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COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study
Peter R. Swiatek1,
Joseph A. Weiner1,
Daniel J. Johnson1,
Philip K. Louie12,
Michael H. McCarthy2,
Garrett K. Harada3,4,
Niccole Germscheid5,
Jason P. Y. Cheung6,
Marko H. Neva7,
Mohammad El-Sharkawi8,
Marcelo Valacco9,
Daniel M. Sciubba10,
Norman B. Chutkan11,
Howard S. An3,4 &
Dino Samartzis ORCID: orcid.org/0000-0002-7473-13113,4
European Spine Journal volume 30, pages 2133–2142 (2021)Cite this article
The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery.
A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020.
902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication.
COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.
Within weeks, the COVID-19 pandemic became one of the greatest global health crises of our time [1]. Excessive strain on the health care system prompted hospitals and practices around the world to pivot in an effort to stop the spread of the COVID-19 and to treat the acutely ill [2]. With the unprecedented redirection of staff and resources toward management of COVID-19 and seemingly universal order to shelter in place [3], subspecialty services such as orthopedic and neurological spine surgery have had to adapt their service offerings to ensure that their patients continued to receive the necessary care. One of the most significant changes has been the rapid adoption and acceleration of "virtual medicine" practices, defined as reliance on telehealth services [4] to facilitate surgeon-to-patient interfacing and use of online educational platforms [5] to support continued physician learning during these times of social distancing [6].
Telehealth involves the use of advanced audiovisual aids to provide care for patients or facilitate physician-to-physician collaboration [7]. Previously considered more of an adjunct service with low reimbursement rates prior to Spring 2020, telehealth capabilities were firmly established in only about half of the US hospitals [7]. Now, with the rise of COVID-19 and increased pressures to treat patients virtually, government agencies are expanding reimbursements to cover telehealth visits, and health care systems are rapidly developing more sophisticated telehealth capabilities [8]. In addition to implementing telehealth services, spine surgeons have swiftly adopted online education as a primary means of continued surgeon-to-surgeon engagement during a time widespread elective case stoppage, in-person gathering restrictions, and travel constraints [9]. Early online education offerings during the pandemic focused primarily on dissemination of information about COVID-19 and its impact on the orthopedic and neurological surgery communities. Online education opportunities rapidly expanded to include local topic-based spine webinars—including journal clubs, case discussions, and indication conferences—to larger spine conferences hosted by professional societies such as AO Spine, the North American Spine Society, and the Scoliosis Research Society, among others [5, 10,11,12].
Despite anecdotal reports that surgeons and health systems are increasingly reliant on technology for surgeon-to-patient engagement and for continuing surgical education—so-called virtual medicine practices—the degree to which virtual medicine has been integrated into the practice of spine surgeons is unknown. The aims of this worldwide survey-based study are (1) to assess the degree to which spine surgeons worldwide have integrated telehealth services into their practice, (2) to determine the interest in online learning and physician engagement platforms for continuing spine surgeon education, and (3) to discuss how this rapid expansion of these virtual medicine practices may impact spine surgery care in a post-pandemic world.
Survey design and distribution
The AO Spine COVID-19 and Spine Surgeon Global Impact Survey were developed to assess the spine surgeons' perspective of the impact of COVID-19 on spine surgery practice, education, and outlook [13]. Questions were prepared via the Delphi method, in which multiple board-certified attending spine surgeons reviewed the appropriateness of each question prior to achieving consensus [14]. Scope of the survey included surgeon demographics/characteristics, impact on practice, and utilization of online platforms for patient care, physician-to-physician communication, and education.
The survey was distributed in English via email to the AO Spine membership who had previously elected to receive surveys for academic purposes. AO Spine members were selected as the target audience, as this group represents the largest international society of spine surgeons in the world. On March 27, 2020, the survey was emailed to 3805 members of AO Spine, representing approximately more than 60% of the total AO Spine membership. Respondents were given a total of nine days to complete the survey prior to the pre-determined end date of April 4, 2020. Each participant was informed that their participation in the survey was completely voluntary; that they could end their participation at any time; and that their response would likely anonymously be aggregated and analyzed for dissemination in peer-reviewed journals, educational and instructional media, or social media.
Analyses were performed using Stata version 13.1 (StataCorp LC, College Station, TX). Means and percentages were made for rank order and count data, respectively. The analysis focused on surgeons as individuals; surgeons as "high telehealth" users, defined as more than 50% of clinic visits conducted using telehealth platforms; surgeons as having increased interest in online education; and "virtual medicine" surgeons, defined as reporting both high telehealth utilization and increased interested in online education platforms. Fisher's exact tests and Chi-squared tests were utilized to determine difference in count data where applicable. Three separate multivariate regressions were conducted to determine predictive factors of being a high telehealth user, expressing increased interest in online education, and being a virtual medicine surgeon. Independent variables used in the multivariate analyses were selected based upon significance determined in the aforementioned between group analyses. Results of the multivariate analyses were reported using odds ratios (OR) with OR = 1 indicating no difference between independent and dependent variables. 95% confidence intervals (CI) were also calculated to assess precision of the risk estimate. A p value of < 0.05 was used to determine statistical significance.
902 spine surgeons from 91 countries and 7 regions responded to this survey. European spine surgeons comprised the largest group by region (242/881, 27.5%). Surgeons from Asia (213/881, 24.2%) and North America (152/881, 17.3%) were the second and third most represented groups by regions, respectively (Table 1).
Table 1 Survey respondent demographics stratified by telehealth usage, interest in online education, and status as a virtual medicine surgeon
Approximately half of all surveyed surgeons (402/800, 50.3%) were using telehealth for at least 25% of clinic visits and 35.6% (285/801) were "high telehealth surgeons," conducting more than half of visits virtually. The majority of high telehealth surgeons are between 35 and 54 years of age (195/284, 68.7%) and practice in Europe (91/281, 32.4%) or North America (94/281, 33.5%). Surgeons interested in online education are primarily between 35 and 54 years of age (400/600, 66.7%) and practice in Europe (160/593, 27.0%) or Asia (132/595, 22.3%). Virtual medicine surgeons, defined as those with > 50% telehealth usage and interest in online spine education, are between 35 and 54 years of age (143/210, 68.1%), practice in large cities with more than one million people (107/211, 50.7%), and live in Europe (68/ 207, 32.9%) and North America (66/207, 31.9%).
Table 2 highlights the practice demographics of spine surgeons who have integrated telehealth modalities into their practice. Most respondents were spine surgeons with orthopedic surgery backgrounds (637/902, 70.6%) who work primarily in academic or private/academic combined institutions. Nearly two-thirds of surgeons reported that their practice is more than 75% clinical (590/893, 66.1%) and the majority dedicated less than a quarter of their work to research (731/893, 81.9%). Academic surgeons, who comprised the largest portion of the respondents (405/802, 45.4%), relied heavily on telehealth, with 54.1% of their group conducting > 25% of visits virtually (p < 0.0001). There was no significant difference in usage of clinical telehealth based upon surgeon specialty, completion of fellowship, years in training, or type of practice (i.e., research, clinic, or teaching). Virtual medicine surgeons (Fig. 1) were primarily orthopedic surgeons (140/210, 66.4%), those with less than 10 years of practice experience (74/146, 50.7%), and those in academic practice (112/211 53.1%).
Table 2 Survey respondent practice demographics stratified by telehealth usage, interest in online education, and status as a virtual medicine surgeon
Profile of a virtual medicine spine surgeon
Predictors of high telehealth usage, interest in online education, and status as a virtual medicine surgeon are displayed in Tables 2, 3, 4 and 5. Working in a purely academic practice (OR 1.68; 95% CI 1.22 to 2.31; p = 0.0015) or practicing in Europe/North America (OR 3.42; 95% CI 2.42 to 4.84; p < 0.0001) was associated with increased odds of being a high telehealth user (Table 3). With respect to online education and engagement platforms, having a practice that dedicated more than 25% to teaching (OR 1.89; 95% CI 1.04 to 3.43, p = 0.037) was the only factor significantly associated with increased odds of expressing interest in spine education (Table 4). Similar to predictors of high telehealth usage, living in Europe or North America (OR 2.28; 95% CI 1.49 to 3.51; p = 0.0002) and practicing in a purely academic practice (OR 1.72; 95% CI 1.15 to 2.58; p = 0.0082) were the only factors associated with increased likelihood of being a virtual medicine spine surgeon (Table 5).
Table 3 Multivariate analysis of > 50% telehealth usage
Table 4 Multivariate analysis of interest in online spine education
Table 5 Multivariate analysis of region, city, population, and practice type on status as a virtual medicine surgeon
Most spine surgeons (686/732, 93.8%) expressed interested in a spine-specific platform through which surgeons could connect, collaborate, and seek support (Fig. 2). European and Asian spine surgeons represented the largest group at 25.5% (187/732) and 22.4% (164/732) of all surgeons, respectively. More than 93% of all surgeons outside of North America would be interested in a blog; however, 16.6% of North American surgeons reported that they would likely not participate in or read a blog. Academic surgeons (308/732, 42.1%) comprised the largest group of surgeons interested in a centralized platform to communicate. When compared to surgeons within the same practice type, more than 92.5% of surgeons reported interest in a blog.
Spine surgeon interest in a centralized online engagement platform. a Geographic heat map of spine surgeons who expressed interest in an online blog or centralized online surgeon-to-surgeon engagement platform. b Breakdown of spine surgeons' levels of interest in an online blog or centralized online surgeon-to-surgeon engagement platform
To our knowledge, this is the largest study of its kind aimed at assessing the impact of COVID-19 on worldwide practice of virtual medicine, including telehealth use for patient care and online platforms for physician education. With more than 900 total respondents, we noted geographic, demographic, and practice-type variations in the general use of telehealth applications for spine surgery clinic visits. We found a high-rate of telehealth utilization among spine surgeons, with more than half of surgeons worldwide leveraging telehealth to conduct a significant number (> 25%) of virtual physician–patient interactions. Moreover, we found that spine surgeons worldwide is interested in continuing online education and connecting with other surgeons during global crises like the COVID-19 pandemic. More than 80% of surgeons reported interest in online education and more than 93% would utilize a centralized communication platform to communicate with other surgeons. Lastly, we identified 211 virtual medicine spine surgeons, who we can expect to lead the charge in the rise of telehealth and online education in the post-pandemic era.
Our findings support the newly published literature and press releases that have described the rapid acceleration of telehealth practices in orthopedic and neurosurgical practices in the wake of the COVID-19 pandemic. In a recent survey of 168 orthopedic surgery departments across the USA, Parisien et al. [15] found that 63% of institutions are providing telehealth services with 23% currently in the process of establishing new telehealth capabilities. Of those institutions with established telehealth services, more than 80% implemented these systems recently in response to the COVID-19 pandemic [15]. Similar to our results, these authors found that increased utilization of telehealth services was associated with academic institutions [15]. Several groups have already begun to evaluate the utility and safety of virtual clinic visits [16]. Two groups of orthopedic shoulder and elbow surgeons groups have published on their findings that most patients undergoing rotator cuff repair [17, 18] or shoulder arthroplasty [18] could have a safe and effective visit virtually, without direct surgeon-to-physician contact. In the realm of spine surgery, conducting a proper neurological exam has been a primary impediment to rapid adoption by spine surgeons. Several studies offer guidance on performance of a virtual physical examination, including specific exam maneuvers that can help spine surgeons assess physical function, motor strength, and sensation [19,20,21,22,23]. Although the maneuvers discussed in these studies can provide a fair impression of a patient's musculoskeletal and neurological status, the need for a complete, validated, and pressure-tested virtual physical examination is apparent [24].
The US government has played a substantial role in facilitating the rapid roll-out of telehealth programs across the country. In mid-March of 2020, the Department of Health and Human Services (HHS), the Centers for Medicare & and Medicaid Services (CMS), and the HHS Office of Civil Rights (OCR) announced measures that would encourage physicians and surgeons to conduct telehealth visits, including temporarily expanding reimbursements for telehealth visits and relaxing restrictions on acceptable technology platforms [25]. This included the CMS 1135 Waiver [26], which broadened access to Medicare telehealth services and removed state licensing restrictions through the duration of the COVID-19 crisis. Several other governmental organizations have developed guidelines and programs to assist providers with implementation and funding of telehealth services [27], including the National Consortium of Telehealth Resource Centers (NCTRC) [27].
To further the cause, the Federal Communications Commission (FFC) approved $200 million in early April to equip hospitals and health care providers with telehealth technology and implementation support [28]. Although all sources point toward continued governmental support for telehealth services during the pandemic, no one can predict exactly how support may change as practices return to business as usual. Potential interventions include medical boards scaling back on interstate licensure flexibility [29] and CMS narrowing the scope of reimbursable activities [5]. Cost will continue to play a major role in the future development of telehealth capabilities. Traditional capital expenditure models, including hardware, software, security platforms, and systems implementation, can start around $42,000 and scale up depending size of practice and specific clinical needs [30]. Importantly, these initial start-up figures often do not include the full costs of maintenance and continuing improvement such as software upgrades, equipment upgrades, and information technology support. To curb the weight of initial start-up costs, some companies have begun offering flat fee services starting anywhere from $49 for a simple single-provider HIPAA compliant web application[31] to more than $800 per month flat fee, which covers workstation, exam camera, and access to the integrated telehealth software without additional per provider costs [30]. As demand for long-term telehealth platforms continue to expand in the post-pandemic era, we expect to see competitive service offerings aimed at lowering financial barriers, allowing a more ubiquitous adoption of health technology.
Although the seemingly ubiquitous demand for telehealth services has spiked across the globe, the feasibility and capability of implanting such services across regions are much more variable. A recent publication by the COVID-19 Pandemic Health System Resilience Program (REPROGRAM) international consortium reviewed this variability in national telehealth programs across various countries/regions with the intent of identifying differences in current telehealth frameworks, gaps in implementation, and future directions for improvement [32]. Prior to the pandemic, countries in Western Europe, such as the UK [33] and France [34], had established systems for moving in-person medical consultations to virtual consultations. The pandemic challenged these health systems by testing the scale of their telehealth infrastructure, by necessitating governmental funding for growth of current telehealth offerings, and by highlighting the need for better communication among national health systems [32].
Countries with less-developed health systems face a different set of challenges with respect to telehealth. For example, many African nations, particularly those in Sub-Saharan Africa, face challenges such as connectivity issues, device ownership, physician shortages, ongoing political conflicts, and lack of governmental support for technological innovation [32]. Overcoming these barriers will likely require intervention at the patient, physician, system, and government level in addition to international support.
At the patient-level, even well-established health care systems will face challenges related to patient computer literacy, patient access to high-quality telehealth compatible devices, and patient access to reliable internet coverage [35]. For example, in the USA, it is estimated that 31.8 million Americans do not have sufficient comfort or competence with technology to use a computer [36]. Moreover, barriers to access disproportionately affect older and underrepresented populations. For example, more than half of US households headed by individuals older than 65 years of age do not have a smartphone and one-third do not have a desktop or laptop [37]. Widespread adoption of telehealth services may be limited to certain populations unless barriers such as digital literacy and access to telehealth-capable technology are addressed.
With respect to online education and the impact on physician-to-physician communication and education, we found that the majority of spine surgeons (> 80%) are interested in participating in online spine education and/or and AO spine-specific blogging. This desire for more virtual learning opportunities echoes the general attitude that regular surgeon engagement, even virtual, facilitates continuous surgeon education and ultimately increases surgeon competency. In their review of the virtual learning environment, Palan et al. [38] discusses how the virtual learning environment can actually enhance surgeon learning. Specifically, learners can easily reference digitally recorded sessions for clarification on difficult to understand topics [38]. Kogan et al. [39] make specific recommendations regarding the use of various team-based platforms, such as Microsoft Teams and Zoom, in an effort to increase team-based learning efforts. In accordance with the results of our survey, participation in these virtual conferences is generally higher than normal in-person conferences [39].
Moving forward, online learning will likely become paramount in the continuing education of spine surgeons around the world. In the short-term, medical groups and societies will likely transform more face-to-face events into virtual lectures and online conferences. In the post-pandemic era, large national and regional spine meetings, once a staple of educational camaraderie, may be transformed into virtual online webinars. Industry-sponsored meetings and exhibitions may digitally convert to three-dimensional virtual learning experiences for spine surgeon participants. In the more distant future, simulators and virtual reality (VR) platforms, although in their infancy, may become more sophisticated and eventually provide the visual and tactile feedback necessary to mimic surgical reality. Online education provides the added benefit of "learning on demand," decreased travel and accommodation costs, more efficient utilization of time, and the opportunity to learn at the comfort of one's home or office while connecting with international colleagues. Several mediums have already started to promote online spine education, such as the eccElearning29 and other academic/society outlets, offering postgraduate certificates, diplomas, and other certifications.
This survey-based study is not without limitation. First, the questionnaire was only disseminated among spine surgeons registered as AO Spine members who previously elected to participate in survey research (n = 3,805), and the overall response—although high in absolute number (n = 902)—was relatively low in rate (23.7%). In absolute terms, this represents approximately 15% of all AO Spine members. Low response rate does not necessarily indicate low validity; however, it may allow for certain biases to affect the generalizability of the findings. Spine surgeons who are active email users may be have been more likely to respond to the survey and AO Spine respondents may be more representative of an academic population. For example, of all 902 respondents, the majority were spine surgeons working in academic practices (45.4%, n = 405) or spines surgeons working in combined academic/private practices (22.9%, n = 204) (Table 1). Additionally, although the study leveraged the Delphi method for construction of the survey, time constraints imposed by the pandemic and the urgency with which the survey was launched prevented our group from conducting the usual pilot study for external validation. Additionally, survey questions aimed at assessing reliance on telehealth, online education, and online surgeon-to-surgeon engagement were high-level. Additional topic-specific questions would undoubtedly add granularity to the analysis and deepen our understanding of the pros and cons of virtual medicine practices. Despite these limitations, the input from responding spine surgeons from around the world sheds a new light on the current role of technology in patient care and physician education and provides a foundational understanding about the future of the virtual medicine spine surgeons.
Without a doubt, COVID-19 has triggered a complete restructuring of how spine surgeons conduct their clinical practice. Telehealth, which was once considered technologically cumbersome, financially unproductive, and difficult from a medico-legal perspective, has now become part of clinical spine surgery. Moreover, medical education platforms, which were previously used intermittently, have now gained more interest by the community and become primary sources for online spine education and physician-to-physician communication. As we move through this COVID-19 crisis and into the post-pandemic era, we are hopeful for a return to some level of normalcy. However, we can expect that our newfound technological capabilities and faith in telehealth may elevate the practice of spine surgery to a new normal, to benefit both patients and surgeons alike.
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The authors would like to extend their sincere gratitude to Kaija Kurki-Suonio and Fernando Kijel from AO Spine (Davos, Switzerland) for their assistance with circulating the survey to AO Spine members.
Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
Peter R. Swiatek, Joseph A. Weiner & Daniel J. Johnson
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
Michael H. McCarthy
Department of Orthopaedic Surgery, Rush University Medical Center, Orthopaedic Building, Suite 204-G, 1611 W Harrison Street, Chicago, IL, 60612, USA
Garrett K. Harada, Howard S. An & Dino Samartzis
The International Spine Research and Innovation Initiative, Rush University Medical Center, Chicago, IL, USA
Research Department, AO Spine International, Davos, Switzerland
Niccole Germscheid
Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
Jason P. Y. Cheung
Department of Orthopaedic and Trauma Surgery, Tampere University Hospital, Tampere, Finland
Marko H. Neva
Department of Orthopaedic and Trauma Surgery, Assiut University Medical School, Assiut, Egypt
Mohammad El-Sharkawi
Department of Orthopaedics, Churruca Hospital de Buenos Aires, Buenos Aires, Argentina
Marcelo Valacco
Department of Neurosurgery, John Hopkins University, Baltimore, MD, USA
Daniel M. Sciubba
Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA
Norman B. Chutkan
Neuroscience Institute, Virginia Mason, Seattle, WA, USA
Philip K. Louie
Peter R. Swiatek
Joseph A. Weiner
Daniel J. Johnson
Garrett K. Harada
Howard S. An
Dino Samartzis
Correspondence to Dino Samartzis.
The authors have no financial or competing interests to disclose in relation to this work.
Swiatek, P.R., Weiner, J.A., Johnson, D.J. et al. COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study. Eur Spine J 30, 2133–2142 (2021). https://doi.org/10.1007/s00586-020-06714-y
Revised: 01 December 2020
Issue Date: August 2021
Virtual medicine


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Music » Music Feature
Burning Palms
Witch rock from the Arizona desert at Leo's.
by Nastia Voynovskaya
9 p.m. Leo's (5447 Telegraph Ave., Oakland). $7, $10. ClubLeos.com
Arizona-based rock band Burning Palms' self-titled debut album is a dense record that pulsates with thunderous drumbeats, reverb-heavy guitar licks, and screeching distortion that render its surf and country roots almost unrecognizable. Singers Julia Deconcini and Simone Stopford harmonize with a howling intensity that conjures images of tearing along the open highway at night. A dark aesthetic accompanies Burning Palms' brooding sound: Its video for "Thorns," one of the album's singles, is a stop-motion animation in which snakes, beetles, and hair braids crawl over Deconcini and Stopford's naked bodies as mysterious, geometric symbols go in and out of focus. The song's rhythmic, repetitive structure and drawn-out, husky vocals make it sound like a hypnotizing hymn — which seems apt, as the band labels itself "witch rock." As part of its current North American tour, Burning Palms plays at Leo's on October 5 with Babewatch and the Peels.

redpajama_set_name: RedPajamaCommonCrawl


throughout the Midlands . . .
Ideal Employment has been successful in finding applicants temporary and permanent employment at many of the Midlands leading employers.
We have many contracts in and around the local areas.
Ideal Employment specialise in supplying clients and candidates throughout the Midlands. We have many contracts in and around the local areas.
We use traffic log cookies to identify which pages are being used. This helps us analyse data about web page traffic and improve our website in order to tailor it to customer needs. We use this information for statistical analysis purposes and then the data is removed from the system.


text:
Siadougou è un comune rurale del Mali facente parte del circondario di San, nella regione di Ségou.

Il comune è composto da 20 nuclei abitati:

Bablé-Wèrè
Bananikélé
Dionkasso
Djéguéna
Dougoubala
Garangata
Gniné
Kakoun-Mankoye
Kama-Bambara
Kama-Marka

Kolébougou
Kouan
Koungota
Moribougou
N'Djébala
N'Dongosso
Nabasso
Pélingana
Siella (centro principale)
Tabara

Note

Comuni della regione di Ségou

redpajama_set_name: RedPajamaWikipedia


text:
<?php
/**
 * Utility class that wraps frequently used datetime functions and makes them
 * application specific (eg. throw exceptions).
 *
 * @package     uUtilitiesPlugin
 * @subpackage  uDateTime
 * @author      Henning Glatter-Gotz <henning@glatter-gotz.com>
 */
class uDateTime
{
  /**
   * Protected helper method that takes care of time zone management and
   * internally calls the date() function to generate a date string in the
   * desired timezone.
   *
   * @param string $timeZone A valid TZ identifier
   *                         (http://us.php.net/manual/en/timezones.php).
   *                         If null, then the default is used (whatever is set)
   * @param integer $hour    Hour portion of the date
   * @param integer $minute  Minute portion of the date
   * @param integer $second  Second  portion of the date
   * @param integer $month   Month portion of the date
   * @param integer $day     Day portion of the date
   * @param integer $year    Year portion of the date
   *
   * @return string          YYYY-MM-DD hh:mm:ss formatted string
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  protected static function makeDateTime($timeZone, $hour = 0, $minute = 0, $second = 0, $month = null, $day = null, $year = null)
  {
    if (null !== $timeZone)
    {
      $currentTZ = date_default_timezone_get();

      if (!date_default_timezone_set($timeZone))
      {
        throw new Exception(__METHOD__.':'.__LINE__.'|'.
                            $timeZone.' is not a valid time zone identifier!');
      }
    }

    if ($month == null && $day == null && $year == null)
    {
      $date = date("Y-m-d H:i:s");
    }
    else
    {
      $date = date("Y-m-d H:i:s", mktime($hour, $minute, $second, $month, $day, $year));
    }

    if (null !== $timeZone)
    {
      date_default_timezone_set($currentTZ);
    }

    return $date;
  }

  /**
   * Wrapper for strtotime that throws an exception.
   *
   * @param string $val The string representing a date time
   * @return int        A unix time stamp
   */
  public static function strtotime($val)
  {
    $ts = strtotime($val);

    if ($ts === false)
    {
      throw new Exception(__METHOD__.':'.__LINE__.'|Invalid date time string: '.
        $val.', cannot convert to timestamp');
    }

    return $ts;
  }

  /**
   * Get the datetime (YYYY-MM-DD hh:mm:ss) string for NOW based on the passed
   * timezone
   *
   * @param string $timeZone The timezone identifier
   *
   * @return string          YYYY-MM-DD hh:mm:ss formatted string
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  public static function now($timeZone = null)
  {
    return self::makeDateTime($timeZone);
  }

  /**
   * Return the datetime (YYYY-MM-DD hh:mm:ss) string for the beginning of this
   * month based on the timezone
   *
   * @param string $timeZone The timezone identifier
   *
   * @return string          YYYY-MM-DD hh:mm:ss formatted string
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  public static function beginningOfThisMonth($timeZone = null)
  {
    return self::makeDateTime($timeZone, 0, 0, 0, date("m"), 1, date("Y"));
  }

  public static function beginningOfLastMonth($timeZone = null)
  {
    return self::makeDateTime($timeZone, 0, 0, 0, date("m")-1, 1, date("Y"));
  }

  /**
   * Return the datetime (YYYY-MM-DD hh:mm:ss) string for the end of last month
   * based on the timezone
   *
   * @param string $timeZone The timezone identifier
   *
   * @return string          YYYY-MM-DD hh:mm:ss formatted string
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  public static function endOfLastMonth($timeZone = null)
  {
    return self::makeDateTime($timeZone, 23, 59, 59, date("m"), 0, date("Y"));
  }

  /**
   * Return the datetime (YYYY-MM-DD hh:mm:ss) string for the end of yesterday
   * based on the timezone
   *
   * @param string $timeZone The timezone identifier
   *
   * @return string          YYYY-MM-DD hh:mm:ss formatted string
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  public static function endOfYesterday($timeZone = null)
  {
    return self::makeDateTime($timeZone, 23, 59, 59, date("m"), date("d")-1, date("Y"));
  }

  public static function beginningOfThisWeek($timeZone = null)
  {
    $ts = uWeek::TimeStampsForThisWeek(1);

    return self::makeDateTime($timeZone, 0, 0, 0, date("m", $ts), date("d", $ts), date("Y", $ts));
  }

  public static function beginningOfLastWeek($timeZone = null)
  {
    $ts = uWeek::TimeStampsForLastWeek(1);

    return self::makeDateTime($timeZone, 0, 0, 0, date("m", $ts), date("d", $ts), date("Y", $ts));
  }

  public static function endOfLastWeek($timeZone = null)
  {
    $ts = uWeek::TimeStampsForLastWeek(7);

    return self::makeDateTime($timeZone, 23, 59, 59, date("m", $ts), date("d", $ts), date("Y", $ts));
  }

  public static function rangeDayBeforeYesterday($timeZone = null)
  {
    $r = array('startDate' => self::makeDateTime($timeZone, 0, 0, 0, date("m"), date("d")-2, date("Y")),
               'endDate'   => self::makeDateTime($timeZone, 23, 59, 59, date("m"), date("d")-2, date("Y")));

    return $r;
  }

  public static function rangeYesterday($timeZone = null)
  {
    $r = array('startDate' => self::makeDateTime($timeZone, 0, 0, 0, date("m"), date("d")-1, date("Y")),
               'endDate'   => self::makeDateTime($timeZone, 23, 59, 59, date("m"), date("d")-1, date("Y")));

    return $r;
  }

  public static function rangeLastWeek($timeZone = null)
  {
    $r = array('startDate' => self::beginningOfLastWeek($timeZone),
               'endDate'   => self::endOfLastWeek($timeZone));

    return $r;
  }

  public static function rangeLastMonth($timeZone = null)
  {
    $r = array('startDate' => self::beginningOfLastMonth($timeZone),
               'endDate'   => self::endOfLastMonth($timeZone));

    return $r;
  }

  public static function daysBetweenDates($startDate, $endDate)
  {
    return uDate::daysBetweenDates(substr($startDate, 0, 10), substr($endDate, 0, 10));
  }

  public static function nDaysAgo($days, $timeZone = null)
  {
    $r = self::makeDateTime($timeZone, 0, 0, 0, date("m"), date("d")-$days, date("Y"));

    return $r;
  }

  /**
   * The first day of the month into which the passed date falls.
   *
   * @param string $date     String representation of a date
   * @param string $timeZone The timezone if any
   * @return string          The datetime of the first day of the month
   */
  public static function firstDayOfMonth($date, $timeZone = null)
  {
    $month = date("n", self::strtotimeTZ($date, $timeZone));
    $year = date("Y", self::strtotimeTZ($date, $timeZone));
    $r = self::makeDateTime($timeZone, 0, 0, 0, $month, 1, $year);

    return $r;
  }

  /**
   * Return the last day of the month for the date passed. The data can be any
   * date, the method will return the last day of that month and year.
   *
   * @param string $date     String representation of a date
   * @param string $timeZone The timezone if any
   * @return string          The datetime of the last day of the month
   */
  public static function lastDayOfMonth($date, $timeZone = null)
  {
    $ts = self::strtotimeTZ($date, $timeZone);
    $month = date("n", $ts);
    $year = date("Y", $ts);
    $daysInMonth = date("t", $ts);
    $r = self::makeDateTime($timeZone, 0, 0, 0, $month, $daysInMonth, $year);

    return $r;
  }

  /**
   * Convert a date string to a timestamp based on the timezone
   *
   * @param string $dateStr  The string to convert
   * @param string $timeZone The timezone identifier
   *
   * @return integer         A UNIX timestamp
   * @throw  Exception       If the passed timezone identifier is not valid
   */
  public static function strtotimeTZ($dateStr, $timeZone = null)
  {
    if (null === $timeZone)
    {
      $timeStamp = self::strtotime($dateStr);
    }
    else
    {
      $currentTZ = date_default_timezone_get();

      if (!date_default_timezone_set($timeZone))
      {
        throw new Exception(__METHOD__.':'.__LINE__.'|'.
                            $timeZone.' is not a valid time zone identifier!');
      }

      $timeStamp = self::strtotime($dateStr);

      date_default_timezone_set($currentTZ);
    }

    return $timeStamp;
  }

  /**
   * Convert an English date time string to an application date time string.
   * The application date time format is YYYY-MM-DD HH:MM:SS
   *
   * @param string $dateTimeStr The string that holds the date time
   * @return string             The app formatted date time string
   * @throw Exception
   */
  public static function strToAppDateTime($dateTimeStr)
  {
    $ts = self::strtotime($dateTimeStr);

    return date("Y-m-d H:i:s", $ts);
  }

  public static function elapsedSeconds($startDate, $endDate)
  {
    $sTs = self::strtotime($startDate);
    $eTs = self::strtotime($endDate);

    return abs($sTs-$eTs);
  }

  public static function format($seconds, $accuracy = 2)
  {
    $seconds = intval($seconds);
    $d = intval($seconds / (3600 * 24));
    $h = bcmod($seconds / 3600, 24);
    $m = bcmod($seconds / 60, 60);
    $s = bcmod($seconds,60);

    $f = '';
    $count = 0;

    if ($d > 0)
    {
      $f .= $d;
      $f .= ($d == 1) ? ' day ' : ' days ';
      ++$count;
    }

    if ($d > 0 || $h > 0)
    {
      $f .= $h;
      $f .= ($h == 1) ? ' hour ' : ' hours ';
      ++$count;
    }

    if ($d > 0 || $h > 0 || $m > 0)
    {
      if ($count < $accuracy)
      {
        $f .= $m;
        $f .= ($m == 1) ? ' minute ' : ' minutes ';
        ++$count;
      }
    }

    if ($count < $accuracy)
    {
      $f .= $s;
      $f .= ($s == 1) ? ' second' : ' seconds';
    }

    return $f;
  }
}

redpajama_set_name: RedPajamaGithub


text:
Tornado confirmed in Pennsylvania, some property damage
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Norwegians collect money to fix penis-shaped rock formation
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Les BIXI gratuits toute la journée dimanche
Les vélos BIXI abondent à cette station, à Montréal. Dimanche, un grand pique-nique sera offert au parc Lafontaine.
South Korean president calls for North Korean Olympic participation
The head of the U.S. Defense Intelligence Agency told Congress last month that North Korea could be on an "inevitable" course to having a nuclear warhead capa...
Faedo fabulous again, Florida beats TCU to go to CWS finals
The LSU Tigers hit three home runs, two of them from junior Michael Papierski , to take the third and final game against the Oregon State Beavers . I had ...
Trump wants apprenticeships in all high schools
These apprenticeship programs are important for the purposes of loading up young people with skills in the modern information age, all the while allowing them t...
United Kingdom man arrested after offensive Finsbury Park attack post
Osborne's sister, Nicola, said her brother had been "troubled for a long time". Representatives of local religious communities stood side by side during a min...
China, US agree on more cooperation during security talks
Mattis says China shares the USA desire for denuclearization of the Korean Peninsula, and "continues to work this issue". Eighty-five percent of North Korea's...
Aus flies out of Syria amid US-Russia tensions
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Hacking attempts on 21 states are tied to Russian Federation
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U.S. jet shoots down Iranian drone over Syria
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Le Président égyptien ratifie la cession de deux îles à l'Arabie saoudite
Il s'agit du dernier rebondissement d'une affaire qui suscite de vives protestations depuis des mois. Le Parlement égyptien était divisé au sujet de l'accord ...
Vilsack speaks out on GOP Senate health care plan
A healthy person might easily decide that several years of no payments was worth the risk of a 30 percent surcharge for 12 months if they wound up needing cover...
Fijiana secure 4th place on Women's World Sevens Series after Clermont 7s
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Iran Escalates Involvement in Syria With Anti-IS Missile Strike
The IRGC missile operation against Daesh was powerful, courageous and dignifying, Rapporteur of the Iranian Parliament's National Security and Foreign Policy Co...
LA County freeway closed as brush fire rages
The fire quickly jumped the freeway and has destroyed at least one structure. LASD deputies remain throughout the area to ensure public safety where also a un...
Hillary Clinton: GOP Is 'Death Party' If O'Care Repeal Bill Passes
So far five Republican senators have announced their opposition. In the narrowly divided Senate, defections from just three of the 52 Republican senators woul...
Amit Shah meets Shiv Sena chief Uddhav Thackeray regarding Presidential polls
He has a nice personality. We decided that whoever willing to do a good work should be supported. The Shiv Sena, the second largest constituent of the NDA , ...
Turkey has no intention of closing Qatar base despite Saudi ultimatum
Saudi Arabia , UAE, Egypt and Bahrain , who have imposed a blockade on Qatar, insisted the Turkish base be closed in a list of demands issued to Qatar yest...
Iran arrests IS-linked group planning attacks
Dozens of suspects were arrested following the attacks, and Iran later said it had tracked down and killed several suspected jihadists, including the alleged ...
Thousands Pay Tribute To Otto Warmbier In Ohio
US President Donald Trump has slammed Warmbier's detention and eventual death as "a total disgrace". KCNA said the North dealt with him according to its...
Milwaukee jury clears ex-cop in black man's death
Paul. He believed all along that he was justified in what he did. During the case, one prosecutor argued that Smith was shot by Heaggan-Brown after he tri...
Germany hope Liverpool's Emre Can fit for Cameroon
The dismissal rattled the Africans and Germany scored a minute later when Werner headed beyond Ondoa. "I won't use the same team we had against Chile , tho...
Taekwondo Team Opens Door to Inter-Korean Cooperation
Per BBC News , the change took place just before the federation's world championships in Muju , South Korea . South Korean President Moon Jae-in was on hand...
Supreme Court Agrees to Hear Gerrymandering Case
Attorneys for Wisconsin voters applauded Monday when the U.S. Supreme Court took up their challenge to partisan gerrymandering . Democrats in Maryland ...
Big cases, retirement rumors as Supreme Court nears finish
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PM Modi greets nation on Ratha Yatra of Lord Jagannath
The India-US civil nuclear deal is expected to figure during talks between Modi and Trump , but a pact between the NPCIL and Westinghouse to build six power re...
Edmonton Eskimos stun BC Lions 30-27
Lions head coach and general manager Wally Buono was blunt in his assessment of the game's turning point after his team had fought back. "We just blew a cover...
GOP sen: 'We should not be voting' on healthcare this week
Republicans view the law, formally known as the Affordable Care Act , as a costly government intrusion and say individual insurance markets created by it are c...
Plan of suspect in Brussels train station blast revealed
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US urges Qatar, neighbors to 'sit together' to ease tension
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Trump Claims Obama Planted Recorders In Oval Office
The interview with Fox & Friends was shown a day after the president tweeted what most people in Washington had already come to believe: that he had not made ...
Pyne jumps on gay marriage grenade
Mr Pyne was addressing the "Black Hand reception" when attention turned to the marriage equality debate, The Daily Telegraph reported. Mr Pyne reportedly sa...
Senator Rhiannon hits back over Greens schools funding split
Education was not Rhiannon's portfolio - and for her to advocate against the Greens leader Richard Di Natale and its education spokesperson, Sarah Hanson-Young,...
J&K policemen asked to avoid Eid prayers in public places
The firing by the cop angered more mob, who pounced on him and beaten him to death. Even after the lynching , the body of the police officer was lying at the N...
Mourners gather for funeral for Otto Warmbier, student detained in North Korea
A spokesperson for North Korea said that the rogue nation did provide medical treatment for Warmbier and that the accusations against the North are "groundles...
Mandhana, Raj lead India to 35 run win
And now she has gone and notched up her seventh consecutive half century, a new world record in women's cricket . Mandhana enjoyed a stylish innings and her pa...
Firefighters Hurt as Blaze Breaks Out at West Village Building
At least nine firefighters have been injured from heat and smoke inhalation, and two have been taken to Lenox Hill Hospital with non-life threatening injuries, ...
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Monde Arabe,golfe:Riyad et ses alliés adressent leurs revendications au Qatar
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U.S. military shoots down Iranian-made drone in southern Syria
Speaking to the Al-Miyadin network, Al-Islam said that the missile strike showed the strength of the Iranian Revolutionary Guards and that Iran "will not allo...
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Death toll from London tower fire reaches 79: United Kingdom police
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North Korea releases USA citizen Otto Warmbier
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Erdogan rejects Arab demands to remove Turkish troops from Qatar
Doha said it was reviewing the list, but said it was not reasonable or actionable. Speaking Sunday after Eid prayers in Istanbul , President Recep Tayyi...
ISIS leader may have died in airstrike near Raqqa — Russian military
In an e-mailed statement , Army Col. Ryan Dillon said Friday: "We can not confirm these reports at this time". The Russian ministry said that among other m...
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Ware's brew - The Vault Fallout Wiki - Everything you need to know about Fallout 76, Fallout 4, New Vegas and more!
Ware's brew is a consumable in the Fallout 4 add-on Far Harbor.
This drink was developed by Zealot Ware, who is one of the few children of Atom who has not been bestowed with Atom's blessing and is sickened by radiation. By distilling coniferous tree sap, Ware found that the concoction could flush accumulated radiation in the body. More specifically, it removes 100 rads, while also providing 100 hit points.
Zealot Ware will provide four of his brews as a reward for completing The Trial of Brother Devin; afterwards, one can visit Zealot Ware every couple of days for more.
Ware's brew can also be crafted at any cooking station.


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22 Games Like DayZ
Our collection of games like DayZ offers other zombie survival games that will leave you alone and struggling to survive.
DayZ started its life as a modification for ARMA 2 and focuses on providing a realistic survival experience where players have to worry about both the infected (zombies) and other players. Eventually the games popularity led to a standalone game edition.
The game takes place in a huge world which includes a variety of landscapes that each present their own challenges for the player. A key component of the gameplay is your battle against both zombies and other players with permanent death requiring players to start again if they are killed. In this unique game other players are just as deadly as zombies with opportunistic players always looking to take you out for your supplies.
DayZ places its emphasis on realism with players having to scavenge anything and everything they can find in the game world. This realism extends to combat with players often better off avoiding large scale zombie conflicts rather than looking for a fight.
The games like DayZ here offer similar zombie MMO experiences with a few single player games thrown in. While some have a heavy focus on survival like DayZ others games on this list take a less realistic approach to a zombie outbreak.
Life is Feudal: Your Own
Step into a massive medieval world in Life is Feudal: Your Own that blends combat, crafting, building, sandbox, realistic directional combat and many other mechanics to create an adventure set far into the past. Alternatively explore the much larger world in Life is Feudal: MMO, the MMO variant of the title with different f...[Read More]
Rust is a survival game that comes from the same brains that brought you Garry's Mod. Drawing inspiration from a wide range of games and genres you'll find plenty of depth to explore while struggling to survive. The game is best described as a mixture of Minecraft and DayZ. In Rust players will spawn with nothing (other tha...[Read More]
LinuxMacPC
Stranded 2
Stranded 2 is a free to play 3D game that challenges you to survive by yourself on an island. Building on the original game by offering improved graphics, larger islands, additional items and better randomisation you'll get plenty of more hours of Stranded gameplay. Allowing players to play either through the story mode tha...[Read More]
FreePC
Contagion offers co-operative and PvP game modes set within a number of zombie infected environments and combined with first person shooter gameplay. With a healthy dose of maps, game modes and weapons underneath the generic setting Contagion has provided a popular framework for fans of the FPS zombie sub genre to sink thei...[Read More]
Don't Starve is a single player survival game that has many unique features and a dark art direction that makes it a stand out open world survival experience. The game was released in April 2013 by Klei Entertainment with a standalone expansion pack released in 2016 under the name Don't Starve Together which introduce...[Read More]
AndroidiOSLinuxMacPCPS VitaPS3PS4SwitchWii UXbox One
Fallen Earth is set in a post-apocalyptic game world and offers it to players with a free to play MMO experience. The game is a mixture of FPS and role playing features making it akin to the later games in the Fallout series. The game is centred around the Grand Canyon area which is now a wasteland after a series of events ...[Read More]
Killing Floor is a co-operative game that matches a team of players against zombie like enemies in a series of increasingly difficult waves. Your key to success lies within leveraging the map designed choke points and complimenting each other through the class system that provides tangible in game benefits as you acquire ex...[Read More]
State of Decay combines the open world genre with a zombie outbreak to create one of the largest and most impressive games in the genre to date. The game started out as a title on the Xbox Marketplace and eventually made its way to Windows. The game plays out in an open world environment with players taking control of their...[Read More]
PCXbox 360Xbox One
Infestation: The New Z offers another iteration of The War Z and Infestation: Survivor Stories with a free to play open world shooter made for PvP play across various game modes. Ignoring the rocky history that this franchise has had with countless development issues and decisions that have been less than well received by t...[Read More]
Focusing on zombie survival the free to play multiplayer game known as Unturned spent 3 years in Early Access before its final release on the Steam platform in July 2017. Since release the game has not only proved popular in its core gameplay but also the Arena mode which is similar to battle royale titles such as PUBG. Reg...[Read More]
FreeLinuxMacPC
Left 4 Dead 2 continues the co-operative zombie adventure with all new characters, locations, enemies and weapons to change up the popular gameplay introduced in the original Left 4 Dead. The popular AI director also makes a return with plenty of tweaks to ensure players are always challenged. Just like the original game pl...[Read More]
LinuxMacPCXbox 360Xbox One
CastleMiner Z
CastleMiner Z is a sequel to the popular Xbox Live Indie Game of CastleMiner while also bringing the series to the computer environment via Steam. While the original CastleMiner was a creatively focused experience the sequel pushes the game into survival orientated gameplay instead aligning it with other games in the genre ...[Read More]
Starting the battle royale craze in 2017 PlayerUnknown's Battlegrounds (PUBG) quickly commanded an audience of millions and gave birth to a wider genre that would dominate the gaming industry for years to come. Subsequent to its success on Xbox One and Windows the game was released on the PlayStation 4 and on mobile d...[Read More]
AndroidFreeiOSPCPS4Xbox One
In Dead Island you'll have to explore an open world environment and try to prevent being eaten by using whatever weapons you can find around the place. Dead Island is a great role playing experience for fans of survival horror and is available on Windows, Xbox 360, and PlayStation 3. Dead Island features a fictional island ...[Read More]
LinuxPCPS3Xbox 360
Sir, You Are Being Hunted
Sir, You Are Being Hunted is one of the more unique games to be released in recent years offering a free roaming sandbox adventure focused on stealth gameplay. As the name might suggest players spend their time in the game being hunted in a procedurally generated game world. In the game you won't be chased by zombies, mutan...[Read More]
Left 4 Dead (L4D) is a zombie survival experience that focuses on co-operative gameplay against a varied and randomised zombie infection. Left 4 Dead separates itself from similar co-operative shooters by promising a different experience each time you load up a game map thanks to the AI director that alters aspects of the m...[Read More]
Dead Island: Riptide is the second game in the Dead Island series and continues on from your previous adventure but takes place on a whole new island. The game launched in 2013 for PC, PS3 and Xbox 360, delivering a very similar experience to the first game. The events in Dead Island: Riptide occur right after those of the ...[Read More]
Parkour across a massive city while also slashing zombies to pieces in Dying Light a game with plenty of open world and RPG elements. The game is available on Windows, PlayStation 4 and Xbox One. Centred around agent Kyle Crane whose objective is to infiltrate the quarantine zone of Harran. This city is overrun with infesta...[Read More]
LinuxMacPCPS4Xbox One
If you want more over the top zombie killing you've probably been waiting for the release of Dead Rising 3 which takes the game series to all new levels of awesomeness. The game was released in mid-2013 as launch title for the Xbox One platform. If you've been following the series closely you'll find that Dead Rising 3 take...[Read More]
PCXbox One
Dead Rising is back with more zombie killing goodness, in Dead Rising 2 players can expect a similar open world horror experience to the original with endless hordes of zombies just waiting to be dealt with. Dead Rising 2 takes place half a decade after the first Dead Rising and introduces a new protagonist into the game (C...[Read More]
Dead Rising combines horror and open world environments to create a fun and unique survival experience for players. The game was released in 2006 and is only available on the Xbox 360 platform. In Dead Rising players take on the role of Frank West in a shopping mall that is simply packed full of zombies. In the game you'll ...[Read More]
ZombiU (Zombi on non Wii U platforms) brings the zombie genre onto Nintendo's platform with an amazing and horrifying experience that shows off some unique mechanics and potential of the Wii U. On non Wii-U platforms some of these features are taken out or redesigned while still retaining the impressive fundamental design o...[Read More]
PCPS4Wii UXbox One
Games Like Ark: Survival Evolved, Games Like DayZ, Games Like Dead Island, Games Like Dont Starve, Games Like H1Z1, Games Like Minecraft, Games Like PlayerUnknown's Battlegrounds, Games Like STALKER, Games Like Subnautica, Games Like The Forest, Games Like Trove, Games Like 7 Days to Die, Games Like Rust, Games Like Dying Light, Games Like Killing Floor , Games Like Unturned, Games Like Realm of the Mad God (RotMG), Games Like The Binding of Isaac, Games Like Destiny, Games Like Fallout, Games Like Far Cry, Games Like Mad Max, Games Like Combat Arms, Games Like Counter Strike, Games Like Crossfire, Games Like Doom, Games Like Warframe, Games Like Grand Theft Auto, Games Like Max Payne, Games Like The Last of Us, Games Like This War of Mine, Games Like Fortnite, Games Like State of Decay, Games Like Borderlands, Games Like Just Cause, Games Like The Division, Games Like Assassin's Creed, Games Like Prototype, Games Like Resident Evil Show More


As a senior international researcher at RAND, David Shlapak has led research on topics ranging from counterterrorism to nuclear strategy. As the codirector of the RAND Center for Gaming, he designs and plays games to explore U.S. national security strategy, the evolving East Asian and European security environments, and defense planning. In this Call with the Experts, David Shlapak talks about how serious games can help find solutions to global problems. Media relations director Jeffrey Hiday moderates the call.
RAND uses gaming techniques to develop insights into a host of 21st century challenges. In this Events @ RAND podcast, David Shlapak, codirector of the RAND Center for Gaming, discusses the strengths, weaknesses, and limitations of using gaming in research.
A series of wargames examined the threat Russia may present to the three Baltic republics. As currently postured, NATO could not defend the territory. What might be done to prevent Russia from attempting to reclaim it?
Some famous historical wargames offer a compelling narrative of what wargames can be at their best and worst, but they cannot illustrate the full range of contemporary wargaming that leaders should strive to achieve. A better understanding of how wargames can be helpful — or backfire — is critical.


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Getting ready to celebrate the spookiest holiday of all! Turn those lovely Halloween sessions into amazing memories your customers will love to treasure and share.
This collection is wickedly fun! This particular photocard features a 5x7 double-sided Halloween theme card design. Use it as an additional printable product for your customers' photo sessions, or digital material for them to share with family and friends.


From the outside, it would be impossible to guess that inside the church, 400 people, mostly strangers, were packed into two large rooms, sitting at tables adorned with red and green ribbons and candles, eating, laughing and smiling at one another on one of the most celebrated days of the year.
"This is a good time to be in the church. This is what the season is truly about, a celebration of our Lord Jesus Christ," said Troy Alesi, a volunteer with the church.
Regardless of creed, the church opened its doors to the entire community Friday afternoon.
"We all know how this time of the year creates loneliness. It's worth it to cook 17 turkeys, it's worth it to bake 30 mashed potato casseroles, it's worth it to give these people a place to be," said event organizer Greg Elliott.
The church has opened the doors and filled the tables for about 25 years, joining members of the community, both volunteers and those in need, with a good meal on Christmas Day.
"There's a good chance they could have been home alone and instead they are here with us," Elliott said.
There's a good chance they could have been home alone and instead they are here with us.
The Presbyterian church on Beaver Avenue is also hosting individuals without a home, for the next two weeks, with the Out Of The Cold Initiative.
"I've been sleeping here the past week," Murray said.
"Years ago there were fewer homeless people and they used to give vouchers for hotels over the holiday. There's more of a need now, so they're staying here with us," said Susan Sanders, a volunteer for the event.
Sanders served as hostess Friday, and created a home-like environment for guests, greeting everyone with a warm smile.
The meal was staffed by volunteers like Alesi, Sanders and Elliott, who work the event and then enjoy sharing a dinner along with the guests and their families.
Their families feel the same.


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DOYLE JOHN 1797 - 1868CARTOONIST
Bookmark:https://archiveshub.jisc.ac.uk/data/gb97-collmisc0443
LSE Library Archives and Special Collections
GB 97 COLL MISC 0443
10 volumes
Political Sketches by HB 1829 to 1844 published by Thomas McLean, Vols 1to 4 and 6 to 8.
An Illustrative Key to the Political sketches of HB, No 1-800" published byThomas McLean, 2 volumes (1840 and 1844).
Volume of miscellaneous political sketches by HB (1831-1844).
Note: key to sketches 1 to 600 in OU 1832/28.
John Doyle 1797 - 1868.
John Doyle was born into a impoverished Roman Catholic family in Dublin in1797. Doyle arrived in London in 1821 where he hoped to establish himself asa portrait painter. Although he occasionally exhibited at the Royal Academyhe failed to sell enough pictures and by 1827 had turned to lithography. Over the next few years he revolutionised the art of caricature,concentrating mainly on politicians for his subjects. His work differedgreatly from previous cartoonists such as Thomas Rowlandson (1756 - 1827) andJames Gillray (1757 - 1815) who attempted to make their subjects look uglyand ridiculous.
Doyle's pictures appeared in The Times between 1829 and 1851. His drawingswere always signed HB and at the time very few people knew his real name.Doyle's cartoons were daily commentaries of political events and weresometimes accompanied by an article explaining their meaning. He diedon 2nd January 1868. One of his sons, Richard Doyle (1824 - 1883), was also a cartoonist. His other son, Charles, was the father of the writer,Arthur Conan Doyle (1859 - 1930), who created the fictional characterSherlock Holmes.
Ten volumes
No further listrequired.
APPLY TOARCHIVIST
Doyle John 1797-1868 Portrait Painter and Caricaturist


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The PHILIPP PLEIN label was founded in Munich in 1998 by the designer and owner of the same name. Today, it boasts clothing, accessory and interior design lines which interpret a new contemporary and cosmopolitan lifestyle. Perfection in every detail, combined with a playful and irreverent spirit, create a new luxury and a new elegance. All strictly made in Italy. The unusual and meticulous use of fine materials, combined with original, sometimes subcultural details, makes every piece truly unique. What counts most is to give life, imagination and precision to a product that remains eternally authentic.
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Four Cryptocurrencies Looking To Close Out March On A Good Note
by Krishna Murthy V April 8, 2022 0 Comment 0 38 Views
The month of March is nearing its end, but the wild race cryptocurrencies are in during March isn't over yet. March has proven to be very interesting for cryptocurrency, as some have seen substantial highs and lows in March. We can blame the flux in the crypto market on many things that happened during March.
Investors acting more like gamblers betting on NASCAR betting odds instead of savvy investors in crypto for the long haul could be one of those reasons. The uncertainty in the market we've seen has caused cryptos to fall. However, there is hope for four cryptocurrencies to close out March on a high note.
Bitcoin is one of the major cryptocurrencies on the market. So seeing Bitcoin make the list is nothing outside the ordinary. Several things have affected bitcoin in the news during March, which has caused the flux in its value.
The first of these is the situation with Russia and Ukraine. Russia is looking to use Bitcoin to get around international sanctions. Ukraine is getting support for their troops with people donating Bitcoin to a non-governmental organization (NGO) in the Ukraine that uses the fund to help the Ukrainian Army.
The other thing that's affecting Bitcoin was when United States President Joe Biden signed an executive order for the investigation and regulation of cryptocurrencies. The order also sought to look into the environmental impact that cryptocurrencies have on the planet. That part was a clear shot at Bitcoin, which consumes massive amounts of power to deal with transactions and mining of Bitcoin.
Bitcoin has weathered all these things, flirting with $45,000 during March. Even with what's going on around the world, Bitcoin looks to be set to have a mild improvement by the end of March.
The meme coin of cryptocurrency, Dogecoin, looks to make a return by the end of March and possibly beyond. Some of the good news for Dogecoin comes from the number of large transactions with Dogecoin. Nearly 500 transactions of $100,000 or more happened with Dogecoin in a 24-hour period on March the 24th. The transactions were a 111% increase over the previous 24-hour period, signaling a possible bull run for Dogecoin.
Another thing in Dogecoin's favor is the proclaimed "DOGE-Father" Elon Musk. Musk took to Twitter on Saturday to air out his feelings about Twitter and ask followers if a new platform apart from Twitter is needed. One of Musk's followers would suggest that he take over Twitter and then change the logo to that of Dogecoin, something that Musk thought would be a good idea. The interaction would help Dogecoin move upward during Musk's tweets.
One crypto that has been steadily improving, mostly, in March is Ripple. The crypto received some good news with a lawsuit that was filed against them by the SEC.
A judge would side with Ripple and tell the SEC that they can't prevent Ripple from the use of their "fair notice" defense in court. The SEC had alleged that the CEO of Ripple, Brad Garlinghouse, along with executive chairman Chris Larsen, made an unregistered securities offering of $1.3 billion worth of Ripple.
The ruling might not be a complete win for Ripple's CEO and executive chairman, but it means that the SEC will have a harder time charging the two with violating securities laws. That was a win for Ripple, whose fate would have come undone if the court ruled in the SEC's favor.
The last crypto looking to close out March on a pleasant note is Ethereum. The crypto is coming off a low near $2,400 from earlier in March and is over $3,100. Ethereum is gaining in part to non-fungible tokens (NFTs) that are being sold using Ethereum as payment.
Another thing that can help Ethereum moving toward the end of March is their recent merge onto the Kiln testnet. The move will turn Ethereum into a proof-of-stake network on the blockchain, as opposed to the proof-of-work network it is currently on. The move will reduce energy consumption by Ethereum, a win for the environment and Ethereum holders.
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Category - News
With a motive of giving students an exposure to international culinary delights, Nepal Academy of Tourism and Hotel Management (NATHM) invited MasterChef Santosh Shah and his team to share their...
Inflation soared over the past year at its fastest pace in more than 40 years, with costs for food, gasoline, housing and other necessities squeezing American consumers and wiping out the pay raises that many people have received. The Labor Department said Tuesday that its consumer price index jumped 8.5% in March from 12 months earlier, the sharpest year-over-year increase since December 1981...
After the success of "Song of clouds", the reputation of Mr. Ankit Poudel has grown far and wide. Getting the Grand Prix at Split Film Festival and Bronze Remi Award at WorldFest-Houston International Film Festival is something even the world's most popular directors and producers still aim for. Moreover, the Honorable mention at Lima Alterna Festival Internacional de Cine and Best Cinematography...
नेकपा (एमाले) को विभाजनले कानुनी मान्यता पाएको छ । माधव कुमार नेपालको नेतृत्वमा नेकपा (एकीकृत समाजवादी) दर्ता भएसँगै एमाले विभाजने मान्यता पाएको हो । आयोगका अनुसार दल दर्ताका लागि एमालेका ५५ केन्द्रीय सदस्य र ३० सांसदले सनाखत गरेका छन् । एमालेका ५४ केन्द्रीय सदस्य र २९ सांसदले आज निर्वाचन आयोगमा नै पुगेर सनाखत गरेका हुन् । पार्टीका वरिष्ठ नेता झलनाथ खनालले भने दिल्ली दूतावासमार्फत् सनाखत...
Reconsider group playdates, parents. Think twice about letting your kids play soccer with friends. Avoid the local playground jungle gyms and monkey bars. "There is evidence corona viruses can live on plastic and metal for up to nine days," said Dr. Asaf Bitton, a primary care physician and executive director of Ariadne Labs, a joint health system innovation center at Brigham and...


Recruiting and retaining talent: In a tight labor market, life sciences companies are establishing dedicated recruitment functions within their organizations, leveraging highly skilled recruiting professionals, both internally and outsourced externally, trained in specific industry needs and an organization's unique competitive landscape. In addition, proposing special incentives like employee referral bonuses or offering new hires student loan payoffs, sign-on bonuses, virtual workdays, career coaching, community engagement and more can be a recruiting and retention differentiator.
Initial public offering (IPO) planning: Taking a company public is an exciting milestone for an organization; however, it requires significant coordination planning. Companies ideally should start operating and reporting like a public company at least a year prior to the IPO kickoff, including performing annual audits and quarterly reviews.
Pricing pressure: According to the pre-conference survey, 60 percent of respondents indicated pricing regulation was an issue that "kept them up at night." Pricing reform is a reality and middle market life sciences companies should anticipate the impact on overall operations.
Corporate tax reform: Life sciences companies have much to consider under the Tax Cuts and Jobs Act, including alternative minimum tax considerations, updated research and development deductions and international tax needs. And, the law continues to evolve. Stay informed regarding ongoing tax reform guidance for life sciences companies.
Third-party risk management: While there are many benefits to working with third parties, there are also risks. Failure to properly manage these relationships can result in financial loss or expose an organization to further regulatory or legal challenges. Middle market life sciences companies must understand the risk factors involved with these relationships to proactively mitigate and manage them.
Lease accounting: Ready to adopt ASC 842, the long-awaited standard on accounting for leases? The standard is complex and could involve numerous corporate functions. Implementation may take many months so now is the time for life sciences companies to act. Implementation deadline is Jan. 1, 2019, for public companies and Jan. 1, 2020, for private companies.
Other conference highlights included an opening keynote panel on the art and science of the chief financial officer in today's cutting-edge biopharma company, a women's leadership breakout on mentorship and career paths, as well as a finance transformation session that focused on leveraging enterprise systems for improved transparency and enhanced decision-making.
RSM was a platinum sponsor for the conference, which was part of CBI's financial series. For more life sciences industry insights, contact us and subscribe to our newsletter.


Transmedic Singapore welcomed the team from St Paul's Hospital, Ilo Ilo, for a visit to our headquarters on 3 March 2016. The group first attended Stryker and RF Ablation product presentations by our product managers, then proceeded to Tan Tock Seng Hospital (TTSH) for a full-day immersion program. Through the program, they were able to learn about best practices from the various departments at TTSH, and form valuable relationships.
Transmedic helped to facilitate and co-organize this program, believing in the importance of providing continuous educational support to our customers.


text:
import os
from pathlib import Path
from types import MethodType
from typing import Type
from unittest.mock import Mock

import pytest
from baby_steps import given, then, when
from pytest import raises

from vedro import Scenario
from vedro.core import VirtualScenario, VirtualStep
from vedro.core._virtual_scenario import ScenarioInitError

@pytest.fixture()
def scenario_():
    scenario = Mock(Scenario)
    scenario.__file__ = os.getcwd() + "/scenarios/scenario.py"
    scenario.__module__ = "scenarios.scenario"
    scenario.__name__ = "Scenario"
    return scenario

@pytest.fixture()
def template_():
    scenario = Mock(Scenario)
    scenario.__file__ = os.getcwd() + "/scenarios/scenario.py"
    scenario.__module__ = "scenarios.scenario"
    scenario.__name__ = "Scenario_0_VedroScenario"
    scenario.__vedro__template_index__ = 0
    scenario.__vedro__template_total__ = 1
    return scenario

@pytest.fixture()
def method_():
    return Mock(MethodType)

def test_virtual_scenario_steps(*, scenario_: Type[Scenario], method_: MethodType):
    with given:
        expected_steps = [VirtualStep(method_), VirtualStep(method_)]
        virtual_scenario = VirtualScenario(scenario_, expected_steps)

    with when:
        actual_steps = virtual_scenario.steps

    with then:
        assert actual_steps == expected_steps

def test_virtual_scenario_unique_id(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        unique_id = virtual_scenario.unique_id

    with then:
        assert unique_id == "c2NlbmFyaW9zL3NjZW5hcmlvLnB5OjpTY2VuYXJpbw"

def test_virtual_scenario_unique_hash(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        unique_hash = virtual_scenario.unique_hash

    with then:
        assert unique_hash == "c6b074186cf075e2044bed1088c30b9af5e6e2c2"

def test_virtual_template_unique_id(*, template_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(template_, [])

    with when:
        unique_id = virtual_scenario.unique_id

    with then:
        assert unique_id == "c2NlbmFyaW9zL3NjZW5hcmlvLnB5OjpTY2VuYXJpb18wX1ZlZHJvU2NlbmFyaW8jMA"

def test_virtual_scenario_path(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        path = virtual_scenario.path

    with then:
        assert path == Path(scenario_.__file__)

def test_virtual_scenario_rel_path(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        path = virtual_scenario.rel_path

    with then:
        assert path == Path("scenarios/scenario.py")

def test_virtual_scenario_subject(*, scenario_: Type[Scenario]):
    with given:
        scenario_.subject = "<subject>"
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        subject = virtual_scenario.subject

    with then:
        assert subject == scenario_.subject

def test_virtual_scenario_without_subject(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        subject = virtual_scenario.subject

    with then:
        assert subject == Path(scenario_.__file__).stem

def test_virtual_scenario_namespace(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        namespace = virtual_scenario.namespace

    with then:
        assert namespace == ""

def test_virtual_scenario_with_subject(*, scenario_: Type[Scenario]):
    with given:
        scenario_.subject = "<subject>"
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        subject = virtual_scenario.subject

    with then:
        assert subject == scenario_.subject

def test_virtual_scenario_is_skipped(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        is_skipped = virtual_scenario.is_skipped()

    with then:
        assert is_skipped is False

def test_virtual_scenario_skip(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario = VirtualScenario(scenario_, [])

    with when:
        res = virtual_scenario.skip()

    with then:
        assert res is None
        assert virtual_scenario.is_skipped() is True

def test_virtual_scenario_init(*, scenario_: Type[Scenario]):
    with given:
        exc_msg = "<message>"
        scenario_.side_effect = (TypeError(exc_msg),)
        virtual_scenario = VirtualScenario(scenario_, [])

    with when, raises(BaseException) as exc_info:
        virtual_scenario()

    with then:
        assert exc_info.type is ScenarioInitError
        assert str(exc_info.value) == ('Can\'t initialize scenario "scenario" '
                                       f'at "scenarios/scenario.py" ({exc_msg})')

def test_virtual_scenario_repr(*, scenario_: Type[Scenario], method_: MethodType):
    with given:
        steps = [VirtualStep(method_), VirtualStep(method_)]
        virtual_scenario = VirtualScenario(scenario_, steps)

    with when:
        res = repr(virtual_scenario)

    with then:
        assert res == f"<VirtualScenario {str(virtual_scenario.rel_path)!r}>"

def test_virtual_scenario_eq_without_steps(*, scenario_: Type[Scenario]):
    with given:
        virtual_scenario1 = VirtualScenario(scenario_, [])
        virtual_scenario2 = VirtualScenario(scenario_, [])

    with when:
        res = virtual_scenario1 == virtual_scenario2

    with then:
        assert res is True

def test_virtual_scenario_not_eq_without_steps(*, scenario_: Type[Scenario]):
    with given:
        another_scenario_ = Mock(Scenario)
        another_scenario_.__file__ = scenario_.__file__
        another_scenario_.__name__ = scenario_.__name__
        virtual_scenario1 = VirtualScenario(scenario_, [])
        virtual_scenario2 = VirtualScenario(another_scenario_, [])

    with when:
        res = virtual_scenario1 == virtual_scenario2

    with then:
        assert res is False

def test_virtual_scenario_eq_with_steps(*, scenario_: Type[Scenario], method_: MethodType):
    with given:
        steps = [VirtualStep(method_), VirtualStep(method_)]
        virtual_scenario1 = VirtualScenario(scenario_, steps)
        virtual_scenario2 = VirtualScenario(scenario_, steps)

    with when:
        res = virtual_scenario1 == virtual_scenario2

    with then:
        assert res is True

def test_virtual_scenario_not_eq_with_steps(*, scenario_: Type[Scenario], method_: MethodType):
    with given:
        steps = [VirtualStep(method_), VirtualStep(method_)]
        virtual_scenario1 = VirtualScenario(scenario_, steps)

        another_method_ = Mock(MethodType)
        another_steps = [VirtualStep(another_method_), VirtualStep(another_method_)]
        virtual_scenario2 = VirtualScenario(scenario_, another_steps)

    with when:
        res = virtual_scenario1 == virtual_scenario2

    with then:
        assert res is False


Thank you for allowing me to testify on behalf of Campaign for Liberty, a free-market advocacy organization founded in 2008 by Dr. Ron Paul.
Campaign for Liberty opposes the renewable fuel standard for several reasons. The standard violates the principles of a free society and harms consumers by forcing them to use biofuels, raising fuel costs and forcing consumers to spend more on fuel, and less on other goods, than they would prefer. The mandate also harms consumers by diverting the use of corn from food to fuel production, thus increasing food prices and even causing shortages.
Furthermore, interventions in the marketplace that favor certain producers encourage those producers and their rivals to spend their time, money, and talent lobbying legislators and federal agencies to maintain and expand their subsidies. The resources spent on lobbying would be better spent developing new products that better serve the needs of consumers.
Finally, the mandate exceeds the powers granted to the government by the United States Constitution. If the renewable fuel standard, and all other interference in the fuel marketplace, was repealed, entrepreneurs could find innovative ways to provide consumers with affordable energy that protects the environment. For all these reasons, the renewable fuel standard should be repealed.