text:
Russia successfully disconnected its homegrown RuNet from the Internet
The new system is expected to be fully operational in 2021
By Adrian Potoroaca December 25, 2019, 13:07 22 comments
Through the looking glass: For Russian President Vladimir Putin, the "free internet" and "sovereign internet" concepts aren't mutually exclusive. The country recently performed several successful tests that simulated how it would respond in case of a foreign cyber attack.
News broke in February that Russia was planning to disconnect itself from the Internet to see what would happen in case of foreign aggression. To that end, the Russian government had to pass a law requiring internet service providers to make it possible to inspect all outbound traffic and maintain an isolated intranet dubbed RuNet if necessary.
This week, the country performed a series of unprecedented tests to simulate the conditions of a foreign cyber attack and its ability to keep its internal infrastructure operational while blocking all inbound and outbound traffic. The tests started last week and involved state-run institutions, as well as telecom providers and internet companies.
Deputy communications minister Alexei Sokolov told reporters "it turned out that, in general, that both authorities and telecom operators are ready to effectively respond to possible risks and threats and ensure the functioning of the Internet and the unified telecommunication network in Russia."
Russia sees the creation of a "sovereign internet" as a necessary move in the context of ever-increasing social media influence and cyber attacks. Not much is known about the specifics of the tests, but a total of 18 attack scenarios were simulated to determine if federal and commercial telecom operators can effectively separate Russia from the Internet while still allowing access to local services using a DNS cache.
While country officials may present these efforts as purely defensive in nature, it's not hard to imagine they could be used as an excuse for different motives. Some speculate that Russia wants to tighten surveillance and censorship in a similar fashion to China, on top of requiring all smartphones to come with Russian software pre-installed.
The results will be presented to President Vladimir Putin next year, and the RuNet system is supposed to become fully operational in 2021.
In related news, the Russian government is planning to invest $31 million to create its own Wikipedia.
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Archive | January 2020
"Moebius syndrome is a rare neurological condition that primarily affects the muscles that control facial expression and eye movement."
U.S. Library of Medicine (NIH.gov)
Part I Moebius Syndrome
Moebius syndrome is a rare neurological disorder characterized by weakness or paralysis (palsy) of multiple cranial nerves, most often the 6th (abducens) and 7th (facial) nerves. Other cranial nerves are sometimes affected. The disorder is present at birth (congenital). If the 7th nerve is involved, the individual with Moebius syndrome is unable to smile, frown, pucker the lips, raise the eyebrows, or close the eyelids. If the 6th nerve is affected, the eye cannot turn outward past the midline. Other abnormalities include underdevelopment of the pectoral muscles and defects of the limbs. Moebius syndrome is not progressive. The exact cause is unknown. It appears to occur randomly (sporadically) in most cases; however, some cases occur in families suggesting that there may be a genetic component.
Congenital facial and abducens palsy was first described by Von Graefe (1880) and Moebius (1888), a German neurologist after whom the syndrome was later named.
Signs and Symptoms:
The abnormalities and severity of Moebius syndrome vary greatly from one person-to-another. The classically accepted diagnostic criteria include: 1) facial paralysis or weakness affecting at least one but usually both sides of the face (7th cranial nerve), 2) paralysis of sideways (lateral) movement of the eyes (6th cranial nerve); and 3) preservation of vertical movements of the eyes. Less often, other cranial nerves, including the 5th, 8th, 9th, 10th, 11th, and 12th may be affected.
Infants with Moebius syndrome may drool excessively and exhibit crossed eyes (strabismus). Because the eyes do not move from side-to-side (laterally), the child is forced to turn the head to follow objects. Infants who lack facial expression often are described as having a "mask-like" face that is especially obvious when laughing or crying. Affected infants may also have difficulties feeding, including problems swallowing and poor sucking. Corneal ulceration may occur because the eyelids remain open during sleep.
There are a wide variety of additional abnormalities. Some children with Moebius syndrome have a short, malformed tongue and/or an abnormally small jaw (micrognathia). Cleft palate may also be present. These abnormalities contribute to feeding and breathing difficulties. Children with cleft palate are prone to ear infections (otitis media). There may be external ear anomalies including underdevelopment of the outer portion of the ear (microtia) or total absence of the outer portion of the ear (anotia). If the 8th cranial nerve is affected, there is likely hearing loss. Dental abnormalities are not uncommon. There is an increased risk for childhood cavities. Some affected children have difficulties with speech and delays in speech development.
Skeletal malformations of the limbs occur in over half of children with Moebius sydrome. Lower limb malformations include clubbed feet and underdevelopment of the lower legs; upper extremities may have webbing of the fingers (syndactyly), underdevelopment or absence of the fingers, and/or underdevelopment of the hand. In a few children there may be abnormal side-to-side curvature of the spine (scoliosis), and in approximately 15% of patients underdevelopment of the chest (pectoral) muscles and the breast on one side of the body also occur (see Poland-Moebius syndrome in the Related Disorder section below).
Some affected children exhibit delay in attaining certain milestones such as crawling or walking, most likely due to upper body weakness; however, most children eventually catch-up. Moebius syndrome rarely is associated with minor intellectual disability. Some children have been classified as being on the "autistic spectrum". The exact relationship between Moebius syndrome and autism is unknown. Some studies have suggested that autism spectrum disorders occur with greater frequency in children with Moebius syndrome; other studies have not confirmed this and suggest that any such relationship is overstated. Moebius syndrome is often associated with a variety of social and psychological consequences. The lack of facial expressions and the inability to smile can cause observers to misinterpret what an affected individual is thinking or feeling or intends. Although clinical anxiety and depression are not more common in children and adolescents with Moebius syndrome, affected individuals may avoid social situations due to apprehension and frustration.
"Once I overcame breast cancer, I wasn't afraid of anything anymore."
"Staying at a healthy weight, being physically active, and limiting how much alcohol you drink can help reduce your risk of breast cancer."
"Winter can be brutal, but research shows you might get some health benefits during the colder months. When it's cold, your body has to work harder to maintain its core body temperature — and as a result, you might burn more calories. Colder temperatures can help reduce both allergies and inflammation."
Is cold weather good or bad for your health?
It depends. Cold weather can be hard on your health in some ways, but it also be good for it, reports the January 2010 issue of the Harvard Health Letter. Most of us spend the winter trying to stay warm, but a little bit of exposure to cold may not be such a bad thing. There are two types of fat in the human body: white fat and brown fat. Brown fat is the heat-producing, calorie-burning fat that babies need to regulate their body temperatures. Most of it disappears with age, but adults retain some brown fat. Dutch researchers reported findings last year that showed that moderately cool temperatures of 61° F activated brown fat in 23 of 24 study volunteers. This is a good thing because brown fat burns calories more efficiently than white fat, and so may help control weight.
It can be tempting to spend the coldest mornings safely tucked under the covers; it's only natural to want to avoid the most brutal temps. But during periods of such weather-induced isolation, we tend to reach out to contact our closest friends and family on the phone, and end up chatting with them for longer than usual, according to studies of 2012.
For some insects and even animals the freezing cold is not suitable for them and regarding our health well look here; during the summer of 2012 — when West Nile cases were climbing — much was made of the milder 2011-2012 winter and its effect on the disease-spreading mosquito population. The pests thrive in milder climates, meaning they were able to survive — and breed — all winter, just waiting to feast come spring. Freezing or below-freezing temps might kill off some skeeters (and ticks), thereby protecting you from the illnesses they are known to spread.
Through Psychology Today, some research suggests that if the weather never changes, you start taking that sunshine for granted. Shivering through the cold makes those warm spring days seem even better when they finally come along.
There's a reason putting ice on an injury works. That drop in temperature reduces inflammation in, say, a sprained ankle or stubbed toe. But the theory works on a much grander scale, too — cold temperatures can reduce inflammation and pain all over. In one recent study, researchers in Finland studied 10 women as they took 20-second plunges into near-freezing water, and also partook in sessions of cold-body cryotherapy (exposing the body to ultra-low temps for brief periods). After being exposed to the cold, participants' blood showed three times as much norepinephrine, a naturally occurring chemical that may help suppress pain. In fact, athletes and spa-goers even have a remedy of sorts available for muscle recovery. A 2011 study found that, at extremely low temperatures, such treatments, called cryotherapy, did more for athletes to recover from physical activity than simply resting. Runners who were exposed to temperatures as low as -166 degrees F recovered from exercise faster than those who given other therapies or told to rest, The Atlantic reported. Live in a cold-weather climate? Then you're well aware that we've got a few more weeks of icy temps to endure. But those bitter winds could be doing you more good than you'd think: Preliminary research shows they may lead to a longer life.
In a study published in a recent issue of cell, researchers from the Department of Molecular and Integrative Physiology at the University of Michigan discovered that worms exposed to cold temperatures demonstrate a genetic response that triggers longer life spans.
Studies have shown that exposure to freezing temperatures, even for short periods, can significantly increase your energy expenditure for hours afterward. Swim a few laps in cool water, or take a power walk in winter weather, to enjoy the perk up for your workout.
So enjoy the cold!
"Cotard delusion, also known as or nihilistic delusion or walking corpse syndrome or Cotard's syndrome , is a rare mental disorder in which the affected person holds the delusional belief that they are already dead, do not exist, are putrefying, or have lost their blood or internal organs."
Cotard's syndrome
One of the main symptoms of Cotard delusion is nihilism. Nihilism is the belief that nothing has any value or meaning. It can also include the belief that nothing really exists. People with Cotard delusion feel as if they're dead or rotting away. In some cases, they might feel like they've never existed.
While some people feel this way about their entire body, others only feel it in regard to specific organs, limbs, or even their soul.
Depression is also closely related to Cotard delusion. A 2011 review of existing research about Cotard delusion notes that 89% of documented cases include depression as a symptom.
Other symptoms include:
hypochondria
preoccupation with hurting yourself or death
Researchers aren't sure what causes Cotard delusion, but there are a few possible risk factors. Several studies indicate that the average age of people with Cotard delusion is about 50. It can also occur in children and teenagers. People under the age of 25 with Cotard delusion tend to also have bipolar depression. Women also seem to be more likely to develop Cotard delusion.
In addition, Cotard delusion seems to occur more often in people who think their personal characteristics, rather than their environment, cause their behavior. People who believe that their environment causes their behavior are more likely to have a related condition called Capgras syndrome. This syndrome causes people to think their family and friends have been replaced by imposters. Cotard delusion and Capgras syndrome can also appear together.
Other mental health conditions that might increase someone's risk of developing Cotard delusion include:
depersonalization disorder
Cotard delusion also seems to be associated with certain neurological conditions, including:
brain infections
How its diagnosed:
Diagnosing Cotard delusion is often difficult because most organizations don't recognize it as a disease. This means there's no standardized list of criteria used to make a diagnosis. In most cases, it's only diagnosed after other possible conditions have been ruled out.
If you think you might have Cotard delusion, try to keep a journal of your symptoms, noting when they occur and how long they last. This information can help your doctor narrow down the possible causes, including Cotard delusion. Keep in mind that Cotard delusion usually occurs alongside other mental illnesses, so you might receive more than one diagnosis.
Treatment for the disease:
Cotard delusion usually occurs with other conditions, so treatment options can vary widely. However, a 2009 review found that electroconvulsive therapy (ECT) was the most commonly used treatment. It's also a common treatment for severe depression. ECT involves passing small electric currents through your brain to create small seizures while you're under general anesthesia.
However, ECT does carry some potential risks, including memory loss, confusion, nausea, and muscle aches. This is partly why it's usually only considered after other trying other treatment options, including:
Berrios GE, et al. (1995). Cotard's syndrome: Analysis of 100 cases. DOI:
doi.org/10.1111/j.1600-0447.1995.tb09764.x
healthline (www.healthline.com) January 2, 2018 Written by Nancy Moyer.
Debruyne H, et al. (2009). Cotard's syndrome: A review.
ncbi.nlm.nih.gov/pubmed/19470281
Grover S, et al. (2014). Cotard's syndrome: Two case reports and a brief review of literature. DOI:
doi.org/10.4103/0976-3147.145206
Huarcaya-Victoria J, et al. (2016). Cotard's syndrome in a patient with schizophrenia: Case report and review of the literature. DOI:
doi.org/10.1155/2016/6968409
Moschopoulos NP, et al. (2016). Cotard's syndrome: Case report and a brief review of literature.
doi.org/10.22365/jpsych.2016.274.296
Sahoo A, et al. (2017). A neuropsychiatric analysis of the cotard delusion. DOI:
doi.org/10.1176/appi.neuropsych.17010018
Samico A, et al. (2017). Cotard syndrome: Pathology review. DOI:
dx.doi.org/10.1016/j.eurpsy.2017.01.1382
Solimine S, et al. (2016). Cotard syndrome: "I'm dead, so why do I need to eat?". DOI:
doi.org/10.4088/pcc.15l01862
"Stone Man Syndrome. Extremely rare disease of connective tissue. A mutation of the body's repair mechanism causes fibrous tissue (muscle, tendon, ligament) to be ossified when damaged. In some cases, injuries can cause joints to become permanently frozen in place. The gene that causes ossification is normally deactivated after a fetus bones are formed in the womb, but in patients with FOP, the gene keeps working."
Fibrodysplasia Ossificans Progressiva/Stone Man Syndrome
Fibrodysplasia ossificans progressiva (FOP)
It is a disorder in which skeletal muscle and connective tissue, such as tendons and ligaments, are gradually replaced by bone (ossified). This condition leads to bone formation outside the skeleton (extra-skeletal or heterotopic bone) that restricts movement.
This process generally becomes noticeable in early childhood, starting with the neck and shoulders and moving down the body and into the limbs. People with FOP are born with abnormal big toes (hallux valgus) which can be helpful in making the diagnosis. Trauma, such as a fall or invasive medical procedure, or a viral illness may trigger episodes of muscle swelling and inflammation (myositis). These flareups lasts for several days to months and often result in permanent bone growth in the injured area.
FOP is almost always caused by a mutation at the same place in the ACVR1 gene (The ACVR1 gene provides instructions for making the activin receptor type-1 (ACVR1) protein, which is a member of a protein family called bone morphogenetic protein (BMP) type I receptors.) and is inherited in an autosomal dominant manner. This condition occurs in about 1 in 1,600,000 newborns and about 800 people worldwide are known to have FOP.
-Fibrodysplasia ossificans progressiva (FOP) is characterized by the gradual replacement of muscle tissue and connective tissue (such as tendons and ligaments) by bone, restricting movement. This process generally becomes noticeable in early childhood, starting with the neck and shoulders and proceeding down the body and into the limbs.
-The formation of extra-skeletal bone causes progressive loss of mobility as the joints become affected. Speaking and eating may also become difficult as the mouth becomes affected. Over time, people with FOP may become malnourished because of the inability to eat. They may also develop breathing difficulties as a result of extra bone formation around the rib cage that restricts expansion of the lungs.
-Any trauma to the muscles of an individual with FOP (a fall or an invasive medical procedure) may trigger episodes of muscle swelling and inflammation followed by more rapid ossification in the injured area. Flare-ups may also be caused by viral illnesses such as the flu.
-Affected individuals may also have short thumbs and other skeletal abnormalities.
-Fibrodysplasia ossificans progressiva is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder.
-Most cases of fibrodysplasia ossificans progressiva result from new mutations in the gene. These cases occur in people with no history of the disorder in their family. In only a small number of cases, an affected person has inherited the mutation from one affected parent.
How this disease is diagnosed:
-Making a diagnosis for a genetic or rare disease can often be challenging. Healthcare professionals typically look at a person's medical history, symptoms, physical exam, and laboratory test results in order to make a diagnosis. The following resources provide information relating to diagnosis and testing for this condition. If you have questions about getting a diagnosis, you should contact a healthcare professional.
-The Genetic Testing Registry (GTR) provides information about the genetic tests for this condition. The intended audience for the GTR is health care providers and researchers. Patients and consumers with specific questions about a genetic test should contact a health care provider or a genetics professional.
There is currently no definitive treatment. However, a brief course of high-dose corticosteroids, such as Prednisone, started within the first 24 hours of a flare-up, may help reduce the intense inflammation and tissue swelling seen in the early stages of fibrodysplasia ossificans progressiva. Other medications, such as muscle relaxants, mast cell inhibitors, and aminobisphosphonates, if appropriate, should be closely monitored by a physician. Surgery to remove heterotopic and extra-skeletal bone is risky and can potentially cause painful new bone growth.
Fibrodysplasia ossificans progressiva. Genetics Home Reference (GHR). August 2007; http://ghr.nlm.nih.gov/condition/fibrodysplasia-ossificans-progressiva.
FOP Fact Sheet. International Fibrodysplasia Ossificans Progressiva Association. http://www.ifopa.org/what-is-fop/overview.html. Accessed 6/5/2014.
Pignolo R, Kaplan F. Pediatric Fibrodysplasia Ossificans Progressiva. E-medicine. July 30, 2009; http://emedicine.medscape.com/article/1007104-overview. Accessed 3/17/2011

redpajama_set_name: RedPajamaCommonCrawl


text:
Deze lijst van voetbalinterlands is een overzicht van alle officiële voetbalwedstrijden tussen de nationale teams van Cuba en Zuid-Korea. De landen hebben tot op heden één keer tegen elkaar gespeeld. De eerste ontmoeting, een groepswedstrijd tijdens de CONCACAF Gold Cup 2002, werd gespeeld op 23 januari 2002 in Pasadena (Verenigde Staten).

Wedstrijden

Samenvatting

Wedstrijden bepaald door strafschoppen worden, in lijn met de FIFA, als een gelijkspel gerekend.

Zuid-Korea
Cuba

redpajama_set_name: RedPajamaWikipedia


text:
Eugen Schönebeck
Date/place of birth
1936 Heidenau
Eugen Schönebeck - Untitled
Works by Eugen Schönebeck buy
Buy works by Eugen Schönebeck in our upcoming auctions!
Works by Eugen Schönebeck sell
Do you own a work by Eugen Schönebeck, which you would like to sell?
Eugen Schönebeck - Works that have already been sold at Kunsthaus Lempertz:
Eugen Schönebeck - Ohne Titel
Eugen Schönebeck - Ohne Titel (Figurenstudie) / Untitled (figure study)
Eugen Schönebeck - Ohne Titel (Soldaten)
Eugen Schönebeck biography
Eugen Schönebeck is among Germany's most important representational painters in the second half of the 20th century. He initially studied painting at the Master School of Applied Arts in East Berlin from 1954 to 1961 and, later, at the College of Fine Arts in West Berlin, under Hans Jaenisch and Hans Kuhn. He and his friend Georg Baselitz wrote the Pandemonic Manifestos in 1961/62, in which they criticised the world of art for being bourgeois and oversaturated. In his paintings, which can be described as Social Realism, Schönebeck focuses on traumatic experiences during the Second World War. He often showed dead or suffering bodies, e.g. in his crucifixion scenes, which were inspired by Francis Bacon, and in his key painting "The True Man" (1964). His large-format portraits of isolated figures, set against a monochrome background, illustrate the artist's profound interest in the human face behind the political icon (his series "Heroes of the East", including "Red Army Soldier" and portraits of Communist politicians such as Leo Trotsky and Mao Zedong, 1965). His ink drawings are hybrids of human beings and animals. Many of his graphic art, too, is about death. Schönebeck stopped painting in 1967 and withdrew from the art business altogether. However, his extensive oeuvre continues to be displayed at exhibitions and collections throughout the world. He was represented at documenta 6 in Kassel and at the Venice Biennial in 1990. In 1992, he was awarded the Fred Thieler Prize for Painting. In 2011, a major retrospective was dedicated to him by Kunsthalle Schirn in Frankfurt.
© Kunsthaus Lempertz
Eugen Schönebeck Prices
Eugen Schönebeck Untitled €24.400
Eugen Schönebeck Ohne Titel €9.520
Eugen Schönebeck - Current offers and reference objects
Estimate 10.000 €


Decorative, lovely form plant with bright green leaves crowded at the tips of the branches.
This small evergreen tree is fast growing in the sun. The green/yellow flowers open in Autumn. This decorative tree is a lovely form plant with bright green leaves crowded at the tips of the branches and long bare stems. The fruit are fleshy and purple when ripe and they attract birds and butterflies. Ideal for a small garden but it does have aggressive roots so don't plant less than 5 meters from a wall or a pool. It requires good drainage and thrives on lots of compost. The Leaves are browsed by elephant and kudu and people eat the roots to obtain moisture. The roots and bark are also eaten by black rhino, baboon and bushpigs. It is frost tender in cold gardens. An infusion of the root is used medicinally for malaria, stomach complaints and V D. The roots are also chewed for virility and strength. They taste similar to sugar cane. The grated bark is used in hot water to make a poultice for cramp and muscle spasm. This solution is also used to bath newborn babies to ensure a strong child and prevent skin rashes and pimples. Some folk believe that it one is planted near the homestead, it will ensure fat, healthy children. Dried flowers are added to snuff. The leaves are used as a fish poison but are palatable to cattle and goats. Named for Pierre Cusson 1727-1783 who was a French Jesuit, mathematician, physician, professor and botanist who traveled extensively and wrote many publications.


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If you are like most of the blog world, you know about our gigantic antique shows here in Texas, specifically in Round Top and in Warrenton. And if you are like me and thousands of other bloggers around the world, who love French Antiques and a great story, you've been following the adventures of antiques dealers, Lynn and Corey A.K.A. Thelma and Louise, via Corey's blog, Tongue in Cheek.
If you are a follower of Corey's blog, you know that she never does things like an ordinary person. Each of us knowing this, another would-be customer and I were still blown away when we attempted to buy antique French letters...Corey gave each of us the letter we had selected for purchase!
This is my 1780 French business letter.
Corey, you are supposed to sell not give the French antiques away. Regardless, I am charmed by the beautiful French letter which you bestowed upon me. Merci, Merci, Merci!!!
Note: More photos from the opening day at Marburger Farm Antique Show are to follow this week.
I can probably translate the letter ... if need be.
What a fabulous place and what a generous person to give you this treasure! How awesome!
Also, Annie, thanks so much for entering my giveaway! Good luck!


text:
In the forgotten margins of the segregated communities of a dystopian future, a woman searches for the daughter that she lost upon her arrest years ago.
Genre: Drama, Sci-Fi & Fantasy, War & Politics
Director: Urmi Juvekar
Actors: Adarsh Gourav, Akash Khurana, Arif Zakaria, Huma Qureshi, Rahul Khanna, Sanjay Suri, Siddharth, Vidhi Chitalia
Studio: Open Air Films
Networks: Netflix
Follow the elite and experimental Clones of the Bad Batch as they find their way in a rapidly changing galaxy in the aftermath of the Clone Wars.
The sleepy Pacific Northwest town of Eureka is hiding a mysterious secret. The government has been relocating the world's geniuses and their families to this rustic town for years where…
Genre: Comedy, Drama, Sci-Fi & Fantasy
Secret Nazi Ruins
From tunnels to towers, artillery sites, resistance nests and communication centers, Nazi Germany left their footprint throughout the world. To this day, silent remains still exist, sentinels guarding clues about…
59,45,42,55 min
The Killing is an American crime drama television series based upon the Danish television series Forbrydelsen. Set in Seattle, Washington, the series follows the various murder investigations by homicide detectives…
The Name of the Rose
Northern Italy, 1327. The Franciscan monk William of Baskerville and his young apprentice Adso of Melk reach an isolated Benedictine abbey on the Alps to aid in a dispute between…
Genre: Drama, Mystery, War & Politics
A hilarious workplace comedy about a unique family of employees at a super-sized mega store. From the bright-eyed newbies and the seen-it-all veterans to the clueless summer hires and the…
Satirical sketch comedy set and filmed in Portland, Oregon that explores the eccentric misfits who embody the foibles of modern culture.
Hundreds of cash-strapped players accept a strange invitation to compete in children's games. Inside, a tempting prize awaits — with deadly high stakes.
Genre: Action & Adventure, Drama, Mystery
A single mother enters a world of twisted mind games when she begins an affair with her psychiatrist boss while secretly befriending his mysterious wife.
Dr. Temperance Brennan and her colleagues at the Jeffersonian's Medico-Legal Lab assist Special Agent Seeley Booth with murder investigations when the remains are so badly decomposed, burned or destroyed that the standard…
An only child finds her life turned upside down when her father reveals that, over the course of his prize-winning career as a pioneering fertility doctor, he used his own…
Trailer: Leila


In honor of Valentine's Day, Dunkin' Donuts teamed up with a wedding chapel in Vegas to throw a bunch of donut themed weddings this weekend.
The first 100 couples who get married at the wedding chapel on Saturday after 11:00 A.M. will get a FREE wedding and it includes a Dunkin' Donuts bouquet.
They're going all out for it too. The chapel will also be covered in Dunkin' Donuts decorations, and the officiant will have their hair dyed the pink color from Dunkin's logo.
This is definitely taking a Vegas style wedding to the next level.


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Home / Energy and Environment / New energy report tilts the cost balance towards renewables
New energy report tilts the cost balance towards renewables
Claire Ginn | December 25, 2018
The national science agency, CSIRO and energy market operator, AEMO have announced a new report on the costs of electricity generation which argues that renewable energy now powers the cheapest new power plants.
The inaugural GenCost report, prepared in collaboration with a range of industry stakeholders, updates estimates of the cost to generate electricity from new power plants in Australia and argues that solar and wind technologies can be built at lower cost than fossil fuel stations.
Paul Graham, CSIRO's Chief Energy Economist and the lead author of the report, said GenCost 2018 is an essential annual benchmark to guide strategic decision making, given technology costs change significantly each year.
"Electricity generation costs are a key ingredient into the electricity sector modelling which underpins much of the sector's strategic planning and policy analysis," Mr Graham said.
"Our data confirms that while existing fossil fuel power plants are competitive due to their sunk capital costs, solar and wind generation technologies are currently the lowest-cost ways to generate electricity for Australia, compared to any other new-build technology.
"At a global level, the investment costs of a wide range of low emission generation technologies are projected to continue to fall, and we found new-build renewable generation to be least cost, including when we add the cost of two or six hours of energy storage to wind and solar.
"This also holds when the cost of fossil generation technology is adjusted for climate policy risk or not.
"Data from GenCost 2018, combined with some of our previous research, indicates we may need additional flexible technologies – such as energy storage, demand management, and peaking gas plants – if the share of variable renewables increases beyond 50 per cent."
The collaborative process involved consultation with a broad range of industry stakeholders, including the release of draft estimates and projections for review and industry workshops and briefings.
Nicola Falcon, AEMO's Manager of Forecasting, said her organisation is looking forward to using the GenCost figures.
"The reports will act as the foundation for initial discussions with stakeholders when we commence our modelling inputs and scenario consultations for the next Integrated System Plan," Ms Falcon said.
The report's authors based their analysis on the "levelised cost of electricity", which includes operating as well as investment costs, and is the most common way to compare the costs of different technologies. Fossil fuel plants require relatively low capital costs and have higher operating expenses, while wind and solar demand high capital outlays but have lower operating costs.
Research planned for 2019 will investigate in more detail the best way to balance the costs of electricity generation as renewables continue to increase their importance in the industry.
Claire Ginn
Claire Ginn is a Communication Manager at CSIRO. She focuses on energy and climate and has led media and publicity activities for public, private and not-for-profit sector organisations on an international scale.
Alan Stevenson
The best areas to build renewable power plants tend to be those situated far from the infrastructure needed to transport the electricity to those areas where it is most needed. The coal and gas plants currently in operation have been experiencing problems especially during the current hot spell, so the argument that they are more reliable s beginning to look a bit fraught.
Since the cost of building a renewable plant is now less than that of a new coal or gas one, surely the best option would be to extend the infrastructure (poles, lines, and transformers) at taxpayers' expense to be repaid from the profits?
A shift in thinking
Is rationality returning to the official debate over the "war on terrorism"?
Brave new thinking in a brave new world II
Employment opportunity at Global Access Partners
Collaboration is Key to Keeping Australians Safe Online
Big Data: Our Future or Censor?
Red tape "threat to growth"?
Business input to privacy & security frameworks that deliver: RSA, End to End Trust & the remarks of Microsoft's Scott Charney


text:
Department scores own coal: firm gets mining rights next to Big Five reserve
By NewsroomNovember 9, 2021Law & legislation, Wildlife Crime
Mining activity near the game reserve could increase rhino poaching in the region. Image: 123RF.com
Tania Broughton, Sunday Times Daily | November 3, 2021
A "Big Five" private nature reserve in KwaZulu-Natal is under threat with the ministry of forestry, fishing and environment, authorising a "prospecting" licence to a private company which seeks to mine coal within its boundaries and on its borders.
Nambiti Private Reserve has gone to court, seeking to stop any mining-linked activity which, it says, will devastate the "delicate ecosystem", affecting not only the tourist attraction but other landowners in the area.
The 23,000 acre reserve is situated near Ladysmith.
The property was the subject of a successful claim by the Senzo'kuhle Nkos'Unodada communal property trust and was transferred to the trust in 2009.
Simultaneously, the trust entered into a 35-year lease agreement with Nambiti to operate the nature reserve. In terms of the deal, the community was given shares in Nambiti and in some of its 10 lodges.
In an affidavit, which came before Pietermaritzburg high court judge Peter Olsen, in an urgent bid to stop prospecting, Nambiti chairperson Clarke Smith said the project had been lauded as one of the most successful land claims in SA.
"Already more than 300 jobs have been created and the community's ownership represents a substantial inroad into the transformation of the industry."
He said in February 20919, Richards Bay-based company ZP Holdings made an application to the minister for prospecting rights on part of the reserve, "which would be an unbelievable incursion, even on the level of research, surveys and so-called invasive work".
He said the reserve and neighbouring landowners were not given notice of the application and it had been brought to his attention after a notice was stuck on a pole in the neighbourhood.
He had immediately noted an objection, pointing out that the application did not disclose that part of the area under consideration for a mining licence included the nature reserve.
"The reserve is well known in the area. It is impossible that they would not know of it. The department also should have been aware, if it had bothered to do any due diligence."
He pointed out that any work, even so-called "non invasive" work, would mean employees would be working close to dangerous wildlife and, further, it could potentially increase the risk of poaching, particularly of rhino.
He said the notice regarding the application had not included a proper map to those potentially affected, so they would have an understanding of the location of the proposed mine.
However, he had engaged the services of land surveyor Mark Turnbull, who had determined that the prospecting rights incorporated an area within the reserve, on its boundaries and within a 5km buffer zone.
Smith said the prospecting and mining would also have an effect on the water quality of rivers and underground water.
He said in June this year, the department of mineral resources and energy advised by email that it had agreed to grant a licence to ZP Holdings.
Smith said in large part it had relied on a basic assessment report provided by ZP Holdings, which set out a prospecting works programme and the potential impact of the activities.
No mention was made that the land formed part of a protected reserve.
In terms of legislation, any appeal had to be lodged with forestry, fisheries and environment minister Barbara Creecy.
Smith said the appeal was submitted late because of Covid-19 and the unrest in the province.
"I applied for condonation and the acting director, appeals and legal review, notified us that condonation had been granted.
"I expected the minister to hear the appeal. But instead she overturned the condonation decision."
In the matter before judge Olsen, which was argued by adv David Saks, Smith sought an interdict stopping any sort of prospecting or mining activity pending a review of the authority given by mineral resources.
However, ZP Holdings's Phumlani Zuma launched a counter application, saying Creecy's decision not to hear the appeal was clearly wrong.
Zuma, in his affidavit, said an internal appeal was the "best forum to traverse the demerits" of Nambithi's stance.
He undertook not to conduct any prospecting activities until that appeal was finally determined.
Judge Olsen issued an order, giving all parties until November 23 to file any opposition as to why he should not set aside Creecy's decision and order that she hear the internal appeal.
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promoting their products as quickly as possible.
Apple Powerbook – Is It Better Than The Other Laptops?


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Editorial Oversight
MedEdPORTAL
Delivering Challenging News: An Illness-Trajectory Communication Curriculum for Multispecialty Oncology Residents and Fellows
Daniel Cannone, DO, Mark Atlas, MD, Alice Fornari, EdD, Maria-Louise Barilla-LaBarca, MD, Mark Hoffman, MD
Published: April 25, 2019 | 10.15766/mep_2374-8265.10819
Fellow Pre- & Postcourse Survey.docx
Adult OSCE 1.docx
Peds OSCE 1.docx
Peds OSCE Parent 1.docx
SP Evaluation Tool.docx
Faculty Evaluation Tool.docx
Faculty Evaluation Tool Score Sheet.xlsx
Role-Play Workshop.pptx
Module 1 Fundamentals of Communication.pptx
Module 2 Patient as Person.pptx
Module 3 Treatment Issues.pptx
Module 4 Breaking Bad News.pptx
Module 5 Communicating With AYA Population.pptx
Module 6 Communicating With Family.pptx
Module 7 Transition to Palliative Care.pptx
Module 8 Mindfulness.pptx
Role-Play Scripts.docx
1-Year Postcourse Survey.docx
All appendices are peer reviewed as integral parts of the Original Publication.
To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.
Introduction: Published curricula to teach communication skills for postgraduate fellows in oncology are few in number despite the fact that oncologists conduct many difficult discussions with their patients and their families. Such discussions may include disclosing initial diagnosis or relapse of a patient's cancer or relaying a poor prognosis or change to palliative care. Methods: An eight-module course on communication in oncology practice was delivered over 2 months for palliative and oncology fellows and radiation oncology residents. Learners were given a precourse survey in which they were asked to rate their proficiency in various communication tasks. Each learner then participated in a videotaped precourse objective structured clinical exam (OSCE) on breaking bad news with standardized patients (SPs). The course took place over 8 weeks with weekly didactics and role-play. At the end of the course, a second OSCE took place. After the course was completed, the fellows again filled out a proficiency survey. Results: Twenty-two learners participated over 2 years of this course. Participants reported a significant increase in perceived competence in all areas on the postcourse survey. SP feedback on OSCEs pre- and postcourse indicated improvement in skills for learners. Pre- and postcourse OSCE video assessment revealed a significant improvement in global communication skills. Discussion: Initial data show that this course successfully improved communication skills and increased fellows' comfort level across several domains of communication. Future directions include validating our assessment tool, expanding the topic base, and investigating the impact on practice after course completion.
Oncology, Editor's Choice, Standardized Patient, Communication Skills, Radiation Oncology, Role-Play, Pediatric Hematology-Oncology, Hospice and Palliative Medicine, End-of-Life/Palliative Care, Psycho-Oncology
By the end of this activity, learners will be able to:
Use fundamental communication skills in the practice of caring for patients with oncologic diagnoses.
Participate in role-play activities as part of an educational session.
Assess the patient with cancer as an individual, including premorbid personality, coping systems, and spirituality.
Demonstrate delivering difficult information (breaking bad news) using the MR. SPIKES model.
Incorporate details of an illness narrative/trajectory into decision making to partner with their patient.
Communication skills in medical care are critical for the success of the doctor-patient relationship and, by proxy, health outcomes. Good communication skills have been associated with improved patient satisfaction, increased adherence, and decreased incidence of malpractice lawsuits.1 Communication skills are now a program educational requirement according to the Accreditation Council for Graduate Medical Education's common program requirements for residents2 (section IV.A.5.d: "Residents are expected to: communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds") and for fellows3 (section IV.B.1.e: "Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals").
In the field of oncology, communication skills are paramount, as the life-threatening or life-limiting nature of the conditions encountered in this field create multiple challenges for practitioners, both those in training and seasoned oncologists. The ability to talk to patients about a new diagnosis, poor prognosis, relapse, imminent death, or death itself is not innate, nor is it commonly taught at any level of training. Kissane and colleagues4 identified eight key communication skills that should be emphasized when training oncology professionals: breaking bad news, discussing prognosis and risk, shared decision making, responding to emotions, dealing with recurrence, transition to palliative care, running a family meeting, and discussing death and dying. In 2016, the European Society for Medical Oncology and the American Society of Clinical Oncology published their updated recommendations for a global curriculum in medical oncology, which feature communication as a competency to be included in medical oncology training.5 More recently, a systematic review by the American Society of Clinical Oncology (with Walter F. Baile as the senior author) was published with more specific recommendations for communication training.6 Recommendations 9.1 and 9.2 are as follows:
9.1. Communication skills training should be based upon sound educational principles and include and emphasize skills practice and experiential learning using role-play scenarios, direct observation of patient encounters, and other validated techniques.
9.2. In order for communication skills training to be most effective, it should foster practitioner self-awareness and situational awareness related to emotions, attitudes, and underlying beliefs that may impact communication, as well as awareness of implicit biases that may affect decision making.6
Curricula in oncology communication skills do exist, with emphasis on most, if not all, of these areas; better-known curricula include EPEC-O, VITALtalk, and I*CARE. Modules on communication skills not specific to oncology can be found in MedEdPORTAL—notably, most of these modules use similar pedagogies of objective structured clinical exams (OSCEs) or modified OSCEs, standardized patients (SPs), and role-play.7-13
In addition to quality curricula in communication, tools for remembering key skills in communication, such as delivering challenging news, have been created. One of the most well-known and commonly used tools in oncology is SPIKES, a mnemonic to help learners plan patient encounters when bad news needs to be given.14 The acronym stands for Setting up the interview, assessing the patient's Perception, obtaining the patient's Invitation, giving Knowledge and information to the patient, addressing the patient's Emotions with empathetic responses, and Strategy and Summary. This tool was designed with oncology patients in mind and has been adapted for use with pediatric oncology patients (changing Invitation to Involvement).13 As a communication tool, it provides a framework for breaking bad news in a structured format, with the intent of having the bearer of bad news be organized, prepared, and empathetic.
Putting such tools as SPIKES into practice does not come naturally for practitioners and perhaps comes even less easily for learners with comparatively little experience. Allowing learners to practice breaking bad news away from the stressful clinical setting and separate from actual patients, with potentially volatile or emotionally impactful encounters, theoretically can decrease learner stress, create a safe learning environment, and improve real-life experiences. The ultimate goal for improving communication education is better patient care by delivering accurate information, ensuring comprehension, navigating emotional responses, setting up follow-up, and monitoring adherence. Creating a learning experience to prepare for these stressful communication encounters requires mindfulness of both the fidelity (how closely the program mirrors reality) and the psychological safety of the program. Simulation—whether it be via role-play, SPs, or simulation technology—can achieve this goal. Most communication curricula use some form of simulation, primarily scripted or semiscripted role-play or SPs.7-13 Several use OSCEs or modified OSCEs as a teaching or evaluation tool. Similar to role-play and SPs, OSCEs approximate real-life experiences with a high-fidelity, low-stakes method. The main disadvantages of SPs or OSCEs tend to be access and cost—not every training program or hospital has immediate access to the facilities or personnel needed to build a curriculum around simulation, and the cost and time needed to train SPs can be prohibitive to some training programs. This does not rule out role-play as a training or evaluation pedagogy, however. Leaders seeking to create faculty development programs emphasizing role-play can certainly find a wealth of opportunity in communication courses for breaking bad news in the field of oncology.
Courses, modules, and training programs centered on communication, difficult conversations, and breaking bad news exist for oncology fellows, pediatric oncology fellows, and palliative care fellows. However, few programs report a multispecialty learning and practice environment, more specifically one combining adult oncology, pediatric oncology, radiation oncology, and palliative care fellows. In addition, support from multispecialty faculty crossing all subspecialties of oncology is not reported in other course modules.
Importantly, current curricula teach difficult communication scenarios (such as discussing relapse and transition to supportive care) as discrete, unconnected tasks. Thus, such curricula do not replicate the complicated evolving longitudinal doctor-patient relationship associated with the illness continuum. For example, the emotional impact on a learner from discussing relapse of disease in a patient with whom the learner has simulated an ongoing relationship is greater, and the tailoring of wording communication more context based, than discussing relapse in an isolated scripted scenario with an SP. As such, our curriculum has very high fidelity.
Our needs assessment consisted of a review of the curricula currently offered by our institution as well as the most current relevant literature on the topic of communication in oncology and end-of-life care. We found that our institution did not already offer a formal course in communication for residents or fellows in any specialty. While curricula exist for communication in oncology and end-of-life care, we did not find any curricula with an illness-trajectory focus. The current literature emphasized the need for quality communication in medical care.1-5
Faculty and Participants
Twelve participants who were trainees in hematology and oncology, pediatric hematology and oncology, and hospice and palliative care programs were selected for the course based on training year. The following year, the course included radiation oncology residents in addition to the subspecialties listed earlier; 10 participants were selected for this second course (five hematology and oncology, two pediatric hematology and oncology, one hospice and palliative care, and two radiation oncology), and one session was added to the curriculum. Radiation oncology trainees were residents; all others were fellow trainees. Trainee level ranged from PGY 1 to PGY 6. Faculty members were primarily attending physicians in the hematology and oncology, pediatric hematology and oncology, and hospice and palliative care programs.
Setting and Delivery of Content
Education took place in two primary settings. First, an interactive presentation focusing on key illness-pertinent communication challenges (45-60 minutes) was held in the classroom with the whole group. Then, immediately following the didactic session, learners and faculty broke out into small groups for hot-seat role-play. Each small group consisted of two to three fellows, a faculty facilitator, and faculty, as actors playing the patient and family members. One faculty member within each group role-played the fictitious patient throughout the 8-week course. The other faculty member was the facilitator for the group. Three role-play scenarios were enacted in each session, and after each scenario, 360-degree feedback was given. After receiving feedback, learners were given the option, if time permitted, to rewind and do a portion of the encounter again.
Institutional review board approval was obtained before the first year of the curriculum (the curriculum was deemed exempt from full review as an educational intervention). Prior to the didactic portion of the course, faculty attended a faculty development workshop focusing on role-play as an educational pedagogy (Appendix H) to prepare them to facilitate small-group role-play scenarios. Following the workshop, weekly face-to-face sessions began for a total of 8 weeks the first year and 9 weeks the second year. Faculty met just before each session for orientation to the session and to review learner outcome objectives and the role-play scenario, practice difficult portions of the role-play, and reach consensus on mandatory discussion points to ensure as much standardization across the small groups as possible. The weekly 2-hour sessions included an initial larger-group didactic presentation given by faculty members (Appendices I-P) followed by small-group active learning via role-play. The didactic session topics and role-play scenarios were longitudinally anchored to the illness trajectory of a fictitious patient, Mary Jones, from her initial diagnosis of advanced ovarian cancer to her ultimate death. A subtext of a pediatric patient with relapsed lymphoma was used to teach difficult conversations with adolescents/young adults.
The course schedule was as follows:
Precourse survey (Appendix A)—Week 0.
Precourse OSCE (Appendices B-D; evaluation tools in Appendices E-G)—Week 1.
Role-play workshop (Appendix H)—Week 2.
Module 1: Essentials of Good Communication (Appendix I)—Week 4.
Module 2: Hoping, Coping, and Spirituality (Appendix J)—Week 5.
Module 3: Communication Issues During Treatment (Appendix K)—Week 6.
Module 4: Delivering Bad News (Appendix L)—Week 7.
Module 5: Communicating With the Adolescent and Young Adult Population (Appendix M, added as a new session in the second year of the course)—Week 8.
Module 6: Communicating With Families (Appendix N)—Week 9.
Module 7: Communicating in the Palliative Care Setting (Appendix O)—Week 10.
Module 8: Mindfulness and Burnout (Appendix P)—Week 11.
Postcourse OSCE (Appendices R-T; can be held prior to or after Module 7; we held it prior to Module 7 as our simulation patient, Mary Jones, dies in that module and is alive in this OSCE)—Week 13.
Postcourse survey (Appendix A)—Week 14.
One-year postcourse survey (Appendix U)—Week 52.
As part of the didactic sessions, guest lecturers discussed certain topics: A psychologist discussed the coping spectrum, a member of the clergy spoke about the role that religion/spirituality may play in the support/coping of the patient with cancer, and a sex therapist raised the topic of sexuality of the patient with cancer. Following each session, we selected several cognate topics for emphasis during role-play. For example, in the first session, learners were asked to start forming a therapeutic relationship with their patient, Mary Jones, by inquiring about her illness narrative; then, they were asked to explore, recognize, and reorient her perspective on her condition and, finally, to assess her strengths and support systems to begin the foundations of their therapeutic relationship. All role-play scripts, as well as our bio for our fictional character and handout materials for Module 3, can be found in Appendix Q.
For our session on breaking bad news, we modified Baile's SPIKES protocol into a broadened MR. SPIKES protocol: Mindfulness before encounter; Rehearse conversation beforehand; Set up the interview; assess the patient's Perception; obtain the patient's Invitation; give Knowledge to the patient; address all the patient's Emotions/Empathic response; and Summarize the discussion, discuss Strategy going forward, Solicit all concerns, Support coping, Sustain hope, and affirm continuing Support. This mnemonic was printed, laminated, and given to learners as a quick reference tool.
Personnel involved in the design and implementation of the curricular content included six faculty or adjunct members who created the didactic sessions and presented them over the course of 8 weeks. The course itself was staffed by four of the content creators and five other faculty members (one acting as facilitator and four acting as role-play actors) for a total of five facilitators and four actors. All actors and facilitators met weekly for 30-60 minutes prior to the didactic session to pick up role-play materials/scripts and train or work out logistics for the specific scenarios for the module. There were four role-play groups with a 2:3 staff-to-learner ratio with the exception of one group that included a fellow as facilitator. The didactic portion took place in a large conference room, and the role-play portion took place in the same room for two groups and smaller meeting rooms for the other two groups.
Prior to starting and then again upon finishing the program, learners completed an online attitudinal survey assessing their perceived levels of readiness and comfort with 15 or 16 topics (depending on which year the survey was taken) featured in the curriculum, rating their comfort level on a scale of Poor, Average, Above Average, and Very Proficient. The full survey can be found in Appendix A.
The program began with a videotaped OSCE that required learners to break bad news to an SP about a cancer diagnosis. There were two clinical scenarios: an adult patient (Appendix B) and a pediatric patient with a parent (Appendices C and D). The scenarios were emailed to participants 1 week prior to the OSCE. These OSCEs were held at the Center for Learning and Innovation (CLI) in Lake Success, New York. CLI staff prepared SPs over several weeks with scripts for the OSCEs and use of the assessment tool in Appendix E. CLI is hosted in a facility that allows for video monitoring and video/audio recording of simulated encounters with SPs or simulation manikins, and the OSCE sessions were implemented under the supervision of at least three key CLI staff members. Owing to the size of the class, two OSCE sessions were held each testing day (before and after the course), with five or six learners being tested each session. During the OSCE, door prompts were given to participants to describe the patient behind the door as well as the goal for the encounter; encounters lasted up to 30 minutes. At the end of the precourse OSCEs, learners received written evaluations (Appendix E) but not verbal feedback from SPs for each encounter. These evaluations were created by faculty based on the major headings of SPIKES in the following domains: a preencounter domain (agenda setting, anticipating patient's concerns), an emotion/empathy domain, an optimization of physical setting domain, a pre–news delivery domain (perception, invitation, and preparation), a delivery of bad news domain, and a post–news delivery domain consisting of strategy, summary, soliciting all concerns, sustaining realistic hope, assessing and affirming coping, and affirming ongoing partnership. These written evaluations were not given to the fellows. This first OSCE was an assessment exercise to establish learners' baseline communication skills for comparison across time.
After completing the majority of the teaching sessions, learners participated in a second OSCE, a scenario involving breaking bad news of a cancer relapse (Appendices R-T). These OSCEs added immediate verbal feedback from the SPs to the structure of the precourse OSCEs based on the SPs' checklist. Pre- and postcourse OSCE checklists were the same, but SPs were randomly assigned to learners. SPs and learners were not intentionally paired for the precourse and postcourse OSCE; thus, if learners encountered the same SP in both OSCEs, it was not intentional. After these OSCEs, the entire group spent 30-45 minutes debriefing from the encounter with course faculty.
Following the final didactic session, a postintervention attitudinal survey (identical to the preintervention survey) was emailed to the fellows. Finally, 1 year after the course, a follow-up satisfaction survey was sent to the first cohort (a year had not passed at the time of writing to report data for the second year's cohort). The survey asked one question regarding how helpful the learners felt the course was in improving their communication skills and 13 questions regarding proficiency in various communication skills or areas as well as two open-ended short-answer questions. See Appendix U for the full text of the survey.
Videos from both the first and second OSCEs were securely stored by the CLI. These videos were evaluated by several faculty members as well as oncologists not connected to the course. Evaluators were given a 23-item scoring instrument (Appendix F) assessing proficiency in each of the items in the MR. SPIKES protocol similar to the one used by the SPs to evaluate the videotaped encounters between SP and learner. This instrument assessed the domains discussed earlier with the exception of the preencounter functions. There were two assessment questions devoted to setting, six for emotion and empathy, four for pre–news delivery, five for delivery of bad news, and one each for summary, strategy, concerns, hope, coping, and partnership. We used a scoring instrument (Appendix G) to aid in the evaluation process. Gwet's AC1 was used to measure agreement among assessors. Cronbach's alpha was used to measure the internal consistency of the assessment tool. A paired-samples t test was used to analyze differences in pre- and postcourse scores.
Twelve learners (five adult subspecialty and seven pediatric subspecialty) participated in this course during the first iteration. Ten learners (eight adult subspecialty and two pediatric subspecialty) participated in the second year of the course.
Pre- and Postcourse Attitudinal Surveys
Participants' self-reported data on the pre- and postcourse surveys (Table 1) showed a significant increase (p < .001 in the first year, p < .0001 in the second year) in comfort level in all areas. Based on responses from all 12 participants on the pre- and postcourse surveys, the mean score (1 = Poor, 2 = Average, 3 = Above Average, 4 = Very Proficient) increased from 1.85 precourse to 2.90 postcourse in the first year; based on responses from seven respondents precourse and eight postcourse in the second year, the mean score increased from 1.99 to 2.78.
Table 1. Comparison of Pre- and Postcourse
Attitudinal Surveysa
Precourse
Postcourse
<.001
<.0001
aSurvey questions were answered on a 4-point
scale (1 = Poor, 2 = Average, 3 = Above Average,
4 = Very Proficient). The first year's survey had
15 questions, and the second year's had 14
questions. Twelve people responded to the first
year's surveys; during the second year, seven
responded to the precourse survey and eight to
the postcourse survey.
SP Scoring of OSCEs
For SPs' assessment tool scoring, each fellow was rated by a separate SP in the precourse OSCE and the postcourse OSCE (Table 2); the rating tool used by the SPs was scored out of 36 possible points and was the same pre- and postcourse. Data were assessable for 10 of the 12 fellows in the first year (two fellows did not participate in the postcourse OSCE), and nine of those improved their scores from the precourse OSCE to the postcourse OSCE; one fellow's score dropped in the postcourse OSCE. Overall, the fellows, as an aggregate group, improved their mean score from 26.7 to 31.5 out of 36 total points (p = .044). Eight of 10 learners' scores were available for evaluation in the second year (one fellow did not take the postcourse OSCE, and one fellow began the course after the initial OSCE). Six fellows' scores increased, one's was stable, and one's decreased from the precourse to the postcourse OSCE. The mean aggregate score improved from 38.6 to 40.9 out of 46 total points from pre- to postcourse (p = .5).
Table 2. Average OSCE Scores as Assessed by
Standardized Patientsa
26.7 (4.88)
Abbreviation: OSCE, objective structured clinical
exam.
aFirst-year score is out of 36 points total; second-
year score is out of 46 points total. First-year data
are based on 10 learners; second-year data are
based on eight learners. Additional learner data
points in both years were not usable because
learners did not complete both pre- and
postcourse OSCEs.
Faculty Scoring of OSCE Videos
Gwet's correlation coefficients (based on Landis-Koch) were all either moderate or substantial. In particular, there was substantial agreement on six of the eight postcourse videos (Table 3). Coefficients were higher for the postvideo assessments, likely reflecting more familiarity with the instrument. With regard to internal reliability, Cronbach's alpha for the assessment tool was .88, indicating good internal consistency. Results of the paired t tests for the different domains were as follows: For both emotion and empathy, there was a positive change; for the pre–news delivery domain, there was a positive change in the preparation function; for the delivering of bad news domain, there was an overall positive change; for the post–news delivery domain, positive change was seen in the assessment of coping function; and finally, postcourse global assessment exhibited a significant positive change with a t value of −3.69 (p = .0077).
Table 3. Faculty Assessment of OSCE Videosa
Preassessment
Postassessment
No. of Assessors
Gwet's AC1
(95% CI)
.531 (.390-.671)
Abbreviations: CI, confidence interval; OSCE, objective
structured clinical exam.
aAgreement between raters of OSCE videos was assessed
using a 23-item tool. A score of .600-.800 correlates with
substantial agreement; a score of .400-.600 correlates with
moderate agreement. Each row represents a different learner.
One-Year Postcourse Survey
From the initial cohort, six of 12 learners responded to the 1-year postcourse survey. In response to the question "Over the last year, how helpful was the course in enhancing communication with your patients?", two learners responded "a moderate amount," and four responded "a significant amount." Questions 2-14 asked learners to rate their proficiency in various communication areas after the course using a scale of Not Proficient, Poorly Proficient, Proficient, and Very Proficient. No learners responded with Not Proficient or Poorly Proficient; there were 21 responses of Very Proficient and 57 responses of Proficient. Learners identified clinical trials and discussions around prognosis as two areas that they felt needed to be emphasized more in the course and stated that the course was "very structured and helpful" and "assisted a lot for difficult conversations that arise in clinic as well as on service."
Communication is a key component of quality patient care across medical practice and one that is emphasized in oncology, palliative care, and hospice settings. Our goal was to improve communication skills in trainees by providing a safe environment to learn and practice these requisite skills. Simulation and role-play best approximate real-life situations, decreasing learner stress while avoiding the use of practice patients. Evaluating the efficacy and success of a role-play-centric course should ideally be done by observing the skills that were taught in the course being implemented in an actual patient encounter. However, given our resources and time, the next-best option was to observe these skills in a structured, simulated patient clinical encounter or OSCE. We believe that this course is ideal for first-year residents or fellows but can be used at any point in training.
This curriculum successfully increased level of comfort in 16 areas covered, based on pre- and postcourse surveys. In fact, each individual area was scored higher in the postassessment in both years, giving us some confidence that our course benefited the learners in being more confident in their communication skills, which could lead to better communication in the clinical environment.
Our needs assessment focused on the dearth of education in communication and the lack of a communication course at our institution. In hindsight, however, we realized that fellows had many questions throughout the course that could have become incorporated into our sessions. In designing the course, we chose topics that were both clinically relevant and challenging for learners. In retrospect, we did not do a thorough needs assessment with our own learners in that we did not ask them which topics they found most challenging or were most interested in learning about in the course. Additionally, there were other sessions that could have been created, such as a session on cross-cultural communication, that we did not take advantage of in this iteration of the course.
When evaluating the success of the course, our data demonstrate significant short-term improvement in learners' comfort levels across multiple domains. We did not repeat the attitudinal survey at later intervals after the initial postcourse survey, which was sent out very shortly after the final session. In hindsight, this may have been beneficial to repeat at regular intervals to assess continued satisfaction and change in attitude. Additionally, almost all learners improved their scores from the pre- to postcourse OSCE as assessed by the SPs involved in the encounters.
The degree of improvement in OSCE scores as assessed by SPs was significant in the first year but not the second, despite a significant increase in comfort in both years. Possible explanations include that our learners ranged from PGY 1 to PGY 6, with varying levels of patient experience and proficiency in communication. Additionally, there may be a bias in which physicians with better empathic and communication skills enter these fields. The small number of learners precluded an analysis based on training levels or training program. Of note, most learners had a high starting score on the precourse OSCE, and SPs did not have access to their precourse scores when assessing learners in the postcourse OSCE. Having high scores left little room for improvement, but by blinding SPs to precourse data, we hoped to remove some bias to give better postcourse scores to demonstrate improvement. This improvement over baseline scores suggests that our interventions—didactic sessions and weekly role-play—were at least moderately successful in catalyzing skill acquisition and behavioral change.
When considering the assessment of the OSCE videos by faculty members and other medical professionals, we developed a tool to measure multiple communication functions involved in the delivery of bad news. The tool was designed to closely measure the domains and curriculum of our training program. This SPIKES-based assessment tool was found to have moderate to substantial interobserver reliability and good internal consistency. In our application of the tool, we were able to detect a global significant change in communication proficiency after an educational intervention (p = .0077). Moderate to substantial agreement between course faculty and senior oncologists broadens the tool's applicability in fellowship settings in which there is no specific faculty expertise. Our hope is that this tool can be used in the future not only in this course but as a stand-alone tool both in learning scenarios such as our communication course and when observing learners (medical students, residents, and fellows in particular) breaking bad news in the clinical environment. An objective, structured, reliable tool such as ours can then be used to give learners specific feedback on areas of strength or areas that need improvement and can be incorporated into rotation evaluations and individual learning plans.
The most innovative aspect of this curriculum is that the presentation topics and cognate role-plays are anchored around a longitudinal course of a cancer patient's illness. Within each role-play group, the same faculty member acts as the patient. For the learners, this overall heuristic generates powerful context-based learning. Each role-play segment corresponds to the patient's positioning within the trajectory, and most of the role-play scripts have been based on real-life encounters from faculty members' experiences, which we hope adds to the realism of the role-play. The initial segment involves teaching fundamental communication skills embedded in the challenge of getting to know a patient in the first consultation. In another module, the patient is undergoing treatment, and the trainees learn how to manage communication challenges, such as discussing sexuality and assessing for depression. Finally, learners communicate the change from curative to palliative intent. Learning this way is thus context based and replicates the communication challenges in a longitudinal doctor-patient relationship—instead of learners having to introduce themselves at each role-play encounter, they are able to approximate a more realistic, long-term therapeutic relationship. We chose faculty members to portray the SPs in our curriculum. Alternatively, in institutions with SP programs, SPs could be used as patients with the provision that they have sufficient expertise or receive training in the methodology of hot-seat role-play.
Another aspect of our curriculum that we did not find commonly represented in other curricula is the multispecialty nature of the learning environment: While all of the learners had contact with oncology patients, their roles in those patients' care as well as the characteristics of the patients they cared for were widely disparate, which added to the quality and richness of discussions around patient care. The curriculum is inclusive and adaptable to different practitioners who care for oncology patients and could be easily modified for other specialties (e.g., nephrology with a patient progressing to dialysis, geriatrics with a patient with progressive memory impairment). While designed to follow an illness trajectory, each module is a stand-alone session. Certain topics will be more relevant to different learners. Finally, we include in our appendices our faculty development session for role-play (Appendix H). Many programs may not have access to SPs for OSCEs on an annual basis or for multiple sessions; thus, the role-play pedagogy is a valuable resource that makes this curriculum feasible.
Our future directions will include continued improvement of the current didactic sessions, more sessions designed around learner feedback, and, importantly, continued faculty development regarding role-play and facilitation. Knowing how to effectively facilitate a role-play session and how to willingly suspend reality to be a patient or family member for a few minutes takes skills that are beyond the scope of the course but are necessary to be successful developers in communications training. Additionally, we will continue to fine-tune our evaluation tool and validate it as a reliable instrument for widespread use. In terms of evaluation of the course, we realize in hindsight that we did not ask learners to evaluate the delivery methods for the course (e.g., hot-seat role-play), and we did not include more objective components beyond evaluations of OSCE videos using our faculty assessment tool. We will seek to include more-thorough course assessment methods and objective learner assessments. Finally, our number of participants was relatively small (22 learners over 2 years); we will need several more years of implementing this curriculum to better analyze the efficacy of our educational intervention.
Ultimately, the goal of this and other communication curricula is to give learners a skill set with which to be able to effectively communicate with their patients. Obtaining feedback from actual patients in some manner attesting to the learner's communication proficiency would be an important means of validation. In the short term, because the same faculty member plays the patient in all role-plays in our curriculum, a formative and summative assessment from that faculty member using an established satisfaction measure would be a good initial surrogate for an actual patient's experience with an individual learner. We plan to use this approach to learner assessment in the future. Designing a way to integrate the impact of our intervention on actual patient satisfaction is an important objective in developing subsequent iterations of this course.
Daniel Cannone, DO: Fellow, Division of Pediatric Hospice and Palliative Medicine, University of Tennessee Health Science Center
Mark Atlas, MD: Attending Physician, Cohen Children's Medical Center; Program Director, Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center; Associate Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Alice Fornari, EdD: Associate Dean for Educational Skills Development, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Maria-Louise Barilla-LaBarca, MD: Associate Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Attending Physician, Division of Rheumatology, Allergy, and Clinical Immunology, Long Island Jewish Medical Center
Mark Hoffman, MD: Associate Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Attending Physician, Division of Hematology/Oncology, Monter Cancer Center
None to report.
Funding/Support
Prior Presentations
Cannone DC. An interdisciplinary communication skills curriculum for oncology fellows. Poster presented at: American Society of Pediatric Hematology/Oncology Conference; May 2-5, 2018; Pittsburgh, PA.
Hoffman M. Development and implementation of an instrument for assessing proficiency of oncology fellows in the delivery of bad news. Poster presented at: American Society of Clinical Oncology Annual Meeting; June 3-7, 2016; Chicago, IL.
Northwell Health Institutional Review Board approved this study.
Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims. Proc (Bayl Univ Med Cent). 2003;16(2):157-16 https://doi.org/10.1080/08998280.2003.11927898
Accreditation Council for Graduate Medical Education. ACGME common program requirements. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Published July 1, 2017.
Accreditation Council for Graduate Medical Education. ACGME common program requirements (fellowship). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf. Published June 10, 2018.
Kissane DW, Bylund CL, Banerjee SC, et al. Communication skills training for oncology professionals. J Clin Oncol. 2012;30(11):1242-1247. https://doi.org/10.1200/JCO.2011.39.6184
Dittrich C, Kosty M, Jezdic S, et al. ESMO/ASCO recommendations for a global curriculum in medical oncology edition 2016. ESMO Open. 2016;1(5):e000097. https://doi.org/10.1136/esmoopen-2016-000097
Gilligan T, Bohlke K, Baile WF. Patient-clinician communication: American Society of Clinical Oncology consensus guideline summary. J Oncol Pract. 2018;14(1):42-4 https://doi.org/10.1200/jop.2017.027144
Cvengros JA, Behel JM, Finley E, Kravitz R, Grichanik M, Dedhia R. Breaking bad news: a small-group learning module and simulated patient case for preclerkship students. MedEdPORTAL. 2016;12:10505. https://doi.org/10.15766/mep_2374-8265.10505
van Zuilen M, Caralis P, Granville L. Breaking bad news: a small group session teaching communication skills for delivering bad news. MedEdPORTAL. 2013;9:9604. https://doi.org/10.15766/mep_2374-8265.9604
Lamba S, Bryczkowski S, Holland B, Nagurka R, Mosenthal A. A teaching OSCE to assess trauma resident skills on how to hold difficult conversations with family of critically injured patients. MedEdPORTAL. 2016;12:10398. https://doi.org/10.15766/mep_2374-8265.10398
Ludwig A, Lee R, Parish S, Raff A. Four-station group observed structured clinical encounter for formative assessment of communication skills for internal medicine clerks. MedEdPORTAL. 2016;12:10444. https://doi.org/15766/mep_2374-8265.10444
Reed DJ-W, Sharma J. Delivering difficult news and improving family communication: simulation for neonatal-perinatal fellows. MedEdPORTAL. 2016;12:10467. https://doi.org/10.15766/mep_2374-8265.10467
Burns R, Mangold K, Adler M, Trainor J. Pediatric Boot Camp series: obtaining a consult, discussing difficult news. MedEdPORTAL. 2016;12:10437. https://doi.org/10.15766/mep_2374-8265.10437
Wolfe AD, Denniston SF, Baker J, Catrine K, Hoover-Regan M. Bad news deserves better communication: a customizable curriculum for teaching learners to share life-altering information in pediatrics. MedEdPORTAL. 2016;12:10438. https://doi.org/10.15766/mep_2374-8265.10438
Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311. https://doi.org/10.1634/theoncologist.5-4-302
© 2019 Cannone et al.
This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.
Cannone D, Atlas M, Fornari A, Barilla-LaBarca M-L, Hoffman M. Delivering challenging news: an illness-trajectory communication curriculum for multispecialty oncology residents and fellows. MedEdPORTAL. 2019;15:10819. https://doi.org/10.15766/mep_2374-8265.10819
Accepted: March 7, 2019
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text:
A Speciális Olimpia a világ legnagyobb sportszervezete az értelmi fogyatékossággal és testi fogyatékossággal élő gyermekek és felnőttek számára, amely 172 országban 5 millió résztvevő számára biztosít egész éves edzéseket és foglalkozásokat. Évente több mint 100 000 eseményt rendeznek szerte a világon. A helyi versenyek mellett, országos és regionális eseményeket is. A Nemzetközi Paralimpiai Bizottsághoz hasonlóan a Speciális Olimpiai Szervezetét is elismeri a Nemzetközi Olimpiai Bizottság. A Paralimpiai Játékokkal ellentétben azonban a Speciális Olimpiai Világjátékokat nem ugyanabban az évben és nem is az olimpiai játékokkal együtt tartják.

A Speciális Olimpiai Világjátékok nyári és téli játékok között váltakoznak kétéves ciklusokban és minden negyedik évben ismétlődnek. Az első játékokat 1968. július 20-án tartották Chicagóban, Illinois államban, mintegy 1000 sportolóval az Egyesült Államokból és Kanadából. Itt jelentette be Eunice Kennedy Shriver a rendezvény tiszteletbeli elnöke a Speciális Olimpia szervezet megalakulását. A nemzetközi részvétel a következő játékokban bővült. 2003-ban az első Egyesült Államokon kívüli nyári játékokat Dublinban, Írországban rendezték, 150 ország 7000 sportolójával. A legutóbbi nyári világjátékokat az Egyesült Arab Emírségekben, Abu Dhabiban tartották 2019. március 14-21. Ez volt az első különleges olimpiai világjáték, amelyet a Közel-Keleten rendeztek. A következő nyári világjátékokat Berlinben, Németországban tartják 2023. június 16. és 25. között. Németország számára ez lesz az első alkalom, hogy otthont ad a Speciális Olimpiai Világjátékoknak.

Az első téli világjátékot 1977 -ben rendezték meg az amerikai Colorado állambeli Steamboat Springsben. Ausztria rendezte az első téli játékokat az Egyesült Államokon kívül 1993-ban. A legutóbbi különleges olimpiai téli világjátékokat Grazban, Schladmingban és Ramsauban, Ausztriában tartották 2017. március 14 -től 2017. március 25 -ig.

Jegyzetek

Kennedy család
Olimpia