Phonemic awareness helps young children learn to read and spell.
Phonemes are the smallest units that make up words in spoken language. The word dog, for example, has three phonemes: /d/ /o/ /g/. Phonemic awareness is the ability for a child learning to speak, read and write to focus on and manipulate phonemes in spoken words. Activities for elementary school children, such as third-grade students, involves auditory-verbal exercises that direct a child's attention to sound and individual letters.
Phonemic awareness is especially important for third graders, and all elementary school-age children, because understanding phonemes builds the basis for spelling, word recognition and reading skills.
According to the WETA "Reading Rockets" program website, phonemic awareness is one of the best predictors of how well children will learn to read during the first two years of school instruction. Third-grade students are typically reading at a more advanced level, developing vocabulary and sounding out difficult words to pronounce. Without a solid foundation in phonemic awareness -- and reinforcement throughout elementary school -- spelling and reading comprehension could suffer as a result.
This phonemic awareness activity sharpens students awareness of initial phonemes. The 3rd graders compare, contrast, and identify the first "sounds" in a set of words. A teacher will need some picture flashcards for the activity. Lay the picture flashcards of interesting objects on a table. Asks students to find the pictures which start with the initial sound they have been given, such as "th" or "ch."
Ask students to identify the name and initial phoneme of each picture and to sort them into two piles accordingly. Because this activity can be made simpler or more difficult, depending on the age group, for 3rd graders, choose engaging pictures with odd spellings, such as "xylophone" or "knight." You can also incorporate homophone words like rose (flower) and rose (past tense of "rise").
Parents or teachers will need a book of familiar stories or poems for this activity. Ask the third graders to sit in a circle, close their eyes and listen to the story or poem you are about to read. Recite or read aloud a familiar story or poem to them, but every so often replace a familiar word with an unexpected one.
For instance, in Alice in Wonderland, you can say that Alice saw a bottle that said "Me Drink." This is an example of word reversing. Other ways of playing with the wording help focus a child's attention to individual words and their meanings. In Alice's famous line "If it had grown up, it would have made a dreadfully ugly child; but it makes rather a handsome pig, I think," you could recite it instead as "If it had grown up, it would have made a dreadfully ugly pig; but it makes rather a handsome child, I think.
You can substitute words, switch a sentence around, reverse the order or make up a non-sense word. The third graders objective is to detect those changes. If you make the exercise creative and fun, students will be involved and excited.
Carver, Noelle. "What Are Phonemic Awareness Activities in 3rd Grade?" Synonym, https://classroom.synonym.com/phonemic-awareness-activities-3rd-grade-7840949.html. Accessed 20 April 2019.


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Mark Shiflett, Strong Pitching - 3391
Fort Lauderdale pitching coach Mark Shiflett explained to The South Florida Sun-Sentinel his organization's approach to prospects in April 1992.
The topic: The top overall selection in the 1991 draft, the Yankees' Brien Taylor.
"The Yankee philosophy is don't rush these kids -- let them have success and enjoy where they are," Shiflett told The Sun-Sentinel. "Brien Taylor's going to be successful here, and he's going to learn a lot. For a kid who hasn't had any college experience, he's got some games to get under his belt."
Shiflett watched over a pre-injury Taylor early on in his career as a minor league coach. Shiflett had his own career as a player. He got into six seasons and made AA. His coaching career spanned a decade, Shiflett spending much of that time at high-A.
Shiflett's pro career began in 1981, taken by the Yankees in the 27th round out of Auburn University.
Shiflett started with the Yankees at short-season Oneonta. The hurler got into 12 games, starting seven. He had a 4.15 ERA. He moved to single-A Greensboro for 1982 and improved his ERA to 2.42.
He made AA Nashville in 1983, staying there for 1984. He had a complete-game win for Nashville in August 1984.
Shiflett moved to the Tigers and AA Birmingham for 1985, throwing a shutout on three hits that June. His final time as a player came in 1987 with the Royals at AA Memphis.
Shiflett returned to the game in 1990 at the spot where he started as a player. Shiflett served that year as pitching coach at Oneonta. He moved to single-A Greensboro for 1991.
Shiflett coached at Fort Lauderdale in 1992 and then high-A Prince William for 1993. That April, Shiflett liked what he saw in his young pitchers, according to The Fredericksburg Free Lance-Star.
"We're loaded," Shiflett told The Free Lance-Star in the preview of a season that included a young Andy Pettitte. "This is a very strong pitching staff."
Shiflett's final recorded coaching time came at high-A Tampa from 1996 to 1998.
South Florida Sun-Sentinel, April 14, 1992: For Taylor, a Few Blots Amid the Blurs
Fredericksburg Free Lance-Star, April 7, 1993: Cannons benefit from trickle-down talent, Part 2
Made the Majors: 921-43.1%
Labels: coach, minor leaguer, Oneonta Yankees, Twice-Other

redpajama_set_name: RedPajamaCommonCrawl


Avior Clothing Men's Matteo French Terry Beige Hoodie is made with a perfect cut and fits true to size. Made with 100% cotton it is the ultimate comfort top to get lost in on a cold day. Complimenting with the distressed black jeans, it's trendy enough to be worn as quality outerwear to be proud of.
The model is wearing a medium size jumper. Wash at 30°C to keep shape.


text:
Sora () è una azienda giapponese di videogiochi. Fondata nel 2005 da Masahiro Sakurai, ha realizzato alcuni titoli della serie Super Smash Bros., oltre ai videogiochi Meteos e Kid Icarus: Uprising.

Lo staff di Gamasutra ha inserito la società tra le migliori software house del 2014 in seguito alla pubblicazione di Super Smash Bros. for Nintendo 3DS e Wii U. Nel 2018 è stato pubblicato Super Smash Bros. Ultimate per Nintendo Switch, sviluppato da Sora in collaborazione con Bandai Namco Studios.

Note

Voci correlate
 HAL Laboratory
 Nintendo

Collegamenti esterni

Aziende giapponesi di videogiochi

redpajama_set_name: RedPajamaWikipedia


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Spirituality goes past who we are. It contains things like beliefs, values, emotions and intelligence. These elements of a person's character will not be simply understood, however profoundly impact who they are and their well-being. There are psychological processes that can show individuals the best way to change your beliefs, values, and emotions. We will do issues to enhance our ability to think and purpose. On the identical time, genetics plays a task in these areas and can affect health and properly-being as do injuries to the brain. These elements are solely a part of the non secular image.
I went to a hot yoga class yesterday, for the primary time in about 6 months. (Try ninety Degree Yoga here ) This puts me off to a terrific begin for this yr!! Between sweating (actually dripping sweat!) and trembling to keep up the poses my body was struggling hard to recollect, my teacher gave us prices to focus on within the upcoming year. These stuck with me, so I wished to share them to also encourage you forward towards a extra peaceful yr of health and wellness!
Doc lessons learnt and greatest practices for expertise sharing and replication. Across the nation, low-income college students and families often wrestle with group limitations to wellness. Many deprived communities are wrestling with reliable access to reasonably priced fresh meals and protected physical exercise. This has all the time been the case, not simply at this hospital, however at many others throughout the United States.
The problem of healthcare and primary service entry for older adults is a vital subject. The Center for Civic Partnerships (2010) states that few communities are ready to fulfill the needs of older residents, or to have interaction these residents in civic life. The Illinois Division on Getting old (n.d.) mentions because the population ages, services and applications for older individuals should evolve as well as a result of longevity means extra when high quality of life is enhanced." All communities should include companies for the elderly, remembering that they're a novel part of the inhabitants.


text:
Boston - NYC 1994
Boston (30:34) / New York City (5:27) / New York City (1:02) / New York City (1:54) / New York City (1:11) / New York City (4:18) / New York City (1:35)
Notes: Lee Ranaldo joined Michael Morley for a single-song 30+ minute guitar duo instrumental extravaganza in Boston, which is reproduced in its entirety here as the first track on this CD. It's followed by six shorter tracks, recorded a few days later in NY, with a trio lineup of Morley, Ranaldo and electric harp improviser, Zeena Parkins. Packaged in Poon Village's elegant trademark screenprinted card-folio.
1995 CD on Poon Village (PV01, US)


text:
TransNexus
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CDRAnalyzer
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Discover SHAKEN
Telecom glossary
Ooma reduces routing costs by 10 percent with TransNexus number portability solution
With the help of TransNexus, Ooma has recently reduced their routing costs by 10% with LRN route optimization.
Ooma is a breakthrough technology start-up, based in Palo Alto, CA which provides a VoIP alternative to traditional home phone service. Founded in 2004, Ooma offers a consumer electronics device that provides free nationwide calling in the U.S. and Canada and advanced telephony services to hundreds of thousands of customers worldwide.
As Ooma grew and began scaling up their network, they began to notice that their calls were not consistently being routed to the lowest cost carrier. According to Toby Farrand, VP of Engineering and Operations at Ooma, "We would route a call to one of our ITSPs who advertised the lowest rate to a particular exchange, but we would often find that the target phone number had moved to another carrier, so our ITSP would not honor its advertised rate."
The simple solution to this problem is to route calls based on the Local Routing Number, or LRN, instead of the dialed telephone number. Traditionally, in order to do this, SIP service providers have had to query the U.S. Number Portability Administration Center (NPAC) for each outgoing call. However, sending a number portability query to an external database adds expense, as well as a critical dependence on an external network resource.
Ooma chose instead to use the TransNexus Routing, Operations, and Billing Support System (ROBSS). ROBSS is a simple and low cost solution for complete VoIP network management. It is made up of the OSPrey routing server and the NexOSS web interface.
What makes this solution unique in number portability solutions is that it allows Ooma to host the NPAC database locally within their own network. Their server then stays automatically synchronized with the NPAC, ensuring that their routing is based on near real time LRN data.
The TransNexus ROBSS solution is simple and easy to use. Operators use NexOSS to provision routes, rates, and number translation rules, which are used to create a Least Cost Routing (LCR) table. NexOSS pushes this table to the OSPrey routing server. When an Ooma customer makes a call, their network queries the OSPrey server, which uses its locally hosted NPAC database and the LCR table to return the least cost route, based on LRN.
"The Transnexus tool provided us with a way to dramatically increase the accuracy of our routes," said Farrand. "Our routing costs were reduced by more than 10% through the LRN optimization. The flexibility we get from the TransNexus tool improves our call quality and call completion rate as well," said Farrand. "TransNexus has given us excellent service and they have been receptive to our suggestions for future improvements to the tool," said Farrand. "We are looking forward to integrating TransNexus' next release, which will allow for us to peer with 11-digit routing."
Read the complete case study here.
Copyright © 2019 TransNexus. All rights reserved.


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Designer launches line at retailer.
For someone who protects his name and image as fiercely as Alexander McQueen, designing a collection for a mass retailer might seem like a compromise, a declaration of "If you can't beat 'em, join 'em." But McQueen stresses the collection he's designing for Target is entirely his own, no holds barred.
This story first appeared in the November 18, 2008 issue of WWD. Subscribe Today.
McQueen's collection for Target's new Designer Collaborations initiative will launch in March. While the collection might appear to mirror the moves by H&M to link with the likes of Karl Lagerfeld, Stella McCartney and, last week, Comme des Garçons, the Target line is actually an ongoing program aimed at bringing a series of established designers to the masses at low prices. Each collection will be in about 250 stores for a limited time. The entire line will also be available at target.com.
Designer Collaborations is a separate program from Target's Go International, which is sold in nearly all the chain's stores and focuses on young or emerging designers. Names the retailer has featured in the past include Luella Bartley, Proenza Schouler, Behnaz Sarafpour, Rogan and Richard Chai. Industry sources have estimated that Go International does more than $100 million in annual sales.
As the first participant in Target's Designer Collaborations, McQueen is eager to expose a new customer to his richly nuanced and atmospheric aesthetic. The line has its roots in McQueen's diffusion collection, McQ, which made its debut in January 2006 and ranges in price from $235 for a lace panel dress to $860 for a wool admiral's coat. "The focus of this collection will be younger and more renegade, but always signature McQueen," the designer said at the launch of McQ. His new venture is called McQ Alexander McQueen for Target.
Participating designers in the Target program will draw inspiration from a muse, creative element or collaborative partner. McQueen chose as his muse Leila Moss, the lead singer of The Duke Spirit (see sidebar). Moss' style gave the clothes their rock 'n' roll–punk vibe and hip Brit accents.
Target is not McQueen's first collaboration — he launched the Alexander McQueen Puma range and Samsonite Black Label Alexander McQueen — but it is his most populist effort. "I cover specific areas of life," the designer said. "Puma has that Generation X aspect with fashion and sneakers and Samsonite was more of an art-based project. Sometimes it's the monetary thing we're doing, but this is more about getting an idea of what I'm about across in the [U.S.]," he said.


Emelia makes other girls jealous.
She's just so stunning. Each time you look at her you see more of the luscious hand-made detailing that will have people re-telling stories about your wedding gown for seasons to come.
It sounds so simple. Spaghetti strapped sweetheart neckline bodice with full ballgown skirt. But take a closer look.
On the bodice you'll notice the hand pleated bust, the ornately beaded torso and the choice of either a lace-up or zip and button back.
Her skirt is layer upon layer of details, from it's full ball shape there is also the hand-cut ruffled layers, a posy of organza roses, all picked up against your hip to swish gently as you walk. And as you leave your guests staring in wonder at your gorgeous gown, the last thing they see are the tiny beaded details and the gently whispers of the sweep/short chapel train.


Can a piece be simple and statement at the same time? We believe it's possible with this beautiful brass piece. Featuring our signature custom cast brass open circle and a natural patina brass circle it's perfectly understated statement.
Finest quality UK manufactured 2mm brass rolo chain measuring 28 inches and finished as a slip over design with fine detail bead accents.


text:
The dark side of fiction.
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Gift of Griffins by by V. M. Escalada
GIFT OF GRIFFINS
by V.M. Escalada
DAW Hardcover
PRAISE FOR HALLS OF LAW:
"The richness of the world is reason enough to immerse yourself in this book. The typical historically based fantasy empire is given a makeover; this is a culture with abundant opportunities for women to wield power, political and otherwise."—Barnes & Noble Sci-Fi and Fantasy Blog
"Halls of Law begins a fresh, engaging new fantasy series set in a world of marvellous texture and magic. Love this one and can't wait for more!" —Julie E. Czerneda, author of A Turn of Light
"I was drawn in by the comforting prose and stayed fully invested because of the characters and world. Halls of Law is a fun, optimistic Epic Fantasy that proved a welcome change of pace from some of the more grimdark fantasy I'd been reading." —SFFWorld
"Kerida's a great protagonist…. She's practical and makes hard decisions about her own survival…. I really enjoyed this and eagerly await the sequel." —Sci-Fi Fan Letter
"If you are looking for a new epic fantasy series to sink your reading teeth into…Halls of Law is definitely a winner…. [A]n epic fantasy for the 21st century, where we have an absolutely marvelous heroine's journey from the outset." —Reading Reality
The second book in the Faraman Prophecy epic fantasy series returns to a world of military might and magical Talents as Kerida Nast continues the quest to save her nation.
Kerida Nast and her companions have succeeded in finding Jerek Brightwing, the new Luqs of Farama, and uniting him with a part of his Battle Wings, but not all their problems have been solved. Farama is still in the hands of the Halian invaders and their Shekayrin, and it's going to take magical as well as military strength to overcome them.
Unexpected help comes from Bakura, the Princess Imperial of the Halians, whose Gifts have been suppressed. As the Voice of her brother the Sky Emperor she has some political power over the Halian military, and she will use it to aid the Faramans, if Kerida can free her from what she sees as a prison. But whether Kerida can help the princess remains to be seen. If she succeeds, Bakura may prove their salvation. But should Kerida fail, all may be lost….
What's Hot Dark Fantasy /
Infernal Parade by Clive Barker
‹ Shadow's Bane by Karen Chance	› Wild Hunger by Chloe Neill
© The Darker Studio 2022
Site by Station L.O. Designs.


Traditional thinline hollowbody ES-330 with the hip addition of a Bigsby™ B-7 vibrato and custom black VOS finish, plus vintage-toned MHS humbuckers, rolled binding and '60s features.
F-Hole emblem engraved truss rod cover The iconic symbol of the Gibson ES line is now the hallmark of Gibson Memphis. Historic truss rod Superior Adjustability due to the Teflon coating, larger diameter rod, original brass anchor and larger washer. Rolled neck binding Binding is rounded off to comfortably fit the contours of the player's hand. Quartered Adirondack Spruce braces Crucial to vintage-style resonance and tone. Memphis Tone Circuit with Orange Drop Capacitors Great sonic control from total clarity to "woman tone". MHS Humbucker Our most accurate vintage PAF-style humbuckers yet.
Width: 4.3358 cm / 1.700"
Pole Piece Position from Nut: 47.4218 cm / 18.670" 59.5173 cm / 23.432"


The South African selectors on Saturday named two uncapped players, Heinrich Klaasen and Wiaan Mulder, in a 15-man squad for the first two Tests against Australia.
Johannesburg: The South African selectors on Saturday named two uncapped players, Heinrich Klaasen and Wiaan Mulder, in a 15-man squad for the first two Tests against Australia.
The first Test starts in Durban on Thursday.
Wicketkeeper-batsman Klaasen is rewarded for his form in the limited-overs matches against India following an injury to Quinton de Kock, while Mulder, who turned 20 last week, is a promising all-rounder.
De Kock is back in the squad, however, and is probably favourite to get the gloves.
Selection convener Linda Zondi said Klaasen had impressed in the white-ball games.
"We firmly believe he can become just as good a player in the five-day format," said Zondi, pointing to an average of nearly 50 in four-day matches this season.
But he added: "We are also keen to have a back-up wicketkeeper to de Kock in the squad."
Mulder was picked ahead of two other all-rounders, Chris Morris and Andile Phehlukwayo, but his chances of playing depend on the make-up of the side.
The squad includes several players who have been injured recently, including captain Faf du Plessis, AB de Villiers, de Kock, Temba Bavuma and Vernon Philander. An exception is fast bowler Dale Steyn, who is recovering from a foot injury.
South African squad: Faf du Plessis (c), Hashim Amla, Temba Bavuma, Quinton de Kock (wk), Theunis de Bruyn, AB de Villiers, Dean Elgar, Heinrich Klaasen (wk), Keshav Maharaj, Aiden Markram, Morne Morkel, Wiaan Mulder, Lungi Ngidi, Vernon Philander and Kagiso Rabada.


text:
Aunts and Butlers by robinjohnson
It's 1920, you're a minor aristocrat fallen on hard times, and your wretched Aunt Cedilla is on the warpath. A society farce in the style of P G Wodehouse, in which you face obstinate policemen, unfriendly poodles, austere aunts and mysterious butlers.
If you like my games, please consider tipping at http://ko-fi.com/robinjohnson
or contributing to my Patreon crowdfunder: http://patreon.com/robinjohnson
Review by Richard Headkid
This is my least favorite out of this author's parser collection.
It's okay, but by no means his masterpiece.
Review by BeautyvsAshes
As a lover of PG Wodehouses' characters of Jeeves and Wooster, I loved this. It was funny and clever. A great game to play through.
Review by LeisureSuit Larry
LMAO from page one
Review by Gothly
creative and funny
Review by snazzy ray
Review by DavyB
This game was written for IFComp 2006 (http://versificator.net/). It is loosely based on the PG Wodehouse Jeeves and Wooster characters, with the player in the role of Bertie Wooster, here called Ampersand. I particularly liked the butler stepping in from time to time to prevent catastrophic player mistakes or provide hints.
The game achieved a very respectable 16th place (of 43 entries) in IFComp 2006 but feels as if it has the potential to be much higher. One factor is that the game was rushed to meet the IFComp deadline (as mentioned in the hint system). This meant that it had an implementation issue when submitted (http://www.versificator.net/blog/). Perhaps more importantly, however, is that the second half of the game doesn't seem as strong as the first. It might have been more in keeping with the Wodehouse theme, for example, if the second half had been located in a country house (reached by train for a weekend visit), instead of a surreal, text-adventure oriented, underground world. Similarly, there is opportunity to integrate hints/help from the butler with the separate hint system provided. It would also be better to remove the one unwinnable position in the game (I fell into the trap! ...so pick up all items when you first see them!!).
Overall, however, this is still an excellent game, with Robin's usual high standard of writing, comic touch, and appropriately pitched puzzles. Another five stars!
Review by Jesse Richardson
Very enjoyable and gave great insight into the life of a 1920s butler.
Review by XanMag
I love the writing - humorous and detailed (without being too much). Very enjoyable game to play. Well constructed with a good story! Give it a play!
Log in to post a review or comment.
Not a Game.
Sir ChickenBiscuit
I have no idea what this is.
Somebody Go Steal Me a Shopping Cart
robinjohnson
HTML Game
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As Speaker of the House Paul Ryan celebrates his birthday, let's take this opportunity to send him a personal and direct message that today — and every day — thousands of Americans will also celebrate their birthday and be eligible to receive Medicare benefits. Yet, these benefits are now in jeopardy thanks to Speaker Ryan's radical agenda that calls for ending traditional Medicare, raising the Medicare eligibility age and increasing out-of-pocket health care costs for beneficiaries.
Your signature on the petition below will serve as a powerful reminder that Americans are paying attention — and we still reject the Speaker's plans to destroy traditional Medicare and cut earned benefits!
I'd like to wish you a happy birthday and take this opportunity to remind you that you share your birthday with thousands of Americans who will become eligible for Medicare today. Yet your proposals for Medicare will place their earned benefits in jeopardy. That's why I respectfully urge you to put the brakes on any budget plan or legislation that would ultimately replace traditional Medicare with a privatized system requiring beneficiaries to pay an increasingly larger share of health care costs.
Ending traditional Medicare by replacing it with a voucher program would not keep pace with the rising cost of health care, and would leave current and future Medicare beneficiaries vulnerable to the whims of profit-driven, private insurers. Under your plan, beneficiaries will pay more for less health care coverage and many seniors will be forced to forgo necessary care simply because it is unaffordable. Furthermore, your previous support for budget plans that would raise the Medicare eligibility age from 65 to 67 would result in millions of Americans who have paid into this program their entire working lives being forced to buy expensive private insurance for those two years. Also, up to 3.8 million seniors age 65 and 66 will become uninsured, leading to worse health under your program.
With record numbers of beneficiaries counting on Medicare in the years to come, I urge you to reject any plan that relies on cutting benefits or changing traditional Medicare in order to balance the budget, reduce deficits or pay for tax cuts benefitting the wealthiest among us. In addition, I encourage you to work with the National Committee to Preserve Social Security and Medicare to ensure access to affordable, available health care coverage to preserve Americans' retirement and health security.


AEON does its best to make our teachers' transition into Japanese society as easy and enjoyable as possible. The staff at your school will assist you in getting settled in to your new home and opening a bank account.
Once a teacher arrives at their school, the staff will assist with opening a Japanese bank account. Many ATMs have a bilingual display in Japanese and English, although some machines are only available in Japanese. ATMs are found at banks and most convenience stores. You can also use your ATM card at the ATMs of different banks for a fee. Banks are closed on weekends and public holidays. There is a service charge for withdrawals from ATMs during weekends and after certain hours during the week.
Japanese ATMs in general do not accept credit or debit ATM cards which are issued outside of Japan. However, the ATMs found at post offices and 7-Elevens will allow you to withdraw money using credit and debit cards issued outside of Japan, including Visa, Plus, MasterCard, Maestro, Cirrus, American Express and JCB cards provided that you ensure that your card is usable in Japan with your own bank before leaving.
Shopping for food and daily necessities is relatively easy in Japan. There are also some 24-hour supermarkets in larger cities. Groceries are relatively inexpensive if you stick to Japanese food and brands. If you visit a supermarket shortly before its closing time in the evening, you can purchase any remaining perishable products at a good discount, including ready-to-eat meals. Foreign import stores can also be found, especially in the larger cities. These are more expensive but they stock a range of imported food products predominantly from the United States. Costco also has stores in Japan and, if you are already a member, your membership card can be used in Japan as well. Another option for purchasing items from home is online. Sites such as FBC (Foreign Buyer's Club) and Amazon.com-Japan are reasonable considering the goods are delivered to your door.
Utility bills (electricity, gas, water, telephone, internet, etc.) are usually mailed to you and are easily paid either through automatic deductions from your bank account or paid in cash at convenience stores.
Most teachers get a mobile phone within their first month in Japan. When getting a mobile phone, you should consider which system provides the best services for your area and for your needs. The top three companies are NTT DoCoMo, KDDI au, and SoftBank Mobile. English speaking staff may be available, but it is often over the in-store telephone. Overseas call services from your mobile phone can be arranged, although they can be expensive.
Internet service is good in Japan. If there is no internet set up in the apartment, teachers have to get internet on their own. Most big providers will have English-speaking staff to help you get set up. Internet services in Japan are typically unbundled with the exception of cable internet. The four main types of broadband internet in Japan are Fiber-optics (FTTH), ADSL, Cable (CATV), and Mobile (Wimax). One company usually provides the line and the other establishes the internet connection. NTT East and NTT West are the main companies that provide the line and the hardware, though KDDI and some other companies also provide these services.
There are a lot of internet service providers to choose from including Asahi Net, Yahoo BB, OCN, So-net, @nifty, and Biglobe. Most only offer support in Japanese. BBaply and Asahi Net are websites in English which can be of assistance when trying to decide. You can sign up with NTT East or NTT West on your own and then sign up for an ISP separately, or you can sign up with an ISP and they will set you up with NTT directly. Depending on what you choose and your location, it can take up to two months for an internet connection to be established.
Larger sizes are becoming more readily available in Japan. More and more stores are stocking plus sizes of both men's and women's clothing and shoes, although what is considered plus size in Japan may be a standard size back in your home country. Men should not have much difficulty in finding clothes that fit but finding larger sizes of dress shoes may be a problem. Tall women may also have difficulty finding clothes and shoes that fit properly. Shopping online overseas and having things sent to you from your home country or shipped to you directly in Japan is a good option. Be mindful of import taxes though, as items like leather shoes or bags can be expensive.
The summer humidity in Japan is much higher than in most other countries so it is best to avoid fabrics that don't breathe well. Clothing that doesn't wrinkle easily will be greatly appreciated. Thick socks for winter are a good idea, as most Japanese apartments are not equipped with central heating. Japanese hair dressers provide good services but some can be expensive, around 10,000 – 15,000 yen for a cut, color and treatment. There are also places where you can get a quick haircut for around 1,000 yen. English speaking salons are available in the larger cities.
Most cities have fitness or health clubs which offer aerobics, swimming pools, and weight rooms. Monthly membership fees may range from 5,000 yen to 13,000 yen depending on the gym and the usage plan that you choose. Community gyms are a cheaper alternative but the equipment can be limited. Many of these types of gyms also have swimming pools.
Both skiing and snowboarding are very popular winter sports. You can rent equipment and ski-wear if you don't have them. The cost of a day on the slopes will be expensive, usually between 10,000 and 15,000 yen. This includes lift tickets, rental equipment and lunch. If you are planning to do a lot of snowboarding or skiing, you might want to buy used equipment after you arrive in Japan, which is available at very reasonable prices.
Many teachers try to make the most of their time in Japan by learning Japanese. A variety of options for learning the language are available. In many cities, Japanese lessons are offered at the local community or international center for a reasonable fee or sometimes even free of charge. Most often these lessons will be taught by volunteer Japanese teachers. For people who would like to study more intensively, there are a number of Japanese schools offering both short-term and long-term courses.
Teachers send money home for a variety of reasons. The most common ways that teachers send money home are through banks which offer wire transfers or by other overseas remittance services. Sending money through banks by wire transfer can be done through a registered account but is expensive. Using an overseas remittance service, such as GoRemit, Western Union Japan, SBI Remit, and JTB Remit, requires some setup (usually going to their office and providing bank details) but they can be cheaper than using banks. Banks in your home country will also charge you for receiving money by wire transfer, so take that into consideration if you decide to send money home. You may also send money overseas from the post office, either to an overseas address or to an overseas bank account for a set fee of 2,500 yen. This service is not available at some post offices though, and certain countries and regions may not be able to use this service.


"Helping to build firm foundations since 1976"
We provide new and used steel beams, and we specialize in new jumbo steel beams with full certification from the producing mill.
Scroll down for easy access; cut and paste into excel for sorting.
2 W 24 x 131 x 65'0"


text:
Friendly Inn Settlement celebrates 145 years of serving Greater Cleveland children and adults
By Harry Boomer | October 30, 2019 at 3:57 PM EDT - Updated October 30 at 6:17 PM
CLEVELAND, Ohio (WOIO) - Each week on CW 43 Focus, we take a look at important issues affecting Greater Cleveland.
This week we talk about the 145th Anniversary of the Friendly Inn Settlement.
A host of staff and volunteers work together to provide local people with many of the missing resources they need.
The Friendly Inn Settlement is a safe place for children to learn and for adults to continue their education with computer classes and more.
Yolanda Armstrong is the new president and CEO of the organization.
"For those of you who may not know, Friendly Settlement is one of the oldest settlement houses in the nation. We have so many program services. We have a five-star childcare center. We have a wonderful after school youth program, and we have programs that address the issues for pregnant mothers and the infant mortality rate. We have a food bank where we're feeding families on Wednesdays and Thursdays. So many other services. We're in the process putting together our new behavior health center."
You can watch this entire CW 43 Focus show with host Harry Boomer and his guests on demand on our Roku and Amazon Fire TV apps, online at Cleveland19.com and on TV every Sunday morning at 6:30 a.m. on CW 43.
Harry Boomer
Cleveland, Toledo, Machine Gun Kelly get mentions in Eminem's new surprise album 'Music to Be Murdered By'
Eminem surprise-released his 11th album Jan. 17 and despite his Detroit roots and in spite of his rivalry with Cleveland's Machine Gun Kelly, the Land, Toledo and Richard Colson Baker all got a mentions.
Mental health professionals speak out after former Cavaliers star Delonte West videos go viral
The viral videos of former Cleveland Cavaliers star Delonte West being beaten on Monday in Maryland, then giving police a discombobulated statement is bringing new focus to mental health issues.
Dan DeRoos


Dundee's £80 million V&A museum has "surpassed all expectations" after recording its 500,000th visitor on Saturday — almost six months earlier than expected.
Dundee played host to its first-ever Trans Pride march in the city centre on Saturday.
More than 300 students faced off in Dundee last night as part of the annual Rock Challenge designed to celebrate creative talent.


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Is Chris Christie Fried? Part 3
People Branch / February 18, 2014
There is no Exit lane for Chris Christie in the Bridgegate scandal.
If Governor Christie were indeed unaware of the lane closures which lasted four days, paralyzed the busiest bridge in the world while his closest staff members were chatting away about it, reveling in their proud work, Chris Christie would not fit for the job; he needs to resign for mismanagement and incompetence. If he knew about it or was involved directly or indirectly, well, Chris Christie should stop holding the New Jerseyans hostage, hanging on to some illusory hope that the key players would keep quiet through the investigations that are most likely going to be lengthy, costly and inevitably scandalicious. In the end, Chris Christie may have to resign in the best case scenario or end up in jail in the worst case scenario. Maybe not.
Notwithstanding this grim prediction for the outcome of the Bridgegate scandal, many politicians had recovered from scandals in the past. Anthony Wiener, Eliot Spitzer of NY fell out of grace but came back to run for office again. Mark Sanford of South Carolina who was involved in extra-marital affairs while in office as governor managed to make a comeback and defeated his opponent to win a congressional seat.
But It's different, very different for Chris Christie. He was catapulted to national stardom due in part to damages done to the state of New Jersey during hurricane Sandy and his no nonsense way of working with President Obama to secure federal funds for the victims; he was widely criticized by Republicans for being too cozy with the President. Interestingly, had there not been any Bridgegate scandal, Christie would easily refer to that moment as his "chrisnique (uniquely Christie)" ability to work with everybody, Democrats, Republicans and Independents alike.
Most politicians, with just a few exceptions (Nixon comes to mind), usually bow out rather quickly and exit the glaring lights of the news media, giving time to time to work out its magic. Chris Christie is however unwilling to take that route, thus dragging a caravan of news junkie to follow him to his inevitable and shameful "fall". The only plausible explanation for Christie to "hang in there" (pun intended) is to grant himself the opportunity to find out that he didn't know that he knew every detail of the lane closures. After all, there is no Exit for Chris Christie.
As they say in Jersey, "All lanes are closed for traffic study."
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February 18, 2014 in Politics, Social Issues.
Is Gov. Christie Fried?
Kudos to NJ Governor Chris Christie!
Gov. Chris Christie Borrowed One Million Dollar to Pay Legal Fees
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Today is the birthday of American film composer Thomas Newman (b. 1955).
Newman's scores include Bridge of Spies (2015), Finding Nemo (2003), Road to Perdition (2002), American Beauty (1999), and The Shawshank Redemption (1994). His father, Alfred Newman, was one of Hollywood's most important and influential composers in the early days of film scoring.
Those early days were often characterized by sweeping, lushly Romantic melodies and large orchestral colors. In recent years, as the style of filmmaking has changed, melodic scores have becoming increasingly rare, replaced by fascinatingly complex layers of ambient, highly processed sound. This is what we hear in Thomas Newman's scores. Newman has said that he considers his work done only after the mixing stage. In this way, the recording, itself, is elevated to a work of art. In this interview, he talks about his approach to scoring. "Should the music in a given movie become the landscape or character?" is a question he considers, frequently.
In American Beauty, this music accompanies a paper bag blowing, aimlessly, in the wind. In some ways, the underlying drone and the open, repeated intervals in the piano are not far off from Arvo Pärt's Fratres, the subject of Monday's post.


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Nierinna Creek Reserve
Location- Margate
Access- Burnaby Drive, Margate
Facilities- Nil
Time- 75 minutes each way
Turn off from the Channel Highway into Sandfly Road and then left into Nierinna Road (which is in front of a church). Burnaby Drive is the first turn on the right. It is a no through road and the entrance to the track is on the left of the turning circle at the end of the road.
The reserve is managed by the Kingborough Council. The track has been well built and has bridges and some seating. Track maintenance is variable, and can be very muddy and slippery in the wetter months. Water availability is not reliable in the drier months.
The track is well signposted. It follows the creek line on a grassy verge to a meadow. The track then begins to climb through bushland. It crosses a private road adjacent to Perrins Road; again this crossing is well signposted. This section takes approximately 20 minutes. The next stage involves a steep 10 minute climb up well-built stone steps to a bridge that crosses the creek.
The track veers south easterly and a steady climb commences followed by a steep descent into rainforest, once again following the creek. A further steady climb takes you to Lawless Road and the end of the track.
The return journey can be completed by returning along the track or by following Lawless Road, which meets Nierinna Road. Turn left and follow Nierinna Road down to Burnaby Drive.
This is a pleasant walk. There are no areas for panoramic views but the diversity of the flora and picturesque creek make it a memorable amble.


This is an electronic reprint, reproduced by permission of Pearson Education Inc. Originally appeared in the Proceedings of the Sixteenth Annual International Conference on Technology in Collegiate Mathematics, Edited by Corinna Mansfield, ISBN 0-321-30456-x, Copyright (C) 2005 by Addison-Wesley Publishing Company, Inc.
Students have a hard time visualizing and drawing mathematical objects in 3D. In this paper, the author shows how to use Derive to help students visualize curves and surfaces in 3D.


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Q: Is it possible to distinguish similarly named properties belonging to same vertex in a MATCH query in Nebula Graph? I'm playing with Nebula Graph 2.0.0.
I create two tags, both contain a property called name:
create tag t1(name string)
create tag t2(name string)

Now I insert a vertex giving it t1.name property:
> insert vertex t1(name) values '1': ('first-name');
Execution succeeded (time spent 2730/95913 us)

I can see that it can be found by ID:
> match (x:t1) where id(x) == '1' return x
+-------------------------------+
| x                             |
+-------------------------------+
| ("1" :t1{name: "first-name"}) |
+-------------------------------+
Got 1 rows (time spent 2713/95756 us)

I can also find it by ID and t1.name:
> match (x:t1) where id(x) == '1' and x.name == 'first-name' return x
+-------------------------------+
| x                             |
+-------------------------------+
| ("1" :t1{name: "first-name"}) |
+-------------------------------+
Got 1 rows (time spent 2827/100963 us)

Now I assign t2.name to the same vertex:
insert vertex t2(name) values '1': ('second-name');

It is added ok:
> match (x:t1) where id(x) == '1' return x

+--------------------------------------------------------+
| x                                                      |
+--------------------------------------------------------+
| ("1" :t1{name: "first-name"} :t2{name: "second-name"}) |
+--------------------------------------------------------+
Got 1 rows (time spent 3579/96685 us)

And I can still search by ID and t1.name:
> match (x:t1) where id(x) == '1' and x.name == 'first-name' return x
+--------------------------------------------------------+
| x                                                      |
+--------------------------------------------------------+
| ("1" :t1{name: "first-name"} :t2{name: "second-name"}) |
+--------------------------------------------------------+
Got 1 rows (time spent 2534/96306 us)

But when I search by ID and t2.name, nothing gets found:
> match (x:t1) where id(x) == '1' and x.name == 'second-name' return x
Empty set (time spent 3383/96788 us)

So, probably, under the hood, the system thinks I want to search by t1.name, so it finds nothing.
In a different session, with tags named differently, I got a different behavior: after adding a second name property, I lost ability to search by first name, but it was possible to search using the second name.
Here are my questions:

*

*Is it even legal to have on same vertex properties with same name (but coming from different tags)?

*If so, how can I ask the query executor to use the specific property (for instance, t1.name or t2.name and not the one that the system chooses automatically)?

A: Good catch! Tag is not that native to OpenCypher actually, we nebula is working work support more and more OpenCypher features, and to make it better.
1 Under the hood, the vertex property matching is based on the nebula index, which is now based on one tag only for now(it's actually left RocksDB key match).
2 when the condition/index matching was done, in MATCH call, you can return all tags' props belongs to it.

Is it even legal to have on same vertex properties with same name (but coming from different tags)?

It's legal. But maybe in most cases, the name could be the same in both tags?
Actually, here the WHERE CLAUSE: where id(x) == '1' is like a Primary Key, thus one Vertex is specified already. In your use case, is it still needed for further AND condition, please?

If so, how can I ask the query executor to use the specific property (for instance, t1.name or t2.name and not the one that the system chooses automatically)?

For the reason: 1(prop index can support only one tag/edge type) now, we can only filter within one tag, thus it's either t1.name or t2.name, like t1.name == "foo" and t1.age > 18.
The interesting case you found() is because the prop-index-selection(which is rule based selection, for now, there will be more improvements on this) cannot be done due to id(v) == 123 is not prop-index based and both tags' prop-indexes are of "name".
To avoid this, maybe we shouldn't allow the same prop-name across tags that belong to the same vertex with different values, this could be improved from docs or code.

redpajama_set_name: RedPajamaStackExchange


I have spent most of my career as a web programmer and digital developer. My teaching responsibilities have increased over the years and these things can cross over and weave together to support students. Creative Hive is a web platform that I developed to support students to create a blog and website to showcase their work. This project I believe ties in varying degrees with the UKPSF Areas of activity A1, A2, A3 and A4,K2 and K4, V2 & V4. These alignments came largely from help and support from staff and students to shape and inspire the project.
We have effectively created a community of practise (Wenger, 2007) consisting of staff and students that use Creative Hive for teaching and learning. I consulted members of this community with regards to its use and alignment with the UKPSF. I recorded a few thoughts on this subject but as the quality was not good I have included a Slideshare below.
Creative Hive was developed originally in response to staff and student feedback. The platform has been particularly popular over the last few weeks and now approaches 1000 members, most of whom are Salford students. The original conception for the project was to allow students to showcase their work both on the web and in the virtual world of Second Life. The virtual world element never really took off. Denielsen (2009, p.7) discusses how Second Life has been used effectively for teaching and learning in over 190 HE institutions worldwide. Embedding Second Life carefully into modules can lead to some positive results and engagement. I think virtual worlds could potentially further enhance some of my teaching and ILO's pedagogically. I've reflected in my previous post about using synchronous technologies like Collaborate in my sessions and virtual worlds can offer additional reflective and experiential learning (Moon, 2004). The video below shows Second Life in action from a launch gathering of students and others.
In 2011 I wrote a paper about what motivated people to join The Hive. I undertook a survey of the things that motivated students to join Creative Hive of their own accord (Fenton, 2011). Results concluded that students at the time were motivated to join and set up an advert free showcase of their work and connect with other people working beyond graduation. At that time I was not involved with teaching and consequently, I had not really considered how the project may benefit teaching and learning. I had effectively built a car but the car had no driver.
allows group pages of students (example) to be set up.
These reasons have attracted several tutors around the University to trial out Creative Hive for activity and assessment within modules meaning that entire cohorts have been joining and using the system. I have run several workshops for students on digital literacy and showcasing work on-line using Creative Hive.
Creative Hive has been used and backed by our University, but it is not officially supported. This is also true of many other technologies used in HE. I wondered if this is in some conflict with the standards of The Quality Assurance Agency. For example, what is the contingency plan if these systems fail (QAA, 2011 P.59). This is a broader question raised once technology is embedded into modules – what is the Plan B and something that I will research and reflect on more over the coming weeks. Creative Hive really is aimed at widening participation (UKPSF v1-v4). It is open to people who are not currently studying at our University and also designed to work for people with disabilities. Beetham (2007 p.140) in a study of disabled users and technology notes that support for online learning materials that are tested to be accessible is crucial for people with disabilities. It is also a legal requirement to make materials accessible to all.
Weaving into modules helps to address the issue of providing an empty experience (Stephenson, 2001). There are more opportunities for research, teaching and learning around Creative Hive both as a synchronous and asynchronous tool. My intention is continue to use and support this platform whilst it is pedagogically sound to do so. In other instances, I have opted to use other alternatives where they are a better match for the learning outcomes of a course. Ultimately, it is vital to choose the correct technologies to support pedagogy, operational aspects and learning outcomes and avoid creating an empty experience.
Stephenson, J (2001). Teaching & Learning Online: Pedagogies for New Technologies. Stylus Publishing, Inc., 22883 Quicksilver Dr., Sterling, VA 20166-2012, 2001.
The Quality Assurance Agency (QAA) for Higher Education (2010).
Wenger, Etienne (2007) 'Communities of practice. A brief introduction'.Communities of practice [http://www.ewenger.com/theory/. Retrieved 26/11/13].


We are currently exploring various strategies to encourage people to let us know when they find errors or omissions in UniProt, or even to contribute data as they publish their research, rather than waiting for a curator to pick up their results from a publication.
In principal all of this has been possible for a long time: We have feedback forms etc, but people don't make use of these often (or not as often as we would like…). The most frequent requests are from people who have published a paper and would like us to cite them.
The most effective improvement, in my opinion, may be to allow people to directly attach comments to each database entry, like in a blog (simple, instant gratification etc). These comments could then be reviewed by curators, and integrated into the database, if appropriate.
Having a system where people could add and update data directly, on the other hand, wouldn't be practical: The amount of training required to enter data in a consistent manner is considerable, and being consistent is essential for large, highly structured data sets like UniProt.
Another approach is to have a hand-picked list of experts who are responsible for certain database entries, according to their area of expertise. These people would be responsible for letting us know if something needs to be updated, though I wonder how many people can be motivated to commit themselves to such a thing.


The military culture is one of unique practices, traditions and beliefs that represent a shared unifying language with a distinct set of guiding principles. With the increasing numbers of veterans and their families reintegrating into civilian life, it is likely that most healthcare professionals, including optometrists, will provide care for veterans and their families at some point during their professional careers. Cultural and linguistic competency can better prepare the optometric healthcare provider and solidify the foundation for proper management and care. Cultural and linguistic competency can also help to ensure effective, understandable and respectful care for all patients, improving patient satisfaction and overall health outcomes.
The military culture is one of unique practices, traditions and beliefs that represent a shared unifying language with a distinct set of guiding principles.1 For many civilian healthcare providers without any prior military experience, immersion in this cross-cultural environment adds a layer of complexity and possible difficulty to the clinical exam that otherwise may not have been considered.
Approximately 80% of current military members are from small populations of multigenerational (legacy) military families. Additionally, nearly half of active duty members originate from only five states (California, Virginia, Texas, North Carolina and Georgia).4 The U.S. Census Bureau reports that only 7.3% of all living Americans have served in the military at some point in their lives with the majority being older than age 65.5 Though there is an appreciation of those who have served, there is an absence of personal exposure by most citizens and, as a result, a lack of cultural awareness of this group as a distinct minority. Many civilians have never felt the personal impact of our most recent global conflicts or personally known someone who has served. This unawareness and knowledge deficiency has become commonplace with the healthcare sector.
In 2010, new-patient applications were found stuffed in the drawers of VA processors' desks.
In May 2014, the VA's Inspector General launched an investigation after managers of a VA hospital in Phoenix, Ariz., were accused of concealing months-long wait times. The probe eventually widened to include 26 medical facilities.
In 2015, it was reported that more than 307,000 veterans may have died before their applications to receive care at a VA hospital were processed.
The VA has struggled to meet unprecedented demand as improved medical care during combat has left more soldiers with lifelong wounds.
Veterans of the Vietnam and Korean wars are living longer and require more care.
While the injuries sustained are more profound, the VA's technical patient management systems are out of date, leading to considerable duplication, delays and errors.
Another study showed that any discussion of traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD), two of the most predominant diagnoses post-deployment, was limited to 56.7% and 47.1%.6 In addition, with regard to healthcare-provider awareness of military status in patients, it was found that only 39% of providers outside the VA/Department of Defense (DoD) were screening for military service.6 These numbers are disheartening because such a simple question about a patient's military history can affect how a provider conducts an exam, determines common pathologies and considers evaluation/treatment techniques.
To practice cultural and linguistic competency is to tailor the delivery of health care to the patient's background, taking into account, among other characteristics, his or her gender, age, ethnicity, socioeconomic status and religious values. It involves the knowledge that such factors shape a patient's perceptions about health, establish expectations for care, and ultimately guide medical decision-making. With the continued concerns about disparities in health care, and the need for healthcare systems to accommodate increasingly diverse patient populations, cultural and linguistic competency has become a matter of national concern and a cornerstone of patient-centered care in recent years. The functional definition of cultural and linguistic competency is "the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes."10 It is within the capacity of individuals and organizations to work and communicate effectively in cross-cultural situations.
Competency occurs through adopting and implementing strategies to ensure appropriate awareness of, attitudes towards, and actions about diverse populations' cultures and languages. Cultural and linguistic competency can better prepare the optometric healthcare provider and solidify the foundation for proper management and care. It can also help to ensure effective, understandable and respectful care for all patients, improving patient satisfaction and overall health outcomes.11 Cultural competence has been deemed so important that the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) includes cultural considerations with each diagnosis.6 The process of cultural competency includes making progress towards adopting certain principles with the understanding that competency is a series of stages of development and a lifelong commitment to learning rather than a specific achievement or one single knowledge point.
Military culture is unique in that it is defined by its organizational structure, rules and framework, which self-regulate its members on a daily basis.9 As a very brief introduction, there are three major departments, the VA, the DoD, and the Military Departments. The VA is responsible for providing vital services such as healthcare, benefits programs and access to national cemeteries to former military personnel and their dependents. The DoD is the organizing body in charge of the Military Departments, which are the armed forces branches that include the Air Force, Army, Marine Corps, Navy and Coast Guard. The DoD is also responsible for providing the military forces needed to deter war and protect the security of our country.
Though the missions and values of the armed forces branches are similar, each has its own subculture2 and serves a different purpose. Each branch has active and reserve components, with active duty military personnel serving full-time and reserve and guard members typically serving part-time. Full-time military members usually live at a military installation and often focus on their duties full-time, while reserve members face the challenge of managing both their civilian and military duties between the times they are called to active duty. Service members can either choose to enlist (minimally requires a high school diploma or equivalent) or accept commission as an officer (minimally requires a bachelor's degree).12 The duties expected of members vary depending on military designation and whether the member is an officer or enlisted personnel.
Each branch has a hierarchal rank or grade system that outlines each person's position, authority and pay. This hierarchal system helps to define the chain of command for seniors and subordinates. As a result there is a huge component of trust ― trust that the senior has the greater good in mind for all, trust that the mission (no matter the sacrifice) is necessary, and trust that the subordinate will follow through on orders with obedience and discipline to successfully complete the mission at hand.12 Although there are great attempts to maintain standardization in the military, large differences exist among its members. To begin, the appeal of joining the service varies from member to member. Studies reveal that members join for different reasons; risk, patriotism, financial security, benefits, challenge, adventure, fidelity and dignity (to name a few), with the latter two being the most common.12,14,15 The personal cultural influences also vary immensely. Each individual brings his or her own sense of values, norms, ideas and meanings.12 In order to unify the culture, the military uses structure and basic training whereby new recruits are introduced to new norms, language, codes and identity through vigorous instruction,12 with the hope that the recruit will relate to his/her new military culture more than his or her previous civilian culture. Once roles are more defined and recruits' occupations are chosen, members may begin to relate more to their specific occupation within their branch, creating yet another subculture.
Consideration of the military culture, structure and values can allow healthcare providers to better serve those who have served our nation.
Unlike previous generations of veterans, modern-day veterans have had multiple (as well as longer) tours of duty with exposure to modern warfare-related injuries and illnesses. This results in medical histories and needs that are more complex than those of previous generations. Veterans returning from combat have a constellation of health concerns, including physical, psychological and psychosocial issues, which persist long after they have left the battlefield. Veterans have also been shown to be at higher risk for conditions specific to their population and their particular wars. In a recent audio podcast, U.S. Sen. Tammy Duckworth (D-IL) discussed the ongoing concern about lack of knowledge among civilian healthcare providers about common service-related illnesses.18 She shared the example of patient in his 60s who visited a civilian doctor and was diagnosed with diabetes mellitus (DM) and prostate cancer. While the patient will most likely receive the best of care for both illnesses, he would have been evaluated differently had he been seen at a VA facility. Because DM and prostate cancer are commonly linked to Agent Orange exposure, he would have been asked whether he was a Vietnam veteran and further evaluated for other related diseases.
The stigma of not being "tough enough" or "weak," along with a negative perception of complaining, can lead members of the military to downplay illness, which can further delay diagnosis, treatment and recovery. For this reason, it is essential for providing proper care and initiating proper referrals that doctors are able to identify and assess the most common service-related health concerns, ocular and non-ocular.
Military members may present with a multitude of issues, some of which may be obvious, e.g., amputations, visible scars, hearing impairment, or gait or balance issues, but others that may be invisible to a clinician. TBI has been labeled as the "signature wound" of the most recent wars due to the nature of the conflicts.19 The Defense and Veterans Brain Injury Center recently stated that 352,619 military members were diagnosed with TBI from 2000-2016 (Q1-Q2).20 Although much effort has been made to improve diagnosis, TBI can still remain undiagnosed and its effects can linger for months to years after the initial injury. Due to the mechanism of the injury, the resulting non-ocular symptoms of TBI can present in any combination of chronic pain, systemic problems, or problems with cognition, sensory processing, communication and behavior.21 A study by Goodrich et al. found that the most common self-reported visual complaints with TBI are blurred vision, sensitivity to light, missing parts of vision, bumping into objects or walls, blurred reading vision, or difficulty reading continuous text.22 Therefore, it is no surprise that the most common ocular diagnoses in the acute or chronic phase are convergence insufficiency, accommodative insufficiency, pursuit/saccadic dysfunction, fixation instability (inability to maintain steady fixation on a single stimulus) and strabismus.14 Based on a retrospective analysis of the records of 160 patients with TBI, Ciuffreda et al. reported that 90% had oculomotor dysfunction, such as deficits in vergence (56.3%), accommodation (41.1%) or version (51.3%), and strabismus (25.6%).23 These residual visual sequelae are vast, but within the scope of optometric management and treatment.
47,000 sexual assaults were reported in 2014 alone.
1 in 7 victims were assaulted by someone in their chain of command.
An estimated 85% of victims did not report the crime.
62% who did report a crime faced some level of retaliation from their superiors and commanders.
1/3 of the above referenced victims were discharged within 7 months of making a report.
MST can lead to a unique combination of psychological issues such as PTSD, depression, anxiety and substance abuse,29 more commonly in women than in men. Women veterans present their own unique set of risks and issues. In addition to being at a higher risk of sexual assault, they are more likely to suffer from depressive disorders,30 obesity and chronic smoking, and lead sedentary lifestyles compared to their male counterparts.
Service in certain parts of the world can also pose increased risk for infectious diseases such as malaria and tuberculosis as well as parasitic infections, some of which may not manifest until years after exposure.31 Combat exposure can increase risk for social exclusion, criminality, homelessness, self-harm, substance misuse, unexplained medical complaints, and mental illness.32 When healthcare providers are aware of the most prevalent illnesses and chronic injuries among military members and veterans, health outcomes can be improved.
What was your specialty while in the service?
Were you ever engaged in combat or exposed to any blasts?
How have things been going for you since leaving the military?
Not all military patients will present with a history of TBI, but given its high prevalence in the veteran population, it should always be considered as a potential cause of symptoms. A streamlined and structured approach should be taken to evaluate this type of patient, as the histories can be very complicated.
Optometrists who do not otherwise have experience with TBI may struggle with which direction the examination should take. Ciuffreda and Ludlam33 present a simplified and systematic approach to the clinical management of TBI patients for the optometric clinician. Their four-tiered approach is briefly described below, but more detailed information can be found in their article "Conceptual Model of Optometric Vision Care in Mild Traumatic Brain Injury.33 Information can also be found on treatment considerations for each potential diagnosis. This guide is meant to address the TBI patient, beginning with basics such as a proper refraction, binocular testing and ocular health examination and ending with non-vision-based problems. Treatment considerations should be given to all aspects of the TBI patient. Even a non-vision-based problem such as short- or long-term memory loss can lead to difficulties with vision-related rehabilitation due to poor comprehension or understanding.
Abnormal spatial localization can mean a shift in one's orientation and localization of straight ahead. These patients may have difficulty with ambulation and localization of objects. They may also present with visual neglect or post-trauma vision syndrome. Though there are multiple methods to formally measure abnormal spatial localization, simply observing the patient as he or she enters the room for balance, gait issues, and posture while standing and in the exam chair can help to diagnose spatial localization problems. Yoked prisms can be used to optically displace the visual field so the subjective vs. objective directional mismatch is reduced. Yoked prisms are usually placed horizontally but can also be placed vertically or obliquely. The prism is placed base in the same direction and the magnitude is slowly increased until the mismatch between the patient's perceived center and the objective true center is observed. The amount of prism varies between 2-6 prism diopters at distance and can be slightly more at near.
Photosensitivity is most commonly experienced with fluorescent lighting due to the flickering nature of this light, but can also be common with all types of lights (indoors and outdoors). The use of tints and the recommendation of wearing brimmed hats can be extremely beneficial to alleviate some of these symptoms. The color and percentage of tint can vary and is based on patient preference.
Motion sensitivity is most common in visually crowded environments such as malls or grocery stores but can also be perceived with a repetitive pattern such as black and white tiles on a floor. These patients tend to report nausea, dizziness or a feeling of unsteadiness. The use of binasal occlusion with black or translucent tape has been used as it can reduce the amount of visual stress seen by both eyes through partial occlusion of the retinal images.
Vestibular dysfunction symptoms can include vertigo, lightheadedness when standing, oscillopsia, fatigue, blurred vision and disequilibrium. Specific history questions about whether the symptoms worsen when moving the head back and looking up or in the dark can be helpful in further pinpointing a dysfunction. If a dysfunction is suspected, referral to a physical therapist and a neurologist is necessary.
Many resources (both local and national) are available to support the care of veterans. For non-vision-based problems, an inter-disciplinary approach is essential, and referrals to the appropriate specialists, such as neurologists, audiologists, psychiatrists, internal medicine physicians, therapists (occupational, physical, speech language), and family/marriage counselors, are key. The Veterans Health Research Institute (https://www.ncire.org/vet_resources/) provides multiple resources for veterans depending on their personal situation and needs.
Treating the patient as a whole within the matrix of family, friends, jobs, etc. can mean the difference for a veteran in their overall recovery and success.
Looking forward to the future, how can optometry improve its military cultural competency? Consideration should be given to introducing service-related visual problems, specifically those related to TBI given its prevalence, into the curricula of optometry schools. The military history should be taught as a routine part of the clinical examination in all optometry schools, as should the simple act of inquiring whether a patient has a military background. Involvement of more military treatment facilities (MTFs) as externship sites or one- to two-day clinical experiences can be extremely beneficial.
Making a conscious effort and taking responsibility as a member of society might very well be one of the most important motivating factors in gaining cultural competency.
Until recently, the military was not considered a culturally distinct demographic. Due in part to mainstream legislative efforts, most notably the Joining Forces initiative, the realization that the military is a unique entity requiring a more nuanced clinical approach has grown. The military overlaps multiple cultures, creating an even more complex and intricate network than previously thought.
The delivery of health care with sensitivity to all aspects of a patient's background is crucial to obtaining the best possible clinical outcomes. Engaging in military cultural competence requires an awareness of the patient's behaviors and values as well as a willingness to help. When providers possess a basic knowledge of military values, the ability to offer culture-specific care improves. This creates a more long-lasting alliance between doctor and patient resulting in better care and outcomes. Although service members may be years removed from their service when seen by civilian providers, they still carry their armed service identity. As the authors Pappamihiel and Pappamihiel mention, "Service members retain values, attitudes, and behaviors that are distinctly military and significantly set apart from civilian ways."35 Core values such as trust, honor, integrity, courage and strength can affect all aspects of the cultural identity and are not forgotten once the uniform is removed. Sensitivity to these values establishes a critical relationship between the civilian optometrist and the service member.
The author wishes to thank our service members and their families who have made the ultimate sacrifice to serve us. Thank you for allowing us to be a part of your road to recovery as well as your lives.
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Dr. Sanghera [nsanghera@ico.edu] is an Assistant Professor at Illinois College of Optometry. She provides patient care at the Illinois Eye Institute and has served United States service members as a civilian provider at Walter Reed Army Medical Center as the Traumatic Brain Injury Clinical Care Director. Dr. Sanghera is continuously involved in traumatic brain injury education through academic lectures and research.