text:
Follow-up care after treatment for prostate cancer: evaluation of a supported self-management and remote surveillance programme
Jane Frankland1Email authorView ORCID ID profile,
Hazel Brodie1,
Deborah Cooke2,
Claire Foster1,
Rebecca Foster1,
Heather Gage3,
Jake Jordan3,
Ines Mesa-Eguiagaray4,
Ruth Pickering5 and
Alison Richardson6
Accepted: 31 March 2019
Alternative models of cancer follow-up care are needed to ameliorate pressure on services and better meet survivors' long-term needs. This paper reports an evaluation of a service improvement initiative for the follow-up care of prostate cancer patients based on remote monitoring and supported self-management.
This multi-centred, historically controlled study compared patient reported outcomes of men experiencing the new Programme with men experiencing a traditional clinic appointment model of follow-up care, who were recruited in the period immediately prior to the introduction of the Programme. Data were collected by self-completed questionnaires, with follow up measurement at four and eight months post-baseline. The primary outcome was men's unmet survivorship needs, measured by the Cancer Survivors' Unmet Needs Survey. Secondary outcomes included cancer specific quality of life, psychological wellbeing and satisfaction with care. The analysis was intention to treat. Regression analyses were conducted for outcomes at each time point separately, controlling for pre-defined clinical and demographic variables. All outcome analyses are presented in the paper. Costs were compared between the two groups.
Six hundred and twenty-seven men (61%) were consented to take part in the study (293 in the Programme and 334 in the comparator group.) Regarding the primary measure of unmet survivorship needs, 25 of 26 comparisons favoured the Programme, of which 4 were statistically significant. For the secondary measures of activation for self-management, quality of life, psychological well-being and lifestyle, 20 of 32 comparisons favoured the Programme and 3 were statistically significant. There were 22 items on the satisfaction with care questionnaire and 13 were statistically significant. Per participant costs (British pounds, 2015) in the 8 month follow up period were slightly lower in the programme than in the comparator group (£289 versus £327). The Programme was acceptable to patients.
The Programme is shown to be broadly comparable to traditional follow-up care in all respects, adding to evidence of the viability of such models.
Patient-led
Patient-triggered
Supported self-management
Remote surveillance
While there is a trend in developed countries of lengthening survival following cancer treatment [1, 2], cancer survivors are often left with symptoms, side effects and psychological concerns as a consequence of their treatment [3, 4]. For men who have been treated for prostate cancer this includes physical needs, such as urinary and bowel problems and hot flushes, and psychological needs related to sexual dysfunction [5–7]. The common approach to cancer follow-up care, of routine clinic/office-based appointments for all patients at pre-specified intervals, does not always lead to these needs being addressed [8, 9]. In addition, the increasing numbers of cancer survivors in follow-up care over a long period of time means a system of review involving direct contact for all patients is unsustainable in resource constrained health care systems such as the British National Health Service (NHS).
There have been efforts to find more efficient ways to deliver follow-up care, with testing of alternatives such as nurse led care, general practitioner led care, shared care and patient led care [10]. In England, current policy advocates a risk stratified approach for post-treatment cancer care, with remote surveillance and supported self-management for those who are at low risk of disease recurrence [11]. The recommended model for delivery of this self-management focussed pathway is a collection of interventions including holistic needs assessment, treatment summaries, rapid re-access to specialised care when indicated, and patient education and support [12]. There has been recognition of the relevance of such an approach to other international contexts [13].
To date, there is some evidence to show that remote surveillance together with patient initiated follow-up (variously referred to as patient triggered, patient-led, on demand, open access, spontaneous or point of need follow-up), is acceptable to patients [14–19], cost effective [17, 20], efficient [16], safe [15–17, 21, 22] and does not lead to an increase in use of GP services [18]. Only a small number of studies have considered the impact of such models on patient reported outcomes, showing no detrimental effects nor improvements in quality of life (QoL) [15, 17, 19] and no improvements in psychological wellbeing [15, 17, 23] .
This paper reports the evaluation of a service improvement initiative for men who have completed treatment for prostate cancer (the TrueNTH Supported Self-Management and Follow-up Care Programme, henceforth termed the Programme). The Programme is part of a global initiative to improve the survivorship outcomes of men with prostate cancer, funded by The Movember Foundation [24] and delivered in the United Kingdom (UK) in partnership with Prostate Cancer UK [25]. The Programme is focussed on providing post treatment follow-up care which is better tailored to men's needs, which supports them to achieve their personal goals in relation to those needs and is cost-effective and scalable. This paper presents findings that relate to the impact of the Programme on patient reported outcomes including unmet need, symptom experience, quality of life, psychological wellbeing, activation to self-manage, fear of recurrence, healthy behaviours, patient satisfaction with care, as well as cost. The key questions addressed are: i) are patient reported outcomes better for men who are managed through the Programme compared to men in traditional appointment-based follow-up care; ii) are any improved outcomes maintained over time; and iii) what is the difference in cost between the Programme and traditional appointment-based follow-up care?
Only brief descriptions of the Programme and the evaluation methods are provided here, further details can be accessed elsewhere [26].
The Programme was evaluated in four prostate cancer treatment centres in the NHS in England. Three of the centres were involved in an expression of interest process and were selected according to readiness for implementation and to represent providers of urology services in both rural and urban areas. The fourth site had been involved in development and piloting of the Programme and was included in the evaluation to boost recruitment.
The evaluation was historically controlled, comparing outcomes for men on the Programme with a comparator group of men recruited whilst attending a follow-up care appointment in the period prior to the introduction of the Programme. Outcome was assessed at four and eight months post-baseline. An embedded, within trial cost comparison analysis compared costs between the two groups from a health care provider perspective. A concurrent qualitative evaluation of factors that facilitated or inhibited implementation of the Programme will be reported separately.
Men were eligible to take part in the evaluation if: their mode of primary treatment was radical prostatectomy (RP), radiotherapy (RT) or primary androgen deprivation therapy (PADT); they were assessed as suitable for the Programme by their clinical team, using predefined clinical eligibility criteria (see Additional File 1); they were within three years of completion of RP or RT, or within three years of commencement of PADT. Men were assessed for the programme from six weeks post RP or RT, or three months post commencement of PADT, and were reassessed periodically if they did not meet the criteria at their first assessment. Men with metastatic disease who met the clinical eligibility criteria were included in the Programme.
Men in the comparator group were managed according to the follow up care protocol in place at their treatment centre prior to the introduction of the Programme, and this varied by centre and by treatment group. National guidance informing this did not prescribe intervals of follow up, mode of follow up or professional involved. Consequently, each centre worked to a different frequency of follow up appointments (commonly for RP patients, 3 appointments during the first year, then 6 monthly in year 2 and then annually; RT patients commonly, 3 appointments during the first year, then annually; and for HT patients commonly between 3 and 6 monthly appointments), setting of the appointment (often face-to-face but some telephone appointments for some patients; all were followed up in secondary care), professional involved (most often a mix of nurse and consultant care), and overall duration of follow-up (varying by clinician and centre, between 5 and 15 years).
The Programme is designed to deliver personalised survivorship care through remote monitoring and supported self-management. The Programme is managed on a day-to-day basis by a healthcare worker, known as a support worker, who acts as the co-ordinator of the patient's follow-up care and as first point of contact for any problems or queries. A uro-oncology Clinical Nurse Specialist (CNS) oversees this work, with overall patient responsibility remaining with the supervising urologist/oncologist. Men's suitability for the Programme is determined according to agreed clinical criteria (Additional file 1). Men on the Programme do not have scheduled urology/oncology follow-up appointments; their follow-up care is instead facilitated through a bespoke Patient Online System (called My Medical Record), with access for both men and the prostate cancer team. Recurrence of prostate cancer is tracked through periodic blood samples to detect Prostate Specific Antigen (PSA). For men in the Programme, blood samples are taken at the man's General Practice or at their hospital phlebotomy service and are transferred to the Online System directly from the pathology laboratory. Results are accessible to the patient through the Online System as soon as they are available, and they can also view other personal information such as treatment summaries and care plans, complete a Holistic Needs Assessment known as a Health MOT, or securely message their clinical team. PSA results and completed Health MOTs are reviewed by the team during 'virtual clinics', and contact made with the man if there is any concern. There is a system of rapid re-access to clinic if needed. Systems are in place for men who do not wish to use Information Technology. Men attend a four-hour face-to-face group self-management workshop to prepare them for the Programme. The workshop is run by the CNS and support worker, and aims to educate men about their follow-up care, consequences of treatment, important signs and symptoms of possible recurrence, healthy lifestyles and setting of health and wellbeing goals.
Study integrity
Ethical approval was granted by the National Research Ethics Service, East of England – Cambridge South (reference number 11/EE/1021). Written consent was sought for participation in the study, with separate consent for access to medical records. As an evaluation of a service improvement initiative, trial registration was not required. Reporting of the study follows appropriate guidance [27, 28].
Patient reported outcome data were collected by postal questionnaire. Outcomes were measured using validated instruments where available, details of these are given below. Demographic characteristics were also collected. Medical details, including cancer stage, grade, date of diagnosis and treatment received, were collected from hospital records.
Resources related to the provision of the Programme and care of the comparator group were collected from the cancer centre teams, databases and finance managers. For the Programme, the clinical teams provided patient-level data regarding utilisation of follow-up services (virtual clinic appointments, telephone and electronic correspondence and face-to face appointments), workshop attendance, registration with the Patient Online System and details of other prostate cancer related hospital service use. Time related to Programme provision (such as delivery of the workshop, registration of men on the online portal and conduct of the health needs assessment) was reported by staff for the estimation of costs. Information on the follow-up care of the comparator group was extracted from treatment centre databases. Data on wider prostate cancer related health service use (primary care, secondary care, allied health professionals and community-based care) were collected from both groups via the questionnaire at four and eight months.
Cancer survivors' unmet needs
The primary outcome was men's unmet needs, as measured by a modified Cancer Survivors' Unmet Needs Survey (CaSUN) [29]. The CaSUN [29] comprises 35 items within five domains: existential survivorship (that is, life perspective), comprehensive care, information, quality of life, and relationships, with an additional six items about positive life changes. This study has followed others in using a simplified four point response format [30] of no need, low need, moderate need and high need. The CaSUN can be scored as totals of strength of unmet need (possible scores of 0 to 140) and number of unmet needs (possible scores of 0–35), or for each of the five domains separately. The range of attainable values for each domain subscale are provided within the table of results. Higher scores indicate more need.
Treatment side effects
The Expanded Prostate Cancer Index Composite Short Form [31] (EPIC-26) was used to measure prostate cancer treatment related symptom and bother. The EPIC-26 comprises five subscales of urinary incontinence, urinary irritative/obstructive, bowel, sexual, and hormonal symptoms and bother. Each subscale is scored from 0 to 100, with higher scores indicating better function.
Cancer specific quality of life
Cancer specific quality of life was measured using the Functional Assessment of Cancer Therapy Scale (FACT-G) [32], which comprises physical, emotional, social and functional subscales, to calculate subscale scores and a total score (0 to 108). Higher scores indicate better functioning. Possible subscale scores are provided within the table of results.
Psychological wellbeing
The General Health Questionnaire (GHQ-12) [33] measures current mental health. The measure has two scoring methods: the 0111 giving a maximum total score of 12 and the 0123 method a maximum total score of 36. A higher score indicates worse mental health.
Fear of cancer recurrence
Fear of cancer recurrence was measured using the 2 item Worry of Cancer Scale [34], which is scored from 0 to 20 with a higher score indicating greater worry.
Activation for self-management
Activation to self-manage was measured with the short form Patient Activation Measure (PAM)® [35, 36]. This measure comprises 13 items and results in a total score with a maximum of 100, a higher score indicating greater activation.
General health behaviours
The Fruit and Vegetable Screening Tool [37] was used to measure healthy eating behaviours. This measure asks about fruit and vegetable consumption within a typical day and was scored from 0 to 10, with higher scores being better.
The Godin Leisure Time questionnaire [38] asks about leisure time physical activity as mild, moderate and strenuous activity, plus activity to work up a sweat, as number of units of 15 plus minutes per week. A total score is calculated (0 to 400 with higher being better), which can be used to classify respondents as active, moderately active and insufficiently active.
Service use
Fifteen questions about contact with health and community services for prostate cancer related issues and patient costs related to prostate cancer were developed for a previous evaluation in which two of the current authors were involved [39].
Satisfaction with care
Eleven questions regarding experience and acceptability of follow-up care were also developed for the previous evaluation [39].
Programme effectiveness
Descriptive statistics were used to compare baseline clinical and demographic characteristics of the programme and comparator groups, as well as to compare those completing both 4 and eight-month follow-up questionnaires with those lost to attrition. Outcome measure total scales and subscales were computed according to the guidelines for each instrument. When guidelines were not available, a prorated score was calculated when at least 75% of the items for a scale/subscale were present, otherwise the score was set as missing. Means and standard deviations were calculated for all available cases for each outcome measure at each time point, along with the change from baseline. Patient satisfaction data were analysed using Mann-Whitney U tests.
Regression analyses were conducted for outcome measures at both follow-up times separately, controlling for pre-specified variables: cancer centre, each outcome at baseline, age, type of treatment, educational attainment, time since diagnosis, living status, co-morbidity, employment status, and ethnicity.
Outcome comparisons were also obtained from a mixed model including an interaction between group and time so that separate programme comparisons were estimated at four and eight months. Results supported the initial regression analyses, with additional significant differences in seven of the outcomes at the eight month time point (not shown).
Three pre-specified sets of subgroup analysis were also conducted: age with pre-specified dichotomisation at 70 years; none versus one or more comorbidity; and being in the 20% most deprived areas according to the English Index of Multiple Deprivation [40]. Separate regression analysis for the difference in outcome between the programme and comparator groups at each time point, with the same controlling variables as used in the previous analyses, was repeated for each subgroup, and the interaction term between each specified subgroup and the programme versus comparator group factor was examined. Estimates of the difference between programme and comparator for each subgroup were examined when the interaction term was found to be significant (at the 5% level). Only one test of interaction was statistically significant (not shown).
For all analyses, terms were deemed statistically significant at the 5% level.
Costs of all items of service use for the programme and the comparator groups were calculated for each patient individually, based on the frequency of service use (Additional file 2) multiplied by the corresponding unit costs sourced from national tariffs [41] or finance managers (Additional file 3). Software and system costs were averaged and applied top down. Mean costs for each item and overall costs were compared between groups. Costs are reported in British pounds, 2015. The analyses were conducted on complete case data, that is respondents who returned service use data at all time points. In cases where some items of service use data were completed but others were missing, simple mean imputation stratified by group and cancer centre was used for the missing items. Health economics analyses were conducted using STATA14 [42] and Microsoft Excel 2013.
The flow of participants through the study is shown in Fig. 1. Of the 1036 patients identified as eligible for the study, 627 (61%) completed a valid baseline questionnaire, and 522 (83%) of these also returned both follow-up questionnaires. Eight participants withdrew from the study and 12 died or became too unwell to continue. Fifteen men did not consent to use of medical records.
Flow diagram of study participation
The programme and comparator groups were broadly similar on a range of socio-demographic and medical characteristics at baseline (Table 1). No characteristics were significantly different between the two groups, but there were slight differences in percentages of men in each group at three of the cancer centres. There were no significant differences in sociodemographic or medical characteristics between those who completed all three questionnaires and those lost to attrition (Additional file 4).
Baseline characteristics of patients included in the study
Programme group
Comparator group
(n = 627)
Ethnicitya
Qualificationsa
No qualifications
GCSE/O level
Employment statusa
Employed part time
Employed on sick leave
Disabled or long term sick
Marital statusa
Married/civil partnership
Living with partner
In own home
In rented home
Caring responsibilities for children or adultsa
Access to the internet at homea
Index of Multiple Deprivation decilea
Age of participant (in years)
Min to max
Time since diagnosis (in years)a
Time from treatmenta
0–1 years
> 1–2 years
Number of comorbidities
Treatmenta
Hormone therapy (HT)
Brachytherapy (BT)
EBRT and HT
BT and HT
BT and EBRT
BT and EBRT and HT
T Stagea
T stage unknown
N Stagea
N stage unknown
M Stagea
M stage unknown
PSA at diagnosisa
Risk stratification (3)
Advanced (metastatic)
Localised high risk
Localised intermediate risk
Localised low risk
Localised risk unknown
Locally advanced
Insufficient data
aPercentages for non-missing categories calculated amongst cases with valid responses
Study outcomes
Primary outcome –Cancer survivors' unmet needs (CaSUN)
Results of the regression analyses for the CaSUN at each time point are shown in Table 2, detailing both scoring methods [29]. There were statistically significant reductions at the four-month follow-up for the programme compared to the comparator group in strength of unmet needs and total number of unmet needs (p = 0.025 and p = 0.020 respectively) and for the existential survivorship needs subscale (p = 0.041 for strength of needs and p = 0.022 for number of needs). These differences were reduced and not statistically significant at the eight-month follow-up point.
Regression analysis of primary outcome measure (Cancer Survivors' Unmet need – CaSUN [29] ) at 4 and 8 month follow up points by group
Outcome (Direction) Subscales (Range)
Programme group Mean (SD) n = 293
Comparator group Mean (SD) n = 334
Programme– comparator difference (95% CI)a
Direction favours Programme
CaSUN Strength of need (higher = more need)
Total score (0 to 140)
24.4 (17.2) n = 288
4 months
−2.4 (−4.5, −0.3) n = 524
−1.7 (−3.7, 0.3) n = 517
Change (b-4 m)
4.8 n = 248
Existential Survivorship (0 to 56)
4.8 (6.7) n = 290
−0.7 (−1.4, −0.02) n = 533
−0.6 (−1.3, 0.04) n = 519
Comprehensive cancer care (0 to 24)
10.0 (5.5) n = 292
7.8 (6.108) n = 287
Information (0 to 12)
0.1 (−0.3, 0.5) n = 524
Quality of life (0 to 8)
−0.2 (− 0.4, 0.02) n = 517
0.08 n = 295
Relationships (0 to 12)
−0.1 (− 0.4, 0.1) n = 531
CaSUN Unmet needs (higher = more need)
Total number of unmet needs (0 to 35)
−0.524 (−0.9, −0.07) n = 533
Comprehensive Cancer Care (0 to 6)
−0.07 (− 0.4, 0.2) n = 521
Information (0 to 3)
−0.03 (−0.2, 0.1) n = 531
Relationships (0 to 3)
−0.06 (−0.2, 0.08) n = 531
−0.08 (− 0.2, 0.06) n = 523
CaSUN Positive changes in life (higher = better)
Number of positive changes (0 to 6)
0.2 (−0.08, 0.5) n = 535
0.221 (−0.1, 0.5) n = 517
−0.06 n = 252
Secondary outcomes
Additional file 5 shows results for the secondary outcome measures. There were statistically significant improvements for the EPIC-26 bowel subscale for men in the programme group compared to the comparator group at both the four (p = 0.016) and eight-month (p = 0.003) follow-up points. A statistically significant improvement in mental health favouring the programme group was found for the GHQ-12 at four months using the most common 0111 scoring method [43] (p = 0.032) but not at eight months, and for neither time point using the alternative 0123 scoring method. There were no statistically significant differences between groups for any of the other secondary outcome scales/subscales at either time point.
Participant satisfaction data are presented in Table 3. The programme group reported significantly more satisfaction for nine of eleven statements at the four-month follow-up point. However, at eight months, only the statement 'I have known who to contact with any problems' showed a significant difference between the groups, with more programme group men strongly agreeing and more comparator group men agreeing to the statement.
comparison of patient satisfaction with follow up care at 4 month and 8 month time points
Strongly agree N (%)
Agree N (%)
Neither agree nor disagree N (%)
Disagree N (%)
Strongly disagree N (%)
Mann Whitney U
I have felt reassured
I have known who to contact with any problems
I have felt comfortable about contacting the doctors and nurses with any problems
I have felt isolated
I have felt that the care received was thorough
I have felt able to ask questions
I have felt that the doctors/nurses spent enough time with me
1 (.5)
I have felt involved in decisions about my care
Has the health care you received been acceptable
Has the health care you received met your expectations
Fell short
How would you rate the quality of care you have received
Health economic analysis
Analyses were conducted on a complete case sample of 206 men in the programme group and 265 men in the comparator group. The direct costs of provision of follow-up care over the eight month period was £102 per patient for the Programme group (Table 4), compared to £59 per patient for the comparator group, with the higher cost being largely accounted for by the cost of the workshop (£63 per participant). Comparison of other prostate cancer related service use showed an appreciable difference between the two groups, with a mean cost (SD) of £186 (411) for the programme group and £268 (1020) for the comparator group. The difference was in part due to a small number of expensive inpatient events in the comparator group. Primary care use was similar for each group. A small number of men in the programme group attended urology service appointments to address problems that arose during the study period. Combining direct costs and costs of service use, the programme group had lower overall average costs of £289 per patient compared to £327 for the comparator group. The utilisation of service items that underlie these cost figures are shown in Additional file 2.
Costs of service provision and service utilisation by group (£ stirling)
Programme group (N = 206)
Comparator group (N = 265)
Direct cost of Intervention
Total cost of Service use
Programme group follow up care costs
Screening Cost
Introduction to support worker
Set up on PSA tracker system
PSA Reviews
Signed up to Online Portal
Conducted Electronic Health Needs Assessment (HNA)
Conducted Paper Health Needs Assessment (HNA)
Staff Member electronic Messages
Patient electronic Messages
Cost of delivery of workshop (per patient)
Comparator group follow up care costs
Face to Face CLINIC, CNS Band6
Face to Face CLINIC, CNS Band8A
Face to Face CLINIC, Registrar Urology
Face to Face CLINIC, Consultant Urology
Face to Face CLINIC, Registrar Oncology
Face to Face CLINIC, Consultant Oncology
Telephone CLINIC, CNS Band6
Telephone CLINIC, CNS Band8A
Telephone CLINIC, Consultant Oncology
Unplanned Clinical calls cost
Telephone Contact, Support worker
Telephone Contact, CNS Band6
Telephone Contact, CNS Band8A
Telephone Contact, Registrar Urology
Telephone Contact, Consultant Urology
Telephone Contact, Consultant Oncology
Other prostate related service use
GP Visit
GP Tel Advice
GP Home Visit
GP Nurse Visit
GP Nurse Tel advice
GP Nurse home visit
Social worker visit
Physiotherapist visit NHS
Dietician visit NHS
Counsellor Visit NHS
Psychiatrist/psychologist Visit NHS
Complementary Therapist Visit NHS
Services Helpline call
Attended Urology Clinic
Other Clinic Cost
Hospital Day Case
Hospital Inpatient Cost
Ambulance use
The increasing number of cancer survivors has resulted in a need to develop more sustainable models of cancer follow-up care which deal with capacity issues faced by healthcare services and also better address the range of cancer-related problems that survivors face. The Programme evaluated here integrates remote surveillance with supported self-management in a follow-up care pathway which aims to provide men with care that better targets their needs, as well as to reduce numbers of clinic appointments. This study is, to our knowledge, the first published evaluation of such a pathway for men with prostate cancer. The Programme differs from most other remote follow-up models in that it has a focus on supported self-management and potential patient entry as early as 6 weeks post-treatment.
The Programme showed some positive influence on men's cancer related problems, with analyses showing significantly greater improvement in the programme group in unmet survivorship needs, bowel problems and psychological wellbeing at the four-month follow-up point, though only the improvement in bowel problems was still found at eight months. Overall, men in the programme group tended to rate their outcomes more highly than men in the comparator group.
Of those outcomes which showed a positive influence, only the EPIC-26 measure has published minimally important differences (MID) [44]. Differences related to the bowel function and bother subscale for the Programme are below the MID of 4–6, reaching 2.7 at four months and 3.6 at eight months.
One reason for the small number of outcomes showing a significant influence of the Programme may be the relatively low rates of need and high functioning and quality of life at baseline, possibly arising from the fact that men are only eligible for the Programme when the cancer care team is satisfied that such issues have been resolved as far as possible. The notable exceptions to this are EPIC-26 sexual and hormonal subscales, for which normative means of 61.4 and 91.7 [45] respectively compare to baseline means of 20.7 and 77.7 for the programme group and 18.4 and 78.1 for the comparator group. The Programme did not result in significant change in these subscales, which suggests that further intervention development is required for these issues.
In line with other studies [14–19], satisfaction with the Programme was high. This was most notable at the four-month follow-up point, shortly after men's attendance at the Programme workshop. It is possible that the intensive time with the nursing team and with peers that the workshop affords men is the reason for this.
While the cost of delivering the Programme was slightly greater than care provided to the comparator group, reduced service use costs in the programme group offset this additional expense. The evaluation only measured outcomes over an eight-month period, whilst men will be followed up by their cancer service for at least five, and sometimes ten, years. It would not be appropriate to extrapolate the findings into the future, since there are no data available about men's service use in the longer term. However, evaluation of costs over a longer time period would spread the upfront costs of the Programme.
This study suggests that a shift to remote surveillance coupled with support for self-management is broadly comparable to appointments-based follow-up care in terms of patient reported outcomes. This supports other evaluations of similar pathways with different cancers [14–19, 21], that cancer follow-up care can be provided remotely with no detriment to patient outcomes. In addition, such a model is acceptable to patients and is largely cost neutral.
There are a number of limitations to the evaluation that warrant discussion. First, being a service improvement initiative, it was not possible or desirable to conduct a randomised controlled trial, with the concomitant requirements for strict control by researchers over participant inclusion and exclusion and highly controlled programme delivery. Instead, a non-random comparator cohort was used and a pragmatic approach was taken [46], allowing for clinical judgement on a patient's suitability for the Programme and for flexibility in how Programme delivery responded to local context. While the programme and comparator groups proved to be similar at baseline on all measured characteristics there remains a possibility, without randomisation, of relevant baseline differences between the groups on aspects that were not measured [47]. Second, in order to reflect the complex nature of the intervention and its theoretical underpinning, the evaluation made use of multiple outcome measures. The analyses presented in this paper involved a total of 26 tests of significance for the primary outcome and 54 for the secondary outcomes across the two follow-up time points. We did not make correction for multiple testing. Overall, however, 17 (21%) of 80 comparisons were found to be statistically significant, where this degree of multiple testing would be expected to yield only four statistically significant differences due to chance [48]. Third, as men in the comparator group were treated by the same healthcare team as the programme group, there is a possibility that they experienced some elements of the Programme, such as contact with the support worker or an enhanced personalised approach because of Programme training, during the follow-up period. However, the clinical teams were made aware of this possibility and asked to minimise this as far as possible. Also, the fact that the introduction of the Programme boosted clinic capacity may have improved the experience of those in the comparator group. Fourth, the evaluation did not assess the ability of the Programme to detect progression or recurrence. Fifth, while men with metastatic disease who met the clinical eligibility criteria were included in the Programme, 95% of the sample comprised men with non-metastatic disease. It is therefore uncertain whether the Programme can be recommended for men with metastatic prostate cancer. Sixth, while Programme cost and hospital service use data were collected directly from the clinical teams involved with the study, the health economics analysis relied on patient self-reported data regarding use of wider, community-based health care, so may have been affected by problems with recall. Finally, some activity related to remote surveillance does not have an NHS reference cost for use in health economic analyses, and a compromise was made to pro rata other costs to represent these activities.
This evaluation adds to the evidence base around remote surveillance, or patient-led follow-up, of post-treatment cancer patients, showing that a shift to a supported self-management model of care with remote surveillance and a transition workshop is at least comparable to appointment based follow-up care in terms of patient reported outcomes, is acceptable to men and is largely cost neutral in the first eight months. The model addresses capacity issues by replacing a 'one size fits all' model of scheduled direct contact with remote surveillance for men who are progressing well, and places emphasis on the patient role in recovery and maintenance of health and wellbeing, which is absent in the more traditional model. Current policy for England [11] recommends such an approach for cancer patients at low risk of recurrence, and this evaluation shows the Programme to be a viable model. Future research to assess impact and cost-effectiveness over a longer follow-up period would be valuable.
CaSUN:
Cancer Survivors' Unmet Needs Survey
EPIC-26:
Expanded Prostate Cancer Index Composite Short Form
FACT-G:
Functional Assessment of Cancer Therapy Scale
GHQ-12:
The General Health Questionnaire
NHS:
National Health Service (NHS)
PADT:
primary androgen deprivation therapy
PAM:
Patient Activation Measure
PSA:
RP:
Our thanks go to the men who took time to complete the study questionnaires and to staff at the study sites who implemented the programme and supported with recruitment and data collection.
This work was funded by the Movember Foundation, in partnership with Prostate Cancer UK, as part of the TrueNTH programme, grant number 250–25/30/40. The funding body had no role in the design of the study, collection, analysis, and interpretation of data nor in writing the manuscript. Professor Richardson is a National Institute for Health Research (NIHR) Senior Investigator. The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Supplementary information is available at the British Journal of Cancer's website.
AR is the overall project lead and grant holder with responsibility for the design and execution of the protocol. All authors contributed to the design of the study. RF and JF undertook data collection. RP and IM-E undertook analysis of effectiveness data. HG and JJ undertook analysis of heath economics data. CF provided expertise on recruitment, data collection, data analysis. DC provided expertise for design of the Programme and on evaluation of self-management programmes. HB managed Programme design and implementation. All authors participated in interpretation of data. JF drafted the manuscript. All authors read, commented on and approved the final manuscript.
The study received ethical approval from the National Research Ethics Service, East of England – Cambridge South (reference number 11/EE/1021.) All participants completed a written consent form, separately for the questionnaire survey and for interview. The study was undertaken in accordance with the Declaration of Helsinki.
Additional file 1: Programme's clinical eligibility criteria. Table containing the clinical eligibility criteria for inclusion in the Programme. (DOCX 12 kb)
Additional file 2: Frequency of service use for programme and comparator groups. Table containing frequency of service use data used to calculate cost of service delivery. (DOCX 18 kb)
Additional file 3: Unit costs used in calculation of provision of follow-up care and other prostate cancer related service use. Table containing unit costs and source of unit costs used to calculate cost of service delivery. (DOCX 15 kb)
Additional file 4: Comparison of baseline characteristics for those completing all three questionnaires and those lost to attrition. Table containing data comparing those who completed all three questionnaires and those lost to attrition. (DOCX 18 kb)
Additional file 5: Regression analysis of secondary outcome measures at 4 and 8 month follow up points by group. Table containing data for the secondary outcomes measures (Patient Activation Measure®, EPIC-26, FACT-G, GHQ-12, Worry of Cancer scale, and lifestyle measurements). (DOCX 20 kb)
University of Southampton, School of Health Sciences, Highfield, Southampton, SO17 1BJ, UK
University of Surrey, School of Health Sciences, Guildford, Surrey, GU2 7XH, UK
Department of Clinical and Experimental Medicine, University of Surrey, Surrey Health Economics Centre, Guildford, Surrey, GU2 7XH, UK
University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Nine Edinburgh BioQuarter, Teviot Place, Edinburgh, EH8 9AG, UK
University of Southampton, Faculty of Medicine, Highfield, Southampton, SO17 1BJ, UK
University of Southampton, School of Health Sciences and University Hospital Southampton NHS Foundation Trust, Highfield, Southampton, SO17 1BJ, UK
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Survivorship, cancer burden and supportive therapy


text:
Q: operator "+=" overload for matrices in python Problem:
generally speaking: it is about reloading matrix operators, i.e. so that they perform algebraic operations on matrices.
How can I implement the algebraic operation of addition on matrices, i.e. call add the right way.
In this case, I would like to overreload the += operator, but I have no idea how to do it.
UPDATED
  class MyMatrix:
       height = 0
       width = 0
       data = tuple()

       def __init__(self, data):
           self.height = len(data)
           self.width = len(data[0])
           self.data = data

       def __getitem__(self, item):
           return self.data.__getitem__(item)

       def __add__(mat1, mat2):
           if mat1.height != mat2.height or mat1.width != mat2.width:
               print("The matrices are not the same size!")
               return

           rows = []
           for i in range(len(mat1.data)):
               row = []
               for j in range(len(mat1.data[0])):
                   row.append(mat1[i][j] + mat2[i][j])

               rows.append(tuple(row))
           return MyMatrix(tuple(rows))

    // in this method I would like to overload the operator +=
   def __iadd__(self, other):
    if self.height != other.height or self.width != other.width:
        print("The matrices are not the same size!")
        return

    rows = []
    for i in range(len(self.data)):
        row = []
        for j in range(len(self.data[0])):
            row.append(self[i][j] + other[i][j])

        rows.append(tuple(row))

redpajama_set_name: RedPajamaStackExchange


Akebono to exhibit brake solutions at Tokyo Motor Show 2017|News|Akebono Brake Industry Co., Ltd.
Tokyo, Japan - (October 17, 2017) - Akebono Brake Industry will exhibit new brake solutions at the 45th Tokyo Motor Show, which will be held from October 27th to November 5th at Tokyo Big Sight.
The highlights of this year in Akebono booth include newly developed 10-pot*1 opposed, 8-pot opposed and 4-pot opposed aluminum calipers, all for high performance vehicles. The 10-pot opposed caliper which will be exhibited at the show is a prototype and has special specifications such as compact and light weight targeting high performance sports cars. Adding the 8-pot and 4-pot variations will further enrich Akebono's high performance product line and reinforce our business in Europe. These high performance brakes adopt Akebono's state-of-the-art technologies which have been accumulated through various motorsports activities and provide superior stopping performance at high speed, under severe load and high temperature, along with comfort which is required for premium vehicles.
Akebono also displays newly developed "Magneto Rheological (MR) Fluid" brake, which has different mechanism from friction brakes, for forthcoming autonomous drive era and environment preservation.


Whiplash is the term used to describe the injury and following medical downturn as a result of a sudden forward then back flexion of the neck, commonly experienced in car accidents. You've likely seen whiplash on the television, and maybe you've experienced a mild degree of it as well. However, severe whiplash is extremely painful and disorientating, and filing a claim for a whiplash injury may be your best chance in some cases to earn compensation for an accident.
If you've recently been injured in a car accident in the state of California, seek medical assistance as soon as possible if you experience even the slightest pain or discomfort. Multiple conditions such as whiplash, back pain, and other soft tissue injuries don't become immediately symptomatic following an accident.
Licensed physicians, when described the events of an accident, will know the signs of whiplash that a typical person couldn't see. It's critical for your injury claim that the first disclosure of medical information come from a licensed physician in California. Insurance adjusters review whiplash cases with suspicion in most circumstances. Never make a statement regarding how you're feeling at the scene of the accident. Instead, get medical help immediately and let the facts speak for themselves.
Do not hesitate to begin a claim process if you possess a medically-addressed instance of whiplash. If you reside in a no-fault state, alert your insurance agent. If you live in a state that permits claims for personal injuries after a vehicular accident, alert the at-fault driver's insurance company in writing detailing your injuries and your plan to submit a claim. The sooner you alert a potential provider for your claim, the sooner you can recover compensation for your medical expenses.
If you're pursuing a suit with an insurance provider, make a note to record all the bills you accumulate from your treatment to your rehabilitation. These include economic damages such as mileage, lost income, medical expenses, prescription costs and insurance co-pays. Any expenditure that is paid out of pocket may be reimbursed later. Insurance adjusters require proof of loss for every dollar they pay out, and it's best to provide documentation for any and all bills. If you help make their jobs easier by maintaining accurate records, then you could notice compensation arriving sooner than later.
When pursuing a personal injury claim, there is never a guarantee that an insurance adjuster will settle with you. There's also the possibility that the driver responsible for your accident possess no insurance. In this case, you could consult a personal injury attorney in Orange County to assist you in receiving compensation for your damages.
In no-fault states, filing a lawsuit for a whiplash injury may not always be successful thanks to the threshold injury and damage requirements. In states without a no-fault law, you could file a lawsuit as a given right. Should your claim go to suit, you could receive compensation for non-economic damages such as pain and suffering as well as your economic damages. An experienced lawyer is best suited to explain the laws of your jurisdiction and determine the strength of your claim.


As I sit here, marking tests, prac reports and assignments in preparation for writing 150 reports, I have my iPod going in the background (I currently have it docked), with the music set to shuffle. To break up the boredom and the frustration, I have been looking at various blogs. I usually read blogs through Google reader, but today, I am going straight to the blog page. I don't have music on my blog, but I know that some people do. I don't have a problem with that. In fact sometimes, I will listen to what you have chosen, and it may influence an iTunes purchase. What I do have a problem with is having to scroll down the whole page just to turn it off. Fur Elise clashes terribly with Shania Twain! If I don't have something specific that I am looking at, I am more likely to skip your blog. Today I have been scrolling down the page.
All I am asking is that you move the music widget higher up your sidebar. Please.


Lay the butterflied leg of lamb, fat side down, on a cutting board and season with salt and pepper. Roll the lamb, starting at a narrow end, into an evenly shaped roast; tie securely with white butcher's string. Make 4 random, 1-inch-deep slits into lamb and insert the garlic pieces. Rub olive oil over the entire surface of the lamb; sprinkle with salt, pepper and oregano. For optimum flavor, cover and refrigerate and marinate 3 hours or overnight.
Preheat oven to 450°F. Place lamb on a roasting rack in a roasting pan just large enough to accommodate the lamb. Roast in oven for 25 minutes. Pour the white wine or chicken broth around the lamb; reduce heat to 400°F and continue roasting 45 to 50 minutes, basting occasionally with pan juices. As liquid in pan evaporates, add chicken broth or water to pan 1/2 cup at a time.
Meanwhile, prepare Marinated Tomatoes and Herb Bread Crumbs (instructions follow). Spoon 3/4 cup of the Marinated Tomatoes over the lamb and continue roasting 10 to 15 minutes. Use meat thermometer to determine degree of doneness: 145°F for medium-rare, 160°F for medium or 170°F for well-done. Sprinkle Herb Bread Crumbs over lamb and cook last 5 minutes of roasting. Remove lamb from oven, cover and let stand 10 minutes before carving. Internal temperature will rise approximately 5 to 10 degrees upon standing. Serve remaining Marinated Tomatoes on the side.
Score the bottom of each tomato with an X. Drop tomatoes, one at a time, into boiling water for a few seconds to loosen skin; remove and plunge into ice water until cool. Remove skin; repeat with remaining tomatoes. Quarter tomatoes; remove and discard seeds and pulp. Cut tomatoes into 1/4-inch pieces and place in medium bowl; add remaining ingredients and toss to coat. Cover and refrigerate until needed.
Combine bread crumbs, garlic, oregano, salt and pepper in mixing bowl. Drizzle lemon juice and olive oil over crumbs and toss to coat.
Tip: Call ahead and order the boneless leg of lamb from your butcher.
SERVING SUGGESTION: Serve Marinated Tomatoes on the side.


This bathroom is equipped with shower, wash hand basin, toilet, hair dryer, bathroom shelf and Handtuchheizkörper und Ablage. The bathroom has a size of2 qm. The floor is tiled.
This living/bed room is equipped with bed couch (120x180), couch, dining table, coffee table, [Schrankwand], commode, 4 chairs, 2 arm chairs, standard lamp and hanging lamp.
This bed room is equipped with 3 single beds (90x200, 90x200, 90x190), wardrobe, chair, 2 bedside tables and hanging lamp. Laminate flooring.
In this green inner courtyard arebalcony table, parasol, bicycle stand and 4 chairs.
You will find: 1 television, Radio alarm und central heating.
Negative: to high markup on the holidays!


Supposedly, 'supposably' is a word, but is it?
A look at the correct way to use these two adverbs.
There are suppositions that supposably is not a word and that what one means to say is supposedly. The thing is, supposably is a word, but because it's often incorrectly used in lieu of supposedly, it sounds wrong, which explains why so many suppose it is.
Let's look at these two adverbs along with a couple of other related words.
Supposedly, it's OK to smoke in here.
He was going to ask her to marry him, supposably.


text:
First introduced to Japan thousands of years ago, sushi is now one of Japan's most famous food exports and served all over the world, from conveyor belt restaurants to fine dining establishments. 18th June is International Sushi Day, so there's no better time to bring you the 101 on all things sushi! Come on a journey of discovery with us as we take you on a whistle-stop tour of this bite-sized Japanese delicacy.
Fish or seafood continue to be the toppings or fillings of choice for most sushi, but there are a few other key ingredients that will usually be involved in your sushi meal. These include rice, seaweed (nori), wasabi paste, pickled ginger and soy sauce. Sushi can theoretically be prepared using any type of vegetable, meat or protein, so vegans or vegetarians can enjoy sushi too, by switching out the fish for vegetables such as avocado or cucumber, or Japanese omelette (tamagoyaki).
Online sushi-making classes and video tutorials have contributed to the rise in sushi's worldwide popularity and are a great way to experience the delights of sushi from the comfort of your own kitchen!
There are a myriad of different types of sushi to enjoy so we'll take a closer look at some of these. But first, let's explore those staple ingredients for a traditional sushi meal.
Key Sushi Ingredients
The most essential ingredient for your sushi is the rice! Akitakomachi is a popular rice choice for sushi as it has a short grain with a glutinous texture when cooked, making it easy to roll and form into different shapes. The rice is mixed in a bowl with a combination of rice vinegar, sugar and salt until each grain has been coated. Check out our guide to cooking the perfect sushi rice on Japancentre.com
Nori is made from sheets of flattened seaweed which are mainly used for the outer layer of maki sushi. Nori has a subtle flavour and enhances the taste of sushi.
Sliced Fish
Fish or seafood is usually the topping or filling of choice for most sushi dishes, and popular options include tuna, salmon, prawns, octopus, squid and mackerel. It takes a trained, skilled chef to slice the fish to perfection using a super-sharp knife.
Pickled sushi ginger (gari) is thinly sliced and used to cleanse the palate between different sushi dishes.
A green hued condiment which packs a punch, wasabi is similar to horseradish. When a chef prepares your sushi they will have chosen just the right amount to complement your sushi dish, so it's not necessary to add any additional wasabi. But if you do want to use more, restaurants may have a little jar available to spoon extra onto your sushi.
One of Japan's staple condiments, soy sauce can enhance the flavour of your sushi. It has a fairly strong and salty taste so use it sparingly. Pour into a shallow dish and dip one corner of the fish into the soy sauce.
Types of Sushi
Now you've got the lowdown on the staple ingredients you'll need to create mouth-watering sushi, it's time to take a look at different types. With so many different formats, we've covered some of the most popular options below. But there are plenty of opportunities to get creative with your sushi recipes. Why not try out our vegetarian sushi doughnuts or spicy tuna and salmon rolls?
Maki Sushi Rolls
Maki sushi (makizushi) means 'rolled sushi'. The rice and other ingredients (such as fish and vegetables) are formed into long rolls which are then sliced into individual pieces. Most types of maki have a sheet of nori seaweed on the outside, apart from uramaki (inside out rolls) where the rice is on the outer layer. Other varieties of maki roll include thin (hosomaki), medium (chumaki) and thick (futomaki) rolls. Temaki are cone rolls which are formed by hand rather than using a sushi mat.
Nigiri Sushi
Another popular option and one you will likely be familiar with if you have ever eaten sushi before, is nigiri sushi (nigirizushi). Nigiri means 'hand-pressed' and consists of rice shaped into small rectangular shapes and topped with fish such as salmon or tuna or Japanese omelette (tamagoyaki). A dab of wasabi holds the topping in place.
Inari sushi (inarizushi) is a simple dish made from pockets of fried tofu (abaru age) which are seasoned and filled with sushi rice. The tofu gives this sushi a slightly sweet flavour and is a vegan-friendly alternative to fish based sushi dishes. For a few Japan Centre variations on the classic inari sushi, including edamame/furikake and carrot/hijiki seaweed recipes take a look at our inari sushi round-up.
Chirashi Sushi
Chirashi sushi (chirashizushi) meaning 'scattered sushi' consists of sushi rice served in a bowl and topped with various meats and vegetables. One of the most popular toppings is fried tofu (abaru age) Japanese omelette (tamoyaki), carrots, beans and fish cake.
Sushi Through the Ages
The origins of sushi actually lie in ancient China. The very first type of sushi was created around the 4th Century BC by wrapping salted fish in rice and leaving it for months to ferment. The salt acted as a preserving agent for the fish and the rice was disposed of. This dish (known as narezushi) arrived in Japan by the 8th Century, and by the 15th Century cooked rice was being added to the interior of the gutted fish. The invention of rice vinegar in the 1700s created another sushi evolution, adding flavour to the rice in an instant, doing away with the need for a lengthy fermentation process.
The first nigiri sushi was created by Hanaya Yohei in 1824, which he sold on a stall in the streets of Tokyo. The popularity of sushi spread across Japan and by the mid 20th century, sushi had become something of a delicacy, predominantly being served in restaurants rather than on street stalls.
Today, sushi is popular worldwide and can be experienced in a variety of different types of restaurants. Sushi fine dining is the most expensive option, where you can enjoy a delicious feast prepared by sushi chefs with years of specialist training. The head chef (itamae) can make recommendations and your sushi will be carefully crafted and served on a wooden board (geta). A less costly option is to visit a conveyor belt restaurant, where the sushi will be transported around the belt under clear domes, so you can reach out and choose whatever takes your fancy. Even convenience stores (conbini) sell sushi in Japan, allowing you to pick up your sushi, condiments and chopsticks on the go.
Japancentre.com has all your sushi essentials, from cookery books, ingredients, meal kits and step-by-step sushi-making guides. Enjoy all this and more by shopping in-store at Japan Centre Leicester Square, Westfield London and Westfield Stratford City. Alternatively you can get fresh produce delivered straight to your door by shopping online at the Japan Centre website.
Words by Emily Lovell
Posted in Culture, Events, holidays & festivals, Food, Healthy Eating, Recipes, Sushi and tagged fish, ginger, inari, International Sushi Day, japanese culture, japanese food, maki, nigiri, rice, sashimi, seafood, soy suace, Sushi, wasabi. Bookmark the permalink.

redpajama_set_name: RedPajamaCommonCrawl


I hope you and your family and friends had a very merry, healthy, and happy holiday.
In today's issue of Mind Power I share the fourth of my Nine Principles for Conscious Living: The Map is Not the Territory. Until next year...Be Well.
There is a tendency to try to protect the old map (your concept of who you are and how you relate to the rest of the universe) as it goes into this initial chaos stage of growth.
This attempt to hold the old map together comes from the mistaken idea that we are the map—that "the map is the territory"—rather than realizing that it is just a convenient tool we use to navigate through life.
It is the limitations of this map (its inability to adequately "map the territory" or otherwise represent whatever is going on in the environment) that creates the "over-threshold" experience and the resulting dysfunctional feelings and behaviors.
Therefore, letting the map go through the evolutionary process of temporary chaos followed by reorganization at a higher level results in relief from the problems and limitations of the old map, and a new ability to deal with what was previously stressful or overwhelming.
When your map begins to fall apart remember that you are not falling apart.
You are merely trading an ineffective tool for a better one. Learn to recognize your favorite methods of holding on to the old map, and learn to stand aside and watch these times of chaos with the knowledge that something new and better is being created.
Click here to continue reading about Principle Number Four: The Map is Not the Territory.
The process of letting an old map go can be difficult. One of the many benefits of Holosync is that it makes this process faster and easier.
Once a day for 5 days you'll watch a short video (the first video is just 3 minutes and 41 seconds long), then you'll experience 14 minutes of world-famous brain-changing Holosync. I also encourage you to post your experiences and read what others have said.
I want you to find out how much your brain can be enhanced in only 5 days. I think you'll be both amazed and impressed.
The 5-Day Holosync Challenge is easy, fun, and completely free.
Please accept my challenge and try Holosync for 5 days.
"If a brain is exercised properly, anyone can grow intelligence, at any age, and potentially by a lot."
"Your [Holosync] tapes* are the best investment I have ever made in myself. They have helped me mentally, physically, spiritually, and financially. I hope to meet you one day so I can shake your hand and give you a hug."


The private flight from London Luton to Newcastle has a distance of about 362 km and a flying time of about 1 hours and 12 minutes. Given the total distance of the flight and the number of flight hours it is advisable to fly with a light jet or jet medium aircraft. Both airports have a long runways and allow the landing of any aircraft. The flight does not need any fuel stop.


Properly proportioned healthy-looking gums can make a big difference in your smile because the shape of your gums affects the shape of your teeth. Gums contouring evens out uneven gums and restores the proper look and proportions to your gumline. Drs. Ricco, Akseizer or Pappas can comfortably remove excess tissue to fix a "gummy" smile, and can add tissue to receded gums that make teeth look too "long".
What will Drs. Ricco, Akseizer or Pappas do to fix my "gummy smile"?
Drs. Ricco, Akseizer or Pappas uses special instruments, most commonly a laser, to trim excess gums and maybe excess bone tissue. This "sculpting" procedure is known as a gingevectomy. It will give your smile a more youthful, natural appearance, since your newly shaped gums will properly frame and showcase your teeth. The procedure will be quick and comfortable, and the laser will actually seal the gum tissue, helping you to heal faster.
What will Drs. Ricco, Akseizer or Pappas do to fix teeth that look too long, because of receding gums?
They will first make sure that you are completely comfortable, and you will hardly feel a thing. Then they will remove a small amount of tissue from the roof of your mouth and carefully graft it to your gumline. This simple procedure will make your gums a beautiful frame for your teeth, giving you a younger-looking smile.
Uneven gums can be evened by taking tissue away where there is too much, and adding tissue where there is too little. First, one of our dentists will use anesthetics, if necessary, to make sure you remain comfortable during the procedure. If the problem is a "gummy" smile, they use special instruments, most commonly a laser, to trim excess gums and maybe excess bone tissue. To correct receding gums, Drs. Ricco, Akseizer or Pappas will remove a small amount of tissue from the roof of your mouth and carefully graft it to your gumline. These are quick procedures that can be completed with little or no discomfort.
Your gums may be tender and a little swollen for the first week following the procedure, and if so Drs. Ricco, Akseizer or Pappas will recommend an analgesic like Ibuprofen. Usually they will have you rinse your mouth with salt water or a special antibacterial mouthwash. You will do this once or twice a day for the next two weeks to prevent infection and aid the healing process.


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Home - Board - Ticket to Ride v2.7.11 APK + MOD (Full Game Unlocked)
Ticket to Ride v2.7.11 APK + MOD (Full Game Unlocked)
Ticket to Ride is a popular board game that has been adapted into a digital version for Android devices. The APK version of the game is the Android Package Kit, which is the file format used to distribute and install mobile apps on Android devices. The MOD version of the game is a modified version of the original game, which may include features or changes that are not available in the original version.
In Ticket to Ride, players collect and play matching train cards to claim railway routes on a map of North America. The goal of the game is to score the most points by building the longest continuous railway route and completing the destination tickets that are drawn at the beginning of the game. Players can also score points by claiming routes that are worth more points or that are more difficult to build.
The Ticket to Ride APK + MOD version of the game includes all of the features of the original game, as well as some additional features that are not available in the original version. Some of these additional features may include new game modes, additional maps, new train cards, or additional destination tickets. The MOD version may also include changes to the gameplay or balance of the game, such as changes to the point values of certain routes or the ability to use certain cards in new ways.
Overall, the Ticket to Ride APK + MOD version is a great way for Android users to experience the popular board game in a digital format, with the added benefits of additional features and possibly modified gameplay.
Train to Gensan v9.2 MOD APK (Dionisia Unlimited Ducks)
Deck Warlords v7.02 MOD APK (Free Shop, Unlimited Money,…


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McQueen ruled suicide
By Lukas I. Alpert
February 18, 2010 | 5:00am
British designer Alexander McQueen penned a suicide note before hanging himself in the closet of his London apartment on the eve of his mother's funeral, an official coroner's inquest confirmed yesterday, listing the official cause of death as asphyxiation.
Although the note's contents were not disclosed, McQueen, 40, had been distraught by his mother's death, friends said.
He also was struggling with a stormy breakup with a boyfriend and professional pressures.
Mentally ill man breaches Olympics security to get near Bi...


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Audio Book 1
Inspirational music
Interviews with Frances
THE TEAM BOOKS
A Gift from the Other Side
HEAR FRANCES SPEAK AT THE
"LIVE YOUR MOST EVOLVED LIFE SUMMIT"
Register for free here
Revolutionary insights
for the spiritual advancement of humanity
"You are not alone. You are not really even functioning as just one person.
Nobody is ... for you are a member of a spiritual Team as close to you as breathing."
NOW AVAILABLE: AUDIO VERSION OF BOOK ONE
at iTunes and Audible.com
To request notification of the release of audio versions of Books 2, 3, & 4 and information about study groups and public appearances, email franceskey@gmail.com
or register through the pop-up box.
ABOUT THE TEAM BOOKS
by Crystal (Teddy) Key
As communicated to Frances Rae Key
On October 9, 2010, at the age of 86, Gloria Crystal "Teddy" Key passed away at her Florida home with her family by her side. Nineteen days later, her lilting Australian voice began to communicate with her eldest daughter Frances, about the scope and wonder of her new perspective from the afterlife state and, most importantly, the practical application of this perspective to the human experience. This remarkable collection of insights, written by hand in less than a year and divided into four books, has astounded friends, family and a growing circle of readers with their unusual outlook on the "story behind the story". Highly advanced concepts, delivered with a tone both encouraging and at times confrontational, are explained as never before.
Teddy conveys that each soul is on the Earth as a member of a spiritual Team, with specific missions in life. She reveals how various Teams work through what appear to be "individuals" and describes how there's so much more than meets the eye to our relationships and environment. These books offer concepts which many readers regard as new, while presenting ancient truths in a fresh format. It becomes evident throughout the progression of the material that a wide variety of teammates join Teddy to add their voices, culminating in a fourth book which urges us to go "beyond the Team."
TEDDY'S MESSAGE
from the Other Side
''I speak to your soul as your Team member, to your heart as your Mother, and to your mind as your teacher and friend. We are so fortunate to have so many layers of connection to each other, making this work so natural and simple for us. I want to tell you of where I am; it is a place that you will recognize from my description, for you have spent more time here than on Earth. It is the familiar treehouse upon the mountaintop that you've seen in your mind, and a candle burns in the window there, waiting for you.'' ~ Teddy Key, Book One
FRANCES' MESSAGE
Scribe of the Team Books
When my Mother and our Team began communicating with me after her transition, my life was instantly transformed. This was not the delicate blossoming of a soul. Rather, it was like an Olympic sport where you zoom through a chute at ninety miles an hour and emerge a few seconds later to find yourself in a new location. When I came down from the mountaintop to work again in the valley, a part of me stayed on that peak. I knew this transformation had been facilitated by the Team, an outpouring of their divine grace. These books are their gift to every soul who has ever called out for them.
franceskey@gmail.com
©2017 BY THETEAMBOOKS.COM


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UF Directory
Stephen Mulkey
CLAS IT
Stephen Shawhan Mulkey
Areas of Interest/Research
Sustainability Science, Climate Science, Environmental Politics
Stephen Mulkey is an environmental scientist dedicated to developing undergraduate and graduate programming to build society's capacity for environmental mitigation, adaptation, and resilience. Mulkey was the president of Unity College in Unity, Maine from 2011 through 2015. His leadership and forward-looking vision resulted in Unity College being the first college in the U.S. to divest its endowment from the top 200 fossil fuel companies, and the first college in the U.S. to adopt sustainability science as the framework for all academic programming. Mulkey believes that higher education has an ethical duty to prepare generations of graduates for the extreme sustainability and climate change challenges of this century. During and after earning his PhD at the University of Pennsylvania, he spent over twenty years as a tropical forest ecologist affiliated with the Smithsonian. Mulkey has served as tenured faculty at three doctoral granting universities, as science advisor to the state of Florida, and as a program officer at the National Science Foundation.
Email:smulkey@ufl.edu
Office: 621 Carr Hall
Office Hours: By appointment only. Please contact to schedule a Zoom meeting
Skip to footer content
© 2022 University of Florida, Gainesville, FL 32611; (352) 392-3261. Site Updated: October 15, 2020
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Running rivals face 'invisible primary'
17 Jan, 2015 2:00pm 7 minutes to read
Sharks keep NSW beaches closed
18 Jan, 2015 12:43pm Quick Read
Two face execution
18 Jan, 2015 5:00am
Myuran Sukumaran. Photo / AP
Indonesia confirms fate of Australians among 'Bali Nine' on drug charges.
Two Australian men convicted in Indonesia over the "Bali Nine" drugs case will be executed at the same time.
Myuran Sukumaran and Andrew Chan, both from Sydney, would be executed together because they had committed their crime at the same time, said Attorney-General MS Prasetyo.
Sukumaran's appeal for clemency was rejected last week and Chan is still waiting for a response to his appeal.
Australia opposes the death penalty and Amnesty International has urged the Indonesian Government to halt executions immediately, and eventually abolish the death penalty.
Indonesia resumed executions in 2013 after an unofficial four-year moratorium.
President Joko Widodo has said he will not grant clemency to anyone on death row who was convicted of drug offences.
The pair and seven other Australians then aged between 18 and 28 were arrested in Bali in April 2005 with more than 8.3kg of heroin.
Sukumaran and Chan were named as ringleaders of the group and sentenced to death in 2006.
Following various appeals, the other seven are now serving either life or 20 years in prison.
Previous executions have been carried out at night by firing squad in Indonesia. Condemned prisoners were shackled, taken to a remote floodlit clearing and strapped to a wooden cross. The prisoners were hooded to face 12 executioners armed with rifles who aimed at targets over their hearts.
Bali remand hard slog for accused
3 Jan, 2015 5:00am
Wedding bells for adventurous teachers
6 Jan, 2015 12:00pm
Robyn Yousef: Problems the Third World would love to have
Kiwi accused of Bali assault will defend himself
"Executions are not clean killings," their Australian lawyer, Julian McMahon, told AAP.
"If the prisoner isn't dead straight away, the commanding officer is meant to walk up and then put a bullet in the head."
Latest from World
Alexandria Ocasio-Cortez is a rising star — but her popularity is also fuelling Donald Trump
The final chapter of El Chapo
Michael Collins didn't walk on the moon. But he got to drink warm coffee


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Home » Celebrities » Gemma Atkinson Instagram: Strictly star thanks fans for support after revealing big news
Gemma Atkinson Instagram: Strictly star thanks fans for support after revealing big news
Gemma Atkinson previously confirmed she was leaving her role on the early morning Hits Radio show as she awaits the birth of her baby. Having told her one million Instagram followers she would be leaving the programme as she would be in "no fit state" to greet listeners in the early hours when she was "being woken up by a baby throughout the night", Gemma Atkinson, 34, was inundated with messages of support. She later uploaded a cute picture which showed her laughing as her boyfriend Gorka Marquez, 28, cheekily squeezed her breast, adding the caption: "Thanks for all your lovely msgs on my last post. We can't wait to be a mum and dad. Keeping it classy as usual,"(sic) she quipped.
The post came after Gemma informed her followers there would be some big changes after her maternity leave.
"It's almost time for me to finish work for my maternity leave and take on my new role as being a mum," she said.
"I'll be hanging up my headphones on Friday 7th June, but not for too long as I'll be returning to @hitsradiouk on a brand new drivetime show with the wonderful @wesbutters.
"I figured being woken up by a baby throughout the night will leave me in no fit state to wake you guys up at breakfast," the mother-to-be explained. "So instead, I'll be getting you all home from work weekdays with Wes 4pm – 7pm."
Gemma continued: "Very much looking forward to our new show with lots of fun stuff to chat to you all about!
"In the meantime, it's mum time. (Wish me luck on nappy duty and sleepless nights)," she added.
Gorka showed his support for his love by commenting on the post: "So proud of you."
Fans also praised Gemma following her announcement, with one saying: "Going to miss listening to you on Hits in the morning but so excited for your new journey!"
"You will ace it I'm sure!" a second chipped in. "It is ridiculously tough but super rewarding at the same time! Welcome to the mummy gang!"
"Good luck lovely lady, I love Wes but even better with you on drive time," a third added.
Gemma and Gorka, who first met on Strictly back in 2017, are thought to be set to become parents in mid-July.
The couple revealed they were expecting back in February, almost one year after going public with their relationship.
Former Hollyoaks actress Gemma was caught up in months of romance rumours with Spanish professional dancer Gorka during her stint on Strictly.
However, they maintained they were just friends until they fell for each other on the live tour at the beginning of 2018.
The hunky dancer is currently on the road with the Strictly Come Dancing: The Professionals live tour.
He is due to embark on the Here Come The Boys tour with fellow Strictly stars Aljaz Skorjanec, 29, and Giovanni Pernice, 28, at the end of next month.
« The Biggest Problems Mick Jagger and Keith Richards Had to Work Out
Mike Thalassitis: Inquest into Love Island star's death delayed before show's 2019 launch »


Words Convey Beliefs. Beliefs Inform Behavior.
Words convey beliefs. Beliefs inform behavior. Words matter. So it amazes me how no matter what Trump has done or said, his supporters desperately grasp at straws to defend him.
They try to dismiss it as him saying mean things while Hillary does bad things. Well Trump has done plenty of bad things and the beliefs his words convey should inform us all that his behavior will only get worse.
It's just absolutely amazing in the most depressing way how loyal and willing his supporters are to deny their own humanity to egg him on more. How? Why? I've really tried hard to give them the benefit of doubt throughout this election but the Trumpkins are the worst of us. Like Donald they are an absolute embarrassment to this country. They're fueled by a demented kind of patriotism as they cheer on the most unAmerican and unqualified candidate in history. The irony is no longer amusing. It is cause for serious concern and soul searching as a society.
If we don't prioritize education, if we don't undo the perverse kind of selfishness that enables people to look at other people as obstacles or burdens, we will know the pain of the people we've oppressed or mistreated throughout history. We will know that pain intimately as we watch our country become the kind of nation we've aggressively condemned before.


Celebrate Spring with our shopping event this Saturday 27th April where we open up our warehouse for our customers to browse our entire collection!
Enjoy a Saturday of relaxed shopping and mingling over a glass of wine - meet like minded people from across the UK whilst wondering through England's premier gallery and showroom for Asian Antiques & Antiquities! Explore Chinese antiques, Indian antiques & Tibetan antiques as well as our eco-friendly collection of reclaimed teak furniture from India.
Satnavs will try to take you off the A345 - ignore them!
The journey from London takes approx. 2 hours.
After Basingstoke take the A303 Westbound.
At the Woodbridge Inn roundabout turn right staying on the A345, following the signs to Pewsey.
We are about 1 hour from London Paddington Station. Our nearest station is Pewsey less than 10 minutes away.


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Q: Why is the @Test annotation necessary? (Java JUnit) I was wondering why it is necessary to put @Test above your test methods and what its use is.
Thanks in advance!

A: In order to run your unit tests, you have to tell JUnit what the tests are. Usually, you have a lot of tests, so individually listing classes/methods in a configuration file somewhere would become a major headache.
So what the framework does instead is scan all your code for classes that look like tests (using reflection). The old way was to have a defined super-class extends Test and methods following a naming pattern. Now that we have annotations, you use the @Test annotation for that.


The Seattle Metropolitan Chamber of Commerce has expanded its support for small and minority-owned businesses with a new executive position. Since February 2012, small business owner Regina Glenn has served as the Chamber's vice president of multicultural and small business development.
The new position will integrate the functions of the Urban Enterprise Center (UEC) into the operations of the Chamber. Established in 1993 as an affiliate of the Chamber, the UEC was charged with helping grow minority-owned businesses. Last spring, UEC and Chamber leaders convened a task force to determine how best to serve this mission. Their top recommendation was to create a Chamber executive role that would build on the UEC's work while taking better advantage of the Chamber's small-business services. These programs include networking events, professional development workshops, policy advocacy and employee benefits like health insurance and 401(k) plans.
"The Chamber is quite the resource if you know how to use it," says Glenn. She brings to this position her decades of commitment to advancing diverse businesses. She first moved to Seattle in the late 1970s as Mayor Royer's director of licensing and consumer affairs. In the early 1990s she began a consulting practice, Pacific Communications Consultants, that specialized in diversity training and contracting outreach to minority-owned businesses. At the same time she published Diversity Business News from 1990-1994.
Glenn's hands are full. She is busy establishing partnerships with organizations such as the Tabor 500, the Northwest Minority Supplier Development Council, Filipino Chamber of Commerce of the Pacific Northwest, King County Hispanic Chamber of Commerce and others.
An online resource for small businesses with information such as how to access capital.
A "how to do business with…" series to help smaller businesses form ongoing relationships with larger corporations.
A business growth and development series starting this winter, featuring successful business speakers.
A business accelerator program that will match established minority businesses with a major corporation in the region, starting in fall 2013.
We will be announcing the Chamber's new multicultural programs as they come on line. It promises to be a great resource for minority entrepreneurs.
Rita Brogan is the CEO of PRR, a public affairs and communications firm based in Seattle, one of Washington's 50 largest minority-owned businesses. Brogan was a recent recipient of the Foster School's Business and Economic Development Center Asian/Pacific Islander Business Leadership Award. She writes the BEDC Brogan blog series monthly. Previously, she covered green economy issues with an emphasis on ways that businesses owned by people of color or women can create a competitive advantage. Her current blog topic focus is on innovation.
You could not have found a better advocate for small business development.


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Items Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866.
Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866.
The Miriam and Ira D. Wallach Division of Art, Prints and Photographs: Picture Collection
Dielman, Frederick (1847-1935)
Image ID 812614
Wallach Division Picture Collection
African-American History -- 1860s
Dielman, Frederick (1847-1935) (Artist)
African Americans -- History -- 1860-1869
celebrations -- Washington (D.C.) -- 1860-1869
Children and adults -- Washington (D.C.) -- 1860-1869
Content: Written on mount: "May 12, 1866"
Source identifier: HW (Hades Legacy Identifier / Struc ID)
Extent: 1 print : b ; 18 x 24 cm. (7 1/4 x 9 1/4 in.)
Dynix: 1660634
Barcode: 33333159331012
Universal Unique Identifier (UUID): bf83c260-c52e-012f-0940-58d385a7bc34
Art and Picture Collection, The New York Public Library. "Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866." The New York Public Library Digital Collections. 1866. http://digitalcollections.nypl.org/items/510d47e1-3f9d-a3d9-e040-e00a18064a99
Art and Picture Collection, The New York Public Library. "Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866." New York Public Library Digital Collections. Accessed July 16, 2019. http://digitalcollections.nypl.org/items/510d47e1-3f9d-a3d9-e040-e00a18064a99
Art and Picture Collection, The New York Public Library. (1866). Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866. Retrieved from http://digitalcollections.nypl.org/items/510d47e1-3f9d-a3d9-e040-e00a18064a99
<ref name=NYPL>{{cite web | url=http://digitalcollections.nypl.org/items/510d47e1-3f9d-a3d9-e040-e00a18064a99 | title= (still image) Celebration of the abolition of slavery in the District of Columbia by the colored people, in Washington, April 19, 1866., (1866) }} |author=Digital Collections, The New York Public Library |accessdate=July 16, 2019 |publisher=The New York Public Library, Astor, Lennox, and Tilden Foundation}}</ref>


text:
using System;
using System.IO;
using System.Runtime.Serialization;
using System.Runtime.Serialization.Formatters.Binary;
using System.Text;

namespace FileManagement
{
    /// <summary>
    /// Serializes and deserializes objects as binary data.
    /// </summary>
    public class BinaryFileSerializer : ISerializer
    {
        private readonly IFormatter serializer;

        /// <summary>
        /// Creates a new <see cref="BinaryFileSerializer"/> instance.
        /// </summary>
        public BinaryFileSerializer()
            : this(new BinaryFormatter())
        { }

        /// <summary>
        /// Creates a new <see cref="BinaryFileSerializer"/> instance.
        /// </summary>
        /// <param name="formatter">The IFormatter implementation to use.</param>
        public BinaryFileSerializer(IFormatter formatter)
        {
            if (formatter == null)
                throw new ArgumentNullException("formatter");
            serializer = formatter;
        }

        /// <summary>
        /// Serializes an object.
        /// </summary>
        /// <typeparam name="T">The type of object to serialize.</typeparam>
        /// <param name="stream">The stream to which the object will be serialized.</param>
        /// <param name="encoding">Not used for binary serialization.</param>
        /// <param name="obj">The object to serialize.</param>
        public void Serialize<T>(Stream stream, Encoding encoding, T obj)
        {
            serializer.Serialize(stream, obj);
        }

        /// <summary>
        /// Deserializes an object.
        /// </summary>
        /// <typeparam name="T">The type of object to deserialize</typeparam>
        /// <param name="stream">The stream from which the object will be deserialized.</param>
        /// <param name="encoding">Not used for binary serialization.</param>
        /// <returns>The deserialized object.</returns>
        public T Deserialize<T>(Stream stream, Encoding encoding)
        {
            // For now just deserialize the file.
            // In the future we may need to check the version first to prevent serialization errors.
            return (T)serializer.Deserialize(stream);
        }
    }
}

redpajama_set_name: RedPajamaGithub