavy and noisy, there's an artier, and sometimes softer side to the Ultraphallus equation too (arty enough for the Sub Rosa label now, following an association with Riot Season).
Practitioners of a peculiar style of downer experimental sludge rock, Ultraphallus' music on The Art Of Spectres can be a difficult, doomed-out listening experience, referencing a variety of diverse, deviant musical influences (a few they cite include the Swans, Autechre, "death-metal," and the Residents!) and rarified cinematic obsessions. For instance, one brief 1:23 interlude here is titled "The Death Of Mark Frechette," memorializing an event which I googled so you don't have to – Frechette, the star of Antonini's cult classic Zabriskie Point, died in 1975 at the age of 27 in a prison weightlifting accident. Ouch.
On November 25th, the stylish, sludgy Swiss death metal duo Bölzer finally released their debut album following a few well-regarded eps. Compared to those eps, the eagerly awaited, but backlash-beckoning full-length has less in the way of "Wolfshook"-worthy riffs and more in the way of, um, shall we say controversial clean vocals.
Kirk: Have any of you sick metal fucks heard the new Bölzer? Lots of clean crooning.
Allan: I've been so curious, it's gotten pretty much universally bad reviews – makes me think I might like it!
Kirk: Yeah exactly! It's out officially now. You can stream it wherever. I think maybe the songs are a little long and drag a bit but they are really catchy and pretty and sad. Lots of wolf-howl croon.
Andee: The vocals are pretty painful, which makes me think Allan WILL like it.
Andee: You know I love bad vox, but those seem bad BAD... to be fair, I've only heard one song, will check out the whole thing today.
Harry: Gonna give it a sneaky spin now.
Kirk: Curious to know what Harry thinks. My biggest complaint is just the song length.
Harry: Listening to first song...now. Enjoying the spooky Boy Scout whistling intro. This sounds immediately extremely good to me.
Kirk: That's good to hear. It's kinda got that Mithras spacey feel.
Harry: It does! But a bit more epic in the traditional metal sense of the word.
Harry: I think the vox are really cool.
Kirk: Yeah I don't know why people don't like 'em.
Harry: I dare say the vocals are putting hair on my chest in a somewhat Hellenic fashion. Lol.
That OOOH AHHHH chorus. Woah.
Allan: Yeah, not bad at all, pretty cool actually... And listening to some more of the tracks on Hero right now, while I'm not ready (yet) to say it's a brilliant work of genius, it seems at least as good or better than a LOT of 'extreme metal' stuff out there that people seem to like – if different. And, honestly, I'd much rather listen to vocals like these on this album than 95% of the samey harsh/guttural/growling 'vokills' on most death and black metal releases.
Andee: Told ya! ...Things I like more than the new Bölzer: the new Witchery, the new Denouncement Pyre, and maybe surprisingly, the new Norma Jean.
Allan: What's Tomb Mold? Sounds cool from the name.
Allan: I like it... but the Bölzer is better.


The lowest previous point in the market was March 9, 2009, the end of the Great Recession, so-called because it was the worst recession since the Great Depression. It may seem distant now, but at the time, the future of the U.S. economic system was in doubt. Two of the major brokerage houses, Bear Stearns and Lehman Brothers, went under. Merrill Lynch was forced into a sale. Hundreds of thousands of Americans lost their homes and savings.
On the other hand, the news on the political front is not very comforting. Trump's former campaign manager, Paul Manafort, was convicted by a jury on eight charges. His personal attorney, Michael Cohen, pled guilty on eight criminal charges, including campaign finance violations. Allen Pecker, publisher of the National Enquirer, under protection of immunity, corroborated that Trump knew about the hush-money payments. Finally, the Trump Organization's financial gatekeeper, Allen Weisselberg, has also been granted immunity in testimony before a federal grand jury. By all accounts, Weisselberg "knows where all the bodies are buried."⁴ All this is happening just a few months before the midterm elections. Midterms often upset the balance of power in government and damage a sitting President. This election could be monumental, and could cause additional volatility in the stock market.
If you're an investor, it would be natural to feel some unease sitting at the top of the market. Does this mean it's going to be all downhill from here? Is it time to get out of the market? In reality, the length of a market upturn is not a good indicator for a market downturn. Better warning signs are declining corporate profits and revenue, high inflation, and a struggling economy. None of this is occurring right now, and few economists expect a recession soon.
Nevertheless, if you're a cautious investor, you might be feeling that you want to hedge your bets. If you are, it's generally better to make small, gradual and reversible steps in your investment strategy rather than large, dramatic ones that you might regret later.
For example, if you're approaching retirement, you might want to increase the proportion of fixed income (bonds) in your asset allocation. This tends to create more stability in your investment, and enhance downside protection.
If you have some extra cash that you're hesitating to put into the market, but you have a remaining mortgage balance, you might want to utilize the cash to pay down your mortgage. You'll save on mortgage interest at zero risk.
You might use Dollar Cost Averaging, an investing strategy that is very effective when the market is volatile. Instead of investing a large, lump sum all at once, break it up into smaller pieces and invest it in equal amounts gradually: monthly, quarterly or semi-annually. If the market is down, your money will buy more shares. If the market is up, you will be buying fewer shares. Statistically, this will give you a better rate of return.
Whatever you decide to do, it's wise to get professional advice. Talk to your estate planning attorney, CPA, or Certified Financial Planner™ for a second opinion on whether your strategy is appropriate for your circumstances and goals.


text:
Q: Could not make proto path relative: java_out=C:\proto\: No such file or directory
I'm learning gRPC and this is my first app.
I'm using windows 10, java Graalvm 11.
my proto file
syntax = "proto3";

package example;

option java_package = "ir.farshad.services";
option java_multiple_files = true;

service EmployeeService{
    rpc getEmployee (EmployeeRequest) returns (EmployeeeResponse);
}

message EmployeeRequest{
    int64 id = 1;
}

message EmployeeeResponse{
    int64 id = 1;
    string name = 2;
    string designation = 3;
}

my run command
set PROTO_FOLDER_PATH=C:\proto\empoloyee
set PROTO_PLUGIN_PATH=C:\proto\protoc-gen-grpc-java-1.47.0-windows-x86_64.exe
set OUTPUT_DIR=C:\proto

protoc --proto_path=%PROTO_FOLDER_PATH% --plugin=protoc-gen-grpc-java=%PROTO_PLUGIN_PATH% --grpc-java_out=%OUTPUT_DIR% java_out=%OUTPUT_DIR%  %PROTO_FOLDER_PATH%\employee.proto

and I get this Error
Could not make proto path relative: java_out=C:\proto\: No such file or directory

my folder tree is
C:\PROTO
│   protoc-gen-grpc-java-1.47.0-windows-x86_64.exe
│
└───empoloyee
        employee.proto
        run.bat

thank you in advance

A: In the code snippet of the command, we see:
java_out=%OUTPUT_DIR%

It should be a flag:
--java_out=%OUTPUT_DIR%

redpajama_set_name: RedPajamaStackExchange


Tamron announced a full frame 24-70mm f/2.8 lens with built-in ultrasonic motor and image stabilization. Price and availability were not revealed.
February 6th, 2012, Saitama, Japan - Tamron Co., Ltd., a leading manufacturer of optical equipment, announced the development of the SP 24-70mm F/2.8 Di VC USD (Model A007), a full-size high-speed standard zoom lens equipped with VC ( Vibration Compensation) image stabilization and USD ( Ultrasonic Silent Drive), with resolution at the top of its class.
The price and availability of the SP 24-70mm will be announced at a later date.
A full-size, high-speed standard zoom with built-in VC ( Vibration Compensation). Even when shooting in low-light conditions with a slow shutter speed to render sharpness, Tamron's acclaimed VC allows for stable handheld camera work, to more fully enjoy the benefits of this high-speed zoom lens.
Uses special high-grade glass in the three LD elements, three glass molded aspherical lenses, one hybrid aspherical lens and two XR (Extra Refractive Index) glasses, delivering top-of-the-class quality images suited to this high-grade lens. Using a rounded diaphragm, the lens achieves gorgeous blur effects. This rounded diaphragm retains a nearly circular shape even when taken two stops down from its fully open state.
Features Tamron proprietary USD ( Ultrasonic Silent Drive) to power a speedy AF drive together with a continuous manual mechanism.
The lens adopts the new technology including the latest optical design, VC ( Vibration Compensation) image stabilization and USD ( Ultrasonic Silent Drive), all in a lighter and more compact package.
* Entire length is the distance between the tip of the lens and the tip of the protrusion.
* The Sony mount does not include VC, because the body of Sony digital SLR cameras includes image stabilization functionality. The product name for Sony cameras is "SP 24-70mm F/2.8 Di USD" without the VC designation.
VC ( Vibration Compensation) is Tamron's proprietary image stabilization system. Tamron's VC is a three-coil system, whereby three driving coils activate the shake-compensating VC lens group electromagnetically via three steel balls. The VC lens elements are held in place only by contact with the steel balls, achieving smooth movement with little friction. This provides a stable viewfinder image with excellent tracking performance. And as the VC lens may be moved in parallel using only the motorized control, the mechanical structure has been simplified, enabling the creation of a more compact lens.