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Cancer diagnoses after emergency GP referral or A&E attendance in England: determinants and time trends in Routes to Diagnosis data, 2006–2015
Annie Herbert, Gary A Abel, Sam Winters, Sean McPhail, Lucy Elliss-Brookes and Georgios Lyratzopoulos
British Journal of General Practice 2019; 69 (687): e724-e730. DOI: https://doi.org/10.3399/bjgp19X705473
Annie Herbert
MRC Integrative Epidemiology Unit, University of Bristol, Bristol; formerly at Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London; National Cancer Registration and Analysis Service (NCRAS), Public Health England, London.
Gary A Abel
University of Exeter Medical School (Primary Care), Exeter; National Cancer Registration and Analysis Service (NCRAS), Public Health England, London.
National Cancer Registration and Analysis Service (NCRAS), Public Health England, London.
Sean McPhail
Lucy Elliss-Brookes
Georgios Lyratzopoulos
Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London; National Cancer Registration and Analysis Service (NCRAS), Public Health England, London.
Background Diagnosis of cancer as an emergency is associated with poor outcomes but has a complex aetiology. Examining determinants and time trends in diagnostic routes can help to appreciate the critical role of general practice over time in diagnostic pathways for patients with cancer.
Aim To examine sociodemographic, cancer site, and temporal associations with type of presentation among patients with cancer diagnosed as emergencies.
Design and setting Analysis of Routes to Diagnosis data, 2006–2015, for patients with cancer in England.
Method The authors estimated adjusted proportions of emergency presentation after emergency GP referral (GP-EP) or presentation to accident and emergency (AE-EP), by patient sex, age, deprivation group, and year of diagnosis using multivariable regression.
Results Among 554 621 patients presenting as emergencies, 24% (n = 130 372) presented as GP-EP, 62% as AE-EP (n = 346 192), and 14% (n = 78 057) through Other-EP sub-routes. Patients presenting as emergencies were more likely to have been GP-referred if they lived in less deprived areas or were subsequently diagnosed with pancreatic, gallbladder, or ovarian cancer, or acute leukaemia. During the study period the proportion and number of GP-EPs nearly halved (31%, n = 17 364, in 2006; 17%, n = 9155 in 2015), while that of AE-EP increased (55%, n = 31 049 to 68%, n = 36 868).
Conclusion Patients presenting as emergencies with cancers characterised by symptoms/signs tolerable by patients but appropriately alarming to doctors (for example, pancreatic cancer manifesting as painless jaundice) are over-represented among cases whose emergency presentation involved GP referral. Reductions in diagnoses of cancer through an emergency presentation likely reflect both the continually increasing use of 2-week-wait GP referrals during the study period and reductions in emergency GP referrals.
Around one in five patients with cancer are diagnosed as an emergency, which is associated with worse clinical and patient experience outcomes compared with other diagnostic routes; these poorer outcomes are partially explained by later stage at diagnosis and disease-related complications.1–5 Welcome reductions in the proportion of patients with cancer who are diagnosed as emergencies have been reported,6 but there is uncertainty about the responsible mechanisms involving tumour, patient and healthcare system factors, and how to achieve further reductions.7,8
Diagnostic processes leading to emergency presentations can involve general practice in two different ways. First, about two-thirds of all patients with cancer who are diagnosed as emergencies would have had prior GP consultations with relevant symptoms, often leading to investigations or referrals.9,10 Second, GPs can be involved in the emergency presentation care episode itself. In England about one-third of all emergency presentations involve an emergency referral to hospital by a GP.1 In this article the authors focus on the latter aspect of general practice involvement in emergency presentations.
In England, the frequency of emergency presentations (denoting diagnosis of cancer following an emergency hospital admission or outpatient appointment) is routinely monitored through the 'Routes to Diagnosis' programme of the National Cancer Registration and Analysis Service (NCRAS) of Public Health England.2,11 Emergency presentations comprise different pathways (hereafter termed 'sub-routes'), chiefly either emergency GP referral (GP-EP) or presentation to the accident and emergency (A&E) department (AE-EP).12,13 As these two sub-routes reflect different patterns of healthcare utilisation before a cancer diagnosis, understanding associated factors can elucidate different mechanisms and pathways, particularly regarding the role of general practice.9,10,14 Some of these pathways will represent appropriate care, for example, an emergency GP referral following presentation with symptoms or signs highly suggestive of cancer in an unwell patient, but others may reflect patient factors, for example, relatively late help seeking, or healthcare factors, for example, use of A&E departments due to difficulties in accessing primary care.8
Primary care has a crucial, though often misrepresented, role in the diagnosis of cancer in symptomatic patients. There have been welcome declines in the proportion of cancers diagnosed as emergencies but reasons are not well understood. The authors observed declining numbers of patients presenting as emergencies of a specific type, that is, those generated after a GP has referred a patient to hospital as an emergency. Reductions in the number of emergency presentations likely reflect continually increasing 2-week-wait GP referrals during the study period as well as reductions in emergency presentations following a GP referral.
How this fits in
This study aims to characterise sociodemographic, cancer site, and temporal associations with emergency presentation sub-routes among patients with cancer diagnosed as emergencies. The objective was to examine patient groups that are either over- or under-represented in emergency presentations directly involving a GP emergency referral to hospital, and establish related temporal trends and their likely contribution to overall changes in how patients with cancer are being diagnosed.
Diagnostic routes data
The authors studied Routes to Diagnosis data for 2006–2015 on patients aged ≥25 years diagnosed with any of 35 common and rarer cancers, responsible for 95% of incident cases. The 'diagnostic route' of each registered tumour is assigned by NCRAS using a rules-based (algorithmic) approach, which incorporates information from linked Hospital Episode Statistics, Cancer Waiting Times, and NHS Cancer Screening Programme data.2 The authors focused on patients diagnosed with cancer through an emergency presentation, defined in Routes to Diagnosis data as diagnosis of cancer during or after an emergency hospital admission (including via GP, A&E, or bed bureau) or A&E department attendance, including through direct presentation or after GP referral. The principal outcome of interest was emergency presentation sub-route, denoting different patterns of healthcare utilisation preceding the emergency cancer diagnosis. These included GP-EP (diagnosis during or after a hospital admission resulting from an emergency GP referral), AE-EP (diagnosis during or after a hospital admission following presentation to A&E), and Other-EP (diagnosis during a hospital admission not during or after an emergency GP referral, or presentation to A&E/dental casualty followed by hospital admission, for example, diagnosis during admission via bed bureau).
Other variable data
Exposure variables included sex, age (grouped as aged 25–49, 50–59, 60–69, 70–79, and ≥80 years), social deprivation (five categories from least to most deprived, using quintile cut-offs for England of Index of Multiple Deprivation [income domain] scores based on residential postcode), cancer (35 different sites as defined by ICD-10 codes), and year of diagnosis.
The analysis had two objectives. The first is to describe associations between exposure variables and each emergency presentation sub-route. The researchers reported the number and proportions (both crude and adjusted) of emergency presenters (n = 554 621) diagnosed via AE-EP, GP-EP, and Other-EP by sex, age group, deprivation status, cancer site, and year of diagnosis. Adjusted proportions were predicted from a multivariable multinomial logistic regression model where the outcome was AE-EP and Other-EP (baseline category: GP-EP) and all of the exposure variables were included as independent variables; reference categories: male, aged 70–79 years, least deprived, colon cancer, 2006.
The second objective was to describe temporal trends in each emergency presentation sub-route, also taking into account time trends across all other diagnostic routes.6 The authors presented the numbers of all incident cases of the studied cancers, that is, diagnosed through any route, including non-emergency presentation, over time, partitioned into adjusted numbers of each of the emergency presentation sub-routes and all other routes, using the same modelling technique as described above. These numbers were predicted from a second multinomial logistic regression model, this time including all cancer cases, as opposed to emergency presenters alone, n = 2 619 067, where the outcome was AE-EP, Other-EP, 2-week-wait (2WW) referral, non-emergency GP referral, screening, and 'Other' (baseline category: GP-EP), and including the same independent variables as in the first multinomial logistic regression model.
Among the 554 621 patients presenting as emergencies during 2006–2015 (Table 1), 24% (n = 130 372) had presented through GP-EP, 62% (n = 346 192) had presented through AE-EP, and 14% (n = 78 057) through the Other-EP sub-route. Absolute numbers and crude and adjusted proportions of emergency presentations by GP-EP, AE-EP, and Other EP sub-routes, by sociodemographic variables, cancer site, and year of diagnosis are available from the authors on request.
Number and adjusted proportions of emergency presentations by sociodemographic characteristic, cancer site, and year of diagnosis, stratified by GP-EP or AE-EP sub-routes (N = 554 621)
Associations between sociodemographic characteristics and sub-route
There was limited variation in emergency presentation sub-route by sex. Patients who were older and presented as emergencies were more likely to be diagnosed both via GP-EP and via AE-EP compared with younger patients, reflecting that patients who were younger and presented as emergencies were more likely to be diagnosed via the Other-EP sub-route; adjusted proportion for those aged ≥80 years was 11% (n = 17 157) versus 21% (n = 7509) for ages 25–49 years (adjusted proportions for age groups for Other-EP are available from the authors on request). The likelihood of GP-EP decreased with increasing levels of deprivation, for example, adjusted proportions for least versus most deprived were 25% (n = 22 997) versus 19% (n = 22 775), while, in contrast, that of AE-EP increased (60%, n = 54493 versus 67%, n = 80 803) (corresponding percentage and number values for the remaining variables are available from the authors on request). There was little variation in the likelihood of Other-EP by levels of deprivation (15%, n = 14 234 versus 14%, n = 17 570). Given the large sample size, there was evidence (P<0.001) for variation in emergency presentation sub-route by variable category for all above variables (sex, age, deprivation group).
Associations between cancer site and sub-route
Patients presenting as emergencies with pancreatic, acute myeloid and acute lymphoblastic leukaemia (ALL), ovarian, and gallbladder cancers were more likely to be diagnosed via the GP-EP sub-route (adjusted proportions of GP-EP ≥27%) (Table 1). In contrast, those diagnosed with oral, oropharyngeal, laryngeal, thyroid, melanoma, brain, and uterine cancers (adjusted proportions of GP-EP ≤18%) were least likely to be diagnosed via the GP-EP sub-route (Table 1). Notably, most cancer sites with low proportions of GP-EP, that is, oral, oropharyngeal, thyroid, melanoma, brain, and uterine cancers, had relatively high proportions of Other-EP. There was evidence (P<0.0001) for variation in emergency presentation sub-route by cancer site.
Time trends
The number of incident cases for the studied cancers, adjusted for changes over time in sociodemographic characteristics and cancer site distributions, increased each year, for example, from 237 799 cases in 2006 to 284 660 cases in 2015, an increase of 20%, while the number of emergency presentations each year decreased slightly (from 56 104 to 54 142 respectively, a decrease of 4%; Table 1). Consequently, there was a progressive reduction in the adjusted number of cancers diagnosed as emergency presentations, and an expansion in the number of cancers diagnosed as non-emergency presentations, particularly via 2WW referrals (Figure 1). There was evidence (P<0.0001) for variation in emergency presentation sub-route by year of diagnosis.
Adjusted numbers of patients with cancer diagnosed via emergency presentation sub-route or any other diagnostic route, estimated using a multivariable multinomial logistic regression, for AE-EP, GP-EP (reference outcome), Other-EP, 2WW, non-emergency GP referral, screening, and 'Other', fitted to all patients diagnosed with cancer (including non-EP), 2006–2015 (N = 2 619 067), where independent variables were sex, age group, deprivation group, cancer, and year of diagnosis. Predicted numbers of AE-EPs, GP-EPs, Other-EPs, and non-EPs were derived by multiplying predicted proportions of these outcomes by the number of observed cancer cases (including non-EP), per year. AE-EP = emergency presentation through presentation to accident and emergency. EP = emergency presentation. GP-EP = emergency presentation through a GP referral. GP ref = non-emergency GP referral. Other-EP = emergency presentation through routes other than through the GP or accident and emergency, for example, through referral during an inpatient admission. 2WW = 2-week-wait referral.
The changing proportion of emergency presentations overall was accompanied by a changing composition of EP sub-routes (Figure 2). GP-EP was less common among patients presenting as emergencies in more recent years of diagnosis (adjusted proportions down from 31%, n = 17 364, to 17%, n = 9155, between 2006 and 2015), while the opposite was true for AE-EP (up from 55%, n = 31 049 to 68%, n = 36 868; Table 1). The proportions of emergency presentation diagnosed through Other-EP slightly increased during this time (from 14%, n = 7691 to 15%, n = 8119). Relatedly, against a slight overall decrease in the absolute numbers of emergency presentations of any type between 2006 and 2015 (Table 1), the absolute numbers of GP-EPs almost halved (n = 17 364 to n = 9155) and that of AE-EPs slightly increased (n = 31 049 to n = 36 868). Absolute numbers and crude adjusted proportions of emergency presentations by GP-EP, AE-EP, and Other EP sub-routes for all years of diagnosis are available from the authors on request.
Adjusted proportions of emergency presentation type among emergency presenters, over time, estimated using a multivariable multinomial logistic regression, for AE-EP, GP-EP (reference outcome), and Other-EP, fitted to all patients diagnosed through EP in 2006–2015 (n = 554 621), where independent variables were sex, age group, deprivation group, cancer, and year of diagnosis. AE-EP = emergency presentation through presentation to accident and emergency. EP = emergency presentation. GP-EP = emergency presentation through a GP referral. Other-EP = emergency presentation through routes other than through the GP or accident and emergency, for example, through referral during an inpatient admission.
Over a recent decade, and against an overall continuous decrease in the percentage of patients diagnosed with cancer through an emergency presentation (from 24% in 2006 to 20% in 2015), the likelihood of emergency presentation via GP referral decreased, coupled with an increased likelihood of emergency presentation via A&E, even after accounting for sociodemographic and cancer site case mix over time. Among patients presenting as emergencies, patients living in areas of greater deprivation were less likely to be diagnosed via the GP-EP sub-route, and more likely to be diagnosed via the AE-EP sub-route. There was large heterogeneity in sub-route profile by cancer site.
Strengths and limitations
The authors used a large population-based dataset covering a 10-year period and presented adjusted proportions of emergency presentation sub-routes by each patient characteristic, cancer site, and year of diagnosis, respectively. All variables included in this study come from high-quality cancer registration data. Diagnostic route, used to capture emergency presentation status and sub-route type, is derived via an algorithmic approach using linked routine population-based datasets.2
As common in observational studies, other variables (not available for inclusion in the analysis) could at least partially account for some of the reported sociodemographic, cancer site, and temporal variation in emergency presentation sub-routes. It could be revealing to examine the potential interplay between stage at diagnosis and emergency presentation, as advanced stage is associated with greater likelihood of emergency presentation,3 but the authors could not address this question within the current study owing to poor completeness of stage at diagnosis information during most of the study years, 2006–2015.15–17
A limitation inherent to all research using routine data is that it does not allow for exact circumstances to be taken into account. For example, a patient presenting for emergency may have attended A&E following verbal GP advice without a formal referral. This hypothetical patient would have likely been assigned an AE-EP sub-route, while GP-EP sub-route may have been more apt, which would introduce misclassification error. The magnitude of such a misclassification is difficult to quantify but is likely to be small.9,10
Comparison with existing literature
There are no other population-based studies of emergency presentation sub-routes for cancer cases in England covering both common and rarer cancers with which to compare the present results.8 Nonetheless, this study builds on previous reports of crude proportions of emergency presentation sub-route by age and cancer site,12,13 by reporting proportions adjusted for patient case mix (age, sex, deprivation, and cancer site). A previous study focusing on patients with lung cancer found that GP-EP sub-route was least likely in patients presenting as emergencies who were more deprived, and vice versa for AE-EP,18 concordant with the present study, which covers a much wider range of cancer sites.
Implications for research and practice
The findings overall indicate that certain cancers that can be associated with painless symptoms that may be tolerable to the patient but where GPs may appropriately request an urgent specialist assessment — for example, pancreatic or gallbladder cancer presenting with painless jaundice; acute leukaemia presenting with pallor; ovarian cancer presenting with abdominal distension — were associated with the highest likelihoods of GP-EP in this study. These findings underline the importance of tumour factors as a contributor to emergency presentations in some patients. As these symptoms have relatively high predictive values for cancer,19 they can lead to appropriately accelerated assessment through 'same- or next-day' clinics, thus explaining the increased likelihood of diagnosis via GP-EPs that nevertheless represent good GP care. Some cancers had particularly high proportions of Other-EP, including oral, oropharyngeal, thyroid, melanoma, and brain cancer. This likely denotes either the involvement of other clinical specialties, for example, dental practitioners in the case of oral/oropharyngeal cancers, or greater than average involvement of hospital department clinics in the diagnosis of certain cancers. Patients who were younger and presented as emergencies were also more likely to be diagnosed through Other-EPs than patients who were older and presented as emergencies. As suspecting the diagnosis of cancer in patients who are younger is typically harder than in those who are older, they may be more likely to be initially referred to specialist clinics, and progress to an emergency presentation through these clinics.20,21
As more deprived patients presenting as emergencies were less likely to have been referred by their GP and more likely to have presented to A&E, help-seeking patterns among otherwise similar patients subsequently diagnosed with the same cancer seem to vary by socioeconomic status.
Against an overall decreasing proportion of patients with cancer who are diagnosed through emergency presentations, the number of patients diagnosed through the GP-EP sub-route is decreasing, while that of patients diagnosed through AE-EP and non-emergency routes is increasing. This decreasing trend in emergency presentations overall has occurred in spite of other evidence for opposite, (increasing) trends in both general A&E attendance and emergency hospital admissions.22–27 Therefore, the overall trend cannot be accounted for by such general A&E/emergency admission trends, and likely reflects a reciprocal rise in the use by GPs of 2WW referrals for suspected cancer in the same period (Figure 1).28 Among emergency presenters, reductions in the GP-EP sub-route could reflect increasing difficulties in accessing in-hours primary care among patients with possible cancer symptoms;26,29,30 and the progressive shrinkage (through the overall increase in 2WW referrals) of the pool of patients who would have otherwise been diagnosed with cancer as an emergency presentation.
This project involves data derived from patient-level information collected by the NHS, as part of the care and support of patients with cancer. The data are collated, maintained, and quality assured by the NCRAS, which is part of Public Health England (PHE).
Annie Herbert and Georgios Lyratzopoulos are supported by a Cancer Research UK Advanced Clinician Scientist Fellowship to Georgios Lyratzopoulos (award reference: C18081/A18180). Georgios Lyratzopoulos is associate director (co-investigator) and Gary A Abel collaborator of the multi-institutional CanTest Research Collaborative funded by a Cancer Research UK Population Research Catalyst award (award reference: C8640/A23385).
Data used in this study were collected by the National Cancer Registration and Analysis Service (NCRAS) under regulation 2 of the Health Service (Control of Patient Information) Regulation 2002.
Freely submitted; externally peer reviewed.
The authors have declared no competing interests.
Contribute and read comments about this article: bjgp.org/letters
Received March 30, 2019.
This article is Open Access: CC BY 4.0 licence (https://creativecommons.org/licenses/by/4.0/).
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Vol. 69, Issue 687
You are going to email the following Cancer diagnoses after emergency GP referral or A&E attendance in England: determinants and time trends in Routes to Diagnosis data, 2006–2015
Annie Herbert, Gary A Abel, Sam Winters, Sean McPhail, Lucy Elliss-Brookes, Georgios Lyratzopoulos
British Journal of General Practice 2019; 69 (687): e724-e730. DOI: 10.3399/bjgp19X705473


Bernard Tomic accuses Tennis Australia of being corrupt.
Bernard Tomic made a stunning allegation about Tennis Australia and no-one was sure what to say.
Bernard Tomic has served up a savage parting shot amid his departure from the I'm A Celebrity jungle, by accusing Tennis Australia of corruption.
The 25-year-old, who is currently ranked 128th in the world, made the claim during an interview on The Project on Wednesday.
"Absolutely. That's going to be my priority coming back. It's tough. I'm not happy with that whole situation with Tennis Australia. Until that clears and a few of the problems come out… We've seen it with the FIFA Federation, how they were corrupt. And I know it's in there. I'm yet to address all the issues there. Hopefully in the coming future I can speak about it.
A seemingly stunned Waleed Aly, co-host of the Channel 10 panel show, asked the sportsman to clarify his position.
"To make sure I've got this right, you want to play for Australia in in the Davis Cup but Tennis Australia is a corrupt organisation?" Aly asked.
Carrie Bickmore quickly clarified that Tennis Australia had declined to comment on the claims, but said it would be happy to look into any specific allegations.
In 2010, Tomic became the youngest-ever player chosen to represent Australia at the Davis Cup, at the age of 17. He shot to a career-high ranking of 17, though slipped in recent years.
After a two day stint on reality television program, I'm A Celebrity Get Me Out of Here, Tomic announced his decision to return to the sport in earnest.


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2018 Open House Great Time to Hang Out with our Stamping Friends!
This year there were 31 stamping friends who dropped in to shop, enjoy each other's company, and have my traditional chicken salad and homemade strawberry ice cream!
Each demonstrator who attended On Stage in Las Vegas last April received one of these signs.
You have the entire alphabet to spell out words!
Everyone did a great job orchestrating the event!
Here's Carol calling out some door prizes!
Here you can see a view of my craft room. As you go out the sliding glass doors in the back, I had four 6 tables of retired merchandise.
Some ladies opted out of pictures and there were some who we missed! But this will give you an idea of what the day looked like!
Pam, GLoria, Terri Pat and Kris making the in color bookmark .
If you couldn't make it this year, hopefully you can join us next June!
Tags: Duarte, Open House, Sandy Hancock, Stampin' Up!


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Kristi Taylor, got sparkles' sole proprietor, is a resident of Carmichael, California and operates her small business out of Sacramento, California.
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As you know we often list expensive new releases box sets with an option of securing your copy at the preorder price by leaving a deposit. This works well with many of our regular customers taking advantage of this offer. It does not work so well when you have multiple releases by an artist where individual prices are not really high but when purchasing 4 or 5 items the total can be high. An example is the new Kate Bush releases.
Therefore I am extending our deposit scheme.
Firstly decide how much deposit you are leaving. The minimium deposit is £25.00.
When completing the paypal, please add the item or items you are securing in the message space and send.
Please send an E mail to orders@whatrecords.co.uk confirming you have left a deposit. This just makes it easier for us as you will have already received confirmation of the transaction from Paypal.


text:
namespace BlueDwarf {

FileInfoQueryException::FileInfoQueryException(const Path& path, const std::string& message, char const* source,
                                               int line)
    : DwarfException((boost::format("Error querying file information for %1%: %2%") % path.ToString() % message).str(),
                     source, line) {
}
}

redpajama_set_name: RedPajamaGithub


text:
Q: How to find remaining scores from score list after a player is ahead by two Basically need to find a list of integers, representing the sequence of points remaining in the match after the current game; this should take the form of the remainder of the points input after the points for the current (complete or incomplete) game have been removed. The points are simply in a 1 or 0 fashion in a list (where 1 is scoring the point). Player wins if ahead by 2 points and the rest of the remaining scores from list need to be separated.
So for example if I have a list [1,0,1,0,1,1,1,0,1,1,1] The player has score 8 times. But since the player by the 5th point they score they are 2 above his/her opponent and thus wins the game, but I need to find the remains scores which should be [0,1,1,1]
I am able to distinguish the scores but I am not sure how to find the point where the winner arises. Any help or guidance would be appreciated.

A: Add 1 to some count when you see a 1, add -1 when you see a 0. Once the count reaches 2 or -2, you can stop and return the remaining part of the array
int count = 0;
for (int i = 0; i < array.length; i++) {
    if (array[i] == 1) {
        count++;
    } else {
        count--;
    }
    if (count == 2 || count == -2) {
        System.out.println("The game ended on round " + i);
        break; // This command just exits the for loop.
    }
}

redpajama_set_name: RedPajamaStackExchange


text:
Q: Using Paste Special > Values with the HYPERLINK function in Excel I have a long list of data in Excel 2007. Using the Hyperlink function:
=HYPERLINK(C2,A2)

I've added individual links to them all. Now I want to get rid of the function and just leave the data with the link.
If I do Paste Special > Values, it does the job but the link will be removed.
How can I paste the values and keep the hyperlink?

A: Errrr, the function is the link. There's no such thing as a clickable link without that function. (Consider this: which value would you expect when pasting something that is both a clickable link and a title? C2 or A2?)
You could replace the function with just C2. After that, using Paste Values will give you a non-clickable link. (But: you would already have that very same non-clickable link in C2 itself, so in the end that's useless.)
Or, if you expect some HTML magic: use something like the following, which is not clickable in Excel, but may be helpful when you use the result elsewhere:
= "" & A2 & ""
(Where & is the short notation for function CONCATENATE.)

A: How about a paste out to Word? (and then copy it there and paste back into Excel if you really need it back in Excel).
This retains both the link and the title, and is clickable.
No paste special required, although depending on your settings you may get some naff formatting inherited from the the default tabel format in Word. You can get round this using the paste options in Word to keep the source formatting.

A: I love these ugly hacks. Looks like some dated info too. Get ready for 3rd party ref info to get obseleted even faster.. If you've got Office 365 business, check out Office Scripts (they finally added an alternative to VBA, but only on the otherwise limited cloud Excel):
https://www.howtoexcel.org/extract-hyperlink-url/
ctrl+f: Extract the Hyperlink URL with Office Scripts
TL;DR: Automate tab -> New Script
paste this typescript-like thingy:
    function main(workbook: ExcelScript.Workbook) {
    // Your code here
    // https://www.howtoexcel.org/extract-hyperlink-url/
    // TODO: extend/input a whole column.. since it balks at
    // empty lines during selection

  //Create a range object from selected range
  let selectedRange = workbook.getSelectedRange();
  //Create an array with the values in the selected range
  let selectedValues = selectedRange.getValues();
  //Get dimensions of selected range
  let rowHeight = selectedRange.getRowCount();
  let colWidth = selectedRange.getColumnCount();

  //Loop through each item in the selected range
  for (let i = 0; i < rowHeight; i++) {
    for (let j = 0; j < colWidth; j++) {
      let currHyperlink = selectedRange.getCell(i, j).getHyperlink().address;
      selectedRange.getOffsetRange(0, colWidth).getCell(i, j).setValue(currHyperlink);
    };
  };
};

Yet another way to own the content you create. If you're doing a lot of this, I'd look into python's openpyxl, and stay away from these subscription text editors. This is ridiculous, but will keep you rolling today!  I would buy a new MS office for this feature, but I am not going to pay subscription for them to change stuff all the time and make even more money on the same thing.  Not being able to open your docs one day is bad enough, but this way you won't even be able to access the file. Microsoft seems like a real arm-twisting business partner, I would consider other options as they continue to tighten the screw and wring every dime out of an OS and Word processor from the 90's.

A: Or, if you cant afford subscription word processor office 365, another take on: https://superuser.com/a/62492/873385
/u/AdamV @AdamV 's  ugly (awesome) hack
or could use other tips here to open all of the hyperlinks at once in a new browser window:
https://www.howtoexcel.org/extract-hyperlink-url/
then use OpenList by Outpox in either Firefox or Chrome:https://addons.mozilla.org/en-US/firefox/addon/openlist/, https://chrome.google.com/webstore/detail/openlist/nkpjembldfckmdchbdiclhfedcngbgnl
Github here:
https://github.com/cdzombak/OpenList
(Outpox used to have one but I can't seem to find)
to generate copy-pasteable plaintext list for your application. Many ways to skin this cat!


Landmark's Director, Dr Anna Keay, walks through the discoveries, triumphs and challenges during Landmark's most complex restoration to date.
I think the thing I most remember about my first visit to Llwyn Celyn was the smell. What it looked like was almost impossible to tell. A great tattered mass of torn and tangled plastic sheeting billowed from the huge emergency scaffolding tent over the building that had been put up years before. Somewhere under this was a house. As you entered the gloom you were greeted by the grim odour of rot, of stagnant water, of sodden, decaying wood. Bats' urine trickled in slow waterfalls down the plaster walls and occasionally a great flapping flock would come careering from the darkness, grazing your hair as they passed. Growing up in the sheep farming hills of the Scottish Highland I had been into my fair share of collapsing farmhouses. But you could see from the moment you entered Llwyn Celyn that, despite its near-dereliction, this was something truly exceptional.
What lay hidden was a medieval house, almost unaltered for the last 350 years. Beautiful, elaborately carved wooden doorways led off what was once a central great hall. A carved bench where the lord sat to eat and receive visitors remained in place. The soaring structure of the medieval roof was still there, its timbers blackened by the smoke from the fire that once burned in the midst of its stone floor. It was built, we would learn, on the lands of the medieval priory of Llanthony and its story would be bound up in that ancient place and the story of Wales itself.
The Landmark Trust has been rescuing historic buildings, and making them into places which everyone can rent for holidays, for over fifty years. But even we took a deep breath at the prospect of this one. The Grade 1 listed house was on the building equivalent of a life support machine, and one that might itself give up at any moment. Acrow props formed metallic copses in the ground floor rooms, holding up the ceilings above; bent coat hangers held scores of the great stone tiles on the roof in place and soggy sandbags dammed the doorways from the muddy streams that trickled through the house.
But we decided to take the plunge, convinced that the building would prove itself worth it. We acquired Llwyn Celyn ('holly grove' in Welsh) in 2012 and embarked upon the monumental task of saving this extraordinary house, trying to unravel its fascinating past and using the finest craftspeople to bring it back to life. It has been an epic journey. To mend the house, its many important ancillary building and repair it as a Grade 1 listed building should be repaired, cost over £4 million. We raised this thanks to a hefty grant from the Heritage Lottery Fund and donations from hundreds of others - many ordinary individuals who felt like us that this was a place worth saving.
The brilliant, assured and highly skilled team of specialists and craftspeople on the project were a pleasure to work with and to watch. Whatever the weather – and it could be truly bleak – they toiled on over almost three years, achieving the near impossible with amazing good grace. On one visit I was flabbergasted to see that the top of a carved medieval door which had over the centuries slumped to a diagonal had been somehow straightened. When I asked how on earth they had achieved this, what they had done to wreak this miracle, the twinkly answer was, 'that miracle is called Mac', their master carpenter.
The challenges they and we had to deal with were real. The bats were a massive headache, how to claim this house back from them without harming them – and without being prosecuted. Like Rumsfeld we knew there were things we did not know, and things we would only discover once we started taking the house apart. As we opened up the building, taking off the roof, lifting the floors, digging out the collapsed hillside behind, things were revealed that we could not have imagined.
Today Llwyn Celyn is quite literally unrecognisable. Its smell is now one of beeswax, fresh paint and warm stone. To have been part of the process has been a renewal in itself. Right at the start we teamed up with More4 in the belief that this rescue would be worth watching. How right we were. If you need a tonic to the troubles of our times look no further than this project. It is the story of us and our ancestors, of their talents passed on, of what it takes to create great strength and great beauty. Above all it reminds you that some things still matter simply because enough of us believe they matter, and if they are broken, we can come together and mend them.


text:
Alexei Dmitriyevich Krasnozhon (; born April 11, 2000) is a Russian-American former competitive figure skater. Competing for the United States, he is the 2017 CS Tallinn Trophy silver medalist, 2017 Junior Grand Prix Final champion, and 2017 U.S. national junior champion. Krasnozhon skated for Russia earlier in his career, making his last international appearance in December 2013.

Personal life
Krasnozhon was born on April 11, 2000, in Saint Petersburg, Russia. His mother, Natalia, is an endocrinologist and his father, Dmitri, is an oncologist. He has two younger sisters, named Dana and Sofia.
In 2014, Krasnozhon moved to Dallas, Texas. While training in Texas, he lived with his coaches, Peter and Darlene Cain, for five years. He later moved to live on his own in Plano, where his parents often visited. After relocating with coaches Olga Ganicheva and Alexei Letov to Boston, Kranoszhon roomed with fellow skaters Jimmy Ma and Misha Mitrofanov in Norwood.

In March 2018, Krasnozhon said that he planned to apply for U.S. citizenship and applied as an alien of extraordinary ability after turning 18. He received his green card in September 2020. Krasnozhon retired prior to the 2021–22 season, as he noted he would have been unable to gain citizenship in time for the 2022 Winter Olympics. Although he originally planned to retire after the Olympics in January 2022, he acknowledged that it would have been difficult for him to make the team regardless of his citizenship and chose to retire earlier and instead pursue a college degree.

While skating, Krasnozhon enrolled in a private online high school and expressed interest in a business degree from Georgetown University or Southern Methodist University. In his May 2021 retirement announcement, he shared that he would be attending Texas Christian University's John V. Roach Honors College. Krasnozhon has expressed interest in becoming an immigration lawyer, as he was thankful for the opportunities afforded to him and his family by moving to the United States.

Career

In Russia
Krasnozhon began skating as a five-year-old. At age seven, he became a student of Alexei Mishin, as well as his wife Tatiana Mishina and their assistant coach Oleg Tataurov. He competed for Russia at the Volvo Open Cup in January 2013, winning gold on the advanced novice level, and placed twelfth at the 2013 Russian Junior Championships.

Krasnozhon won the junior silver medal at the Denkova-Staviski Cup in December 2013. He missed much of the season due to a back injury.

Switch to the United States
In March 2014, Krasnozhon announced that he planned to compete for the United States and would be coached by Peter Cain and Darlene Cain in Euless, Texas. He qualified for the 2015 US Championships on the junior level and won the pewter medal.

On July 1, 2015, the Russian Figure Skating Federation released Krasnozhon so that he could compete internationally for the United States. While training in Moscow, Krasnozhon performed full run-throughs of his programs about once a week, but he began doing them daily after moving to Texas.

2015–2016 season
Making his Junior Grand Prix (JGP) debut, Krasnozhon won the bronze medal in August 2015 in Riga, Latvia. He then placed fifth in Torun, Poland. After receiving the junior gold medal at the Midwestern Sectionals, he closed his season by winning the junior bronze medal at the 2016 U.S. Championships, finishing behind Tomoki Hiwatashi and Kevin Shum.

2016–2017 season
Competing in the 2016 JGP series, Krasnozhon won silver in Ostrava, Czech Republic, and then gold in Ljubljana, Slovenia. He qualified to the Junior Grand Prix Final in Marseille, France, where he finished fifth. At the 2017 U.S. Championships, he won the junior men's title. He qualified to the free skate at the 2017 World Junior Championships in Taipei, Taiwan.

2017–2018 season
Making his senior international debut, Krasnozhon placed fourth at the Philadelphia Summer International in early August 2017. Competing in the Junior Grand Prix series, Krasnozhon won gold medals in Brisbane, Australia, and Zagreb, Croatia, which qualified him for the Final for a second time.  Competing at his first Challenger event, and he won a silver medal at the 2017 CS Tallinn Trophy.  Krasnozhon then won gold at the Junior Grand Prix Final in Nagoya, Japan.  He outscored the silver medalist, Camden Pulkinen, by more than 19 points and set a new personal best total score, 236.35 points, at the competition.

Krasnozhon competed in the senior ranks at the 2018 U.S. Championships, placing eighth in the short program, thirteenth in the free skate, and tenth overall. In March, he placed first in the short program at the 2018 World Junior Championships in Sofia, Bulgaria. While attempting a quad salchow during his free skate, he sustained a Grade 2 sprain of all three major ligaments in his right ankle, causing him to withdraw.

Krasnozhon changed coaches during the off-season, deciding to train under Olga Ganicheva and Alexei Letov at the Dr. Pepper Starcenter in Plano, Texas.

2018–2019 season
Krasnozhon started his season off at the 2018 CS Nebelhorn Trophy, where he placed fifth overall. Krasnozhon was invited to two senior Grand Prix events, the 2018 Grand Prix of Helsinki and 2018 Rostelecom Cup. Making his Grand Prix debut, Krasnozhon placed sixth at the Grand Prix of Helsinki and eighth at the Rostelecom Cup. Krasnozhon withdrew from the 2018 CS Golden Spin of Zagreb in December 2018.

At the 2019 U.S. Championships, Krasnozhon placed fifth.  Assigned to compete at the 2019 World Junior Championships, he placed fifth in the short program, making a minor error on his Lutz-loop combination. In March 2019, he won gold medal at the Egna Spring Trophy.

2019–2020 season
In early August, Krasnozhon received the bronze medal at the Philadelphia Summer International.  Krasnozhon next placed fourth at the 2019 CS U.S. Classic.  In the free skate, he landed the quad loop for the first time. At his first Grand Prix of the year, 2019 Skate America, he placed tenth in the short program after underrotating and falling on an attempted quad flip, a new jump for him.  In the free skate, he had a "hard, painful" fall on his quad flip attempt, but executed the rest of his planned triple jumps successfully, and rose to ninth place overall.  He was tenth at the 2019 Rostelecom Cup. three week later he finished ninth at the 2019 CS Golden Spin of Zagreb.

Competing at the 2020 U.S. Championships, Krasnozhon placed sixth in the short program, attempting only triple jumps.  In the free skate he underrotated an attempted quad loop and put a hand down on a triple Axel, but remained in sixth place.

2020–2021 season
With the coronavirus pandemic raging, the ISU chose to assign the Grand Prix based largely on training location, leading to Krasnozhon attending the 2020 Skate America.  Krasnozhon landed another quad loop in the short program, placing fifth, but struggled in the free skate and fell to seventh place overall.

Krasnozhon competed at the 2021 U.S. Championships, placing sixteenth out of seventeen skaters in the short program after falling on every jump. He rallied in the free skate, placing seventh in that segment, rising to eleventh place overall.

On May 12th, he announced his retirement from competitive skating, saying that he would be attending Texas Christian University starting in the Fall of 2021.

Programs

Competitive highlights

GP: Grand Prix; CS: Challenger Series; JGP: ISU Junior Grand Prix

For the United States

For Russia

Detailed results
Small medals for short and free programs awarded only at ISU Championships. ISU Personal best highlighted in bold.

Senior results

Junior results

References

External links

2000 births
Living people
American male single skaters
Russian male single skaters
Figure skaters from Saint Petersburg
Russian emigrants to the United States

redpajama_set_name: RedPajamaWikipedia


● To head the human resources function for the automotive division. The role serves as a consultant to management on all people related issues as well as an employee champion and change agent. The focus must be to manage the human resources function to drive business results.
● This will include assessing and anticipating HR needs; communicating needs proactively, partnership with the key HR functions and seek to develop integrated solutions as well as deliver value-added services to meet people orientated goals.
● Partner with leaders to identify, prioritize and build organizational capabilities, behaviors, structures and processes.
● Overseas the development of the annual HR Plan in partnership with the business.
● Provide business insights and connections from internal networks, ensure solutions are tailored to address business needs (e.g. structure vs cultural change required).
● Support change management as it relates to structures, teams and people processes through professional project management. Build measures to review the success of change initiatives to validate the business impact.
● Develop and promote ongoing feedback mechanisms for employees to influence the continuous improvement of the employee experience.
● Review and benchmark effective channels of communication for the employee group, supporting leaders to improve communication with their people.
● Design relevant people metrics to support actions and measure effectiveness.
● Review key business performance targets and their related people implications.
● Define talent needs, and support leaders to forecast and plan their workforce and talent pipeline requirements in line with the function or business strategy.
● Support leaders in providing employees with development opportunities that align with current and future business requirements.
● Collaborate with colleagues in HR departments to deliver tailored solutions for the customer.
● Lead key projects, reviews and initiatives to deliver change and improvements. Review and benchmark the internal and external environment, translating good practice into proposals that are aligned to business goals.
● Take ownership as a Business Partner team, working together to make decisions in line with direction provided by senior HR leaders.
● Drive business results through performance improvement, encourage, and reward behaviour aligned to company leadership values.
● Participate in selection activities for mid- senior roles, in collaboration with colleagues in Recruitment, to ensure the right fit for the department and potential for future needs of the company.
● Provide inputs on strategic HR direction and performance reporting to the BU leadership team.
● Act as an ambassador for the HR Business Partner model, actively improving standards to highlight the benefits of the model for all stakeholders.
● Experience gained within a large organization and must have led a team overseeing a range of HR initiatives and services.


The result left Huddersfield in 19th position on seven points from 12 games, one behind Cardiff City and 17th-placed Crystal Palace.
FILE: Manchester United suffered their first defeat of the season with a shock 2-1 loss at promoted Huddersfield Town. Picture: Twitter @htafcdotcom.
LONDON - Huddersfield Town missed a chance to climb out of the Premier League relegation zone when they were held to a 1-1 home draw by West Ham United in an entertaining clash on Saturday.
The result left Huddersfield in 19th position on seven points from 12 games, one behind Cardiff City and 17th-placed Crystal Palace, who were at home to Tottenham Hotspur in the day's 1730 GMT fixture.
West Ham were fortunate not to fall two goals behind in the first half as Philip Billing's swerving cross-turned-shot came off the inside of the post and Mounie forced another good save from the busy Fabianski.


text:
Sel é uma comuna da Noruega, com 908 km² de área e 6 088 habitantes (censo de 2004).

Comunas da Noruega


Customer service can be a very demanding field. It takes a certain type of personality to succeed in this work, but even the most patient and persistent people can find customer service to be challenging. When you're experiencing a high volume of calls, it can definitely stress you out. Here's how to keep your cool when you work in customer service.
Most customers aren't calling because they're happy about something. They're typically calling to get a problem resolved and some of them might be very angry and frustrated. Try not to take it personally when you get an angry or irate customer on the line. They're ultimately mad about the situation, not at you.
Before you respond angrily to a customer's verbal abuse, take a second to think about the best way to respond. Don't reply in anger, and don't rush to make promises that aren't reasonable or even possible to achieve. Instead, reassure the customer that you understand their frustration and resolve their issue, if possible. If the matter requires you to seek help from a supervisor or a different department, assure the customer that you will see the issue through to its resolution and call them back. Not everything can be resolved in a few minutes, but make sure you do follow up with the customer.
Don't skip breaks on busy days. You may have to delay them if your call volume is high, but you need those few minutes of time away from the phone to stretch, breathe, and relax. Consider doing a short session of focused breathing during your break. Try to get outside, or listen to some relaxing music on your break. Taking even a few minutes to yourself can help you calm down and refocus your energy for the next call.
Try to put yourself in your caller's shoes. Maybe they're having a really terrible day. Maybe they're not angry about the situation, but about something else entirely. Try not to take their problems personally, but treat them with respect as you resolve their issues.
Answer 365 can help you with all your customer service call centre needs. Call or schedule an appointment today to find out what services your business can benefit from.


Join us at Lillie's Bordello Dublin for a cocktail masterclass with their of our expert mixologists. Their cocktail masterclass will begin with a brief history of the origins of the cocktail, from where it all began to the modern cocktails we enjoy today.
There will be a demonstration on some of 'the classics', this useful tutorial will give tips on how to refine your shaker skills. Participants will then be able to sample some of the expertly crafted classic cocktails, as well as a favourite cocktail of their choice. The class will include light bites and all participants can enjoy a reserved area for when Lillie's famous nightclub begins at 11pm, plus admission.
This Experience takes place on Saturday 20th October from 8-10.30pm and is strictly over 21s, tickets cost €30 per person.


CONTRACTORFIND.co.za™ is proud to showcase only the best, registered and certified Cement Screed Flooring Contractors in Durban. Need qualified Cement Screed Flooring Contractors for the job? CONTRACTORFIND.co.za™ is the place to find them! All the listed Cement Screed Flooring Contractors below have been screened and certified, ensuring that their service and quality is the best in Durban. Find the top Cement Screed Flooring Contractors in Durban now.


text:
Home » Budget Industry » 30-Year Plan: Navy Puts 355-Ship Cap on Fleet Size; Plans to Introduce Large Combatant, CHAMP Auxiliary Hull
30-Year Plan: Navy Puts 355-Ship Cap on Fleet Size; Plans to Introduce Large Combatant, CHAMP Auxiliary Hull
USS John C. Stennis (CVN-74) steams through the Pacific Ocean on Oct. 26, 2018. US Navy Photo
The Navy's latest 30-year shipbuilding plan outlines a path forward that includes less near-term growth in fleet size but reaches and sustains a 355-ship fleet sooner than last year's plan.
According to the "Report to Congress on the Annual Long-Range Plan for Construction of Naval Vessels for Fiscal Year 2020," the Navy would decommission its cruisers and mine countermeasures ships sooner, creating more gradual growth in the overall fleet size in the short term. Due to life extensions on other ships – primarily destroyers, but also a few Los Angeles-class attack submarines – the Navy would reach 355 ships in 2034 and then remain at that exact fleet size through the remainder of the 30-year plan. Both factors create a smooth path from today's 289 ships to 314 in 2024 to 355 in 2034 – whereas last year's plan sharply rose to hit 326 ships by 2023, then dipped back down in the late 2020s and rose again in the next decade without ever hitting 355.
"Absent this dip, the aggregate profile now provides a more predictable forecast for fleet planners, shipbuilders and the numerous supporting acquisition programs and enabling contributors – maintainers, trainers, recruiters, etc," reads the FY 2020 plan.
From FY 2020 Long-Range Plan for Construction of Naval Vessels.
While the shape of the fleet expansion is starkly different under this year's 30-year ship plan compared to last year's, the document notes that an ongoing force structure assessment (FSA) due out by the end of this year could overhaul the pathway forward for the Navy yet again.
"In response to the latest National Defense Strategy, Navy Strategy and CNO's Design for Maintaining Maritime Superiority 2.0, the Navy is on track to complete the next FSA by the end of 2019. Some of the key elements that will be reviewed include ongoing threat-based fleet architecture review, logistics in support of [the Distributed Maritime Operations strategy], surface ship mix with the inclusion of the new frigate, deterrence per the National Defense Strategy, and legacy capital investments versus the efficacy of next generation capabilities."
Implications of Fleet Size
USS O'Kane (DDG-77), USS Preble (DDG-88), USS William P. Lawrence (DDG-110) and USS Sterett (DDG-104) are moored during the harbor phase of the 2018 Rim of the Pacific (RIMPAC) exercise on July 4, 2018. US Navy Photo
Though the Navy calls the 2016 FSA's results "the Navy's validated minimum requirement of the correct mix of 355 battle force ships," the 30-year plan specifically does not go above 355 ships at all. The 355-ship figure is treated as a cap, rather than a minimum requirement, due to the cost of sustaining such a large fleet.
"The Navy has been getting smaller for the last four decades, recently falling below 280 total ships, with aggressive measures now in place to reverse this trend in response to the reemergence of Great Power Competition and the attendant larger, threat-based FSA requirement of 355 battle force ships. Coincident with the relatively new dynamic of purchasing more ships to grow the force instead of simply replacing ships or shrinking the force, is the responsibility to 'own' the additional inventory when it arrives," reads the report.
"Consistent annual funding in the shipbuilding account is foundational for an efficient industrial base in support of steady growth and long-term maintenance planning, but equally important is the properly phased, additional funding needed for operations and sustainment accounts as each new ship is delivered – the much larger fiscal burden over the life of a ship and the essence of the challenge to remain balanced across the three integral elements of readiness–capability– capacity. Because the Navy has been shrinking not growing, and because of the disconnected timespan from purchase to delivery, often five years or more and often beyond the FYDP, there is risk of underestimating the aggregate sustainment costs looming over the horizon that must now be carefully considered in fiscal forecasting."
The report notes that, as the fleet grows from 301 to 314 to 355 – the anticipated fleet sizes by the end of FY 2020, 2024 and 2034 – the annual cost to sustain the fleet will grow from $24 billion to $30 billion to $40 billion.
To stay within the 355-ship cap, the Navy's long-range plans show new ship construction dipping right after the 355-ship goal is reached – falling to just seven ships a year in 2037 and 2038 and sitting at only eight ships a year in 2036 and 2039 through 2044, compared to 12 ships in FY 2020. At the same time, ship decommissionings spike, with 14 ship set for retirement in 2035, compared to five in FY 2020.
Virginia-class fast-attack submarine USS Missouri (SSN-780) on May 31, 2018. US Navy Photo
The plan notes that, of all the ship types, attack submarines are furthest away from their goal under the 2016 FSA. The Navy today has 51 SSNs, compared to a goal of 66.
"Options are being explored regarding expanding production," the report reads.
However, expanding production will likely prove challenging. General Dynamics Electric Boat and Huntington Ingalls Industries' Newport News Shipbuilding are co-building Virginia-class attack submarines at a rate of two a year while also getting ready to add in a Virginia Payload Module section to the boats and begin Columbia-class ballistic missile submarine construction that is roughly the workload equivalent of two SSNs per one SSBN. Industry and congressional officials have stated concerns about the fragility of the supplier base and that the increase in workload may put more strain on suppliers rather than provide the benefits that usually come with higher workload volume and stability.
The 30-year plan states that the FY 2020 budget includes a third SSN in FY 2020 compared to the previously planned two-a-year sustained rate, but it notes that, "because it was added to the shipbuilding plan this year, advanced procurement was not programmed for the third FY2020 SSN. This will result in delivering it over a timeframe similar to a ship procured in FY2023. Per Congressional direction, the next SSN multi-year procurement contract will include options for a third submarine in FY2022 and FY2023, the years when not procuring an SSBN."
Several sources have told USNI News that, if industry were to be asked to build a third Virginia-class sub in any given year, that submarine would likely deliver late and cost more – a fact the 30-year ship plan partially confirms.
The Sea Hunter, a Medium Displacement Unmanned Surface Vehicle (MDUSV). US Navy Photo
The Navy's FY 2020 budget request shows a new and significant focus on developing and fielding unmanned vehicles – particularly unmanned surface vehicles, investment for which has lagged behind unmanned underwater and aerial vehicles. The Navy wants to buy a medium and a large USV as part of its Future Surface Combatant family of ships that will also include a frigate, or small surface combatant, and a large surface combatant.
In the 30-year ship plan, the Navy writes that "Unmanned systems continue to advance in capability and are anticipated to become key enablers through all phases of warfare and in all warfare domains. Significant resources were added during PB2020 to accelerate fielding the full spectrum of unmanned and optionally manned capabilities, including man-machine teaming ahead of full autonomy. These systems are now included in wargames, exercises and limited real-world operations. They are funded in the Navy's research and development investments and accounted for in detail in each warfare domain's Capability Evolution Plan (CEP)."
However, it continues, these unmanned systems are not counted in the 30-year plan as battle force ships – those that count towards the 355-ship goal – even though the Navy included the Large USV in its shipbuilding construction plans in the budget request and intends to use shipbuilding funds to pay for those vehicles beginning in 2021.
"The physical challenges of extended operations at sea across the spectrum of competition and conflict, the concepts of operations for these platforms, and the policy challenges associated with employing deadly force from autonomous vehicles must be well understood prior to replacing accountable battle force ships," the 30-year plan notes.
"Accordingly, the Navy will continue to move quickly to assess the resultant naval power delivered by these systems, moving forward based on demonstrated, evidence-based capability."
The Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72) illuminates its hull number on the ship's island structure with holiday colors while moored pierside at Naval Station Norfolk. US Navy photo.
The Navy in December signed a contract to buy two Ford-class aircraft carriers together, but despite the massive amount of money involved in the contract, the Navy will actually spend less per year than previously planned, according to the long-range ship plan.
Under the current plan, the Navy will spend $2.35 billion in 2020, $2.65 billion in 2021, $2.32 billion in 2022, $1.93 billion in 2023 and $1.72 billion in 2024 to pay for activities related to the two carriers' construction at Newport News Shipbuilding.
In contrast, under last year's plan – where the Navy would be buying the future Enterprise (CVN-80) under one contract while also paying advance procurement costs for the unnamed CVN-81 separately – the service planned to spend slightly less in 2020 – at $2.15 billion – but then spend significantly more in later years, with a planned $3.24 billion in 2021, $2.91 billion in 2022 and $3.38 billion in 2023.
USS Mobile Bay (CG-53) conducts a replenishment-at-sea with the fleet replenishment oiler USNS Guadalupe (T-AO-200) in the Indian Ocean on Jan. 24, 2019. US Navy Photo
The long-range ship plan notes several updates for surface ships, including:
Eight cruisers will be retired – four in 2021 and two each in 2022 and 2024, while newer cruisers continue through the congressionally mandated cruiser modernization plan already underway.
The Navy would buy Flight III Arleigh Burke-class guided-missile destroyers through FY 2025 – three years and eight hulls beyond the end of the current multiyear buy – and then switch over to buying the first two Large Surface Combatants in 2025. Though the LSC is now planned for a 2025 start, compared to a previously stated data of 2023, the plan adds that "industry engagement over the next year will determine the feasibility of accelerating the effort in accordance with the imperatives of the CNO's Design for Maintaining Maritime Superiority 2.0."
The Navy intends to buy the sixth and final Expeditionary Sea Base in FY 2023, after a flurry of buying ESBs in 2016, 2018 and 2019.
Mine Countermeasures Ships
The Avenger-class mine countermeasures ship USS Chief (MCM-14) pulls into Jeju Island in the Republic of Korea (ROK) as part of a routine port visit on Sept. 26, 2017. US Navy Photo
The retirement of Avenger-class MCM ships, which had previously been pushed back, would be accelerated under this 30-year ship plan.
"The Navy is focused on both future MCM capability and near-term improvement of operational availability (Ao) of the aging Avenger-class MCMs, with priority on the forward deployed naval force (FDNF). Accordingly, the homeland threat environment supports retiring the three remaining continental United States based MCM ships in FY2020 and harvesting parts that are no longer manufactured in order to improve FDNF Ao," according to the report. Three MCMs are stationed in San Diego, with the remainder of the fleet in Bahrain and Japan.
The report notes that the Navy is moving away from the MCM ships and towards the Littoral Combat Ship's MCM mission package and Expeditionary MCM companies.
USNS Tippecanoe (T-AO 199). US Navy Photo
The ship plan outlines the timeline for the upcoming Common Hull Auxiliary Multi-Mission Platforms (CHAMPs) program that would replace five or more Navy auxiliary ship types with just two hulls: one for people-based missions, like a hospital ship, submarine tender or command and control ship; and the other for volume-based missions such as sealift and aviation logistics support.
"The Navy has funded CHAMPs development and has approved top-level requirements (TLRs) as the basis for industry studies. The request for proposal for these studies was released 2nd quarter of FY2019 and both Capability Development Documents (CDD) and Concepts of Operations (CONOP) reviews are in progress. Although early in the process, upfront collaboration with industry on CHAMP options has indicated two hull designs may be needed to meet both RO/RO and non-RO/RO requirements, in lieu of significant compromise and increased cost across the five mission areas. As program options and costs mature, additional detail will become available," the plan reads.
"This appendix shows an initial procurement of the sealift variant in FY2025 and delivery in FY2028, with the intention to accelerate procurement for a FY2026 delivery."
Article Keywords: Arleigh Burke-class destroyer, Avenger class, Common Hull Auxiliary Multi-Mission Platform (CHAMP), CVN-81, Enterprise (CVN-80), Expeditionary Sea Base, Fiscal Year 2020, Ford-class carrier, future surface combatant, large surface combatant, large unmanned surface vehicle, MCM, medium unmanned surface vehicle, SSN, Virginia-class submarine
Categories: Budget Industry, News & Analysis, Submarine Forces, Surface Forces, U.S. Navy
About Megan Eckstein
Megan Eckstein is a staff writer for USNI News. She previously covered Congress for Defense Daily and the U.S. surface navy and U.S. amphibious operations as an associate editor for Inside the Navy.
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redpajama_set_name: RedPajamaCommonCrawl


That's what BP could have bought with the money they lost because of the recent oil spill if you believe the article compiled by visualeconomics.com. But that obviously isn't all. It's just a small, very small percentage of what they could've bought.
1. BP could have bought 10 years of clean water for each of the 884 million people in the world without access to it.
The cost would be $8.84 billion, or $1 per year per person.
2. BP could also have bought a new home to replace each of the 275,000 lost in Hurricane Katrina. The cost would be $48.125 billion at the median New Orleans market rate of $175,000.
3. With the lost money, BP could also have bought an ice cream sandwich for everyone on Earth. The cost of $3.395 billion included a 0.50 sandwich from Walmart for each person.
Just imagine what a massive PR stunt something like that would be. In another world maybe.
Read on on visualeconomics if you want to see the rest of the entry.
Pennsylvania Judge Hands out Condoms. Gets Arrested.


We're very excited to return to TT's for the first time since we rocked and rolled our way through the Rock 'n Roll Rumble back in April. Tickets are $16 in advance. Buy them online or save a few bucks and go to the TT's box office. Get there early — we go on first in support of Langhorne Slim and the Law.
OldJack performing at Patriot Place Rock The Plaza at Gillette Stadium (Photo by Sooz).


Location: Atlanta airport - 50 miles.
General Information: Treat yourself to a holiday in the sunny South at Fairfield Plantation. You'll find top-notch facilities on site for almost all forms of recreation. Golfers will be impressed with the high quality of the resort's championship 18-hole course. Set among rolling hills and 3 beautiful lakes you can also enjoy bass fishing, waterskiing or just lounging around a shady beach. This luxury resort is known for its southern hospitality and beautiful scenery.
Types of Units: Studios for 2 have an efficiency kitchen, 2 full beds and 1 bed. 1B units for 5 have a full kitchen and 2 full beds, a queen sleeper sofa and 2B. 2B units for 7 have 4 full beds, a queen sleeper and 3 baths.
Area Attractions: Aside from great golf, vacationers will enjoy swimming, tennis and mini golf. It's a perfect getaway, just 45 miles from the shopping and excitement of Atlanta.


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The eastern side of Singapore can be considered a cycling wasteland with relatively flatter terrain as compared to the northern and western parts of the island. Even though it does not have the hills of Mount Faber or the flat roads of Lim Chu Kang, there are many riders who still head down to East Coast Park on weekends to have their weekly dose of saddle-time. In this article, I will be introducing two cycling routes in the East which are Changi Coast Road and Selarang.
Often referred to as "Coastal", Changi Coast Road is a place where you see lots of cyclists on weekend mornings as well as weeknights, some in groups, others training individually. It is a place where various cycling races such as those held by organisers like Tribob and Cyclone take place regularly. Though the road is long and stretches all the way from Changi Village to East Coast Park, I am going to concentrate on the road bounded by Tanah Merah Coast Road and Aviation Park Road.
This flat route is approximately 6km long with only about four meters of elevation-change throughout. The route is sheltered with trees on both sides, thus making it shady and cooling to ride along. Due to its location being very near the shoreline, crosswinds can be relatively heavy, but can also make your ride nice and breezy. Cyclists who want to do interval trainings can simply make U-turns at both ends of the route. When you are done, proceed to the nearby Changi Village Hawker Centre to have a cool and refreshing drink, or to replenish the calories which you have lost.
Less experienced cyclists also have the luxury of the Coastal Park Connector at their disposal. It is a smoothly paved pathway which runs throughout the length of Changi Coast Road. Amateurs who may be unsure of their bike-handling skills or wary of road conditions can use the connector for a more confident ride.
More experienced cyclists usually use the two-lane road, where they need not contend with joggers and skaters for the space. Road traffic is only heavy during peak-hours on weekdays and is relatively light otherwise. Also due to the amount of cyclists there, cars and heavy vehicles generally give plenty of clearance while overtaking, doing so from the outer lane.
It might also be a good idea to bring an extra bottle of juice if you are doing interval trainings as there are no shops available near the area.
In conclusion, cycling on Changi Coast Road is an enjoyable experience with cool winds and a consistent terrain. Taking a break midway also has its perks, offering quite a view with aeroplanes taking off and landing at the neighbouring Changi International Airport.
Not for the faint-hearted, Xilin Avenue is located at the junction of Simei Avenue and Upper Changi Road East. From there, cross over the flyover and Changi Coast Road is straight ahead. Be alert and watch out for traffic filtering in and out of the expressway.
Selarang is situated in between Tampines and Changi Village. When cyclists in the East mention Selarang, they are actually referring to the road Upper Changi Road North. Although the hills here pale in comparison to those of Mount Faber or Upper Thomson Road, they do offer a refreshing alternative to the generally flat roads of the East.
Approaching from Loyang Avenue, a climb immediately greets you, forcing you to scale up this two- lane road. A short descent to recover your legs and it's time to gain momentum for a second climb, this time shorter but steeper than the first. While it might seem relaxing to simply pedal uniformly all the way, racers who frequent this hill for personal bests know better, as this route can present quite the challenge due to the double-ascent. The route is approximately 3km long with a total elevation gain of 36m.
Although Selarang does not have a park connector, it is surrounded by several tall buildings and historical sights. Traffic is not heavy but due to each road having only one lane, it is advisable to cycle on the left side of the road. Cyclists who do not have good bike-handling skills may be spooked by trucks running beside them and end up taking the footpath instead. However, cars will normally keep their distance especially when you're climbing up-hill and may even wait patiently behind you if they are not in a hurry.
In conclusion, though slightly more congested than Changi Coast Road, Selarang is one of the few places where cyclists from the East can get to experience climbs without going to the opposite end of the island. Unlike Coastal, there is a petrol kiosk and other shops along the way, so parched cyclists without a spare bottle need not worry as long as you have some cash with you.
Approaching from the western side of Singapore there are two ways into Selarang, either through Pasir Ris or Loyang Avenue.
Coming from Changi Coast Road, make a left turn at the junction of Loyang Way and Loyang Avenue. The uphill on Selarang immediately commences.
Coming from this road requires a decent sprinting ability and good road awareness as it is at the convergence of two expressways. Watch out for traffic going into the TPE, with Upper Changi Road North on the right.
These routes are just two of the more popular options available in the East, where cyclists can ride for fun or to train. The popularity of these two routes is evident on weekends, where you can see many cyclists. Some along Changi Coast Road are even decked out in skin-suits and full time-trial setups doing interval trainings, oftentimes in groups of 20 or more. Experienced cyclists who want to do more training can even combine Changi Coast Road with Selarang to form a route of approximately 30km, which is commonly referred to as the Selarang Loop.


Logline: UNTITLED SABRINA SERIES imagines the origin and adventures of Sabrina the Teenage Witch as a dark coming-of-age story that traffics in horror, the occult and, of course, witchcraft. Tonally in the vein of Rosemary's Baby and The Exorcist, this adaptation finds Sabrina wrestling to reconcile her dual nature — half-witch, half-mortal — while standing against the evil forces that threaten her, her family and the daylight world humans inhabit.
Based on the Archie Comics characters and coming on the heels of the success of Riverdale, which is also based on characters from Archie Comics.


Each year the Karlsberg Brewery (Karlsberg Brauerei) in Homburg/Saar in Germany sponsors an excellent season-ending golf tournament, the Karlsberg Team Trophy for Jungsenioren ("young seniors", players who are 35 years of age and up).
It is a friendly competition among the participating golf club teams that play each season in the young seniors German golf leagues in Saarland and Rheinland-Pfalz (the Rheinland-Palatinate), which are 2 of the 16 German states.
The tournament takes place at the Golf Club Homburg/Saar, a championship 6527-yard par 72 golf course in Saarland at Websweiler Hof.
PROmotion Golfevents has many photographs of this year's tournament online, of which there is also a comparable Picasa Web Album.


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Tamra's Relationship Drama Is Getting Intense
Imeh Akpanudosen/Getty Images Entertainment/Getty Images
Tamra Judge has found herself at the center of controversy both on and off of Real Housewives of Orange County this year. While on the show she argued with old friend Vicki about her relationship with Brooks Ayers, behind the scenes Tamra is embroiled in serious family problems. The source is Tamra's ex-husband, Simon Barney, who you may remember from Tamra's first few seasons on RHOC. Their divorce was contentious, and Simon is battling his ex-wife for custody of their three children, Sophia, Sidney, and Spencer. The kids don't appear on the show anymore, and Simon is accusing Tamra of failing to provide a safe environment for the kids while she has custody.
Like any custody battle, it's bitter, vicious, and feels too private to be public knowledge. But the Barneys are fighting it in tabloids and blogs as much as they're fighting in the courtroom. Simon claimed that Tamra is neglectful, and in return, Tamra reminded the public about Simon's arrest for domestic abuse in 2010, and allegedly in 1997 as well. Daughter Sidney has reportedly voiced support for her father on Twitter, while Tamra has made a concentrated effort to show her other daughter, Sophia, at home doing homework, cooking dinner, and goofing off with her on Instagram.
But there's another layer to the story, and one that rips away whatever sympathy is granted to Tamra for Simon's sleazy behavior and the unfortunate situation of being forced to battle in court for the right to see her own children. She very well may have leaked fake divorce/cheating rumors in order to drive up interest in her storyline this season, as reports about Tamra and husband Eddie's relationship by Celeb Dirty Laundry suggest. Not only is Tamra and Eddie's gym, CUT Fitness, subject to a good deal of negative reviews, but in large part because of the divorce rumors, Bravo wanted Eddie to appear on the reunion, and when he declined, the rumors got even stronger. Tamra blames her ex, telling All Things Real Housewives that Simon is friends with a reporter for Radar Online who is throwing out fake stories, her relationship has always been healthy, and she hasn't implied differently at any point.
There's no level Tamra won't stoop to to keep her job, but as a wife and mom, let's hope she has some scruples and chooses to preserve her marriage, business, and relationship with her children over another season of Real Housewives of Orange County. If what they want is a dramatic, tense marriage on the verge of breaking up, honestly at this point, it's not worth it —even if that means those of us in the audience lose a few months of Tamra gossiping and running through hotel lobbies in tears. We'll live to watch another wine glass get thrown. There's no shortage of hot-tempered Southern Californians. Tamra should prioritize her actual family, not her Bravo "family."


GT TDi, FSh- NOW SOLD!!
Here is a nice 2009 VW Golf Plus 2.0 GT TDi. NOW SOLD!!
Upgrades include metallic paint and cruise control.
Standard spec includes Air-Conditioning (Automatic), 6 speed gearbox, Alarm, Alloy Wheels (16in), Computer (Driver Information System), Electric Windows (Front/Rear), Electric door mirrors, In Car Entertainment (Radio/CD), Folding rear seats, Power steering, Front Fog Lights. 5 seats.
This Golf Plus will be sold with 12 months MOT, service and our 3+3 month warranty.


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Q: Reconstruction of Normal Distribution Function (NDF) using Wheeler's algorithm I have a polydisperse bubble in liquid simulation which calculates statistical moments, and my next target is to reconstruct the Normal Distribution Function (NDF) that represent bubble size distribution using the moments data. I found this equation to approximate the NDF
$$
n\left(\xi\right)=\sum_{\alpha=0}^{N-1}w_\alpha\delta\left(\xi-\xi_\alpha\right)
$$
but I have no idea how to calculate the weights and abscissas from the calculated moments data. Some sources said that I can calculate it with Wheeler's algorithm. I've read the paper but I found it difficult to understand.
Does anyone know how to calculate the weights and abscissas from statistical moments using Wheeler's algorithm or maybe an example program that performs Wheeler's algorithm? multiphase simulation is a brand new topic for me.


The Consumer Virtual Assistant landscape was pretty uneventful in 2017 but it felt more like business model stagnation than any limit in the longterm technologies. Humans are still involved in much of the supply-side fulfillment and, well, human labor is still expensive. In addition, I wonder if consumers will trust Apple, Google, Facebook and Amazon AI assistants to truly represent their best interests given ongoing investigations into bias in algorithms, designing for addiction (err i mean engagement), and the regulatory conversations occurring around 2016 elections.
What Virtual Assistants did I rely upon in Year Three 2017?
Facebook Messenger M: While M moves more towards auto-replies, I believe I still have access to the fuller version of M that more closely resembles the original virtual assistant beta (remember when you could ask M to do nearly anything?). I use M to make reservations for restaurants and such when there's not an online booking option clearly available. Also light amounts of information retrieval (call XYZ and ask 123), but stay away from anything more complex.
Are there other virtual assistant services you use that I should give a try?


Overt and Subclinical Hypothyroidism in the Elderly: When to Treat?
Practical resource for many common conditions in gynecology.
Presented at the American College of Cardiology (ACC) 2019 Scientific Session.
Adults with an acute respiratory infection who have normal vital signs (temperature < 37,8 / respiratory rate < 20 / heart rate < 100) and a normal pulmonary examination are very unlikely to have CAP.
"There is solid evidence to support a flexible, individualized screening regimen. In particular, it is possible to prolong screening intervals to 24–48 months for patients with no or mild nonproliferative diabetic retinopathy".


In today's world we face an increased risk of toxin accumulation in our body. Toxic substances can enter our body via direct contamination of the water we drink or bathe in, the air we breathe and the food we eat, since we use more chemical substances in every step of our food chain. Using fossil energy also creates air pollution, especially in metropolitan areas. Secondly, a series of toxins come from our daily cooking process, especially when we cook protein enriched food i.e. meat and poultry. Heating protein will create heterocyclic amine and we've found that heterocyclic amine is a potent carcinogen and causes DNA damage to a greater extent than earlier thought. Even though we try to avoid meat, a recent study revealed that healthier food like grilled salmon still has some level of heterocyclic amine - enough for having carcinogenicity. The third series of toxins come from our own metabolic processes which create metabolic waste products and also the function of the liver itself when liver metabolizes harmless organic substances it may also produce heterocyclic amine as a by-product. When our body accumulates more and more toxins, our natural body detoxification process will become less and less effective. The Intercellular matrix will become congested with different kinds of toxin. A congested matrix blocks the intercellular connection pathway and the messenger molecule (i.e. hormone, peptide) from the bloodstream cannot reach the target cell, so the target cell cannot function or accept control from the neurovegetative center. This will lead to degenerative disease such as Type II diabetes, Alzheimer's disease, cardiovascular disease, liver disease or cancer.
AH detox™ offers intensive detoxification programs including intravenous detoxification, multiple vitamin mega-dose infusion, homeopathy, homotoxicology, heavy metal detoxification, free radical quenching, liver detoxification etc.


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1931 Librado 2021
Librado Cerda
August 17, 1931 — September 10, 2021
Weslaco: Librado Cerda, 90, passed away at his home in Weslaco, surrounded by his loving family, on Friday, September 10, 2021. Librado was born on August 17, 1931, to Victorio and Ignacia Sandoval Cerda in San Luis Potosí, Mexico. Librado came to the United States during the bracero program, traveling across the country to work in agriculture. During this time, Librado nurtured a passion for the natural world, which he would maintain throughout his life. When Librado wasn't working up north, he stayed and worked in Weslaco, where he met his soulmate, Gelacia Lopez. Librado and Gelacia were an instant match, and they were married on May 18, 1958, at St. Joan of Arc Catholic Church in Weslaco.
Librado and Gelacia were pioneers of Weslaco and worked tirelessly to provide for their children. Librado was an entrepreneur, and Gelacia was the perfect partner. The couple started selling fresh fruits and vegetables. The business thrived. They, as a family, would deliver fresh produce to regular customers and make new ones along their routes and would soon establish themselves at local flea markets. Eventually, Librado and Gelacia added a full nursery to their business. Librado was very particular about the quality of the produce and plants, which earned him the respect and trust of many loyal customers and a reputation for perfection.
Although Librado never received a formal education, he was an excellent businessman and believed in the value of education. Librado was very strict and held his children to the highest standards, demanding that they take full advantage of an education and apply themselves to the best of their ability. Librado's high expectations paid off when all of his children earned a college degree. The value of education continued to grandchildren, and Librado's high expectations and perfectionist nature will be a legacy passed on for generations to come.
Though strict, Librado possessed a loving soul, quick with a joke or a witty remark. He had become a sight for sore eyes to his friends and family. Seldom were the moments where he was not surrounded by his children and a plethora of animals. For as long as he lived in Weslaco, he provided comfort and shelter to numerous chickens, parrots, cats, and dogs. Though Librado had achieved much in his life, he never let it get the better of him, insisting on remaining humble.
Librado is preceded in death by his parents, Victorio and Ignacia Cerda and son, Antonio "Tony" Cerda.
He is survived by his loving wife and partner, Gelacia Cerda, children, Victoria "Vicky" Cerda-Ortega (Richard+), Jorge Cerda (Sandra), Jesus Cerda (Elizabeth), Lupita Martinez (Carlos), Alicia Cerda, and Miguel Cerda (Sandra), all of Weslaco, and many grandchildren, Elizabeth Marie Ortega, Carolina Cerda, Angelica Cerda, Adriana Cerda, Mariana Cerda, Aaron Cerda, Klarissa Martinez, Krystal Martinez, Carlos Martinez Jr., Kaylee Martinez, Karina Cerda, Miguel Cerda Jr., Kristina Cerda, Kasandra Cerda, Andres Cerda, and Antonio Cerda.
To order memorial trees or send flowers to the family in memory of Librado Cerda, please visit our flower store.
McCaleb Funeral Home
900 West 4th Street, Weslaco, TX 78596
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109 S Illinois Ave, Weslaco, TX 78596
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1001 South Illinois, Weslaco, TX 78596
1001 S Illinois Av, Weslaco, TX 78596