On January 30th, 2019 Counter-Strike Online will have new Update which is New Epic Weapon (Gungnir), New Decoder (Epic Decoder), New Zombie Scenario (Episode Rendezvous), New Weapon (Windrider), also Event (Weekend Ultimate Hot Time Event, Daily Report, Build Magnum Launcher, Spear of Destruction, Epic Worker, Advance Epic Piece Box Bonus, Shark hunter, Season Worker). We also added new features, Season System.
Gungnir Gungnir is a super-technology weapon that is dug from the bottom of the sea and strikes with great force. With energy bomb mode for long distance battle, causing light splash damage.
Item that used to open coded box. You can get new epic weapon or Top 50 weapon with higher chance, get mileage in a certain amount and 2 epic piece boxes.
* Can get duplicate permanent weapons.
Episode Rendezvous is the latest Map in Zombie Scenario. This map tells about Lucia and Enzo who were conducting an inspection of the seaside facilities allegedly related to Kronos. But they met Michaela, the old enemy and rival of Lucia. Then a terrible enemy appeared from under the sea.
Windrider are two automatic guns given to guards who protect the goddess of the wind. It has a 30 round .44 caliber optimized with special magnum ammunition and combines shots with martial arts. Kill the nearest enemy quickly and accurately .
- Mileage Boxes obtained from Free Pass / Season Pass will provide 1000 Mileage Points, not 100 Mileage Points.
Event Period : January 30th - February 13th, 2019 before maintenance.
Play CSO Studio mode (Creation mode) for 30 minutes for 5 days to get the Build Scanner License. Build Scanner License is needed to be able to use the Build Scannerin Studio Mode.
Bonus Rewards can only be received once per account.
Epic Pieces can be exchanged many times.
Unused Epic Box will be retrieved and replace with Gungnir (Permanent) at March 13th, 2019.
Event Period : January 30th - March 6th, 2019 before maintenance.
Login CSO everyday to get 3 Epic Piece Boxes . Play CSO for 30 Minutes to get 2 Epic Piece Boxes, Max 10 Epic Piece Boxes daily. Kill Zombie in Zombie Z or Zombie Hero to get 1 Epic Piece Box for each zombie killed, Max 30 Epic Piece Boxes daily.
Max 43 Epic Piece Boxes can be obtained daily.
Total 600 Epic Piece Boxes can be obtained troughout the Event Period.
Unused Epic Piece Boxes will be replaced with 15 Mileage Points at March 6th, 2019.
Use Decoder to get Advance Epic Piece Boxes. You will get Advance Epic Piece Box as a rewards according to the Decoder that you use.
Unused Advance Epic Piece Boxes will be replaced with 30 Mileage Points at March 6th, 2019.
4 or more people required in the room.
Season is a new reward system that runs routinely.Complete missions and events during the Season to get 'Season Badges' to increase your 'Season Grade'!You can directly get rare rewards depending on Season Grade. Rewards from season-grade cannot be obtained again after the season ends!
'Season Grade' is different from the player level. Representing the level of 'achievement' of the missions and events that have been participated during the Season period. Collect Season Badges and increase your Season Grade to get various rare rewards.
Every time you finish daily or weekly mission, you will get season badge. Season Badge can also be obtained from events, so don't miss it! Season Grade can also be directly purchased using Mi-Cash.
There are 2 types of rewards: 'Freepass Rewards' and 'Season Pass Rewards'. Freepass Rewards can be obtained simply by increasing the Season Grade. Season pass rewards provide more rare rewards, which are only available after buying the Season Pass! Buyer Season pass will get both rewards, Freepass Rewards and Season Pass Rewards. Season pass buyers will be able to increase the Grade Season quickly because they get additional missions.
If you buy Season Pass during the season, you can get a reward from the current grade, as well as the previous grade.
When the season ends, all season badges will be removed and season grade will be reset to 1. You can participate in the next new season and get another new rewards!
Of course, the rewards that you have obtained from the previous season will still be there!
With the addition of the Season System, we also make changes to the mission section. Now Mission will be divided into 2: Daily Mission and Weekly Mission. The Daily Mission and Weekly Mission if completed will give the Season Badge needed to increase the Season Grade.
The Daily Mission is a mission received by the soldier every day. Every day the soldier will receive 3 missions, which will change every day. You can change missions that you receive 6 times a day, 1x free and 5x require items Refresh Daily Mission. For Season Pass users, you will get an additional 1 mission each day.
4 people or more required in a room to finish Daily Mission.
Weekly Mission is a mission received by the soldier every week. Every Monday at 00:00 WIB the soldiers will receive 4 missions. The Weekly Mission received will not replace the previous mission, but will stack. Season Pass users will receive an additional 1 mission each week.
4 people or more required in a room to finish Weekly Mission.


Providing for our loved ones the best place to stay is everyone's priority. It is no secret that people who have the opportunity to belong in such a great environment are more successful and better achievers in their professional and personal lives. Choosing the right land for sale near Point Cook, therefore, is key to all to achieve such goals. You may find some helpful ideas below to find your ideal home here.
Whether you prefer to take it easy or you would love to spend your life in the fast lane, your choice of a location to build your home spells much of the difference. Some would want to be at the middle of the action in money making ventures during week days and look up to the peace and quiet of the countryside on weekends. Fortunately, many areas in the region have made strides in giving you this pleasure in a thoroughly planned property.
When you live in a place that is masterfully planned, you are assured that all your needs are well taken care of. Property near Point Cook that was designed to cater to the various family sizes is available to the discriminating public. The community is a peaceful neighbourhood full of established facilities that provides everything you might need at only minutes from your home.
Raising a family especially when you have kids can be stressful when you have not so pleasant people as neighbours. You will be glad to know that there is a strong sense of community because of the kind of neighbourhood present around Point Cook. It will be a gratifying experience knowing that you are raising your kids in a community that makes sure they all grow up properly.
Make sure that you look for a company that makes sure you are afforded the service when you opt to acquire your property through bank financing or from your own choice of financial institution. Friendly and able staff should be present to help you out with the various aspects of your loan applications and the different stages you go through in your plan to purchase your piece of heaven. The staff will be too glad to assist you with their brand of service.
Investing in real estate is a surefire way to make your money grow. More so when your choice of one is within an area of a very high growth rate such as Melbourne, Australia's premier city. The great thing about real estate investments is that they very rarely depreciate. The more developments around the area, the bigger the chance that you'll experience exponential growth in the value of your property. The smart way to go is to research the area, of course.
Whether it's for your own future home, or as a potential business investment, real estate is a great way to go. Just take into consideration the above tips, and you can be sure that you find the best investment. Point Cook is a great area, so don't miss out on the chance.


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The Parent's Incomplete Guide to Fortnite
If you're a parent and your child is over the age of 5, you've been asked the million-dollar question, "can I play Fortnite?"
The answer, of course, is "I don't …
Assistive Tech in Video Games is Great for Both the Disabled and Children
(Disclosure: I am a Nintendo Ambassador and was provided one or more products mentioned in this article, but not for the purpose of this article. Words, opinions and ideas are mine.)
When we were kids, games were unforgiving and brutal. They taught us lessons about persistence and adaptation, but they also only catered to able-bodied people with lightning quick reflexes.
These days, games are different. One of the biggest criticisms I hear is that games are "soft" – that they're not as punishing on folks and that some of the modes and options actually make games too easy. Well, I think some of these technologies and options are great.
NBA Playgrounds Is More NBA Jelly Than NBA JAM
I heard about NBA Playgrounds and knew I had to have it. An arcadey 2-on-2 basketball game promising big dunks and fast action harkening back to the days of NBA JAM.
Spoiler alert: some of these big dunks and fast action are delivered. But the game trips over its own shoelaces all too often. This is not an updated NBA JAM you can play with your kids.
Duh, Science: Parents that Play Pokémon GO with Their Kids Say the Game Has Non-Gaming Benefits
In this week's news that should have come out last calendar year, a recent study found that parents have reported benefits of Pokémon GO with their kids, aside from the obvious clout of catching 'em all.
A small-scale, qualitative survey out of the University of Washington found that parents reported spending more quality time and engaging in more conversation with their kids – in particular, fathers of girls, mothers of boys and parents of teenagers. No word in the study if parents reported the elation of hatching a fully-evolved Charizard from a 10km egg.
Z-Ro, the Last Game Counselor, with Tips & Tricks for the NES Classic Edition
By	Zach Rosenberg	• Partnered
(Disclosure: I'm a Nintendo Ambassador and they sent me an NES Classic Edition to play with. Boom!)
Sup, nerds. It's been great walking among the people, but the truth is that for years, I've been hiding my true identity, and I think it's finally time you know it.
The truth is, I'm Z-Ro, the last Nintendo Game Counselor. Born in the 80s, honed by playing with power until I bled pixels. By the time the Nintendo Power Line faded away, I had gone into hiding with nothing but an NES and a dream that one day I may use my power again. That day, friends, is today.
There can only be one, baby, and I'm it! Cowabunga!
Yo-Kai Watch is Japanese Weird-Cool, Gives Me a Farting Excuse
"No, I know. It sounds weird to me too," I assured the mother of my son's friends. "I did just ask if your kids could come over and I could show them Japanese cartoons and take pictures of them. I get it."
Let's rewind back to mid-December: my son and I were Christmas shopping, and Nintendo had a game kiosk set up in the mall. Among the games was one called Yo-Kai Watch. My son and I wouldn't have paid too much attention to it, except that one of the game's characters was a butt. Like, literally, a butt. A Nintendo rep asked my son if he wanted a Yo-Kai Watch mask. "THE BUTT I WANT THE BUTT," my son yelped because he's seven years old and he's my son and I love him as much as anything could love anything.
Canadian Teen Buys Almost $8K of FIFA DLC With Father's Credit Card
Too bad, so sad for a father in Pembroke, Ontario (Canada, y'all) whose son managed to buy almost $8,000 of in-game content in a FIFA game on his Xbox recently.
Lance Perkins' 17 year old son dropped $7,625.88 CAD (about $5364.86 in USD) on EA's FIFA game store content, which, assuming he's playing FIFA 16, consists of "FIFA Points" – an in-game currency that allows you to buy "FUT Packs and Draft Entries" – basically, stuff to beef up your soccer/football/fútbol club. That's a lot of draft entries; EA sells packs in increments ranging from 100 points — for $0.99 — all the way up to 12,000 points, which will set you back $99.99. Even if Perkins the Younger bought the 12,000 point packs alone, it'd still take him over 50 transactions to hit his total.
That's dedication to the game, people.
Finding the Perfect Games To Play With Family & Friends this Holiday Season
The holidays are a time of family. Awkward family you haven't seen in foreves. I mean, sure, you follow them on Facebook, but once you've covered the catching-up phase, what do you do?
My suggestion: make the holidays a time of family gaming. I think you can, and I think it's easy. But it's not a one-size fits all approach. There are plenty of great board games, card games and video games out for folks of all ages – and with a little forethought, you can be the hero that emcees the whole thing.
Here are some suggestions of games you can break out once family starts showing up, and there's bound to be something for everyone.
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redpajama_set_name: RedPajamaCommonCrawl


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Risk of disseminated intravascular coagulation in patients with type 2 diabetes mellitus: retrospective cohort study
Kenichiro Nogami1,2,
Isao Muraki1,3,
Hironori Imano1,
Hiroyasu Iso1
1Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
2Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
3Osaka Center for Cancer and Cardiovascular Disease Prevention, Osaka, Japan
Correspondence to Kenichiro Nogami; kenichiro_nogami{at}yahoo.co.jp
Objectives To determine quantitatively the association between type 2 diabetes mellitus (T2DM) and disseminated intravascular coagulation (DIC).
Design Retrospective cohort study using a claims database.
Setting Medical care institutions representing 9% of all secondary hospitals (acute care hospitals) in Japan.
Participants In total, 797 324 admissions, comprising 435 354 patients aged 18–79 years at the time of admission, were enrolled between January 2010 and September 2014. All patients were diagnosed with diabetes or admitted to hospitals that provided laboratory data.
Main outcome measures Incidence of DIC reported by physicians in claims data.
Results Logistic regression analysis found that the risk of DIC was significantly higher in T2DM patients than in non-DM patients (fully adjusted OR: 1.39 (95% CI 1.32 to 1.45)), independent of age, sex, admission year and potential underlying diseases. The higher risk of DIC in T2DM patients was apparent in those who were treated with insulin within the 30-day period prior to admission (1.53 (1.37 to 1.72)). When stratified by the potential underlying diseases, the risk of DIC was higher in T2DM patients with non-septic severe infection (1.67 (1.41 to 1.97)) and with solid tumour (1.59 (1.47 to 1.72)) than in non-DM patients with those underlying diseases. The risk was similar between T2DM and non-DM patients with sepsis (0.98 (0.90 to 1.08)) and lower in T2DM patients with acute leukaemia (0.70 (0.59 to 0.84)).
Conclusions T2DM was associated with a higher risk of DIC, particularly when recently treated with insulin, as well as among admissions with solid tumour or non-septic severe infection.
anti-diabetics
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
To the best of our knowledge, this retrospective cohort study using a claims database is the first study quantitatively determining the association between type 2 diabetes mellitus and disseminated intravascular coagulation (DIC).
The strengths of the present study include large sample size and the use of a nationwide claims database which minimised sampling bias and the possibility of type II error.
The robustness of the findings of the primary and sensitivity analyses suggest that the probability of type I error in these findings is small.
The possible misdiagnosis of DIC and limited availability of data before the admission are the major limitations of this study.
Disseminated intravascular coagulation (DIC) is a serious condition characterised by the widespread and persistent activation of coagulation. This results in diffuse microthrombi and consequent organ failure. Coagulation is followed by fibrinolysis of varying degrees, depending on the underlying disease. Owing to ongoing activation of the coagulation system, haemostatic factors such as platelets and coagulant factors are depleted. This may in turn lead to consumption coagulopathy with bleeding from various sites. The three most common clinical conditions associated with DIC are sepsis, acute leukaemia and solid cancers.1–4 According to a nationwide epidemiological survey conducted in Japan, the frequency of DIC was 1.9% of admissions to medical universities. The rate of fatality was 56.0%, and the annual occurrence of DIC was estimated at 73 000 in Japan.5 DIC has been shown to be an independent and strong predictor of mortality in patients with sepsis.6 ,7 Relevant diagnosis and treatment in the acute phase are thus important for improving the poor prognosis of this disease.
Diabetes mellitus (hereafter, diabetes) is characterised by fasting hyperglycaemia and is an established risk factor of atherothrombotic disorders. These affect the coronary, cerebral and peripheral arterial trees. Patients with diabetes have increased thrombotic tendency due to platelet hyper-reactivity. They also have increased activation of prothrombotic coagulation factors coupled with decreased fibrinolysis.8 ,9 These clinical features of diabetes have the potential to promote DIC. Furthermore, diabetes patients are more likely to develop the diseases underlying DIC, such as severe infection and some cancers.10 These, in turn, may enhance the development of DIC. However, to the best of our knowledge, there are limited data regarding the extent to which diabetes increases the risk of DIC. We therefore investigated this association, hypothesising that type 2 diabetes mellitus (T2DM) is associated with a higher risk of DIC, using data from acute care hospitals across Japan.
To examine the association between T2DM and the development of DIC, we used the claims database of acute care hospitals provided by Medical Data Vision Co (MDV, Tokyo). The MDV database contains data on health insurance claims and the results of laboratory tests from 138 acute care hospitals. These represent 9% of acute care hospitals across Japan, as of 2014. Acute care hospitals are secondary hospitals defined as medical institutions that offer 24-hour medical care for acute diseases and severely ill patients, primarily providing specialised investigation and treatment. The claims data include patient ID, date of birth, disease, date of diagnosis, medications, laboratory tests, date of prescription or laboratory test, dates of admission and discharge. The laboratory data for roughly 40 test items were available for around 20% of the current study population. The MDV data are unlinkable and anonymised and have been used for epidemiological and health economics and outcomes research.11–15
Eligible population in the current database
Admissions were eligible to be part of the overall study cohort if they met all of the following criteria: (1) were of patients who had been diagnosed with diabetes in the database or admitted to hospitals providing laboratory data; (2) occurred between January 2010 and September 2014 and (3) were of patients aged 18–79 years (figure 1). This population consists of 797 324 admissions, comprising 435 354 patients.
Study flow diagram. Number of admissions/patients with T2DM on admission is shown in the parenthesis. T2DM, type 2 diabetes mellitus.
Study population A
Study population A is formed excluding the following admissions from eligible population: (1) admission of patients with type 1 diabetes; (2) admission of T2DM patients without any record of previous antidiabetic medication use (to minimise the impact of overdiagnosis and misclassification of T2DM); (3) admission of patients with a history of DIC; (4) admission due to liver failure, liver cirrhosis, vitamin K deficiency and hypersplenism (to differentiate DIC from these diseases, which can exhibit similar symptoms and laboratory findings) and (5) admission with obstetric complications (because examination of DIC that develops with underlying obstetric complications was outside the scope of the current study). A total of 566 191 admissions were included in the study population A (260 091 admissions for T2DM, and 306 100 admissions for non-DM).
Study population B
We first examined the association between T2DM and risk of DIC based solely on the diagnosis in the health insurance claims, because of the limited availability of laboratory data. To evaluate the robustness of these primary findings, we also added the criteria of laboratory data for the diagnosis of DIC in the study population B restricting to the admissions in the hospitals which provided laboratory data.
Study population C
To evaluate the effect of antidiabetic medication on the development of DIC, we selected admissions from study population A which had T2DM and had used antidiabetic medication within the 30-day period prior to admission. These admissions formed study population C.
Definition of T2DM and DIC
In the current study, we defined T2DM as patients with any records of previous antidiabetic medication use in addition to past or present physician's diagnosis of T2DM (ICD-10 code E11–14) in the claim data.
The DIC was defined by the physician's diagnosis of DIC (ICD-10 code D65) based on clinical symptoms and related laboratory findings in study population A and C, but the data for any clinical symptoms and most of laboratory findings was not available in the current database. In study population B, we defined DIC as when patients met the following three criteria during a period of hospitalisation: (1) reported diagnosis of DIC and laboratory findings of (2) platelet counts <80×109/L and (3) international normalised ratio of prothrombin time (PT/INR) ≥1.2 on the same day. Owing to the unavailability of laboratory data, we used PT/INR instead of prothrombin ratio (PR) as the criteria of DIC in study population B, although the diagnostic criteria for acute-phase DIC established by the Japanese Association for Acute Medicine are platelet counts, fibrin/fibrinogen degradation product (FDP) levels, PR and the presence of inflammatory clinical symptoms (abnormal body temperature, tachycardia, hyperventilation and abnormality of white cell count). We considered the misclassification of DIC non-differential between T2DM and non-T2DM patients, because diabetes is a non-major risk factor for DIC. As a result, any misclassification in this study would more likely dilute rather than skew the true association.
All patients had one or more admissions in the study period, and all comparisons were performed on an admission (not patient) basis. Mean age and proportion of sex, comorbidity and admission year were compared between T2DM and non-DM patients, tested for differences between mean values using Student's t-tests, and for proportions using χ2 tests. We estimated ORs and 95% CIs for the development of DIC using a logistic regression analysis. Primary adjustment variables were age (continuous), sex (male or female) and admission year (≤2010, 2011, 2012, 2013 or 2014).
To examine whether T2DM was directly or indirectly associated with DIC risk, we additionally adjusted for potential underlying diseases that cause DIC, such as sepsis, non-septic severe infection, solid tumour and acute leukaemia (yes or no, for each). To examine the potential interaction between T2DM and underlying conditions in relation to the development of DIC, we stratified analyses by the presence of sepsis, non-septic severe infection, solid tumour or acute leukaemia. To investigate the effect modification by the antidiabetic medications on the development of DIC, we assessed the associations stratified by antidiabetic medications given within the 30-day period prior to admission in study population C.
For all statistical tests, we used a two-tailed significance level of 0.05 and conducted analyses in SAS 9.3 (SAS Institute, Cary, North Carolina, USA).
DIC was diagnosed in 1.4% (7927/566 191) of admissions in study population A (1.1% (3287/306 100) of non-DM patients and 1.8% (4640/260 091) of T2DM patients), and diagnosis of DIC with supporting laboratory data was seen in 0.4% (1128/313 426) of admissions in study population B (0.3% (821/259 633 ) and 0.6% (307/53 793), respectively) (figure 1).
Of the 7927 admissions with DIC in study population A, DIC was diagnosed on admission in 75% and after the date of hospitalisation in 25%. The average period of hospitalisation was 59.0±68.8 days, and the outcome was fatal in 32.0% of admissions. In study population A, the average admission period was 17.4±27.9 days, and the outcome was fatal in 3.4% of admissions without DIC. The DIC was treated by anticoagulant treatment, replacement therapy (platelet concentrates, fresh frozen plasma) or antifibrinolytic treatment in 84.8%, 42.3%, and 18.8% of admissions, respectively. At least one of these therapies was given to 88.1% of admissions.
In study population B, the timing of diagnosis of DIC with supporting laboratory data was almost the same as for study population A: diagnosis occurred on admission in 76%. The average period of hospitalisation of admissions with DIC and supporting laboratory data was longer (68.5±80.5 days) and fatal outcomes were more common (53.7% (606/1128)) than in study population A. At least one of the three treatments for DIC described above was administered in 95.3% of admissions. The diagnosis of DIC (with and without supporting laboratory data) was made in 0.9% (2961/313 426) of admissions, and fatal outcome was observed in 36.3% (1074/2961) of the admissions in the study population B.
Compared with non-DM patients, T2DM patients were older (mean±SD: 66.9±9.7 vs 60.3±15.2 years in study population A; 66.7±9.8 vs 59.4±15.6 years in study population B) and more likely to be men (67.7% vs 54.6% in study population A; 67.9% vs 53.0% in study population B) (table 1).
Baseline characteristics of each study population (non-DM vs T2DM)
T2DM was associated with more prevalent comorbidity in most of the organ systems. This was particularly the case for complications that had resulted from the diabetes, including diseases of the cardiovascular, renal, ocular and nervous systems. With respect to potential diseases underlying DIC, T2DM patients were either equally or more likely to have sepsis, non-septic serious infections and acute leukaemia than non-DM patients, while solid tumour was more prevalent in non-DM patients.
The age, sex and admission year-adjusted OR for the incidence of DIC in T2DM patients was 1.60 (95% CI 1.52 to 1.67; table 2).
ORs for the risk of DIC in each study population*
After further adjustment based on the diseases underlying DIC, the association was attenuated but remained statistically significant. The fully adjusted OR was 1.39 (1.32 to 1.45). We stratified analyses by the presence of sepsis, non-septic severe infection, solid tumour and acute leukaemia. Compared with non-DM patients, the risk of DIC was higher in admissions with non-septic severe infection (fully adjusted OR: 1.67 (1.41 to 1.97)) or solid tumour (1.59 (1.47 to 1.72)). The risk of DIC was unchanged in admissions with sepsis (0.98 (0.90 to 1.08)), lower in admissions with acute leukaemia (0.70 (0.59 to 0.84)) and even lower in admissions with acute promyelocytic leukaemia (APL) (0.36 (0.16 to 0.82)). In study population B, for which laboratory data were available, we used the reported diagnosis of DIC with supporting laboratory data as the outcome, instead of only the reported diagnosis. These analyses showed that the association between T2DM and the development of DIC was quite similar to the results from the primary analyses.
We calculated case fatality rate of admissions with DIC for total population and according to underlying diseases in study population A (table 3).
Case fatality of admissions
The overall case fatality rate in T2DM group is 1.18 times higher than that in non-DM group. When stratified by underlying disease of DIC, the fatality rate in T2DM group is 1.09 times for patients with sepsis, 1.23 times for those with non-septic severe infection and 1.33 times for those with acute leukaemia higher than that in non-DM group.
Since some antidiabetic medications may modify the association between T2DM and DIC, we performed an analysis stratified by these medications, when given in the 30-day period prior to admission (study population C, comprising 148 105 admissions; table 4).
Effect of antidiabetic medications* on risk of DIC
Higher risk of DIC was observed in T2DM patients treated with insulin, relative to those not treated with insulin (fully adjusted OR: 1.53 (1.37 to 1.72)). Recent use of dipeptidyl peptidase-4 (DPP4) inhibitor, α-glucosidase inhibitor (α-GI) or metformin, however, was significantly associated with a lower risk of DIC.
We found that T2DM was associated with a higher risk of DIC, particularly when it had been treated recently with insulin. When stratified by the diseases underlying DIC, the association between T2DM and DIC was positive for admissions with non-septic severe infection or solid tumour, null among admissions with sepsis and negative among admissions with acute leukaemia.
DM is characterised by a high risk of atherothrombotic disorders. As a result, the association of diabetes with coagulation, thrombosis and fibrinolysis has been studied extensively. Despite this, we were able to find only a dozen case reports on DIC in diabetes patients, and no observational research examining the association between diabetes and DIC. Several recent studies of DIC have used the administrative database in Japan, the Japanese Diagnosis Procedure Combination (DPC). The DPC database includes administrative claims and discharge abstract data for all hospitalised patients discharged from more than 1000 hospitals.16–21 Most of these studies have examined the association between DIC and the administration of antithrombin or thrombomodulin, but they do not consider the association between DIC and diabetes. Atherothrombotic complications are the main cause of mortality in patients with diabetes. Premature atherosclerosis, increased platelet reactivity and activation of coagulation factors with associated hypofibrinolysis all contribute to increased cardiovascular risk in diabetic patients.8 ,9 Increased plasma levels and/or activity of haemostatic factors, including tissue factor,22 Factor VII (FVII),23 ,24 thrombin,22 ,25 fibrinogen26–28 and plasminogen activator inhibitor-1 (PAI-1),29 ,30 have all been reported in diabetes patients. The pathogenesis of DIC is similar, in terms of persistent widespread activation of coagulation in the presence of underlying disease.
The degree of fibrinolysis nevertheless varies among the underlying diseases and results in the patient developing three types of clinical manifestation.1 First, DIC with suppressed fibrinolysis is usually seen in sepsis. In sepsis, coagulation activation is severe but fibrinolytic activation is mild. This is because PAI is overexpressed in the vascular endothelium as a result of the action of lipopolysaccharide and cytokines. Many microthrombi remain, therefore, and microcirculatory dysfunction leads to the progression of multiple organ failure.3 ,31 Second, DIC with enhanced fibrinolysis is seen in APL. In APL, coagulation and fibrinolytic activation are severe, and fibrinolysis is strongly activated in response to the slightest elevation in PAI. As a result, haemostatic plugs (thrombi due to haemostasis) are more easily dissolved, and the symptoms of severe bleeding appear. However, organ dysfunction seldom occurs. Third, DIC with balanced fibrinolysis is usually seen in solid tumours, with an intermediate pathogenesis between the first two types described above. In this study, a higher risk of DIC was observed in T2DM patients with non-septic severe infection or solid cancer. A potential cause of this higher risk is the suppressed fibrinolysis by increased PAI due to T2DM, which might promote organ failure. Contrary to our expectation, the risk of DIC was not elevated in T2DM patients with sepsis. One potential explanation is that because fibrinolysis is so suppressed in sepsis that the antifibrinolytic nature of T2DM does not contribute to the development of DIC in patients with sepsis. A lower risk of DIC was observed in T2DM patients with acute leukaemia. This may be the result of the elevated PAI in T2DM suppressing the activated fibrinolysis, which may lead to attenuated bleeding symptoms, resulting in fewer DIC diagnoses than in the non-DM population. In fact, the risk of DIC was even lower in the subgroup including patients with APL only. In T2DM patients, platelets are thought to adhere to the vascular endothelium and aggregate more readily than in healthy people,32 which increase the risk of DIC. The contribution of platelets to the development of DIC is thought to be relatively lower in T2DM patients with acute leukaemia because their platelet count is decreased. For study population B, the association with diabetes for each of the diseases underlying DIC was similar to that for study population A. The higher fatality rate in T2DM group presented in table 3 may be due to augmented organ failure caused by increased coagulation and/or suppressed fibrinolysis in T2DM.
In the analysis stratified by type of antidiabetic medication given within the 30-day period prior to admission, T2DM patients treated with insulin had a higher risk of DIC than patients not treated with insulin. Insulin-treated T2DM subjects were reported to be at greater risk of cardiovascular events, which may simply be a reflection of longer disease duration increasing the risk of complications.33 Hyperinsulinaemia is associated with prothrombotic changes (increases in fibrinogen and PAI levels) in T2DM patients and community-based cohorts.34 ,35 The higher risk associated with recent insulin use that we observed may thus be the result of increases in fibrinogen and PAI associated with hyperinsulinaemia. Insulin resistance is thought to increase in T2DM patients immediately before hospitalisation, because of the stress of the disease necessitating hospitalisation. Hyperinsulinaemia is therefore likely to develop in such situations, when insulin is administered. However, we cannot identify the cause of the higher risk with certainty, because of a lack of data regarding the duration and severity of diabetes, degree of insulin resistance and the dosage of insulin needed to control blood glucose. The lower risk of DIC observed in recent users of DPP4 inhibitor, α-GI or metformin is supported by previous research. Specifically, reports have shown that DPP4 inhibitor decreases PAI in T2DM patients,36 α-GI decreases PAI and fibrinogen by improving hyperinsulinaemia,37 and that metformin reduces elevated levels of PAI and FVII.38
The strengths of the present study include our large sample size and the use of a nationwide claims database. Both of these design elements minimised our sampling bias and the possibility of type II error. In addition, a number of medical institutions also provided laboratory data, which were useful for validating outcomes. The robustness of the findings of the primary and sensitivity analyses suggest that the probability of type I error in these findings is small. Moreover, the generalisability of this study is relatively high. In study population A, 1.8% (T2DM group) or 1.1% (non-DM group) of admissions had been diagnosed with DIC, and the case fatality rate for DIC admissions was 34.2% (T2DM group) or 28.9% (non-DM group). These DIC diagnosis numbers were comparable to those from the nationwide questionnaire survey conducted by the Japanese Society of Thrombosis Hemostasis/DIC subcommittee in 2009 (in that survey the prevalence of DIC was 1.3%, and the frequency of fatal outcomes was 40%).39
In terms of limitations of this study, first, we acknowledge that misdiagnosis of DIC is probably inevitable. In study population B, the frequency of diagnosis of DIC was more than double that with supporting laboratory data (0.9% vs 0.4%). One potential explanation for this difference in frequency is that the DIC diagnoses based on supporting laboratory data only took platelet count and PT/INR into account. It did not include other important parameters such as PR, PT, fibrinogen or FDP, because such data were unavailable. Another potential explanation is that the difference in the case fatality rate (53.7% vs 36.3%) implies that patients with DIC and supporting laboratory data were in a more serious condition than those without laboratory data. Overdiagnosis of DIC probably also contributed to this difference. Although such misclassifications may occur, we found similar associations in both the primary analysis, using the reported DIC cases, and the sensitivity analysis, using the DIC cases defined according to the reported diagnosis of DIC and the supporting laboratory data. FDP/D-dimer level is especially important for the diagnosis of DIC. Although these values are not available in MDV database whether FDP/D-dimer was measured can be known from the claim data. Of the 1128 admissions with diagnosis of DIC supported by laboratory data in study population B, FDP/D-dimer were measured together with platelet counts and PT in 73.4% of the admissions (828 admissions). Second, due to the limited access to the MDV data, we cannot include admissions of non-DM patients in the hospitals not providing laboratory data, which may induce selection bias. The impact of the selection bias, however, may be small since the baseline characteristics for admissions of T2DM patients were similar between hospitals providing laboratory data and those not providing laboratory data. Third, the data regarding the use of antidiabetic medication within 30 days prior to admission may not be complete, because data from the primary care clinics and hospitals were not available. Finally, we were unable to eliminate the impact of potential confounding factors such as levels of haemostatic factors, insulin resistance and hydration status, because of the lack of data.
In summary, we found that T2DM is associated with a higher risk of DIC, particularly in patients treated recently with insulin, and among admissions with solid tumour or non-septic severe infection. In clinical practice, physicians should be more suspicious in T2DM patients who present with typical signs and symptoms of DIC, especially in patients treated recently with insulin, and among admissions with solid tumour or non-septic severe infections. However, as this is the first study to show a quantitative association between T2DM and DIC, it would be important to see whether other studies support our study findings.
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Contributors KN and IM designed the study, performed statistical analysis and drafted the manuscript. IM and H Iso provided statistical expertise. All authors contributed to the interpretation of the data and the critical revision of the manuscript and approved the final version. KN, IM and H Iso are the guarantors of the current investigation.
Funding This study was conducted using the data from MDV purchased by the Takeda Pharmaceutical Company by which the lead author, KN, was employed.
Competing interests KN received salary from the Takeda Pharmaceutical Company.
Ethics approval The present study was approved by the Ethics Committee of the Graduate School of Medicine/Faculty of Medicine, Osaka University (approval number 16090).
Data sharing statement No additional data are available.
Transparency declaration The lead author affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/


I received some sneak-peek samples of the Zoya Ultra Glitters today and I just couldn't wait to show you. GLITTER!!!!!
There's also a silver glitter called Luna, but it's on backorder. I'll be sure to post it when it's available.
I did put a coat of topcoat on these. They're not very bumpy, they're actually quite smooth as far as glitter polishes go, but I feel like they need a shiny topcoat to reach their full potential. This is also three coats. The glitter is pretty dense and the base builds color well, but I don't like being able to see my nail through my polish and three coats takes care of that for me.
The word that keeps popping into my head is GLAM. Total glam.
I'd never really put much thought into pink glitter until a friend was looking for recommendations for bright pink glitter. I couldn't actually think of any! All the pink glitters out there seem to be this odd pale pink, like Milani Disco Lights... No true, rich, vibrant bright pinks. That's really strange, isn't it? I'm glad to see these new pink glitters. They've filled a gap in the market.
Ah, what a wonderful glitter-filled winter!
These are incredibly beautiful, although I'm a little bit confused! I pre-ordered Astra because I wanted a lighter pink color, and Nova looked too bright magenta for my tastes. From the swatches, though, Astra looks like the bright magenta one while Nova is darker and more purple. Still, they're both gorgeous and I appreciate you showing them to us. Thank you!
Astra and Nova are stunning! I love these glitters!
Thank you SO MUCH for posting these! I pre-ordered them, and was a bit worried that I wouldn't like them, but now I'm sure that I'm going to LOVE them! I particularly love Astra...so different!
I need the Nova and Astra to be happy! They are very beautiful! Pure glamour!
Darn, I need more glitters! Love these on you. Nice and dense. Just the way I like them.
I can't wait to get these!!! :D Also wanted say thanks for the post on Depression Awareness, a very important health issue for millions, though severely un-talked about!
OMG I need this in red for Christmas!!
Pretty! But...how and the heck do you get them off! I've got through millions of cotton balls and about a 1/4 of a bottle of remover already!
Gorgeous! I don't even like pink, but I want these.
And to all those who have asked about removal, I buy no name nail polish remover pads from my local drugstore (Shoppers Drug Mart in Canada). They come in a box of about 6 pouches, and each pouch contains a felt pad soaked with remover. I find one pad will do both hands and takes off glitter really well (takes about 2-5 minutes with no residue). I assume that most big drug stores worldwide have an equivalent, so ask at your cosmetic counter if you can't find them.
You are so right about the pink glitters. I got a bottle of OPI Princess Pink and was disappointed with how pale and pastel it was. Thus began my search for serious pink glitters. I couldn't find any and was ecstatic when I learned Zoya had these coming out. Mine should arrive any day now.
I'm usually a shimmer-type of girl, but I'm starting to rethink the red toned glitters.


Back for more Friday Night Drabble Party, eh? Well then welcome!
Tonight's is a bit of the mundane in a post-apocalyptic world. Just what a Friday needs!
Disclaimer: You gotta do what you gotta do when the world goes to hell!
PS- Take a look at that button up top that says "BUY SIGNED EBOOKS!". Pretty nifty, eh?
Posted on November 11, 2011, in Friday Night Drabble Party and tagged apocalypse, baseball, bible, bubble gum, cannibals, castles, curse, dead, dead mech, drabble, dragons, exclamation, fantasy, fiction, future, genre, heartbreak, horror, jake, Jake Bible, keeps, mech, mummies, mummy, mythology, novel, podcast, podcasts, ponies, rainbows, science, science fiction, scifi, screwdriver, shotgun, social networking, summit, theology, tyrants, undead, unicorns, vampires, writing, zombie, zombies. Bookmark the permalink.	Comments Off on Friday Night Drabble Party!.


Teknoform is a polymer based material that mimics a variety of textures including mosaic tiles, stone, marble and timber. This is achieved through the composition of stone powder and resin. The benefit of this amazing feature is that it creates beautiful textures found in nature without the associated costs and ongoing maintenance.
The advantages for artisans working with polymer based material is that it allows for precision. It also allows the designers to be more experimental, more defined and sculptural, all the while producing a finish that replicates the look and texture of a natural surface.
Pittella's Teknoform basins address the trend toward minimalist and natural surfaces in bathroom fittings. These basins are sealed after manufacture allowing for easy cleaning with the wipe of a damp cloth.


Single-serving websites are a bit what the name describes. They typically do one thing and one thing only. They still exist in this giant mix of the internet as a beacon to simplicity. They're typically not fancy; they typically don't take long and often they're funny. I remember my first fore into this arena is what I still consider the greatest single-serving site ever: http://zombo.com/. This site was ironically brought to my attention by one of the premier masters of this genre, David Kraftsow, to whom will be my final post regarding this space.
Posted on February 11, 2011 by Justice Mitchell and filed under Interactive, LOL, Trends and tagged LOL funny humor shocking simple single serving websites.


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Known as Tree Honey or Honey dew Honey Forest Honey, is unique and one of a kind. It is made from honey dew excreted by plant sucking insects such as aphids and not from blossom nectar. A favourite of connoisseurs and honey lovers across the world, it works wonders on your digestive system.


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Home/World News/Middle East/Iraq/Video-Iraqis call for expulsion of MKO
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Video-Iraqis call for expulsion of MKO
http://www.islamicinvitationturkey.com/video/iraqis.flv
Hundreds of Iraqis from different parts of the country held a protest to show their opposition toward the presence of the Mojahidine Khalq Organization or MKO in Iraq.
Carrying banners with anti-MKO slogans, protesters also called on the Iraqi government to close their camp and evacuate MKO members as scheduled for December 31st.
Camp Ashraf, situated 60 kilometers north of Baghdad, has been the principal home of the anti Iranian group since the group allied itself with Saddam Hussein in the 1980s, receiving weapons and training from his regime.
A number of Iraqi clerics and tribal leaders were among those who had gathered to have their voice heard. The presence of the MKO is also described as a threat to the national security.
The MKO is listed as a terrorist organization by much of the international community, and is responsible for numerous terrorist acts against both Iranians and Iraqis. The group is especially notorious in Iran for siding with former Iraqi dictator Saddam Hussein during the 1980-1988 Iran-Iraq war.
Hezbollah and Iraqi reinforcements arrive in southern Aleppo
Imam Khomeini: The founding father of Hezbollah
Leader of Islamic Ummah Imam Khamenei Pays Tribute to Late Imam Khomeini
You are a helper for us and beloved by Hakk. May this body and soul be sacrificed for your bright path.


The form below is designed to submit your request for Father Jenkins' participation in events or speaking engagements. Note that submitting this request does not guarantee Father Jenkins' availability. Please email the Office of the President with any questions. Thank you.


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Home > For Patients & Professionals > about saint francis hospice > Our Choir > Hospice takes on battle for Christmas number one
We are saying it loud and saying it clear,
Saint Francis Hospice could be number one this Christmas!
Seventeen members of our hospice choir have joined forces with 300 fellow singers from 18 London hospices to produce a cover of the 1980s hit The Living Years which was originally sung by Mike and the Mechanics.
The London Hospices Choir, which features patients, staff and volunteers of all ages recorded their new take on the classic track at the world famous Abbey Road Studios, with Paul Carrack who performed the original.
Husband and wife Paul and Rita Gersh, both 69, from Ilford, have been volunteering at the hospice for the past seven years and are excited to be part of the project.
SFH choir at Abbey Road Studios.
"It was a privilege and an immensely thrilling experience to have been involved in this recording at Abbey Road Studios," said Rita, who set up the hospice choir in 2012.
"the dream for the song to get to number one this Christmas will be a great reward for all involved."
Sisters Tracey Parkin, 54, and Lyn Fasulo, 59, both from Romford, initially joined the Saint Francis Hospice choir after the charity cared for their mother Eileen Parkin and are thrilled to be part of the exciting project.
"The song is a fantastic opportunity to raise awareness of the wonderful work hospices do, "said Tracey.
"The song is very poignant and resonates with me about things I wish I had said.
"The whole experience has been great fun and I am so pleased to have been able to participate.
"It is something I will look back on with pride."
Christine Smith, 55, from Harold Wood, who is a Staff Nurse at the hospice, said, "It was a real privilege to work with people from other hospices.
"In the hospice we work as a team and accumulatively we are singing from the same song sheet.
"The main reason for taking part is to raise public awareness and understanding of hospice care, secondly to raise funds and thirdly, hopefully get to number one!"
All profits to be shared between the hospices and help make a difference to end of life care to patients and their families.
You can pre-order the track from Monday 14th November ahead of its release on Monday 16th December via iTunes or Amazon, and it will be available for streaming on Spotify.
Watch the music video below that was also shot at Clapham's Royal Trinity Hospice, under the direction of top Hollywood film director Annabel Jankel.
Return to Our Choir


Cllr Roger Lawrence, WMCA portfolio holder for transport and leader of the City of Wolverhampton Council, said: "Using Swift on Mobile and Google Pay is the latest way to buy your tram ticket.
"To celebrate the roll out we are delighted to offer a discount to encourage more people to try it out for themselves.
This follows the recent launch of the West Midlands Metro app through which passengers can buy 'show and go' tickets. Travellers now benefit from two great ways to pay.
Please note this is only available on smartphone devices with NFC (contactless communication) capability running the Android Lollipop 5.0 operating system or later.


Be more efficient when delivering your content and more!
"The sooner you get ready to be ready, the more you're going to get the process into your world, into your life, and into your business."
"Timer is your best friend"


If you didn't know already, chef makes the best sausage rolls and scotch eggs in the City and these are available ever day.
We also stock a range of healthy and nutritious snacks and if you are feeling naughty our wonderful cakes are all home made.
We have also introduced a range of our own vegan smoothies, made fresh every day. You won't believe how good they taste!


Here is the list has just been released by Skyscanner.
Brazil is well known of being place where took place big events such as World Cup 2014 or Summer Olympic Games 2016, Brazil opened number of airports, upgrades railway system to help visitors move easier.
Visiting the land of samba, you will discover a very varied life, and people are always open to participation many tours to explore shantytowns or crossing the Amazon rainforest.
Nicaragua is the combination of nature life and the lavish treatment. This Central American country is the perfect destination for travelers to explore the majestic volcanoes, forests and picturesque beaches. You also get relaxation in the new 5 stars resort.
Wave music and the influence of these famous stars have helped Korea possesses a large number of tourists. Besides the unique culture, this country has a good hotel system that is quality, reasonable price to ensure spending for tourists.
Taiwan has unique traditions, stunning scenery and stunning delicious cuisine. In the coming year, this small island is expected to receive great attention of travelers around the world.
Mykonos is island which attracts many famous persons such as LeBron James, Jean-Paul Gaultier, Cristiano Ronaldo hay Jennifer Lopez. They are ambassadors that contribute its fame on the map of tourist around the world when they find a great holiday resort. Tourist come here have chance to experience colorful night life.


Spencer Johnson spent his summer serving at Springfield: First UMC in Springfield, NE. The Pastoral Leadership internship program is for young adults aged 18-22. This ten-week program will provide young leaders the opportunity to experience pastoral work in the most "hands-on" way possible while being supported by a mentoring pastor and a teaching congregation.


Summary: We manufacture auto label rewinders, auto label dispensers, label cutting machines, etc. High quality & low price! The smallest area occupation, becomes to everywhere with its pretty and class design for stick small sticker, barcode Ideal for most labels, various sized label Ideal for removing liner scrap frequently due to the long label length.
1, the failure rate is low, the use is convenient, the model is small and easy to put aside.
2, electronic control system, fully automatic peeling, the label is smooth, do not wrinkle.
3, the operation is simple, many people use a machine.
4, automatic counting 0-999999, convenient production management automation.
5 types: self-adhesive labels, label, barcode, anti-counterfeiting, laser, packaging labels.
6, the application of the industry: electronics manufacturing industry, chemical industry, food processing industry, logistics and distribution industry.
1 tag paper. The label reel is hung on the label hanging plate and fixed with a positioning board.
2 sandwich plate. Between the middle rod of the label paper into the paper feeding guide, a U shape, according to the label width adjustment plate.
3 attach the label to the paper reel. The opening device is arranged on the 3 supporting rod of the paper roll device.
4 cover interlock lever. Press the locking lever until a padlock sound.
5 power switch. Turn right rear power switch.
6 use time. When you take out the label, remove it from the bottom.
Note: pull the label will pull lineless labels from the sensor, please pay more attention to.


Mobile Home Transporters - Feast Assumption Downwardly Mobile. These Two Natures Appear Working Together Frictionlessly Dispatches Angels Carry His Aging Blessed Mother Into Her New Eternal Home Divine Side Extracting Woman Certain Age Sickbed Transporting.
Below are 19 best pictures collection of Mobile Home Transporters photo in high resolution. Click the image for larger image size and more details.


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author: Jack Jenkins, RNS
William Barber II to Headline Virtual Interfaith Inauguration Prayer Service
WASHINGTON (RNS) — The Washington National Cathedral will host a virtual iteration of its traditional interfaith worship service the day after Joe Biden's inauguration, with activist and pastor the Rev. William Barber II preaching the sermon. The gathering, a long-standing inaugural tradition, will be hosted by the Rev. Randy Hollerith, the cathedral's dean, and Bishop Mariann Budde, the Episcopal bishop of Washington.
The Washington National Cathedral on June 12, 2015. (Sally Morrow/Religion News Service)
"This Cathedral is a House of Prayer for All People and a sacred space where America gathers in moments of deep significance, and we are honored to welcome the nation to pause, give thanks and seek God's help in the hard work ahead," Hollerith said in a press release. "We thank President Biden, Vice President Harris, and all our leaders for beginning this work in prayer as we strive to become the people God calls us to be."
During his campaign for president, Biden delivered remarks at two events hosted by Barber, co-chair of the Poor People's Campaign. Barber also personally endorsed Biden, and his group met with the president-elect's transition team. But the activist pastor — who is known for his fiery sermons and bold rhetoric — told Religion News Service in November that he stands ready to demonstrate against Biden should the need arise.
Neither the president nor the vice president will be in attendance, but organizers say they expect the newly inaugurated leaders and their families will watch the service from home — just as millions of Americans have throughout the pandemic.
Faith leaders representing a wide array of American religions and traditions will also appear during the service, including the Rev. Jim Wallis, founder of Sojourners; Rabbi Sharon Brous, senior rabbi of the IKAR community; Otis Moss III, pastor of Chicago's Trinity United Church of Christ; Debbie Almontaser, senior adviser for Emgage NY and president of the Muslim Community Network; Greek Orthodox Archbishop Elpidophoros; and Anuttama Dasa, global minister of communications for the International Society for Krishna Consciousness.
The most prominent evangelical to speak will be not a clergyperson but Jen Hatmaker, evangelical author and speaker. Valarie Kaur, Sikh activist and founder of the Revolutionary Love Project, will also speak, as will Jonathan Nez and Phefelia Nez, president and first lady of the Navajo Nation. The Rev. Rob Fisher, rector of St. John's Episcopal Church in Washington, D.C., where President Donald Trump stood outside holding a Bible during the Black Lives Matter protests last year, will also make an appearance.
Patti LaBelle, Josh Groban, and the cathedral's choir will provide music.
While hosting the service online is a break from tradition, the inclusion of a sermon is a return to form abandoned during the 2017 inauguration of Trump, when the Rev. Gary Hall, a former dean of the cathedral, publicly criticized the decision to host a prayer gathering for Trump, saying the then-incoming president "violates any possible norm of Christian faith and practice" and that holding the gathering for his inauguration amounts to "legitimizing his presidency, which is something I don't think the Christian community should give him."
Biden is also reportedly slated to attend church at St. Matthew's, a Catholic church, in downtown Washington with a bipartisan group of lawmakers on Wednesday (Jan. 20), the day of his inauguration. That, too, is something of a break from tradition: Many presidents (including Trump) have attended church at St. John's the morning of their inauguration.
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Clovis Unified School District trimmed another $1.25 million from its $28 million budget gap when trustees voted Wednesday night to reduce extra-duty stipends, leave jobs vacant and shift some costs in divisions such as catering and child care.
The district, which earlier had cut about $15 million, is considering cutting pay by 2% and instituting up to three furlough days for its 4,300 employees. The combined cuts would reduce employees' pay by more than 3.5%.
Each furlough day, which would fall on in-service days, would save about $800,000, said Kelly Avants, the district's spokeswoman.
The 2% wage cut would represent about $3.8 million, she said.


Reversal of associations between Spanish language use and mammography and pap smear testing.
Latina women are less likely to utilize cancer screening services than are non-Latina White women. The purpose of this study is to examine the relationship between preferred language (English vs. Spanish) and receipt of mammography and Pap-smear testing among US Latinas and non-Latinas. Cross-sectional analysis of the 2008 and 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys. While Latinas responding to the BRFSS in English or in Spanish had unadjusted lower odds of receiving mammography testing, in multivariable analysis Latinas responding-in-Spanish had 2.20 times the odds (OR = 2.20, 95 % CI, 1.90-2.55) of reporting mammography compared to non-Latinas. Similarly, Latinas responding-in- Spanish had lower unadjusted odds of receiving Pap-smear testing. However, Latinas responding-in-Spanish had 2.37 times the odds (OR = 2.37 CI, 2.04-2.75) of reporting having received Pap smear testing compared to non-Latinas in multivariate analysis. The results of this paper further confirm the "reversed associations" among Latinas and mammography and Pap smear testing described in previous studies and suggest that in addition to insurance status, preferred language may be a key variable contributing to the reversal phenomenon observed among Latinas.


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Time Management Tips for Radiologists
Deborah Abrams Kaplan
Tips for radiologists on managing time efficiently.
Radiologists have always been busy. But with decreasing payment for increasing amounts of work, along with administrative pressures, managing time is of paramount importance.
"Radiologists in general do twice the amount of work volume than we did 10 years ago," said Mike Esposito, MD, president of Radiology and Imaging Specialists in the southern Tampa Bay area. One reason for the explosion in work is technology; digital images replaced the hanging X-ray film. "But that's twice as many cases you have to sit and think about, and every year it grows even more."
The best way to manage the work is by having a smoothly operating system. "You really want to have your group working efficiently," Esposito said. "The biggest expense in your group is the physicians." In order to hire top talent, you have to maintain a certain income and quality level to attract them. "We have to be efficient to compete."
One way to start looking at efficiency is to examine what's getting in the way of radiologists managing their time. Are they designating specific reading time? Are they physically interrupted or interrupted via phone? Are personal issues getting the way?
Here are some ways to manage your time at work.[[{"type":"media","view_mode":"media_crop","fid":"38087","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4577078595637","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3780","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 134px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Peter Gudella/Shutterstock.com","typeof":"foaf:Image"}}]]
One of the most important time management techniques is controlling interruptions in the reading room. "The way to get through readings quickly is to have no interruptions," said Judy Capko, founder of Capko and Morgan a medical practice management consulting group, and author of Take Back Time: Bringing Time Management to Medicine.
While some interruptions are inevitable, radiologists should decide for themselves what's worth being interrupted for. "It should be pretty darn important if it's in the reading room," Capko said. "If you're focused and it can wait, let it wait. You're taking away valuable time. You could have answered a phone call when you're in transition or in the car, not when you have important rich time to be dedicated to a topic."
Halting interruptions can mean setting boundaries with colleagues and staff members. Sometimes the matter doesn't require the radiologist's attention, but someone else can solve the person's problem. "If they're allowed to interrupt they'll do it. They won't think about how it impacts you," she said. "People learn to solve their own problems if left to it."
Handling Phone Calls
Phone calls are disruptive, said Esposito, even though they're often helpful from a clinical perspective. While he takes calls from referring physicians, he recommends having a phone screener and someone like a physician assistant or technologist to run interference when necessary. "They're very good at being extenders for us, interacting with physicians and doing some procedures. That helps keep us in our chairs," he said.
Phone calls can pile up quickly, especially if left until the end of the day when it's more difficult to reach people. Capko recommends calling early in the day, and if the person isn't free, leave a message saying when you'll be available, so you control when you'll accept interruptions. If a question can be answered by email or text, do it that way. "Take the shortest route to get there," she said.
Staff members taking down a message clearly and completely can save radiologists a lot of time. Ask your staff members to get as much information as possible, so you have all the information needed when calling back. The staffer should also ask the best time to call back, to ensure the parties can connect more easily.
Worklists
Radiologists used to get their films in a stack, like a deck of cards, with everything computerized; the to-do list now comes electronically. By using a smart worklist system that assigns cases based on a radiologist's specialty and availability, doctors know their workload. "Now with individualized work lists, it makes you feel like you have your day back again," Esposito said.
Not all radiologists use this type of feature, he said, and he helped develop one at PACS Harmony, a workflow distribution software company. The technology was licensed to the Mach7 Enterprise Imaging Platform that his radiology group is now installing. "Every large group wants [worklists] but some doctors don't like to be told what to do. But everything is moving this way," he said.
Without worklists, it's hard to manage productivity of individuals in radiology groups. "The discrepancy between high and low producers can be 50%; that's a big difference," he said. Most PACS don't have workflow management, said Esposito, and it's a big problem when one doctor spends too much time online, and only reads 10 cases while another is reading 100, yet they both go home at the same time and get paid the same.
Don't Procrastinate
Spending time online is a big time suck and doctors are no exception. "E-mail and internet surfing – it's a big problem with doctors," Esposito said. "We strive to have everyone read about 75 cases a day. If you want to be on the internet all day, that's fine but you still have to do your work."
Set realistic boundaries for your schedule, said Capko, and get to work on time. "For all of us with a demanding schedule, and radiologists certainly do, if we're disciplined about it, we can manage," she said.
Prioritizing work is important, but radiologists have their own preferred way. After completing the emergency cases, they can focus on the rest.
"Some people will read all X-rays first if they're faster to read, to make their list look shorter. Others like to get through the difficult cases first when they're not tired. It's all the same volume of work whether you do it one way or the other. If you read the harder cases when you're fresh and just came in, you have more time and you don't feel rushed," said Esposito.
When reading the same type of films repeatedly, you get a momentum going, said Capko. "Package your readings according to the nature of the reading."
Use Technology
Technology, when used appropriately, can mean that prior studies are available for viewing when you need them, and they're in the format you need as well. Esposito said that the enterprise imaging platform they're installing does this. "What you don't want to be doing is waiting for priors," he said. "As soon as you open your case you want to be ready to go. That means technology has to be correct, the network has to be at the appropriate speed." Esposito said that they have a large budget for network speed so that the radiologists don't have to wait for something to load in order to begin reading.
With technology constantly changing, doctors sometimes get used to what they already have and don't want to learn something new. Adding new technology is only beneficial if it's used, so any changes should be communicated, with radiologist buy-in, said Capko.
Templates and Voice Recognition
Dictating reports from scratch is time consuming. "We've gone almost exclusively to voice recognition," Esposito said. With voice recognition they use templates with a normal report broken into segments. "You only change the part that's abnormal. Not having to speak so much has improved efficiency," he said.
Taking breaks is a personal preference, said Capko. "If you take breaks that are too frequent, you do yourself a disservice, because it's hard to get back up and running and it takes longer to finish," she said. You risk taking what you think is a five-minute break and it turns into 20 minutes. "You have to honor your time and understand how valuable it is."
System-wide Problems
Even if everyone is using their time wisely, system errors can cause time delays. Sometimes a film gets lost or is of low quality and no one caught it, said Capko. "Wherever the bottlenecks are, visit them and understand how they're inhibiting the progress and get it solved. You can do a time study to find the glitches," she said.
Meetings are often time-consuming, and it helps if the organizer has an agenda and sticks to it. An attendee can tell the organizer that if it goes on longer than planned, that the attendee will need to leave at the scheduled stop time. If there's something the physician wants to say at the meeting, they should ask to say it early to make sure their voice is heard. Capko said she doesn't have a problem as an attendee asking to table a topic that's not on the agenda. "There's nothing wrong with chiming in in a polite way. What you don't want to do is revisit the same thing over and over that you can solve."
If you're feeling there's not enough time in your day, look at where you're sabotaging your time. "There are solutions," Capko said. "Some are behavioral. Some are other people's behavior, putting boundaries in place."
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Physicists Say They've Figured out How Spacecraft Could Make It Through a Wormhole
Well, it seems that black holes might not be dead-ends after all.
Science Alert June 10th 2016
/ Hard Science
/ Black Hole
/ Physics
/ Wormhole
/Black Hole
/Physics
/Wormhole
A physical object, such as a person or a spacecraft, could theoretically make it through a wormhole in the centre of a black hole, and maybe even access another universe on the other side, physicists have suggested.
In what looks like the logical extension of the plot of Interstellar – where astronauts try to hunt down another universe after the catastrophic effects of climate change destroy Earth – physicists have modelled what would happen to a chair, a scientist, and a spacecraft, if each one ended up inside the spherical wormhole of a black hole.
"What we did was to reconsider a fundamental question on the relation between the gravity and the underlying structure of space-time," said one of the team, Diego Rubiera-Garcia from the University of Lisbon in Portugal.
"In practical terms, we dropped one assumption that holds in general relativity, but there is no a priori reason for it to hold in extensions of this theory."
So let's take a step back first, and go through some of the basics. According to Einstein's theory of general relativity, at the centre of a black hole lies a singularity – the point at which the forces of gravity are at their most intense, and time and space effectively end.
Watch: What are Wormholes?
If an object approaches the event horizon, it would be crushed in one direction, and stretched in another, thanks to the extreme tidal forces of gravity at play inside a black hole. If the object stays intact long enough to make it to the centre of a black hole, it will be infinitely long and thin: basically, it's been spaghettified beyond recognition.
Physicists have been playing around with the assumption of a singularity in the centre of a black hole for years, because until we can actually prove it exists, there could be any number of possibilities that still work – in theory.
Earlier this year, physicists from the University of Cambridge in the UK argued that there's no reason why a singularity necessarily has to be on the inside of a black hole. They suggest that in a universe with five or more dimensions – which isn't out of the question for us – a 'naked' singularly could exist, which is not bound by an event horizon.
Of course, this would mean big, huge things for our current understanding of how the laws of physics govern our Universe, because it basically needs Einstein's theory of general relativity to be wrong.
"If naked singularities exist, general relativity breaks down," said one of the team, Saran Tunyasuvunakool, back in January. "And if general relativity breaks down, it would throw everything upside down, because it would no longer have any predictive power – it could no longer be considered as a standalone theory to explain the Universe."
If you feel you are in a black hole, don't give up. There's a way out.
Einstein being wrong isn't out of the question, either. Stephen Hawking has been battling for decades with the way general relativity appears to clash with quantum mechanics in black holes – a problem known as the information paradox.
So assuming that the stipulations of general relativity aren't set in stone, the new study from Rubiera-Garcia's team argue that if you remove singularity from a black hole, what you get in the centre instead is a finite-sized wormhole.
Then, they figured out what could happen if various objects – a chair, a scientist, and a spacecraft – made it beyond the event horizon and into the wormhole. These objects are referred to as 'observers'.
They modelled these observers as an aggregation of points connected by physical or chemical interactions that hold everything together as the object travels along a geodesic line. A geodesic line is simply the path in spacetime that a free-falling object follows.
"Each particle of the observer follows a geodesic line determined by the gravitational field," says Rubiera-Garcia. "Each geodesic feels a slightly different gravitational force, but the interactions among the constituents of the body could nonetheless sustain the body."
Publishing in the journal Classical and Quantum Gravity, the researchers demonstrate this by showing how the time spent by a light ray in a round trip between two parts of the body is always finite.
This means that finite forces, no matter how strong, could compensate for the impact of the gravitational field near and inside the wormhole on a physical body travelling through it.
"Thus, different parts of the body will still establish physical or chemical interactions and, consequently, cause and effect still apply all the way across the throat of the wormhole," they explain.
So while the theory of general relativity predicts that an object approaching a black hole will be crushed along one direction and stretched along another infinitely, if we assume that the centre of a black hole is a wormhole with a finite radius, the object can only be crushed just as much as the size of the wormhole.
This means according to Rubiera-Garcia's hypothesis, an object could survive a journey through a wormhole and make it out the other side – and potentially to another universe – technically intact, but it would be crushed to the size of the finite wormhole. At least it's not completely destroyed, right?
"For a theoretical physicist, the suffering of observers is admissible (one might even consider it part of an experimentalist's job) but their total destruction is not," Rubiera-Garcia and his team quip in an opinion piece.
Until we figure out how to actually see a black hole, all of this is going to remain well and truly in the realm of pure hypotheticals. But we're beginning to see how black holes might not be the horrible, existence-obliterating death traps we thought they were.
As Hawking said at a conference back in August 2015 about his solution to the information paradox: "The message of this lecture is that black holes ain't as black as they are painted. They are not the eternal prisons they were once thought. … If you feel you are in a black hole, don't give up. There's a way out."
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