text:
Patterns of Multimorbidity
View ORCID ProfileKien Wei Siah, Chi Heem Wong, Jerry Gupta, View ORCID ProfileAndrew W. Lo
Kien Wei Siah
1Laboratory for Financial Engineering, Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
2Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
ORCID record for Kien Wei Siah
Chi Heem Wong
Jerry Gupta
3Digital Catalyst, Swiss Re, Cambridge, Massachusetts, United States of America
4Sante Fe Institute, Santa Fe, New Mexico, United States of America
ORCID record for Andrew W. Lo
For correspondence: alo-admin@mit.edu
Background With multimorbidity becoming the norm rather than the exception, the management of multiple chronic diseases is a major challenge facing healthcare systems worldwide.
Methods Using a large, nationally representative database of electronic medical records from the United Kingdom spanning the years 2005 to 2016 and consisting over 4.5 million patients, we apply statistical methods and network analysis to identify comorbid pairs and triads of diseases and identify clusters of chronic conditions across different demographic groups. Unlike many previous studies, which generally adopt cross-sectional designs, we examine temporal changes in the patterns of multimorbidity. In addition, we perform survival analysis to examine the impact of multimorbidity on mortality.
Results The proportion of the population with multimorbidity has increased by approximately 2.5 percentage points over the last decade, with more than 17% having at least two chronic morbidities. We find that the prevalence and the severity of multimorbidity increase progressively with age. Stratifying by socioeconomic status, we find that people living in more deprived areas are more likely to be multimorbid compared to those living in more affluent areas at all ages. The same trend holds consistently for all years in our data. In addition to a number of strongly associated comorbid pairs (e.g., cardiac-vascular and cardiac-metabolic disorders), we identify three principal clusters: a respiratory cluster, a cardiovascular cluster, and a mixed cardiovascular-renal-metabolic cluster. These are supported by established pathophysiological mechanisms and shared risk factors, and are largely consistent with existing studies in the medical literature.
Conclusions In this paper, we use data-driven methods to characterize multimorbidity patterns in different demographic groups and their evolution over the past decade. Our findings contribute to the better understanding of the epidemiology of multimorbidity that is needed to develop more effective primary care for multimorbid patients.
Multimorbidity, defined as the coexistence of two or more chronic medical conditions in an individual patient1, is a growing public health concern for healthcare systems worldwide. It has been found to be associated with adverse health outcomes, including a higher risk of mortality, a lower quality of life, increased utilization of healthcare, and correspondingly higher healthcare costs.2–14 It is most prevalent in the elderly population, as organs gradually lose full function with the aging process.8,15–17 With an increasing life expectancy and an aging population, the number of people with multiple health conditions is set to rise, as is public expenditure on long-term medical care. Unfortunately, current healthcare systems are largely designed to treat single diseases, resulting in the need to use multiple services to manage multimorbidity.11,18–20 Due to poor coordination and integration in medical care, causing a lack of continuity in treatment, disorders not designated as the primary condition are often undertreated.21
In order to align primary care more closely to the needs of patients suffering from multiple health conditions, a better understanding of the epidemiology of multimorbidity in the general population is necessary. However, previous studies on multimorbidity have mostly been limited in focus to elderly patients, due to its high prevalence in that population.2,19,20,22– 25 Since this data is typically collected through self-administered questionnaires and research interviews, it may be subject to self-reporting bias. Analyses based on small sample sizes from selected populations are known not to generalize well. Furthermore, many studies employ only a narrow range of methods to study multimorbidity patterns.
In this paper, we aim to characterize multimorbidity patterns not only in older patients, but also across groups with different demographic and socioeconomic statuses, using a large, nationally representative primary care electronic medical records database. We apply standard statistical methods to identify common comorbid pairs and triads of diseases, and use network analysis algorithms to identify clusters of chronic conditions. Unlike many previous studies, which adopted a cross-sectional design (i.e., analyzing data at a single point in time), we examine temporal changes in the patterns of multimorbidity across a decade of patient data. In addition, we analyze the impact of multimorbidity on mortality using survival models. In the discussion, we compare our findings with related works in literature.
2 Methods
a Data
We use anonymized electronic medical records from The Health Improvement Network (THIN)26 database for our analysis. The database contains longitudinal patient data collected at primary care clinics throughout the UK, covering approximately 6% of the UK population. We extract demographic information (e.g., date of birth, sex, geographical location, and socioeconomic group), baseline vitals (e.g., smoking and alcohol status), and medical history (e.g., medical condition and date of diagnosis) from patient records between 2005 and 2016. We categorize the subjects into seven mutually exclusive age groups based on Medical Subject Headings (MeSH) definitions (see Appendix A).27
Diagnoses are recorded in the THIN database using Read Codes, a coded thesaurus of clinical terms used by the UK National Health Service since 1985.28 There is no standard method for the selection and definition of morbidities in the literature. After consulting with medical officers and Life & Health (L&H) actuaries at Swiss Re, we identify chronic conditions in the records, that is, diseases that are either permanent, caused by nonreversible pathological alterations, or require long periods of rehabilitation and care,19,29 and map them to a list of 46 higher level morbidities. Furthermore, we classify the morbidities into 14 System Organ Classes (SOCs) as defined in the Medical Dictionary for Regulatory Activities (MedDRA) dictionary. (See Appendix A for list of morbidities and classifications.) As in similar studies, we define multimorbidity as the presence of at least 2 of the 46 morbidities in a patient.
b Statistical analysis
We examine the distribution of multimorbidity in relation to age and socioeconomic status, as done in Barnett et al.11 However, we use the Index of Multiple Deprivation (IMD) as a proxy for socioeconomic status. The IMD is a widely used measure of relative deprivation or poverty of wards and districts in the UK. It is computed using census data as a weighted index of deprivation in seven domains, including income, employment, education, health, crime, barriers to housing and services, and living environment.30 (IMD data was available only for a subset of the patients. See Appendix B for the sample sizes used in this analysis.) We note that the same approach, defining socioeconomic status by the area of residence, has been used in previous studies.11,31
For each age group, we also compute the observed prevalence for all individual, pairs, and triplets of morbidities. By the assumptions of probability theory, we expect diseases that are independent to co-occur at a rate close to the product of the observed prevalence of each individual constituent disease (i.e., the expected prevalence). Therefore, by comparing the ratio of the observed prevalence versus the expected prevalence (i.e., the lift), we can identify pairs and triads of diseases that occur together more frequently than expected by chance, possibly driven by an underlying pathophysiological mechanism. As a second metric, we estimate the odds ratio using logistic regression models to determine the association between each pair of diseases, both without adjustment and adjusted by age, sex, and all other diseases.
Next, we construct multimorbidity networks to study the natural clustering of diseases in the dataset. We consider diseases as nodes with sizes proportional to their observed prevalence. For each pair of diseases, we connect their nodes with an undirected edge weighted by the estimated lift, a measure of the strength of the association between the comorbid pair. This creates a dense network where each node is linked to almost every other node. This density, however, makes visualization and inference difficult. As a pre-processing step for subsequent analysis, we extract the main graph structure by removing edges from the adjacency matrix that are peripheral and relatively unimportant. We prune the edges between nodes that have joint prevalence below the 90th percentile, and keep only the edges that have a lift above 2.0, i.e., those edges between pairs that co-occur two times more frequently than expected by chance. Similar thresholds have been used in related studies.2,32–35
We compute measures of centrality to identify the most important vertices in the multimorbidity network. In particular, for each node, we compute the degree centrality, which is defined as the number of links incident on a node, a direct measure of the connectivity of a node. In this context, a disease with high degree centrality is important because it often co-occurs with a large number of pathologies. We also estimate the eigenvector centrality, a measure of the transitive influence of nodes. To calculate the eigencentrality, each node is assigned a score that is proportional to the sum of the scores of all of its neighbors. Nodes with high eigencentrality either have many connections, or are connected to important neighbors. In addition, we compute the graph clustering coefficient (also known as the transitivity) as a quantitative measure of the network's tendency to aggregate in smaller subgroups. To identify any clusters embedded in the multimorbidity networks, we apply a community detection algorithm based on modularity maximization36– 38 to partition nodes into groups that have dense intra-group connections and sparse inter-group connections.
To gain insight into temporal disease associations, we construct directed multimorbidity networks. We extract from each patient's medical history a sequence of diseases ordered by the time of diagnosis. Using these trajectories, we can derive the probability of any given disease conditional on some prior diagnosis, i.e., Prob(Disease B given Disease A). We use these probabilities as weights of the directed edges in the network. As before, we prune the network based on node prevalence and edge weights. Since these connections are directed, we can compute the in-degree and out-degree centralities, defined as the number of edges directed to the node, and the number of edges directed from the node to others, respectively. A node with a high in-degree centrality is often diagnosed following other diseases; a node with a high out-degree centrality often leads to subsequent diagnoses in other diseases. These metrics are useful for understanding disease progression, and any causal or contributory relationships between diseases.
Finally, we examine the impact of multimorbidity on mortality by performing survival analysis on the dataset. We use the five-year overall survival as the primary outcome variable, and consider in our models a range of features, including demographic group, baseline vitals, baseline medical history, the severity of multimorbidity as quantified by the number of co-occurring chronic conditions, and the presence of any of the top ten most prevalent pairs and triplets of morbidities as observed in the aged and elderly age groups. We exclude those subjects aged 65 or less from this part of the analysis, as younger age groups have five-year overall mortality rates close to zero.
We explore three standard methods used in survival modeling, the Cox proportional hazards model39, the regularized Cox model, and the accelerated failure time model, and additionally, we apply a nonlinear and non-parametric neural network survival model.40 For model estimation and validation, we randomly split the original dataset into two disjoint sets, a training set that comprises 70% of the data, and a testing set that comprises the remaining 30%. We use the training set to estimate our models, and keep the testing set as an out-of-sample dataset for performance validation. We use the concordance index (C-index) as the metric for model performance. This metric is commonly used in survival analysis to evaluate its predictive power.41 It is a measure of the concordance between orderings of observed survival times and the predicted times or risks. (A C-index of 0.5 corresponds to a random model, while a value of 1.0 corresponds to a perfect model.) We use cross-validation to tune the hyperparameters of the models.
In addition to discriminative power, we assess the calibration of our models by comparing the actual and the predicted survival probabilities at 36, 48, and 60 months of overall survival. For each time cutoff, we divide the test set into quintiles based on the predicted risk scores. We then compute the average predicted score and the true survival probability observed in each of the quintiles. Lastly, we create calibration plots by plotting the observed probabilities against the predicted probabilities. In the ideal case, the points should lie as close as possible to the diagonal line, which represents perfect calibration.
We summarize the demographic statistics of the study population in Table 1. On average, the dataset consists of approximately 4.6 million patients each year, with an even mix of both sexes in all years. Most of the patient records were collected in England, which makes up the largest part of the population of the United Kingdom. However, the distribution in geographical location has evolved over the years, shifting towards other regions in the country. Over 60% of the patients are in the Adult (19 to 45 years old) and Middle-Aged (45 to 65 years old) age groups, as defined by the MeSH classification (see Appendix A). Approximately 15% are over 65 years old.
Table 1. Demographics of the dataset between 2005 and 2016.
The proportion of the population with multimorbidity has increased by approximately 2.5 percentage points over the last decade, with more than 17% of all patients having at least two chronic morbidities in 2016. We find that the prevalence and the severity of multimorbidity increase progressively with age (see Figure 1). By age 60, approximately half the population has been diagnosed with at least one chronic condition, after which we observe a steep rise in multimorbidity, with close to 1 in 3 patients suffering from at least two morbidities by age 70. Stratifying the prevalence of multimorbidity by IMD in Figure 2, we find that people living in more deprived areas are more likely to be multimorbid compared to those living in more affluent areas at all ages. The same trend holds consistently for all years in our data.
Figure 1.
Number of co-occurring chronic conditions by age in 2016. See Appendix C for other years.
Prevalence of multimorbidity by age and IMD in 2016. See Appendix C for other years. Higher score corresponds to greater deprivation.
We characterize the epidemiology of individual diseases by plotting heat maps of disease prevalence in different age groups separately. We find that asthma and respiratory conditions have high prevalence across all age groups, with the former occurring especially frequently in the Adolescent age group (13 to 19 years old). We observe the onset of metabolic and cardiovascular diseases in the Middle-Aged and older age groups, in particular, of diabetes and hypertension. Not surprisingly, diseases such as dementia, kidney diseases, and stroke occur most frequently in the oldest patients (65 years and above). We observe an increasing trend in prevalence for some diseases. For example, the prevalence of diabetes in the Aged age group (65 to 80 years old) has increased by almost 35% in the past decade (see Figure 3). In contrast, the prevalence of diseases such as angina has been falling over the study period.
Single disease prevalence in the Aged subgroup between 2005 and 2016. See Figures 7 and 8 for disorder to index mapping and MedDRA SOC abbreviations. See Appendix C for other age groups.
In Table 2, we summarize the lift and odds ratio of the top ten most frequently co-occurring pairs of diseases in the Aged age group in 2016. (See Appendix C for other age groups and years.) In all age groups, asthma occurs in combination with other respiratory-related diseases approximately twice more often than expected by chance (i.e., the lift is greater than 2.0). Additionally, the estimated odds ratios, both unadjusted and adjusted, indicate that patients with asthma are at least twice as likely to suffer from other respiratory conditions at the same time, and vice versa.
Table 2. Lift and odds ratio of the top 10 most prevalent multimorbidity pairs in the Aged subgroup in 2016. See Appendix C for other age groups and years.
Hypertension is most associated with a second condition in the older age groups, although most pairs do not necessarily occur more frequently than by chance. The combination of hypertension and diabetes stands out with a relatively high lift and an odds ratio that is greater than 2.0, suggesting that this disease pair may be comorbid. Angina and coronary artery disease (CAD) also demonstrate a strong association in the Aged and Elderly age groups with unusually high lift and odds ratio.
To better visualize the data, we plot the lift of all combinations of disease pairs in heat maps, stratified by MedDRA system organ classes. (See Figure 4 and Appendix C for other age groups and years.) The co-occurrence of cardiac-cardiac and cardiac-respiratory disorders is a major risk across all age groups. We observe significant coupling between cardiac and hepatobiliary disorders in the Adolescent and Child (2 to 13 years old) age groups. On the other hand, combinations of cardiac-vascular and cardiac-metabolic disorders are the most dominant in the Middle-Aged and older age groups. We observe the same general patterns across time.
Heat map of lift of multimorbidity pairs in the Aged subgroup in 2016. See Figures 7 and 8 for disorder to index mapping and MedDRA SOC abbreviations. See Appendix C for other age groups and years.
As shown in Figure 1, the proportion of patients with three or more co-occurring disorders is small in the younger age groups. For patients aged 45 years and older, triplets involving angina, CAD, hypertension, diabetes and myocardial infarction (MI) occur most frequently with high lift, suggesting strong correlations between these diseases (see Table 3).
Table 3. Lift of the top 10 most prevalent multimorbidity triplets in the Aged subgroup in 2016. See Appendix C for other age groups and years.
In Figures 5 and 6, we plot the undirected and directed multimorbidity networks observed in the Aged age group in 2016. (See Appendix C for other age groups and years.) Instead of a force-directed layout, we place the nodes in fixed positions around a circle to allow easy visualization of temporal changes in connections and clusters when comparing plots from different years. The edge thickness is proportional to the lift between each disease pair. Apart from single-node clusters, the communities detected using modularity maximization are given different colors.
Undirected multimorbidity network in the Aged subgroup in 2016. Edge thickness is proportional to the lift between each disease pair. Intra-group edges and inter-group edges are represented by solid lines and dashed lines, respectively. Only communities with more than one node are colored. See Figures 7 and 8 for mapping of disorder to index and MedDRA SOC abbreviations. See Appendix C for other age groups and years.
Directed multimorbidity network in the Aged subgroup in 2016. Edge thickness is proportional to the lift between each disease pair. Intra-group edges and inter-group edges are represented by solid lines and dashed lines, respectively. Only communities with more than one node are colored. See Figures 7 and 8 for mapping of disorder to index and MedDRA SOC abbreviations. See Appendix C for other age groups and years.
Mapping between index and chronic conditions.
Abbreviations for MedDRA SOCs used in figures.
In Tables 4 and 5, we identify clusters that remain relatively stable throughout the years in undirected and directed multimorbidity networks, respectively. We find between one and four clusters for each age group. The number of diseases in each cluster ranges between two and twelve. In general, the communities found in Adolescent and younger patients can vary greatly from year to year compared to older age groups, where the clusters evolve very little over time. This is expected, given that only a small proportion of the former cohort suffers from more than two co-occurring disorders (see Figure 1), so the results are sensitive to small changes in prevalence each year.
Table 4. Clusters identified in undirected multimorbidity networks in different age groups.
Table 5. Clusters identified in directed multimorbidity networks in different age groups.
A respiratory cluster of asthma, chronic obstructive pulmonary disease (COPD), and respiratory-related diseases appears to be present in all age groups in both undirected and directed graphs. Similarly, a vascular-metabolic-hepatobiliary-renal cluster that is characterized by hypertension, diabetes, liver diseases, and kidney diseases, with the occasional appearance of cardiac disorders, is also present in almost all cohorts. As observed in previous analyses, we also find several clusters dominated by cardiovascular disorders such as angina, CAD, myocardial infarction (MI), atrial fibrillation, cardiac arrhythmia, heart failure, heart valve disorder (HVD), stroke, peripheral artery disease (PAD), and transient ischemic attack (TIA).
In Tables 6 and 7, we summarize the top five diseases for each centrality measure. (See Appendix C for the full set of results.) The degree centrality and eigencentrality for hypertension, diabetes, CAD, and angina are the highest when all age groups are aggregated in undirected multimorbidity networks. In the Adolescent and younger age groups, kidney disease shows both high degree centrality and eigencentrality. Other important nodes include respiratory-related diseases and HVD, which have high degree centrality and high eigencentrality, respectively. For the Adult and Middle-Aged age groups, hypertension and diabetes are the most central nodes with respect to both measures. In the Aged and Elderly age groups, we find that cardiac disorders make up all of the top five most connected nodes.
Table 6. Centrality measures for top five diseases in undirected multimorbidity networks with mean computed over time.
Table 7. Centrality measures for top five diseases in directed multimorbidity networks with mean computed over time. We exclude eigencentralities that are close to zero.
We observe similar results in directed networks. In general, hypertension, diabetes, and respiratory-related diseases demonstrate high in-degree centrality and eigencentrality, while cardiac disorders show high out-degree centrality. In the Middle-Aged and younger age groups, asthma emerges as a new central node with high in-degree centrality, while the top five diseases for the Aged and Elderly age groups remain dominated by cardiovascular diseases.
We summarize the dataset used for survival analysis in Table 8. The sample consists of approximately 390,000 patients in the Aged and Elderly age groups for each year between 2010 and 2012. More than 50% of the patients are multimorbid. In terms of predicting five-year overall survival, we find the performance of the linear and nonlinear survival models explored to be very similar (see Appendix D). We focus on the Cox model here due to its ease of interpretability. The model achieves a promising C-index of 0.81 (95% CI 0.80–0.81) on out-of-sample data in 2012. In addition, its calibration curves lay close to the ideal diagonal, indicating that the model is well calibrated, i.e., the model does not systematically overestimate or underestimate survival rates in any of the quintiles. (See Appendix C for plots.)
Table 8. Summary statistics of dataset used for survival analysis.
In Table 9, we extract the top ten coefficients in the Cox model to identify specific risk factors. To correct for multiple testing, we perform the Benjamini-Hochberg adjustment with a 5% false discovery rate for identifying significant factors. Apart from cancers, we find the presence of multimorbidity to be a strong adverse risk factor, i.e., the higher the number of co-occurring chronic conditions, the greater the mortality risk. For example, the hazard ratio of having four or more chronic conditions is 2.44 (95% CI 2.22–2.69). We also find a high IMD, corresponding to a lower socioeconomic status, to be significantly associated with increased risk, although this factor is not in the top ten coefficients.
Table 9. Top ten risk factors of the Cox Proportional Hazards model for 2012. Asterisks denote factors that are significant after the Benjamini-Hochberg adjustment.
With multimorbidity becoming the norm rather than the exception2,12,17,22,42,43, the management of multiple chronic diseases in older adults is a major challenge facing healthcare systems worldwide. It is clear that a better understanding of the epidemiology of multimorbidity is required to develop more effective preventive interventions and better primary medical care for multimorbid patients. In this paper, we use data-driven methods to characterize multimorbidity patterns in different demographic groups and their evolution over the past decade, using a large, representative electronic medical records database consisting of over 4.5 million patients.
Consistent with other studies, we find that the prevalence and severity of multimorbidity increase substantially with age. In addition, we observe social inequalities in multimorbidity, with patients in socioeconomically deprived areas more likely to be multimorbid.11,12,31,42,44– 46 Our findings also support the role of hypertension as an important risk factor in older adults, as reported in the literature.2,33,47 Hypertension is one of the most prevalent and most central chronic conditions in our dataset, and one that serves as an important bridge between many diseases in our networks. Other trends identified in our analysis, such as the falling prevalence of angina48–51 and the growing prevalence of diabetes52, are also well documented in previously published population studies.
In our pairwise analysis, we find strong association between multiple pairs of chronic conditions, including between asthma and respiratory-related diseases53,54 in the Adolescent age group, between hypertension and diabetes25,55–57 and between CAD and angina58 among older patients, and between cardiovascular and respiratory disorders in all age groups.2 Triplets involving cardiovascular and metabolic disorders, such as CAD, hypertension, and diabetes, also occurred more frequently than expected by chance.2,22,25,59
Our network analysis further identified several meaningful communities that are common across all demographics, including a respiratory cluster (e.g., asthma and COPD)60, a cardiovascular cluster19,61, and a mixed cardiovascular-renal-metabolic cluster32,62–64, all of which are supported by either established pathophysiological mechanisms or shared risk factors. For example, it is well known that cardiovascular diseases are one of the most common complications of diabetes. While we do not find any particular multimorbidity pattern to have a significant effect on mortality, our models do indeed verify the substantial burden of multimorbidity (as quantified by the number of co-occurring chronic conditions) on overall survival in older patients.7,12,23,65,66
However, we must emphasize that our results do not necessarily imply any causal link between diseases identified to be in the same cluster. The association might be attributable to shared risk factors (e.g., smoking) or other adverse events, and any temporal relationships to be inferred from the multimorbidity directed networks might be administrative in nature (e.g., incomplete medical records that are rectified in subsequent visits) or biased by delayed diagnosis.
In general, the lack of an accepted standard for defining multimorbidity makes it difficult for any meaningful comparison of results across different studies.67,687 Moreover, because results can be highly dependent on the study population, the disease ontology used, and the number of chronic conditions considered, it is not uncommon for studies to report seemingly conflicting findings. In this paper, we consider a wide range of demographic groups and a total of 46 morbidities, which is more than most similar studies,11 and well above the minimum of 11 to 12 as recommended by systematic reviews in this field of research.68,69 In addition, our findings are largely consistent with existing studies in the medical literature.
Lastly, we note that cancer appears to be under represented in the THIN database. This is because many cancer patients are treated separately in cancer centers under the care of specialized clinical teams. Unfortunately, data on such patients rarely make their way back to the primary care clinics where the THIN data is collected, leading to a gap in this area.
Current healthcare systems are largely centered on single-disease approaches to treatment, resulting in the fragmentation of care and a lack of continuity in the management of multiple diseases. Even most clinical trials exclude multimorbid patients. Because multimorbidity is more common in disadvantaged groups, the current structure exacerbates health inequalities in society. In this paper, we apply statistical methods and network analysis to characterize multimorbidity associations in the general UK population using a large electronic medical records database spanning the years 2005 to 2016. Our findings contribute to a better understanding of multimorbidity that may be useful for the early detection and prevention of comorbidities, for example, recommending that hypertension patients reduce sugar intake as a preventive measure for diabetes.
There is a pressing need for a universal framework that standardizes the way that multimorbidity is assessed (e.g., the minimum number of diseases and the choice of chronic conditions to include) in order to facilitate comparisons between studies and populations. With the "Omics" revolution, the combination of phenotypic, genomic, and epigenomic data has the potential to provide deeper insights into the underlying pathophysiological associations between comorbid diseases. Unfortunately, the availability of such linked datasets remains very limited. Further research is also needed to better understand the impact of multimorbidity on different health outcomes, such as the quality of life and healthcare costs, in order to align the primary healthcare system more closely to the needs to multimorbid patients.
The data supporting the current study have not been deposited in a public repository due to its proprietary nature. The data are available from The Health Improvement Network (THIN) at https://www.the-health-improvement-network.com/en/. Restrictions apply to the availability of the data, which were used under license for this study.
This study was approved by the Scientific Review Committee at IQVIA.
The data that support the findings of this study are available from The Health Improvement Network (THIN; https://www.the-health-improvement-network.com/en/) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of THIN.
K.W.S. and C.H.W. declare no competing interests. J.G. is an employee of Swiss Re and declares no competing interests. A.L. reports personal investments in private biotech companies, biotech venture capital funds, and mutual funds. A.L. is a co-founder and partner of QLS Advisors, a healthcare analytics and consulting company; an advisor to BrightEdge Ventures; a director of BridgeBio Pharma, Roivant Sciences, and Annual Reviews; chairman emeritus and senior advisor to AlphaSimplex Group; and a member of the Board of Overseers at Beth Israel Deaconess Medical Center and the NIH's National Center for Advancing Translational Sciences Advisory Council and Cures Acceleration Network Review Board. During the most recent six-year period, A.L. has received speaking/consulting fees, honoraria, or other forms of compensation from: AIG, AlphaSimplex Group, BIS, BridgeBio Pharma, Citigroup, Chicago Mercantile Exchange, Financial Times, FONDS Professionell, Harvard University, IMF, National Bank of Belgium, Q Group, Roivant Sciences, Scotia Bank, State Street Bank, University of Chicago, and Yale University.
No direct funding was received for this study; general research support was provided by the MIT Laboratory for Financial Engineering and its sponsors. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper).
Conceptualization, K.W.S., C.H.W., J.G., and A.L.; Resources, J.G., and A.L.; Methodology, K.W.S., C.H.W., J.G., and A.L.; Software, K.W.S.; Formal Analysis, K.W.S.; Writing – Original Draft, K.W.S. and A.L.; Writing – Review & Editing, K.W.S., C.H.W., J.G., and A.L.; Supervision, A.L.; Project Administration, J.G., and A.L.
Research support from the MIT Laboratory for Financial Engineering is gratefully acknowledged. The views and opinions expressed in this article are those of the authors only, and do not necessarily represent the views and opinions of any institution or agency, any of their affiliates or employees, or any of the individuals acknowledged above.
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You are going to email the following Patterns of Multimorbidity
Kien Wei Siah, Chi Heem Wong, Jerry Gupta, Andrew W. Lo


THE NORTH CONWAY FIRE CHIEF SAYS A FIRE WEDNESDAY MORNING AT A SINGLE FAMILY RANCH STYLE HOME IN NORTH CONWAY WAS PROBABLY CAUSED BY A BATHROOM VENT FAN THAT OVERHEATED.
PAT PREECE SAYS HIS FIREFIGHTERS AND NORTH CONWAY AMBULANCE WERE CALLED TO 57 ARTIST FALLS RD. SHORTLY AFTER 6:30 A.M.
FIRST RESPONDERS QUICKLY CHECKED THE HOUSE AND DETERMINED NO ONE WAS IN IT.
A FIRST ALARM WAS QUICKLY DECLARED, BRINGING MORE FIREFIGHTERS FROM FIRE DEPARTMENTS IN CONWAY AND REDSTONE – AND AN ADDITIONAL AMBULANCE.
FIREFIGHTERS FROM BARTLETT COVERED THE NORTH CONWAY STATION HOUSE.
THE FIRE WAS BROUGHT UNDER CONTROL SHORTLY BEFORE 7 A.M. PREECE SAYS THE DAMAGE WAS MINOR.
NO ONE WAS HURT, AND ALL THE HOME'S PETS, INCLUDING SOME CHICKENS, SURVIVED.


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Paul Justin Bishop
February 7, 1929 - October 13, 2021
Paul Justin Bishop, age 92, of Knoxville, TN, previously of Elizabethton, went home to be with the Lord on Wednesday, October 13, 2021 at his residence. Paul was born in Jenkins, KY to the late Eugene Chalmer and Mary Simandle Bishop. In addition to his parents, he was preceded in death by his wife of 60 years, Joyce Murray Bishop; brothers, Albert Bishop, Ernest Bishop (Sally) and Chalmer Bishop (Ella Mae). Paul was a member of First Freewill Baptist Church of Elizabethton, TN, where he served as Deacon and taught men's Sunday school class. He retired from Raytheon Company in Bristol, TN with over 37 years' service as a Mechanical Test Engineer. Paul joined the Army-Air Force in 1947 and was stationed in the Aleutian Islands in Alaska. He was a Past Master for the Elizabethton Dashiell Masonic Lodge #238 F&AM. He also held office in the Grand Lodge in Nashville. His favorite hobbies were leatherwork, reading, puzzles, hunting and camping. Those left to cherish his memory include children, Paula Bishop Richards (Gary) of Knoxville, TN and Phillip Bishop (Anna) of Kingsport, TN; grandchild, Melanie Richards Young (Carl) of Knoxville, TN; brother, Gary Bishop (Hazel) of Tallahassee, FL; sister in laws, Brenda Rogers of Elizabethton and Betty Murray of Elizabethton, TN; brother in law, Lee Murray (Jane); special friends, Penny Minton and Family of Elizabethton, TN, Howard and Jewel Ensor of Watauga, TN, Jane Montgomery of Brevard, NC, Doris Glass of Knoxville, TN, Family of Charlie Burrow of Elizabethton, TN, Linda Williams of Elizabethton, TN and Jim Kent of Elizabethton, TN. Several nieces and nephews also survive. A graveside service and committal to celebrate the life of Paul Bishop will be conducted at 3:00 pm on Monday, October 18, 2021 at Happy Valley Memorial Park with Pastor Gary Roe officiating. Pallbearers will be Steve Hubbard, Mike Hubbard, Carl Young, Chuck Bruce, Rich Minton, Ricky Estep. Honorary pallbearers will be Mark Richards, Jeb Bishop, Lee Bishop, Eddie Moore, Steve Campbell, Obie Grindstaff, Steve Blevins, Randy Johnson and Jay Dugger. Those wishing to attend the service are asked to meet at the funeral home at 2:15 pm. Those who prefer memorials in lieu of flowers may make donations to St. Jude Children's Research Hospital, 501 St. Jude Place, Memphis, TN 38105. Online condolences may be shared with the family on our website, www.tetrickfuneralhome.com Tetrick Funeral Home, Elizabethton is honored to serve the Bishop family. Office 423-542-2232, service information line, 423-543-4917.
Paul Justin Bishop, age 92, of Knoxville, TN, previously of Elizabethton, went home to be with the Lord on Wednesday, October 13, 2021 at his residence. Paul was born in Jenkins, KY to the late Eugene Chalmer and Mary Simandle Bishop. In addition... View Obituary & Service Information
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TVD Radar: Music from the Motion Picture Baby Driver in stores now »
The Soft Boys,
Underwater Moonlight
By Michael H. Little | Published: June 26, 2017
The Soft Boys are one of those bands that failed commercially for lack of a straight-talking high school guidance counselor. Because a straight-talking high school guidance counselor could have sat Robyn Hitchcock and Kimberly Rew down and said, "Look boys, your desire to make psychedelic rock is laudable. But it's 1976, everybody's wearing safety pins through their noses and screaming about anarchy, and to be perfectly blunt lads your desire to make a go of it as acid rockers makes about as much sense as pursuing careers as lamplighters. Oh, and while we're on the subject, I have an employer here who is looking for a dependable rat catcher."
Alas, they had no one, which is why their magnum opus, 1980's Underwater Moonlight, sold approximately 18 copies. The Soft Boys were at the right place but at the wrong time, and as the Velvet Underground will gladly inform you, timing is everything. Underwater Moonlight has gone on to become a neo-psychedelic masterpiece, but it hit the record stores well before everybody and his sister hopped aboard the paisley bandwagon just in time to enthrall a listening public looking for something completely different from post-punk. And by that time the Soft Boys were no more—the whimsical and eccentric Hitchcock having gone on to form Robyn Hitchcock and the Egyptians, and Rew the commercially successful Katrina and the Waves.
The Soft Boys' influences aren't too hard to discern—The Beatles, The Byrds, Syd Barrett, and when it comes to sheer lyrical absurdity, the Bonzo Dog Band. But they are far more than the sum of these influences. Opening track "I Wanna Destroy You" is punk in attitude—less 1967 than 1976—but has a power pop heart, and is the catchiest anthem this side of Cheap Trick's "Surrender." And "Old Pervert," which features some truly wonderful drum pummel, lots of fractured guitar, and some insane laughter, is nobody's idea of a flower power Day-Glo acid rocker. The guitars are just too mean, and the lyrics are a million miles away from the Summer of Love. "I'm an old pervert and I hang around under the bridge/I won't do you no harm I just wanna show what's in my fridge," sings a lecherous Hitchcock, before adding, "They said that I'm weird and disinfectant is all that I drink/Ah, but cleanliness of the soul is more important, don't you think?"
"Queen of Eyes" is another power pop masterpiece, and could well be both inspiration and template for all 36,497 of Robert Pollard's songs. Or maybe not, because you can also hear the future echo of Pollard on the Captain Beefheart-meets-the-Raspberries "I Got the Hots." Inspirational lyric: "When you see her your eyes awake/Electric bulbs on a birthday cake/Would you care for a lump of steak?" "Positive Vibrations" is positively giddy-making, what with its big happy guitar hooks and dizzying vocal harmonies. Meanwhile, "Kingdom of Love" comes on like a distant cousin of the Hollies "Long Cool Woman (In a Black Dress)," and you can only wonder what love means to Hitchcock when he sings, "You've been laying eggs under my skin/Now they're hatching out under my chin/Now there's tiny insects showing through/And all them tiny insects look like you."
The title track is about as whimsical as they come, and boasts a great chorus, to say nothing of an excellent instrumental passage that is guaranteed to open your third eye. And the way the song builds and builds to a grand climax will set your heart chakra on fire. On the green-eyed "Insanely Jealous of You" Hitchcock goes from a whisper to somewhat less than a scream, and says to hell with biological determinism with the lines, "I don't know why the people want to meet/When all they know is that they'll breed like rabbits in the end."
Unlike most of the neo-psychedelic bands—yes, I'm talking about you Brian Jonestown Massacre—that would follow in their footsteps, the Soft Boys refrained from ornamenting their songs with such ticky-tacky trappings as sitars, tablas, and drones, although a rogue sitar does sneak its way onto "Positive Vibrations." The Soft Boys didn't ape their predecessors; they merely took from them what already came naturally, such as a taste for the surreal and a knack for writing groovy melodies, man. The Soft Boys are proof that everything that goes around comes around again, which brings us back to our mythical high school guidance counselor. Who, having failed to talk the Soft Boys into seeking careers as costermongers, ends his counseling session with Hitchcock and Rew by asking, "Oh, by the way… which one's Soft?"


The enormous potential of India's air transport market can't be underestimated.
This was driven home by a comment former IATA CEO Tony Tyler made a few years back when he said if Indians flew to the same extent as Americans, there would be a market potential of two billion people each year.
That is extraordinary and in the next few decades a likely reality. India is already expected to become the world's third biggest aviation market behind the US and China by 2020 with 370 million passengers traveling to, from and within the country.
Yet this growth is not without it challenges. India simply cannot build or expand its airport infrastructure quickly enough to accommodate this growth. For airlines, the competition is intense and remaining profitable a constant struggle. Regulations are onerous.
Unlocking the full potential of Indian aviation over the coming decades is multi-faceted and complex. How much of and how fast India's potential is realized depends on how quickly airlines and airports embrace the efficiencies and passenger convenience that advanced IT systems and services bring. This is where SITA plays a key role. Technology can help make the business of air travel easier and smarter. This is supported by the finding of SITA's SITA's India IT Trends Benchmark study.
We strongly believe that technology has the real potential to transform air travel in India. For example, airports facing physical constraints on their capacity, can leverage self-service technology to improve passenger flow while business intelligence systems can help proactively identify and avoid potential bottlenecks along the journey. That means more passengers through the same airport infrastructure available today.
For airlines, the ability to leverage connected aircraft will help smooth aircraft operations while offering passengers more options to stay connected inflight.
The benefits of technology and the fact that Indian travelers are high connected – 98% of Indian passengers carry at least one mobile device – is encouraging a strong push by both airlines and airports to invest in self-service and mobile technologies. Overall all airlines and 80% of airports in India expect to see IT budgets increase in 2017 compared to 2016.
This investment in technology is important. While there are many impediments to transforming India's air transport industry, with the technology available today making your business smarter at every step should not be one of them.


Life is far too important to ever talk seriously about.
Fic journal! *waves* And...that's it, really. If you want a super complete list of fic, link to my FF.net profile is above. I update that a bit slower than LJ these days, though.


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Hollie Cavanagh Goes Home On American Idol
With the coveted home town hero visit on the line, four became three tonight on the "American Idol" results show.
But before their fate was revealed the foursome kicked the show off with a snoozy version of "California Dreamin"" by the Mamas and Papas.
Then, we got down to business, or so we thought. First up, double P as Ryan said. Jimmy called Phillip's performance the beginning of Phillip coming into his own. But Ryan didn't reveal a thing. He told Phillip to return to "the couch," but said, those are not the results. Which means what?
Next up was Hollie, who struggled on her second showing last night. Jimmy understood why the judges were okay with Hollie's Journey showing, but he didn't agree. And of her Bonnie Raitt performance, Jimmy said, "she hit the opera button" and "crashed and burned." But still, the torture for us and them continued as she too was sent back to the couch.
Read more: http://blogs.wsj.com/speakeasy/2012/05/10/american-idol-season-11-who-was-voted-off-tv-recap-4/?mod=google_news_blog
By Roy • Posted in Entertainment, Music, Reality Television	• Tagged American Idol, American Idol tour, David Cook, elimination night, Hollie Cavanagh, hometown hero visits, Jennifer Lopez, Jessica Sanchez, Joshua Ledet, Music, Phillip Phillips, Randy Jackson, Reality Television, results night, singing competition, Steven Tyler
Early Oley Valley School District Budget Includes Tax Hike, Job Cuts
Map of Berks County, Pennsylvania, United States Public School Districts (Photo credit: Wikipedia)
The Oley Valley School Board passed a tentative budget for the 2012-13 school year Wednesday night, but board members are still looking for any possible places to cut.
"I will support this tonight, but I am not pleased with certain aspects of the budget," board member Ralph C. Richard said. "We still have some work to do, but we'll get the proposed budget on the docket as we move to get a final budget."
The $28.21 million budget includes a 0.4013 mill increase, which would bump the tax rate to 24.5563 mills. The annual tax bill on a property assessed at $100,000 would be about $2,456.
By Roy • Posted in Reading/Berks	• Tagged Berks County, Board of Education, budget, Business Manager Tracy Detwiler, Dr. Tracy Shank, job cuts, Oley Valley School District, program cuts, property tax, Tax, tax hike
Reading City Schools Finances Not So Dire, Officials Say
The budget outlook in the Reading School District isn't good, but it's not quite as bad as originally advertised, district officials said Wednesday night.
The Reading School Board held a public budget meeting at Reading High School, providing the dozens of parents, teachers, students and others who attended an update on the 2012-13 budget and a chance to speak about potential cuts.
From the outset, administrators and board members challenged the picture painted by former administrators – eight of whom were fired two weeks ago – that the district is facing a $53 million budget shortfall.
By Roy • Posted in Reading/Berks	• Tagged Berks County, budget deficit, budget shortfall, education, pay freezes, Pierre V. Cooper, program cuts, Reading PA, Reading School District, Reading School District Board of Education, School district
Some Reading Neighbors, Officials Leery Of Liquor License At Perkiomen Avenue Site
The owner of the planned Shop Smart Buy Smarter grocery has spent more than $1 million on the building at 1626 Perkiomen Ave. and wants to open a 38-seat restaurant that's in the same building but separate from the store.
To do that, state law says he needs City Council's OK to transfer an out-of-town liquor license to the restaurant.
But city officials and neighbors told council at a hearing Wednesday that they don't need yet another liquor outlet in the area that's already got plenty of taverns.
Council plans a vote on the measure May 29.
By Roy • Posted in Entertainment, Food, Reading/Berks	• Tagged alcoholic beverages, Berks County, Council President Francis G. Acosta, Frank Gussoni, Liquor license, neighbors, parking, Police Chief William M. Heim, Reading PA, Restaurant, safety, Shop Smart Buy Smarter
Deal Reached On John Updike Home Sale
John Updike giving the 2008 Jefferson Lecture for the National Endowment for the Humanities. Found via USAsearch.gov]. (Photo credit: Wikipedia)
The John Updike Society has signed an agreement to buy for $200,000 the late author's childhood home in Shillington, Pa.
James Plath, president of the 250-member society, said in a press release Wednesday that the agreement is contingent upon receiving a zoning variance to operate the house as a historic site.
Updike lived in the two-story home at 117 Philadelphia Ave. for the first 13 years of his life before moving to a family homestead in Plowville.
The author, who died in 2009, was heralded for his literary style and prolific output, including the four "Rabbit" novels, which often evoked Berks County places and geography. The last two, "Rabbit is Rich" in 1981 and "Rabbit at Rest" a decade later, won Pulitzer Prizes for fiction.
By Roy • Posted in Reading/Berks	• Tagged Berks County, historic preservation, historic site, John Updike, John Updike Society, Literature, novelist, Plowville PA, Pulitzer Prize, Rabbit At Rest, Rabbit Is Rich, Rabbit Run, Shillington PA, Writer
Christina Aguilera Apologizes To Tony Lucca, May Still Lose Job
Editor's note: GOOD, she should lose her job!
Christina Aguilera has apologized to The Voice contestant Tony Lucca for being a little more catty than judge-like. That however may not be enough to save the diva, who is reportedly disliked by many crew members working at the show.
Christina Aguilera and Tony Lucca are both former "Mickey Mouse Club" stars, but long lost history didn't seem to go far between the two, who kept up a steady back and forth battle during season two of The Voice.
After Lucca's Monday night performance of "99 Problems" Aguilera charged that the singer's song pick was "derogatory towards women" adding "if that's what you have to do." Later when her own contestant Michael Kiwanuka performed, she remarked "Now that's how a real man sings."
Read more: http://global.christianpost.com/news/christina-aguilera-apologizes-to-lucca-may-still-lose-job-video-74669/
By Roy • Posted in Entertainment, Music, Reality Television	• Tagged 99 Problems, Christina Aguilera, contestant, feud, judge, Michael Kiwanuka, Mickey Mouse Club, Music, Reality Television, singing competition, The Voice, Tony Lucca


Audience members at the 2011 Oxford Film Festival Awards Show got a surprise preview of Matthew Graves' latest film "Oh, Christmas Triage". The Christmas-themed short comedy was directed and co-written by Graves, a long time member of the production staff at OFF, as well as a contributing filmmaker. The short played just before the awards ceremony to a packed house was received with enthusiastic laughs from the crowd of over 225. It was the perfect start to 2011 ceremony, which once again featured some of the best and brightest films and filmmakers working in independent cinema today. The Oxford Film Festival says "thank you" to Matthew Graves, Andy Harper, and everyone at Media and Documentary Projects for sharing this film with us, and for their hard work behind the scenes to make the festival run smoothly.


Hi, I'm Jessica! I'm a portrait, family and editorial photographer based in the Pacific Northwest. I've been photographing people, places, and stories since 2011.
Aside from photography, I'm also a designer, wife, cat mom, and youth group leader! As busy as life can be, I love moments where we get to slow down, be with family and friends, try new recipes, paint, and explore places close to home and far away. Traveling is definitely where I find a lot of new inspiration and perspectives. It's been a goal of mine to try to visit a new country each year, though there are so many places I'd love to visit again!
Jessica was incredibly fun to work with! She was very easy to take photos with, and she led our session with great fluidity! The photo session never felt awkward or at a loss. Not to mention the great ideas that she posed us in. Definitely would recommend Jessica to anyone not only for great photos, but also compatibility to work with. Thanks Jessica for allowing us to be a small platform for your talent to be shown!
My husband and I loved our whole experience with Jessica! She moved us through our shoot with ease all while having a sweet and laid back demeanor. Receiving our pictures sealed the deal, as we loved every single photo we received. As a photographer myself, I couldn't be more happy with it all!
Jessica did a great job with our engagement photos. She was willing to travel to our rural location and worked so well with our schedule. My fiance and I had such a fun time taking photos with her despite the elements. It was fun session and I LOVED the way our pictures turned out!


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Phát triển doanh nghiệp bền vững
Corporate leadership anchored in responsibility
The unceasing advancement of excellence and efficiency in our corporate leadership and our services allows us to preserve and grow the trust anchored in us.
As a globally operating TIC company, we consider good corporate governance to mean transparent and responsible management. This definition is explained in greater detail in clear policies and regulations that apply throughout the company.
The Board of Management and Supervisory Board of TÜV SÜD AG take their guidance from the provisions of the German Corporate Governance Code (DCGK) for capital-market-oriented companies, thus laying the foundations for a common understanding of responsible, transparent and value-oriented corporate leadership at all levels of the company.
Compliance with all applicable laws and international rules and dealing fairly with our business partners and competitors are among our company's most important principles. Our customers rely on the integrity of TÜV SÜD. To ensure the services they receive offer the maximum safety, security, and objectivity, TÜV SÜD takes a preventive approach to compliance and endeavors to achieve a corporate culture that proactively excludes potential breaches and risks from the outset by raising employee awareness, educating the workforce, and establishing appropriate processes.
TÜV SÜD's compliance management system provides the organizational basis for compliance with valid law. It is based on the principles of the IDW AsS 980 assurance standard and is continually improved. Our compliance organization is headed by our Chief Compliance Officer (CCO), who reports directly to the Chairman of the Board of Management. The CCO acts autonomously without instructions from above. Compliance Officers are appointed for all our companies and regions worldwide. They coordinate compliance training and activities and ensure the compliance management system is up to date at all times. All TÜV SÜD employees undergo mandatory compliance e-learning courses at regular intervals.
In 2008 TÜV SÜD adopted a Code of Ethics under which all TÜV SÜD employees commit to lawful and responsible conduct and to fair and ethical treatment of all.
TÜV SÜD Trust Channel is an electronic whistleblower site for all TÜV SÜD employees, customers, suppliers, and other third parties to report any actual or suspected infringements of applicable law or our ethical standards. The channel enables whistleblowers to set up a protected electronic mailbox for anonymous and secure communication with the TÜV SÜD Corporate Compliance Team.
Consistent respect for human rights is also anchored in the relevant guidelines and policies, foremost among them the TÜV SÜD Code of Ethics, the TÜV SÜD Supplier Code of Conduct, and the respective policies for our Procurement and Human Resources corporate functions.
QUALITY AND RISK MANAGEMENT
Quality management (QM) is a core constituent of TÜV SÜD's Integrated Management System and is the mandatory prerequisite for all of our national, European, and international authorizations and qualifications that are essential for the company's recognition as a testing, inspection, and certification (TIC) organization. It is based on regulations including the ISO/IEC 17000 family of international standards.
TÜV SÜD currently holds some 700 accreditations and further recognitions worldwide, which are regularly verified by supervisory bodies. These audits simultaneously provide evidence of our expertise in areas including product testing and certification, management system certification, laboratory testing, and inspection and monitoring of technical systems, assets, and vehicles. Our integrated management system further includes occupational health and safety, safety and security management, data protection and data security, and physical safeguarding of assets. In 2021, a global online QM training program was held comprising a compulsory module for all employees, an additional compulsory module for all executives, and eight elective modules. Available in 17 languages, the online compulsory employee module has now been completed by over 90 percent of the workforce.
Addressing potential risks with care and prudence is all in a day's work for us. Not only where our customers are concerned, but also within our own company. Our risk management system is designed to identify risks, assess existing risks, and mitigate risks taken. Against this backdrop, we held a pre-assessment of TÜV SÜD's risk management system prior to an effectiveness review in accordance with the IDW PS 981 audit standard. The review was passed without qualification.
We also revised the relevant opportunity and risk management policy; changes included adjustment of reporting thresholds and further expansion of requirements concerning the structuring of risk management organizations at local TÜV SÜD organizational units. The revised guideline came into effect in the first quarter of 2021.
SUSTAINABILITY IN THE SUPPLY CHAIN
As a globally operating company, TÜV SÜD accordingly has an international supply chain. Our procurement team sources goods and services from over 10,000 suppliers in more than 70 countries. To achieve this, we use regional or local suppliers for around 90 percent of our procurement needs. The short transport routes contribute to climate protection, while our use of local suppliers supports local employment markets and local infrastructures. Our procurement decisions take social and environmental criteria into consideration as well as ensuring ethically and legally flawless conduct and avoiding risks. To achieve this, we are increasingly turning to suppliers that have a similar philosophy of entrepreneurial responsibility to our own.
To communicate our sustainability goals more clearly across our entire supply chain, we issue a binding Supplier Code of Conduct, (SCoC) under which our suppliers undertake to comply with our TÜV SÜD sustainability requirements. The SCoC is available in German and now a further 13 languages. In the future, our suppliers will further undergo evaluation with respect to compliance with sustainability criteria prior to receiving orders. Our target is for all our suppliers to have signed the SCoC by 2026. Around 34 percent had already signed by the end of 2021, equivalent to around 70 percent of our purchasing volume.
TÜV SÜD AG is a legal entity with its registered office and central administration in Germany. As such, its entire global revenues are subject to unlimited tax liability. The subsidiaries of TÜV SÜD AG are subject to unlimited tax liability in the countries where their registered offices are located. In addition, cross-border business transactions may incur limited tax liabilities for TÜV SÜD AG or its affiliates. TÜV SÜD undertakes to comply with applicable national and international laws in all business decisions and actions in order to fulfill its fiscal obligations in a complete, correct, and timely fashion.
TÜV SÜD AG reports on its tax positions in detail in its Consolidated Financial Statement, in which the provisions of the International Financial Reporting Standards (IFRS) are implemented and assessed by the group auditor. For more information, see the TÜV SÜD Annual Report.


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#1119 The inequities of the selfish and the tyranny of evil men
Air Date: 7-11-2017
Today we look at many of our misconceptions of the nature of poverty, the interconnectedness of economics with all aspects of life and some suggestions on how to pursue justice
Ch. 1: Opening Theme: A Fond Farewell - From a Basement On the Hill
Ch. 2: Act 1: Dividing the generations to distract from the class war - CounterSpin @FAIRmediawatch - Air Date 1-8-16
Ch. 3: Song 1: Class-Warfare - Chris Priest
Ch. 4: Act 2: The frames through which we look at low-income aid programs - @offkiltershow - Air Date 6-9-17
Ch. 5: Song 2: Call It Even - Scott Simons
Ch. 6: Act 3: Does prolonged exposure to poverty have a lasting effect on the brain? - The Inquiry - Air Date 5-25-17
Ch. 7: Song 3: Sur Le Fil - Yann Tiersen
Ch. 8: Act 4: Everything is economic - The Other Washington from @civicskunkworks - Air Date 5-25-17
Ch. 9: Song 4: Poverty (Single (Stereo)) - Bobby "Blue" Bland
Ch. 10: Act 5: Rutger Bregman: Poverty isn't a lack of character; it's a lack of cash - @TEDTalks - Air Date 6-13-17
Ch. 11: Song 5: Protect & Serve - Stiff Little Fingers
Ch. 12: Act 6: Bryan Stevenson: the opposite of poverty is not wealth, the opposite of poverty is justice - The Ezra Klein Show - Air Date 5-16-17
Ch. 13: Final comments asking the question of the age: What the f**k is wrong with economists?
Closing Music: Here We Are - Everyone's in Everyone
Recommended Reading/Sharing:
Why do we think poor people are poor because of their own bad choices? (Outclassed, The Guardian)
45 million Americans rely on food stamps. Trump wants to gut the program. (Vox)
The Problem Isn't Food Stamps, It's Poverty (Editorial Board, New York Times)
What Works to Reduce Poverty (Center of Budget and Policy Priorities)
Trump's Budget Cuts Deeply Into Medicaid and Anti-Poverty Efforts (New York Times)
Welfare programs shown to reduce poverty in America (The Guardian, 2014)
Curated by BOTL Communications Director, Amanda Hoffman
Produced by Jay! Tomlinson
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Inequality Poverty Economics Benefits Medicare Medicaid Basic Income Labor
Do you like this episode?
Danarene Kalina commented 2017-07-17 16:54:51 -0400
I think your anger at the end of this episode is perfectly justified. I found the NPR/Medicare Researcher story especially odious. You definitely hit many of the points that, as was listening, I thought, "…but what about…" in particular, the flawed reasoning the economist used. A lottery method didn't allow the researchers to determine the age, race, education, resident neighborhood, and many other demographic factors that might provide them a clear picture of the experimental vs. control group. And as you pointed out, the fact that people finally have insurance makes sense that they would use it. Those without insurance may be avoiding the emergency rooms because of the cost, that doesn't mean the insured were now "abusing" access to emergency rooms. And, it seems that it was a pretty short-term study, I think the long-term effects would paint a clearer picture as to whether or not giving access to healthcare to people is a worthwhile endeavor. Sloppy science is what I heard in that NPR interview. One of the Koch brothers is on the board at NPR, no surprise their stories are going to have a more Libertarian spin.
Scott Smith commented 2017-07-15 09:07:10 -0400
Not sure where else to post this, but it's regarding your announcement and something from the rerun episode.
1) I'm glad you're taking time for yourself. Personally, I had no idea the amount of time you have to commit in order to put together a show. I appreciate your efforts and enjoy the shows.
2) One of the clips from David Pakman was about Costco and Trader Joe's. The argument he was making was about Costco's membership and how people are using that as a way to explain their financial success. One thing that I don't think was taken into consideration is that you actually get money back (well, a check to use at Costco) that is a percentage of the money you spend there. So, my membership costs $120/year. But. last year I got an $80 check to use to purchase things that I would be purchasing there anyway. And, while I know that doesn't actually cost them $80, it does subtract from their profits. Also, people that use their memberships more than I do would get more back, up to $2k. Again, I understand the benefits to Costco, but it does need to be factored in to their bottom line. Just a small argument against the WalMart idea that they can't pay their workers a livable wage.
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MGMT planning Chemical Brothers collaboration
Plus band reveal double album plans
By NME
MGMT have revealed that they are planning to collaborate with The Chemical Brothers.
The duo also explained that they hope to follow up their debut album 'Oracular Spectacular' with a double album.
The band told NME.COM that they had been exchanging emails with the UK dance producers and hoped to get to work on new material with them soon.
"We'll experiment with them to create a different sound," Ben Goldwasser explained. "They've collaborated with people like Noel Gallagher before and they have this psychedelic side to them, so we'll find common ground."
Speaking of their double album plans, the pair said that they were thinking about showcasing different sides of their music on the double discs, with one for pop music and another for their more psychedelic songs.
"We thought we'd go for the clichéd, overly-ambitious sophomore album," Andrew Van Wyngarden declared.
The pair did, however, warn fans not to expect the double album too soon – and said they may well change their minds about it in due course.
"It's several months off," said Goldwasser. "There is always the risk that by the time we get there we'll be on to something different."
See the current issue of NME, out now, for the full interview with MGMT.


Archives|THE MEDIA BUSINESS: ADVERTISING; Among the nation's schoolchildren, there is a booming and puzzling market for key chains.
THE MEDIA BUSINESS: ADVERTISING; Among the nation's schoolchildren, there is a booming and puzzling market for key chains.
PARENTS shopping this month for pencils, notebooks, crayons and backpacks can add a new item to the school supplies list -- key chains, and lots of them. Dangling from the backpacks of the country's schoolchildren, they signify a booming market that barely existed two school years ago.
Puzzled by the sudden demand for key chains, toy and entertainment industry executives and analysts are questioning their own children, who decorate their backpacks with dozens of dangling doodads. Their explanation is simple.
''I just like how they look on my backpack and the sound they make when they click together,'' said Isabel Zuckoff, 9, who owns around 30 key chains and no keys.
Whether the motivation is how the chains look or how they sound, or both, the trend has translated into a hot business for a handful of companies with names like Basic Fun Inc. and the Fun 4 All Corporation. All told, toy industry analysts say, key chains priced at $3 to $10 generate around $50 million a year in retail sales to children.
The popularity of key chains has caught the big toy companies by surprise. After all, it is not easy to guess that children, few of whom carry much more than a single house key, would become some of the nation's most frequent repeat buyers of key chains.
Why children are buying so many key chains is a complicated story involving cheap jewelry, the Internet and Isabel's backpack.
It begins in 1989, with Alan Dorfman, now the president of Basic Fun, working at Larami Ltd. in Philadelphia, selling Super Soaker water guns and dreaming of starting his own business. After he left Larami to start Basic Fun, Mr. Dorfman started noticing young women wearing miniature water guns as necklaces, and he asked his former bosses for a license to market shrunken Super Soaker key chains.
Basic Fun began shipping Super Soaker key chains in January 1993, following them the next year with Etch-a-Sketch key chains, made under a license from the Ohio Art Company. Sales have jumped 30 percent to 60 percent a year since 1993, Mr. Dorfman said.
The company's products now range from those made under license, including cartoon characters like Nickelodeon's Rugrats and toys like Hasbro's Mr. Potato Head, to public domain games like Tic Tac Toe. Most of the new key chains have one thing in common: as the grade-school set might say, they do stuff.
Adults are generally satisfied with key chains that look nice or serve as mementos or souvenirs. But for children raised in the age of computers, the most popular key chains are, of course, interactive. That includes all of the miniature games and most of the licensed characters. Curious George was fun as a quizzical little monkey, but as a key chain, he is more fun because the hat he wears comes off.
The popularity of toy and game key chains initially sent established purveyors of old-fashioned key chains scrambling to catch up. Mickey Mouse and Winnie the Pooh key chains have been a staple at the gift company Applause Inc. for years, but sales went soft for a while after Basic Fun started luring children to interactive key chains, a spokeswoman for Applause said.
Then gift companies like Applause added moving parts to some of their offerings in an effort to reclaim part of their lost sales, and the interactive key chains settled in as a separate category from the souvenir and trinket key chains.
The story might have ended there, except for Isabel's backpack. Because it seems that when children became interested in key chain toys and games, they turned the products into a new kind of collectible -- the nirvana of marketing.
Key chain-sized Monopoly is not easy to play. But that's no longer the point, according to Stevanne Auerbach, a San Francisco-based analyst who writes a syndicated column under the name Dr. Toy.
And unlike some bygone crazes, like pogs, stickers and lunch boxes, key chains can be marketed outside an identifiable niche. Boys and girls both buy key chains to attach to their backpacks, and adults will sometimes buy them to, well, attach to their keys.
Mr. Bachrach pitches Basic Fun's key chains to toy stores, clothing outlets and drugstores, among others. For the big toy makers, sales of key chains licensed from established products can mean increased exposure without the need to develop miniatures on their own or take the initial risk.
But some analysts say the toy giants may have passed up a profitable venture. The thing is that for all their advertising muscle, big toy makers and entertainment companies cannot create a collectible. Only the 9-year-olds can.
In the board rooms of the big companies, executives consider new products. Industry staples like key chains are considered a stagnant but reliable market best left to licensees. But with key chains reaching collectible status, major toy makers have started to take notice, approaching the niche companies with licensing offers.
But while the key chain makers have stumbled upon a collectible, it is not necessarily the stable kind, which can be expected to increase in value. Not even Mr. Bachrach would say that is likely to be true of key chains. And so opinion is divided on how long the market can be expected to remain viable.
Declining to guess at the whims of adolescents, Mr. McGowan, the analyst, predicted that key chains -- if not miniaturized toys -- would remain popular for some time. But Ms. Auerbach and some retailers pointed to the start of the new school year as the big test for any product aimed at young consumers.


Very nice coloring! My C140 are all greyish-green.
Is it possible that the file names of the inserted photos are not displayed as text for reading? I think it's not necessarily useful if under the photo for example img0001.jpg stands as a signature. I did not find a function to hide this text.
Thanks for your efforts. I'm ready to pay more for shipping, but expect delivery on the same day or one day later than in the UK.
Hopefully the 1st edition 2018 will not be so badly delivered.
If it is just annoyed with the other issues, at the issue with the seed list is such a distribution unacceptable.


WIFI is available to all guests throughout the hotel including Rooms, Terrace, Lobby and Café. There is a computer in the lobby that guests can use to access their email and use the internet. We are also happy to help you print out any documents you may need including boarding passes and e-tickets, just contact our concierge for help.
Guests are welcome to visit our rooftop terrace featuring stunning views of the Bosporus River, Mamara Sea, Hagia Sophia, the Blue Mosque and Sultanahmet any time day or night.
A fresh breakfast buffet is laid out every morning on our rooftop terrace from 7-11 am and is served free of charge for all guests. Enjoy a selection of cereals, eggs, dried and fresh fruit, vegetables, nuts, toast, butter, jams, honey and a variety of local cheeses. Breakfast also includes turkish tea, a variety of herbal teas, coffee and much more.
We are happy to set arrange tours for groups and individuals who are interested in seeing Istanbul's very famous landmarks. Our concierge can help you to organize the perfect tour tailor made to suit your interests, schedule and budget.
Hagia Sophia (or Aya Sophia) was originally built as a Church in 360 by the greeks who had settled the area 9 centuries before. In 404 there was a shift in power and in the resulting riots the Church was burned to the ground. In 415 a second Church was opened, but was burned in a great fire in 532. Hagia Sophia was rebuilt and though the dome and some of the other potions of the building have had to be rebuilt a few times, this is the current structure which after several riots, earthquakes, fires and invasions, has arisen like a Phoenix reborn with the design each time becoming more spectacular and intricate. With its rich Christian and Muslim heritage, Hagia Sophia was converted into a museum in 1935. It has been one of the most renovated holy structures in the world with the result that snapshots of history can be found all through the site.
The Basilica was originally constructed in the 3-4th centuries as a legal and artistic center. It was reconstructed after a fire in 476 and again after riots in 532. It is said that 7000 slaves were conscripted to convert the Basilica into a cistern. It has a 100,000 ton capacity and was used to supply water right through the Ottoman Empire.


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Сигма-скінченна міра в функціональному аналізі — міра, така що довільна вимірна множина може бути представлена у вигляді зліченного об'єднання вимірних множин скінченної міри.

Визначення

Неай  - простір з мірою, де  — деяка множина,  — задане на ній кільце підмножин,  — міра визначена на кільці.
Міра  називається σ-скінченною, якщо для довільної множини  існує зліченна сім'я вимірних множин , така що  і
. Якщо міра визначена на деякій алгебрі  підмножин множини , то необхідною і достатньою умовою σ-скінченності є виконання поданих вище умов для єдиної множини

Приклади

 Будь-яка скінченна, зокрема ймовірнісна міра скінченна.

 Міра Лебега  на  σ-скінченна, оскільки
.

 Зліченна міра  на , тобто така, що  не є σ-скінченною, оскільки зліченне об'єднання будь-яких множин скінченної міри в цьому випадку буде зліченним, тоді як весь простір незліченний.

Властивості

σ-скінченні міри мають багато властивостей не характерних для інших видів мір, тому вони часто виступають припущеннями при формулюванні теорем теорії мри та інтегралу, зокрема теореми Радона-Нікодима, теореми Фубіні та ін. σ-скінченність також є достатньою умовою єдиності продовження міри заданої на кільці до міри на породженому цим кільцем σ-кільці (теорема Каратеодорі).

Література

 Колмогоров А.Н., Фомин С.В. Элементы теории функций и функционального анализа. — изд. четвёртое, переработанное. — М.: Наука, 1976. — 544 с.
 Халмош П.Р. Теория меры. М.: Изд-во иностр. лит., 1953

Теорія міри

redpajama_set_name: RedPajamaWikipedia


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Breeding for a Machine Harvestable Berry
By Josie Russo, University of Wisconsin-Madison
Blueberry harvesting is complicated—a balancing act between a tight, expensive labor market and soft, finnicky fruits.
Increased labor costs over the past few years have more growers looking to turn from hand-harvesting to machine harvesters. But traditional machine harvesters cater to the processing market where fruit durability and bruising are not a concern.
Many blueberries can get damaged during the traditional machine harvesting process—up to 60 percent, in fact. While this damage doesn't impact the domestic fresh-markets with short shelf lives as much, it is not conducive for important export markets and storage over a longer period of time. Damaged berries are lower in quality and will have a shorter shelf life, which can result in another financial hit for growers.
So, how can we make blueberry harvesting less complicated and more cost effective? There is no one, simple solution. It is a perfect storm of tweaking and refining different factors, from adapting the harvesting equipment all the way down to improving the fruit's genetics.
Researchers are trying to find out if there is a way to combine the cost efficiency of new machine harvesting technologies with the quality of hand-picked blueberries. Dr. Lisa Wasko DeVetter, a VacCAP Co-PI and Associate Professor at Washington State University, is working on another project that aims at implementing "soft-catch" technology onto machine harvesters, using softer materials on high impact sites to reduce damage to the berries. But the machines are only as good as the fruit they have to work with. Different cultivars have different reactions, but overall, new cultivars that do not bruise as easily are desirable. That's where the genetics comes in.
Dr. Patricio Munoz, a VacCAP Co-PD and Assistant Professor at the University of Florida, is tackling the challenge by developing improved blueberry cultivars with a focus on firmness.
"Plants need several characteristics to be considered a good machine harvestable. By far, fruit firmness is the most important. If you don't have firm fruit, nothing else matters. You'll just get jam if it's not firm." Munoz said.
And it sounds like they're making good progress in that aspect.
"We did a review of fruit firmness from all the blueberry cultivars that have been released since the beginning of the domestication of the species and had data in the literature," Munoz said. "It showed a linear trend in firmness improvement for all low-chill varieties. Almost all varieties—over 30— can be machine harvested, as conformed by growers and machine harvest service providers, with the exception of two cultivars, and those two cultivars are known to have soft fruit."
While advances in fruit firmness among new cultivars is progressing, Munoz says the next issue is going to be how to reduce fruit loss to the ground during harvesting operations. Other relevant traits needing to be addressed include how easily the fruit releases from the plant and bush architecture.
"Almost all blueberries do not produce a single trunk; they have lots of canes. It would be easier to machine harvest with a single trunk," Munoz said. "With multiple, spread-out canes, this creates spaces for fruit to fall to the ground when using most current machine harvesters."
There is a lot more variability in the architecture of blueberry plants to work with to help address this, though. Munoz noted the extreme differences in the more tree-like Meadowlark cultivar compared to very bushy cultivars that many associate with blueberries.
Growers can modify plant architecture to better suit machine harvesting by pruning, using cartons or zip ties to narrow the crown after planting, and/or using a trellis system. However, this requires additional labor and costs. Having an optimal plant architecture through genetics would be more cost-effective for growers who are already dealing with thin margins.
At the end of the day, the key goal is to improve cultivars as a way to keep blueberry harvesting successful and cost-efficient for growers.
"In 2017, we released a cultivar specifically for machine harvest for fresh market (cv. Optimus). This trait has become a standard practice to check for in new cultivars, such as in 'Colossus'. We hope to keep developing cultivars that can be machine harvested," Munoz said. "That's the objective of the program and the main goal is make producers be more profitable and stay in the game."


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Home Community Development ISIS claims responsibility for killing of 11 soldiers in Borno
Security & Development
ISIS claims responsibility for killing of 11 soldiers in Borno
Chief of Army Staff, Lt.-Gen Tukur Buratai
The world's deadliest terror group, the Islamic State of Iraq and Syria, has claimed responsibility for the attack on soldiers in Borno State last week which took the lives of 11 soldiers, Reutersreports.
ISIS said its men were responsible for the Friday attack of Gajiganna town through its news agency AMAQ.
The terrorist network on Saturday published pictures of burnt barracks and dead bodies it claimed belonged to the soldiers.
Three sources, including one hospital source, confirmed the attack to the Reuters news agency. The sources said the fighters stormed the town on a motorbike at roughly 6.30pm and opened fire on residents and the military in sporadic shootings.
The fighters fled after the military called in air force support and reinforcements from a battalion in a neighboring town.
Islamic State West Africa Province, an affiliate of ISIS, has carried out a string of attacks in Nigeria in recent months.
The group split in 2016 from Boko Haram, which has waged a decade-long insurgency in North-East Nigeria that has killed some 30,000 people and displaced over two million people.
The Federal Government had declared in December 2015 that it had technically defeated Boko Haram.
While attacks in most parts of the country have ceased, bombings have continued to take place in the North-East particularly Borno State.
A top military officer blamed the recent surge in attacks to the lack of cooperation as well as high wired politics taking place among the top military brass.
The source said, "The attack is true. We lost a lot of men but unfortunately, many things are being hidden from the press. Normally, in military operations, when there is a joint mission, the Chief of Defence Staff is supposed to be in charge.
"Unfortunately, that is not the case. The Chief of Army Staff is the one calling all the shots at the moment. And there is a lack of synergy among the services."
When contacted on the telephone, the Director of Defence Information, Col. Onyeama Nwachukwu, declined comment, said the military had recorded several successes.
He said troops of 121 and 192 Battalions of Operation Lafiya in collaboration with Civilian JTF and local vigilantes, have cleared Surdewalla, Ranwa, Baladayo, Sabon Gari and Shetimeri villages in Borno State, in a simultaneous operation code-named, 'Operation Hardstrike.'
The troops reportedly killed three terrorists at Ranwa 11, while many were wounded and others escaped.
He said troops of 192 Battalion advanced along with Sabon Gari and Shetimeri villages where they cleared a scout of Boko Haram terrorists. A makeshift shelter for suspected insurgents was also destroyed.
Nwachukwu added that two soldiers were injured during an encounter with insurgents at Gajigana town by troops of 212 Tank Battalion.
He said, "Additionally, 177 Task Force Battalion in collaboration with the Civilian JTF cleared Mboa, Mboa-Kura, Yarchida, Bombula, Tshata andBamzir villages. At Furfur village, troops exchanged fire with BHTs which led to the death of one terrorist and recovery of one AK47 rifle, three magazines, 50 rounds of 7.62mm special ammunition and one magazine bandolier."
Chief of Army Staff
Lt.-Gen Tukur Buratai
The Nigerian Army
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