Pam joined the Friends of Karen Board in 2002 and has served as President from 2011-2017. Her professional experience has been in engineering, finance and corporate management, with positions on Wall Street and in the telecommunications industry. Pam holds a BS in electrical engineering from Lafayette College and an MBA from Boston College, with a concentration in finance and strategic management. Pam is an active supporter of Caramoor Music Center, Boys & Girls Club of Northern Westchester and Harlem, Pegasus Therapeutic Riding, and Northern Westchester Hospital among others. Pam is the drummer in the Indie rock band, Lawless, and lives with her husband and two daughters in Katonah, NY.


text:
HomeCheck: Anything odd with Russell Simmons being the godfather to ex wife Kimora's kids with other men?
Check: Anything odd with Russell Simmons being the godfather to ex wife Kimora's kids with other men?
Russell Simmons is pictured above with ex wife/model & fashion designer Kimora Lee Simmons' (she kept his name) two youngest children; Kenzo Lee and Wolf Lee.
A little history: Russell met Kimora when she was 17 back in 1992 and they got married in St. Bart's on December 20, 1998. They have two daughters, Ming Lee Simmons and Aoki Lee Simmons. However, they separated in March 2006 and finalized their divorce in January 2009.
Kimora went on to have a son named Kenzo Lee Hounsou with actor and model Djimon Hounsou. They were never legally married in the United States and announced their separation in November 2012.
Now in February 2014, she married her third husband - Tim Leissner and they have since welcomed a baby boy named Wolfe Lee Leissner.
To cut the long story shut, her first (now ex) husband shared via Instagram that he's the godfather to her other kids. He has a big heart!

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Upgrading from Microsoft.Net.Compilers to Microsoft.Net.Compilers.Toolset I have an ASP.NET (full framework) MVC application that is currently using Microsoft.Net.Compilers which is now deprecated.  On my first pass, I missed this and attempting to upgrade the version (via Nuget Package Manager), this went very very wrong for my project (corrupted .csproj file).
Now that I realize I need a different package (Microsoft.Net.Compilers.Toolset according to the package manager), I want to make sure I know what I'm doing before another debacle.
Can I simply remove the package Microsoft.Net.Compilers and add the .Toolset?  Will this necessitate any other shenanigans?
Any thoughts or best practices I should be aware of?

redpajama_set_name: RedPajamaStackExchange


Are you interested in hosting a VISTA?
A VISTA can be an incredible capacity-building asset for your organization, helping you make lasting change that endures long after their term of service. If you believe you would benefit from a VISTA, there are a few steps you'll need to take.
First, learn about the program by reviewing the VISTA Strong Communities Program Overview and the What is a VISTA? handout, as well as the AmeriCorps website.
Think about the project you'd like the VISTA to support.
How can a VISTA help you reach them?
Does my organization have the resources to sustain the project after they leave?
What support can I provide to a VISTA candidate in return?
VISTA Strong Communities host sites are asked to provide $1000 per month to offset the high cost of housing in DC. Is your organization able to provide this support?
Can you organization provide workspace and internet access?
Can your organization offer professional development opportunities?
Who will supervise the VISTA?
Each VISTA is paired with an organizational supervisor who helps them fulfill their duties – who at your organization will take that on?
Read through the pre-application document prior to submitting a proposal to the online portal below.
Applications are considered on a rolling basis. The final deadline is 5:00 pm on Monday, October 1, 2018.
READ THE MATERIALS? READY TO APPLY?
Is VISTA Right for Your Organization?


In PlastCraftGames you will find everything you need to build your own personalised sceneries. Our models, materials, tools, tips and tutorials will lead your battles to a new dimension. Specialise in PVC sceneries.


As I write this, people in the U.S. are beginning their prep to welcome in 2015. Parties are rising from boxes and bags, special "good luck" dinners are being cooked, candles lit (raise the energy level), etc.
Some folks will look back on this year remembering events of great joy such as weddings, babies, dream careers going up several notches, and the year will have been a banner for them.
Others, myself included, will not mourn its passing. For us, it has been a year of trial, loss, and in some cases, the masks being ripped away from so-called friends to show the nastiness hidden behind.
This was a year of losing what no longer served, learning who friends are, and figuring out what the lessons were I needed to learn. And figure them out, I did.
Thanks to those who helped me quickly and efficiently leave a hostile living situation with an increasingly unstable roommate.
2) George Lucas was right. In an interview after "Return of the Jedi" was released, he referenced Joseph Campbell discussing the Ewoks: "When you're nice to the little bunny on the side of the road…" I forget the rest of the quote, but it had to do with help from unexpected sources.
There are other lessons learned that I am not sharing here. Important ones, but they're for me.


Peer pressure has taken on a bad connotation. It's something we want our children to avoid. We often blame it for our own vices and excesses. So when Pulitzer Prize-winning journalist Tina Rosenberg offers a book on how peer pressure can be used for good, it may be time to take note.


text:
Вилар-даз-Алмаш () — населённый пункт и район в Португалии, входит в округ Виана-ду-Каштелу. Является составной частью муниципалитета Понти-ди-Лима. По старому административному делению входил в провинцию Минью. Входит в экономико-статистический субрегион Минью-Лима, который входит в Северный регион. Население составляет 343 человека на 2001 год. Занимает площадь 5,21 км².

Районы округа Виана-ду-Каштелу

redpajama_set_name: RedPajamaWikipedia


text:
import React from 'react'
import { findDOMNode } from 'react-dom'
import { render } from '../TestUtils'
import ColumnSizer from './ColumnSizer'
import Grid from '../Grid'

describe('ColumnSizer', () => {
  function getMarkup ({
    columnMinWidth = undefined,
    columnMaxWidth = undefined,
    columnsCount = 10,
    width = 200
  } = {}) {
    function renderCell ({ columnIndex, rowIndex }) {
      return (

          {`row:${rowIndex}, column:${columnIndex}`}

      )
    }

    return (
      <ColumnSizer
        columnMinWidth={columnMinWidth}
        columnMaxWidth={columnMaxWidth}
        columnsCount={columnsCount}
        width={width}
      >
        {({ adjustedWidth, getColumnWidth, registerChild }) => (

            <Grid
              columnsCount={columnsCount}
              columnWidth={getColumnWidth}
              height={50}
              ref={registerChild}
              renderCell={renderCell}
              rowHeight={50}
              rowsCount={1}
              width={adjustedWidth}
            />

              {`adjustedWidth:${adjustedWidth} columnWidth:${getColumnWidth()}`}

        )}
      </ColumnSizer>
    )
  }

  it('should distribute column widths evenly if no min/max boundaries have been set', () => {
    const rendered = findDOMNode(render(getMarkup()))
    expect(rendered.querySelector('.debug').textContent).toContain('columnWidth:20')
  })

  it('should respect :columnMaxWidth if specified', () => {
    const rendered = findDOMNode(render(getMarkup({
      columnMaxWidth: 10
    })))
    expect(rendered.querySelector('.debug').textContent).toContain('columnWidth:10')
  })

  it('should respect :columnMinWidth if specified', () => {
    const rendered = findDOMNode(render(getMarkup({
      columnMinWidth: 30
    })))
    expect(rendered.querySelector('.debug').textContent).toContain('columnWidth:30')
  })

  describe('recomputeGridSize', () => {
    function helper (updatedProps, expectedTextContent) {
      const renderedA = findDOMNode(render(getMarkup()))
      expect(renderedA.querySelector('.debug').textContent).toContain('columnWidth:20')

      const renderedB = findDOMNode(render(getMarkup(updatedProps)))
      expect(renderedB.querySelector('.debug').textContent).toContain(expectedTextContent)
    }

    it('should recompute metadata sizes if :columnMinWidth changes', () => {
      helper({ columnMinWidth: 30 }, 'columnWidth:30')
    })

    it('should recompute metadata sizes if :columnMaxWidth changes', () => {
      helper({ columnMaxWidth: 15 }, 'columnWidth:15')
    })

    it('should recompute metadata sizes if :width changes', () => {
      helper({ width: 300 }, 'columnWidth:30')
    })

    it('should recompute metadata sizes if :columnsCount changes', () => {
      helper({ columnsCount: 2 }, 'columnWidth:100')
    })
  })

  it('should pass the :width as :adjustedWidth if columns require more than the :width to be displayed', () => {
    const rendered = findDOMNode(render(getMarkup({
      columnMinWidth: 30
    })))
    expect(rendered.querySelector('.debug').textContent).toContain('adjustedWidth:200')
  })

  it('should pass an :adjustedWidth if columns require less than the :width to be displayed', () => {
    const rendered = findDOMNode(render(getMarkup({
      columnMaxWidth: 10
    })))
    expect(rendered.querySelector('.debug').textContent).toContain('adjustedWidth:100')
  })

  it('should error if the registered child is not a Grid', () => {
    expect(() => {
      render(
        <ColumnSizer
          columnMinWidth={100}
          columnMaxWidth={100}
          columnsCount={100}
          width={100}
        >
          {({ adjustedWidth, getColumnWidth, registerChild }) => (

          )}
        </ColumnSizer>
      )
    }).toThrow()
  })
})

redpajama_set_name: RedPajamaGithub


Electronic patient records provide a valuable source of information for detecting adverse drug events. In this paper, we explore two different but complementary approaches to extracting useful information from electronic patient records with the goal of identifying candidate drugs, or combinations of drugs, to be further investigated for suspected adverse drug events. We propose a novel filter-and-refine approach that combines sequential pattern mining and disproportionality analysis. The proposed method is expected to identify groups of possibly interacting drugs suspected for causing certain adverse drug events. We perform an empirical investigation of the proposed method using a subset of the Stockholm electronic patient record corpus. The data used in this study consists of all diagnoses and medications for a group of patients diagnoses with at least one heart related diagnosis during the period 2008--2010. The study shows that the method indeed is able to detect combinations of drugs that occur more frequently for patients with cardiovascular diseases than for patients in a control group, providing opportunities for finding candidate drugs that cause adverse drug effects through interaction.
Background: Adverse drug events (ADEs) as well as other preventable adverse events in the hospital setting incur a yearly monetary cost of approximately $3.5 billion, in the United States alone. Therefore, it is of paramount importance to reduce the impact and prevalence of ADEs within the healthcare sector, not only since it will result in reducing human suffering, but also as a means to substantially reduce economical strains on the healthcare system. One approach to mitigate this problem is to employ predictive models. While existing methods have been focusing on the exploitation of static features, limited attention has been given to temporal features.
Methods: In this paper, we present a novel classification framework for detecting ADEs in complex Electronic health records (EHRs) by exploiting the temporality and sparsity of the underlying features. The proposed framework consists of three phases for transforming sparse and multi-variate time series features into a single-valued feature representation, which can then be used by any classifier. Moreover, we propose and evaluate three different strategies for leveraging feature sparsity by incorporating it into the new representation.
Results: A large-scale evaluation on 15 ADE datasets extracted from a real-world EHR system shows that the proposed framework achieves significantly improved predictive performance compared to state-of-the-art. Moreover, our framework can reveal features that are clinically consistent with medical findings on ADE detection.
Conclusions: Our study and experimental findings demonstrate that temporal multi-variate features of variable length and with high sparsity can be effectively utilized to predict ADEs from EHRs. Two key advantages of our framework are that it is method agnostic, i.e., versatile, and of low computational cost, i.e., fast; hence providing an important building block for future exploitation within the domain of machine learning from EHRs.
Electronic health records contain a wealth of epidemiological information about diseases at the population level. Using a database of medical diagnoses and drug prescriptions in electronic health records, we investigate the correlation between outdoor temperature and the incidence of epistaxis over time for two groups of patients. One group consists of patients that had been diagnosed with epistaxis and also been prescribed at least one of the three anti-thrombotic agents: Warfarin, Apixaban, or Rivaroxaban. The other group consists of patients that had been diagnosed with epistaxis and not been prescribed any of the three anti-thrombotic drugs. We find a strong negative correlation between the incidence of epistaxis and outdoor temperature for the group that had not been prescribed any of the three anti-thrombotic drugs, while there is a weaker correlation between incidence of epistaxis and outdoor temperature for the other group. It is, however, clear that both groups are affected in a similar way, such that the incidence of epistaxis increases with colder temperatures.
When using electronic health record (EHR) data to build models for predicting adverse drug effects (ADEs), one is typically facing the problem of data sparsity, i.e., drugs and diagnosis codes that could be used for predicting a certain ADE are absent for most observations. For such tasks, the ability to effectively handle sparsity by the employed machine learning technique is crucial. The state-of-the-art random forest algorithm is frequently employed to handle this type of data. It has however recently been demonstrated that the algorithm is biased towards the majority class, which may result in a low predictive performance on EHR data with large numbers of sparse features. In this study, approaches to handle this problem are empirically evaluated using 14 ADE datasets and three performance metrics; F1-score, AUC and Brier score. Two resampling based techniques are investigated and compared to two baseline approaches. The experimental results indicate that, for larger forests, the resampling methods outperform the baseline approaches when considering F1-score, which is consistent with the metric being affected by class bias. The approaches perform on a similar level with respect to AUC, which can be explained by the metric not being sensitive to class bias. Finally, when considering the squared error (Brier score) of individual predictions, one of the baseline approaches turns out to be ahead of the others. A bias-variance analysis shows that this is an effect of the individual trees being more correct on average for the baseline approach and that this outweighs the expected loss from a lower variance. The main conclusion is that the suggested choice of approach to handle sparsity is highly dependent on the performance metric, or the task, of interest. If the task is to accurately assign an ADE to a patient record, a sampling based approach is recommended. If the task is to rank patients according to risk of a certain ADE, the choice of approach is of minor importance. Finally, if the task is to accurately assign probabilities for a certain ADE, then one of the baseline approaches is recommended.
Adverse drug events (ADEs) are known to be severely under-reported in electronic health record (EHR) systems. One approach to mitigate this problem is to employ machine learning methods to detect and signal for potentially missing ADEs, with the aim of increasing reporting rates. There are, however, many challenges involved in constructing prediction models for this task, since data present in health care records is heterogeneous, high dimensional, sparse and temporal. Previous approaches typically employ bag-of-items representations of clinical events that are present in a record, ignoring the temporal aspects. In this paper, we study the problem of classifying heterogeneous and multivariate event sequences using a novel algorithm building on the well known concept of ensemble learning. The proposed approach is empirically evaluated using 27 datasets extracted from a real EHR database with different ADEs present. The results indicate that the proposed approach, which explicitly models the temporal nature of clinical data, can be expected to outperform, in terms of the trade-off between precision and specificity, models that do no consider the temporal aspects.
Heart failure is a serious medical conditions involving decreased quality of life and an increased risk of premature death. A recent evaluation by the Swedish National Board of Health and Welfare shows that Swedish heart failure patients are often undertreated and do not receive basic medication as recommended by the national guidelines for treatment of heart failure. The objective of this paper is to use registry data to characterize groups of heart failure patients, with an emphasis on basic treatment. Towards this end, we explore the applicability of frequent itemset mining and disproportionality analysis for finding interesting and distinctive characterizations of a target group of patients, e.g., those who have received basic treatment, against a control group, e.g., those who have not received basic treatment. Our empirical evaluation is performed on data extracted from administrative health records from the Stockholm County covering the years 2010--2016. Our findings suggest that frequency is not always the most appropriate measure of importance for frequent itemsets, while itemset disproportionality against a control group provides alternative rankings of the extracted itemsets leading to some medically intuitive characterizations of the target groups.
Shapelets have recently been proposed for data series classification, due to their ability to capture phase independent and local information. Decision trees based on shapelets have been shown to provide not only interpretable models, but also, in many cases, state-of-the-art predictive performance. Shapelet discovery is however computationally costly, and although several techniques for speeding up the technique have been proposed, the computational cost is still in many cases prohibitive. In this work, an ensemble based method, referred to as Random Shapelet Forest (RSF), is proposed, which builds on the success of the random forest algorithm, and which is shown to have a lower computational complexity than the original shapelet tree learning algorithm. An extensive empirical investigation shows that the algorithm provides competitive predictive performance and that a proposed way of calculating importance scores can be used to successfully identify influential regions.
Shapelets are discriminative subsequences of time series, usually embedded in shapelet-based decision trees. The enumeration of time series shapelets is, however, computationally costly, which in addition to the inherent difficulty of the decision tree learning algorithm to effectively handle high-dimensional data, severely limits the applicability of shapelet-based decision tree learning from large (multivariate) time series databases. This paper introduces a novel tree-based ensemble method for univariate and multivariate time series classification using shapelets, called the generalized random shapelet forest algorithm. The algorithm generates a set of shapelet-based decision trees, where both the choice of instances used for building a tree and the choice of shapelets are randomized. For univariate time series, it is demonstrated through an extensive empirical investigation that the proposed algorithm yields predictive performance comparable to the current state-of-the-art and significantly outperforms several alternative algorithms, while being at least an order of magnitude faster. Similarly for multivariate time series, it is shown that the algorithm is significantly less computationally costly and more accurate than the current state-of-the-art.
Although electronic health records (EHRs) have recently become an important data source for drug safety signals detection, which is usually evaluated in clinical trials, the use of such data is often prohibited by dimensionality and available computer resources. Currently, several methods for reducing dimensionality are developed, used and evaluated within the medical domain. While these methods perform well, the computational cost tends to increase with growing dimensionality. An alternative solution is random indexing, a technique commonly employed in text classification to reduce the dimensionality of large and sparse documents. This study aims to explore how the predictive performance of random forest is affected by dimensionality reduction through random indexing to predict adverse drug reactions (ADEs). Data are extracted from EHRs and the task is to predict whether or not a patient should be assigned an ADE related diagnosis code. Four different dimensionality settings are investigated and their sensitivity, specificity and area under ROC curve are reported for 14 data sets. The results show that for the investigated data sets, the predictive performance is not negatively affected by dimensionality reduction, however, the computational cost is significantly reduced. Therefore, this study concludes that applying random indexing on EHR data reduces the computational cost, while retaining the predictive performance.
Diagnosis codes for adverse drug events (ADEs) are sometimes missing from electronic patient records (EPRs). This may not only affect patient safety in the worst case, but also the number of reported ADEs, resulting in incorrect risk estimates of prescribed drugs. Large databases of electronic patient records (EPRs) are potentially valuable sources of information to support the identification of ADEs. This study investigates the use of machine learning for predicting one specific ADE based on information extracted from EPRs, including age, gender, diagnoses and drugs. Several predictive models are developed and evaluated using different learning algorithms and feature sets. The highest observed AUC is 0.87, obtained by the random forest algorithm. The resulting model can be used for screening EPRs that are not, but possibly should be, assigned a diagnosis code for the ADE under consideration. Preliminary results from using the model are presented.
Time series classification has received great attention over the past decade with a wide range of methods focusing on predictive performance by exploiting various types of temporal features. Nonetheless, little emphasis has been placed on interpretability and explainability. In this paper, we formulate the novel problem of explainable time series tweaking, where, given a time series and an opaque classifier that provides a particular classification decision for the time series, we want to find the minimum number of changes to be performed to the given time series so that the classifier changes its decision to another class. We show that the problem is NP-hard, and focus on two instantiations of the problem, which we refer to as reversible and irreversible time series tweaking. The classifier under investigation is the random shapelet forest classifier. Moreover, we propose two algorithmic solutions for the two problems along with simple optimizations, as well as a baseline solution using the nearest neighbor classifier. An extensive experimental evaluation on a variety of real datasets demonstrates the usefulness and effectiveness of our problem formulation and solutions.
We present a subsequence matching framework that allows for gaps in both query and target sequences, employs variable matching tolerance efficiently tuned for each query and target sequence, and constrains the maximum matching range. Using this framework, a dynamic programming method is proposed, called SMBGT, that, given a short query sequence Q and a large database, identifies in quadratic time the subsequence of the database that best matches Q. SMBGT is highly applicable to music retrieval. However, in Query-By-Humming applications, runtime is critical. Hence, we propose a novel embedding-based approach, called ISMBGT, for speeding up search under SMBGT. Using a set of reference sequences, ISMBGT maps both Q and each position of each database sequence into vectors. The database vectors closest to the query vector are identified, and SMBGT is then applied between Q and the subsequences that correspond to those database vectors. The key novelties of ISMBGT are that it does not require training, it is query sensitive, and it exploits the flexibility of SMBGT. We present an extensive experimental evaluation using synthetic and hummed queries on a large music database. Our findings show that ISMBGT can achieve speedups of up to an order of magnitude against brute-force search and over an order of magnitude against cDTW, while maintaining a retrieval accuracy very close to that of brute-force search.
Cyrptocurrency price prediction has recently become an alluring topic, attracting massive media and investor interest. Traditional models, such as Autoregressive Integrated Moving Average models (ARIMA) and models with more modern popularity, such as Recurrent Neural Networks (RNN's) can be considered candidates for such financial prediction problems, with RNN's being capable of utilizing various endogenous and exogenous input sources. This study compares the model performance of ARIMA to that of a seq2seq recurrent deep multi-layer neural network (seq2seq) utilizing a varied selection of inputs types. The results demonstrate superior performance of seq2seq over ARIMA, for models generated throughout most of bitcoin price history, with additional data sources leading to better performance during less volatile price periods.


text:
How to Become an iPhone Application Developer in 7 Strategic Steps
Mark Lassoff
The iOS mobile platform exploded onto the scene in 2007 with the launch of the iPhone, and has been increasing in popularity ever since. With the recent successful releases of its fifth operating system (iOS5), the iPhone 4S and the New iPad, the beast that is Apple's mobile device market shows zero signs of slowing. The success found by many iPhone application developers plus the increasing popularity and versatility of iOS devices have inspired many new and established programmers to pursue careers in iPad and iPhone application development.
For the non-programmer, however, the road to creating iOS applications for the iPhone and iPad can be a long one. Even for the casual programmer the iPhone application development experience can prove challenging; iOS utilizes a suite of technologies that are not often seen elsewhere, and iPhone's operating system includes technologies with a high degree of complexity that can be unwieldy for beginners. Beginners can go here to learn more about the iPhone Application Developer career path.
For those visionaries who are up to the challenge, here are the seven strategic steps to becoming an iPhone Application Developer:
01: Get the Necessary Tools
To create mobile apps for the iOS you need a Mac computer. Next you need to obtain the necessary development environment, called XCode. The XCode software is available on Apple's Developer Web Site or through the Mac App Store. With XCode installed you will now be able to write and compile iPhone applications directly on your Mac desktop or laptop.
XCode contains two very important tools for iOS developers. First is the iOS Simulator. The iOS simulator allows you to test most functions of the iPhone & Pad directly on your Mac. The simulator is limited, however, and it is recommended that you obtain an Apple smartphone or tablet for final testing. The second vital tool inside XCode is the Interface Builder. The interface builder provides all of the programming objects and controls needed to construct standard iOS application interfaces, such as buttons, calendars and data entry fields.
02: Learn C Programming
The C programming language is the ancestor of Objective C - which is the programming language used in iPhone application development. I strongly recommend that new programmers learn C first however, as it will allow you to grasp the basics of programming, and more importantly the basics of computer memory management, without the complex layer of Object-Oriented Programming (OOP) introduced in Objective C. I have always seen that it is easier to learn a procedural language first (such as C), and then move onto an Object Oriented Language.
03: Add the Objective C Layer
Objective C will be much easier to learn once you grasp the underlying C code. Objective C is a superset of C - meaning it takes everything that is the C programming language and adds more to it. Objective C adds Object Orientation to C. Object Orientation is a programming methodology which allows you to break programming problems into various objects that interact to solve a problem. While most major programming platforms today use some version of object orientation, it is still a steep hill to climb for a new programmer to become proficient. Once you're comfortable writing Objective C programs it's time to crack open the iOS!
04: Learn the iOS Environment
Now that you can code in Objective C, you can effectively learn the iOS programming environment. You'll use the Interface Builder to create custom iPhone application user interfaces (UI), and write Objective C code to make them work. There are many Objective C classes (libraries of commands and functions) designed specifically for the iOS - for example classes that operate the on-board camera or address issues related to local data storage.
05: Write your First iPhone App
Choose a project you'll enjoy completing and work it all the way through. Be careful not to choose an application that is overly complex or it will take a great deal of time. Don't give up when it gets frustrating or seems difficult. Overcoming obstacles the first time you create an application is important, and the sense of pride you get from completing your first iPhone application will motivate you to create more complex and useful apps.
06: Sign-up as an Official iOS Developer
When you're ready to release your iPhone app prototype, you'll need to register with the iOS Developer Program. The cost is $99/year, and it involves registering as an Apple developer, and selecting the program(s) you want based on the platforms (devices) you wish to develop for. Even if you're not close to completing the project, you'll need to be an iOS Developer to test and debug your code on an actual iPhone or iPad, as opposed to the simulator. Once you're registered as an official iOS Developer, you will also be able to submit your application to Apple's App Store, making it available to millions of potential customers.
07: Market Your Application
A good way to build an audience for your iPhone applications is submitting a free "Lite" version to the app store. Creating a Lite version will enable you to expose your iPhone app to the masses, as many mobile application consumers want to try before buying. If your app is special/entertaining/useful, users will get hooked on the Lite version and gladly pay your asking price. To further promote your iPhone app for free, write it up in blogs, forums, and social sites like Facebook, Twitter, LinkedIn and Google+. Utilizing the multitude of mobile application review sites is another great way to garner free press for your iPhone app; just send these sites a request to review your app. If you have an advertising budget, I suggest buying a moderate amount of mobile ads in the top iPhone Ad Networks, such as Admob & Quattro. If these ads are profitable you can increase your spend and expand into more ad networks.
You're now on your way to becoming an iPhone Application Developer. Keep in mind that the career of a programmer involves a lifetime of learning and that learning the iOS platform and its related technologies is just part of that journey. Good luck!
Mobile Application Developer Resources
Deep dive into the mobile application developer career path
Compare salaries of mobile developers and related positions
Research mobile developer career education requirements
Find mobile app development training courses and degrees
Browse & apply to local mobile application development jobs
Blog: Best Computer Jobs for the Future (#1 App Developer)
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Personal Branding Part 1: How to Define Your Brand
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Mark Lassoff is an accomplished technical trainer and sought-after keynote speaker in the web and mobile development arenas. With over a decade of experience teaching advanced software development courses and an extensive background in mobile computing he easily understands the impact of new technologies and the skills web and mobile application developers need to succeed.
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text:
Jews in American Film and Television
America's motion picture industry is so keenly attuned to Jewish concerns and sensibilities that even some Jewish observers seem amazed. Noting that a Jewish-theme film has received the Oscar award in the documentary film category for three years in a row, Ami Eden, a writer for the Jewish Exponent – a paper serving the Jewish community of Philadelphia – offered this tongue in cheek commentary in a recent column (March 30, 2000, p. 5):
Rumor has it that non-Jewish films are actually eligible to win the Oscar for best documentary, but someone seems to have forgotten the judges. This year, the choice was "One Day in September," which examines the murder of eleven Israeli athletes at the 1972 Munich Olympic Games. Two Holocaust-related films, "The Long Way Home" and "The Last Days," took home the honor in 1998 and 1999, respectively.
So as not to raise any more false hopes among producers of non-Jewish films, rumor has it that the Academy of Motion Picture Arts and Sciences has decided to change the name of the category. Next year, expect the announcement to read something like this: The Oscar for Best Documentary on a Jewish Topic goes to ...
'Incredibly Favorable' Media Treatment
No less than Hollywood, American television is keenly sensitive to Jewish interests and concerns. Joseph Aaron, a regular writer for the Chicago Jewish News and other Jewish community papers, candidly observed in a recent column: "The fact is that Jews get just about the most favorable media treatment of any group in this country ... Not only are we not covered unfairly but we are, in fact, portrayed incredibly favorably ..." (Jewish Journal, Los Angeles, April 7, 2000, p. 66)
Aaron went on to write glowingly of a recent episode of the popular television series "Touched by Angel," in which Judaism is portrayed in affectionate detail. One of the episode's script writers, Aaron noted, is an Orthodox rabbi. So sympathetic to Jews and Judaism is this episode that Aaron gushes: "Amazing, remarkable ... How many other religions get their sacred moments shown lovingly and accurately on national TV on a prime time series?"
"Part of our problem, I think," Aaron goes on to tell his Jewish readers,
is that we've elevated being suspicious to an art form. Even though no one is chasing us anymore, we can't shake the feeling that there must be someone out there gunning for us. And so if there isn't, we imagine it.
... We complain and moan about how the media treat us, portray us and yet we fail to see how often and how much they portray us as they did on Sunday night's "Touched by an Angel."
Title: Jews in American Film and Television
Jewish Power + Influence
www.ihr.org


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Mirnoe este un sat situat în sud-estul Republicii Moldova, în raionul Taraclia. Aparține de comuna Vinogradovca.

Demografie

Structura etnică
Structura etnică a localității conform recensământului populației din 2004:

Note

Localități din raionul Taraclia


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Home » Health News » Are Children With Atopic Dermatitis More Likely to Fracture Bones?
Are Children With Atopic Dermatitis More Likely to Fracture Bones?
Children with atopic dermatitis (AD) may be at increased risk for broken bones, results of a national cohort study in Korea suggest.
"In this nationally representative cohort study, we observed that AD development was associated with an increased risk of subsequent fracture," and fracture risk increased with AD severity, lead author Seung Won Lee, MD, PhD, of the Department of Precision Medicine of the Sungkyunkwan University School of Medicine in Suwon, South Korea, and colleagues write in a research letter in Allergy.
Earlier studies that found a link between AD and fracture risk may be inconclusive due to inappropriate study design, recall bias, confounders, small sample size, short follow-up, and adult-only participants, they add.
The research team investigated the timing and locations of fractures in children with AD using a dataset of 1,778,588 children, roughly evenly split between girls and boys. The children, born between 2009 and 2015, were included in the National Health Insurance Service in South Korea and in the first National Health Screening Program for Infants and Children. Participants had ICD-10-code–defined AD, with at least two claims within 1 year and at least two records for AD therapy.
The authors determined fracture timing and body location, and they continued follow-up through 2019, death, or first fracture diagnosis. They generated exposure-driven propensity score-matched cohorts to determine the robustness and generalizability of their results and to reduce immortal time bias. They used Cox proportional hazards regression to estimate the effects of AD on fracture risk.
During the follow-up period that averaged 7.52 years, 342,601 children (19.3%) were diagnosed with AD. In the matched cohort, children with AD were 14% more likely to develop fractures (33.37 vs 28.88 per 1000 person-years, respectively) after adjusting for confounders.
Fracture risk increased with AD severity in the control, mild AD, and moderate-to-severe AD groups (28.88, 33.08, and 35.54 per 1000 person-years, respectively). Fracture risk increased by 12% in children with mild AD (adjusted hazard ratio [aHR], 1.12; 95% CI, 1.11-1.14) and 23% in those with moderate-to-severe AD (aHR, 1.23; 95% CI, 1.20-1.26).
Early AD onset increased fracture risk: aHR for diagnosis at younger than 2 years was 1.19 (95% CI, 1.18-1.21); between 2 and 4 years, aHR was 1.08 (95% CI, 1.06-1.10); and at 5 years or older, aHR was 1.03 (95% CI, 1.01-1.06).
Excess risk for fracture after AD diagnosis was greater up to 1 year after AD diagnosis (aHR, 1.53; 95% CI, 1.49-1.57), and this risk persisted 3 to 5 years post-diagnosis (aHR, 1.35; 95% CI, 1.33-1.38).
Effect sizes were similar for various fracture sites: head (aHR, 1.13; 95% CI, 1.10-1.15), spine (aHR, 1.33; 95% CI, 1.13-1.58), upper limb (aHR, 1.06; 95% CI, 1.05-1.07), lower limb (aHR, 1.13; 95% CI, 1.12-1.15), and other sites (aHR, 1.21; 95% CI, 1.14-1.23).
Possible Underlying Factors Suggested
Lee and colleagues suggest that diet, calcium and vitamin D intake, physical activity, sleep quality, psychological and behavioral disorders, interaction between immune and bone cells, and the effect of systemic corticosteroids on bone mineral metabolism in children with AD may contribute to the fractures.
Limitations to the study, they note, include omitting children who were not in the national health examination survey, confounding factors or mediators (vitamin D level, malnourishment, sleep quality, psychological status, and physical activity), and possible CD-10 code inaccuracy.
Peck Ong, MD, pediatric allergist and immunologist at Children's Hospital Los Angeles, told Medscape Medical News that multiple studies have suggested that atopic dermatitis affects metabolism, leading to obesity or cardiovascular disease, but the link has not been proven.
Dr Peck Ong
"The association of fracture with early onset atopic dermatitis is interesting, as these patients tend to have more severe, life-long atopic dermatitis," Ong, who was not involved in the study, added by email. "There has not been a study this size to date that focused on fracture in children with atopic dermatitis.
"As the authors write, multiple factors may explain the result," he said. "The finding is unlikely due to topical medications, including topical steroids."
Ong cautioned that, although children with more severe atopic dermatitis were more likely to have fractures, severity based on insurance claim studies are not as accurate as severity assessments made by clinicians.
"The study will hopefully encourage further studies in other populations to investigate the cause of fracture in atopic dermatitis," he said.
The authors and Ong reported no relevant financial involvements. The National Research Foundation of Korea supported the study.
Allergy. Published online November 9, 2022. Abstract.
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Q: Integration of Gaussian noise process Let $\{X_t\}_{t \in \mathbb R}$ be a Gaussian noise process with $X_t \sim N(0, \sigma^2)$ and $\phi$ a "sufficiently nice" function. (Say that $\phi$ is compactly supported and either smooth, continuous, or $L^2$.) I'd like to know about
$$
\int_\mathbb{R} X_t \cdot \phi(t) \, dt.
$$
Of course, this isn't really a well-posed question because that integral isn't defined. Can one explain this somehow as an Ito integral wrt a Brownian motion?
If one has finitely many functions $\phi_1, \dots, \phi_n$, then what can be said about the distribution of
$$
\mathbf x = \left( \int_{\mathbb R} X_t \cdot \phi_1(t) \, dt, \dots, \int_{\mathbb R} X_t \cdot \phi_n(t) \, dt \right)?
$$
I've read in the context of engineering papers/books that $\int_{\mathbb R} X_t \cdot \phi_1(t) \, dt$ follows the normal distribution $N(0, \|\phi_1 \|^2 \sigma^2)$, where $\| \cdot \|$ is the $L^2$ norm, however nothing is made rigorous, so I don't know why this is true. Does $\mathbf x$ follow a multivariate normal distribution with covariance matrix something like $\Sigma_{ij} = \sigma^2 \langle \phi_i, \phi_j \rangle$? (Here $\langle \cdot, \cdot \rangle$ is the usual $L^2$ inner-product.)
I apologize that this isn't a very coherent or well-formed question, but it's all that I have to work with (after searching on stochastic processes a bit). I do have experience with analysis, but not extensive experience with more formal probability; with this in mind, I'd be grateful for any references you recommend relating to my questions.

A: You should think of the white noise $X_t$ as the distributional derivative
of a Brownian motion $B_t$. Formally, $X_t dt = dB_t$ and the integral you are trying to compute becomes $\int \phi(t) dB_t$. But this formal expression is given a rigorous meaning as the Ito integral of $\phi$
with respect to the Brownian motion $B$.
A well-known fact is that the Ito integral of a deterministic function
in $L^2$ is always Gaussian. You can see this, for example, by
computing its characteristic function. The fact that the variance
is given by the squared $L^2$ norm is even easier to see and follows
from the Ito isometry:
\begin{equation}
\mathbb E \left(\int \phi(t) \; dB_t\right)^2
= \mathbb E \int \phi(t)^2 \; dt
= \int \phi(t)^2 \; dt = \|\phi\|^2_{L^2}.
\end{equation}
Maybe see here for a more detailed discussion.


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Nintendo made the only real news over the past week, when they announced a cardboard box peripheral for the Switch that you have to build yourself. The crazier bit is that Jeff and J.D. actually think this is an awesome idea. Before getting to that, though, they need to talk about the various games they managed to try out this weekend, including the new infuriating 2D fighter where you scream at each other a lot, and the new stealth/horde/zombie/crafting/survival game that's a spinoff of… whatever Metal Gear is. Stealth, I suppose.
This entry was posted on January 24, 2018 by jwaxo in Podcasts and tagged bitcoin, cryptocurrency, dragonball fighterz, game news, graphics cards, konami, labo, metal gear survive, Nintendo, podcast, screen peekers, sea of thieves, switch, xenoblade chronicles.


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Emergency Care and SUD during COVID 19
For Medical and Health Professionals
I-Science: On-the-Spot Interviews With Scientists
NIDA Research
Emergency Care and SUD during COVID-19
In this edition of the Science Behind Addiction LIVE video series, Yale emergency care and addiction medicine physician, researcher, and advocate Dr. Gail D'Onofrio and NIDA Director Dr. Nora Volkow discuss COVID-19 and emergency room care.
[Dr. Volkow speaking]
It's a pleasure for me to have today as a guest, Doctor Gail D'Onofrio. So, Doctor D'Onofrio, thanks very much for being with us today. I know that you've been on the frontlines of emergency medicine, in addressing substance use disorder in patients. And as the chief of the emergency services at Yale New Haven Hospital. That has placed us in a position of tremendous responsibility, but also opportunity for innovation. Nor does it relate now just to your past work with substance use disorder, but now with the challenges that we have with COVID.
And of course, you bring those together, and you speak about the challenges of the intersection between these two epidemics. So as your personal experience in the emergency department, what have you seen? What has changed in the emergency department since… In the last few months when we have been overcome by the COVID pandemic?
[Dr. Gail D'Onofrio speaking]
So, Nora, thanks for having me. You know, we all throughout the country, have really seen similar things in that our overall volume has decreased. In most places that's been as much as 40% less than what we generally see. It's really scary because we know that people aren't coming to the ED that have heart attacks, or strokes, or other symptoms, or even use disorder withdrawal, or seeking treatment. Because they're so afraid to come, they're paralysed that they may get COVID while they're there.
On the other hand, we've seen really lots of patients, at least in my area, New England, and at Yale New Haven Hospital, we've seen an overwhelming amount of COVID. And at one point we had, oh, more than 450 patients in our hospital. And most of our patients in the ED were either there or people of interest, and that was overwhelming.
Right now those numbers have gone significantly down. But it… In Yale New Haven, our numbers of pretty much all of our diseases or all of our presentations have really paralleled that decrease. And we're starting now to come up.
And now we know that vulnerable populations are… There are certain groups that are much more at risk, greater risk of developing COVID, and if they do get COVID they have much worse outcomes. Among them are people with substance use disorders. But also we have all become very sensitive about that overrepresentation of minority as it relates to very, very negative outcomes from COVID. So how is your team and you experiencing these big challenges, and what are you trying to do to address them?
So that's totally right. I think in general, the emergency department is there for everyone. You know, we're open 24 seven, 365. We're the only part of the health system that is open at any time for people to come to. We often have people who are disenfranchised. As long as all the people who just get access care. But we certainly are there for the entire population of people.
What we're seeing now is that we're just having more, really more barriers of care for those people who are disenfranchised. So for example, in the group of substance use disorder, no matter what, we have many homeless populations. And it's really difficult to manage the homeless, obviously, in something like COVID. So in all EDs around the country, they've been grappling with this, and as we've moved on, we've been better at it.
And recently, here in New Haven, they opened up a high school for, what we call, shelter one. They put patients in there who are COVID positive that were homeless. And we're working with that. But in a… On the other hand, we had difficulties in that our one real in patient, out… It's outpatient, but it was for the homeless and shelter for substance use disorder emptied out. And they would no longer take more patients.
So we were then trying to figure out what are we going to do with these. And we also know that people who are homeless, or people who are disenfranchised are not going to have the proper equipment to do Telemedicine. And with the closures of the… Of anywhere they might go, like the library, or any public facility that where they might be able to use the internet, or whatever, were also closed. So that added another level of barrier that you can't even imagine.
And we'd done all kinds of innovative things regarding that. Our opiate treatment program for example. Even though for most of their patients, they're giving multiple doses. If someone needed to come in and see the doctor, or do a Telemedicine, they could come in and use their facility, and they would call the doctor.
In fact, one of our doctors, Doctor Kim [inaudible] says to me, she's available at six o'clock in the morning. She might be at home in her bathrobe, but she's taking a call because a patient came in, and really needed help. And so the one nurse that was there was able to connect them together. And so we've done all different creative things like that. But it is really hard for people that don't have options for Telemedicine.
Also, people don't want to use their phones and the minutes that they have on them to do all this, because that's all they have to communicate with their families and other things. So that's another barrier. But we've tried, you know, as the weeks went on, we have tried all these innovative processes. And with the regulations now being really lightening in terms of that we can and have inductions for people [inaudible], for example, over the phone.
And Telemedicine, this is great, we've done that. If patients come to the ED, they don't have to show up at the clinic. They will call them if they can negotiate that and do it over the phone. So that's great. My friends in Philadelphia, Dr. Jean Marie Perrone
have actually… Was able to get a pregnant woman inducted right on the phone, and she's been following her routinely, and doing great. Where she would never have been able to get to a place to get that medication in the past.
So, there is sight of a silver lining in many respects, in that we're able to get a lot of people the care that they couldn't get before. And a lot of people, who because of COVID can't… Have no public transportation or anything, because most of those are closed. They could take homes of their methadone. So, there was some kind of a silver lining for many in being able to do that. And of course, we're seeing really both ends of the spectrum. We're seeing people that flourish with all of this, and are doing great, and are hoping it never goes back to the old way.
And then we see people who are really hurting, because they needed that human connection. And they're not doing as well. So pretty much it's on both ends. It doesn't seem to be in the middle either. It's working really well, or it's not working so well. And those patients that need a little bit extra now, we're able to be opened up a little bit more and getting them into the system, and to see a human.
It's interesting what you're saying, and I basically, to a certain extent, resonates with what we have heard from other investigators that are working with the healthcare system, and specifically emergency departments. And one of the points that has been brought up quite consistently, is that they have seen a decrease in the number of patients that end up with an overdose in the emergency department. Has that been your experience, and if so, what are your thoughts of what's going on?
Well, it's different… I understand it's different, really, all over the country. We are seeing a decrease in everything, really, that just sort of mirrors our decrease in overall by [inaudible]. But other places, like Ohio, have seen an increase in overdoses. And we've certainly seen some alerts come out from health departments, Indiana, and Ohio. And at a few… there were a few more that were seeing massively more overdoses since… That they reported in the early parts of May than they've seen before.
It's a problem in some places because maybe they cannot get into treatments. And not every place, like New Haven, we have a lot of treatment. There are so many places that don't. In a centre in Ohio that we're working with, with one of our implementation science programs. They are giving out one case, almost a month's worth of buprenorphine because they were not able to get people into treatment. Or people couldn't come back and get refills of buprenorphine. So, there are some highlighted places that can do that.
But in other areas of the country, we're seeing it. Tennessee, Ohio, Milwaukee have all reported massive increases in… I don't know if I should say massive, but large, significant increases in overdose. And they're putting that out there. We have actually surveyed the EMS Directors Fellowship directors to try to see what was going on there. And overall, most of them said they were using less, they were getting less calls. That the calls for overdose were less.
And that was sort of mirroring their less use of NARCAN, or naloxone. Others showed that there was an increase in calls in a few. And we were really concerned, because we didn't know if people were not using Naloxone. So, there was this big fear because there was one state that came out and said they didn't want their prehospital providers using the NARCAN version, the internasal. Because it was aerosolised, and therefore was a greater risk of transmitting COVID.
And so, our EMS partners that can would give NARCAN IM, or they would give NARCAN even intravenously. But of course, those prehospital providers like police or fire, they wouldn't have those options. So, the question is, are they resuscitating people in the field or not? Because there's been a lot of consideration with not resuscitating people.
And there's been a lot of not… States that maybe not even doing autopsies on people, because of afraid, and not having the protective gear to do that for potential COVID. So, there's all these things in the background, and it's not the same everywhere. There are just people suffering more in certain communities. And because the overdose rates are always delayed, we can't see them now.
I can tell you in Connecticut, we've had an increase in overdoses in January, February, and March. And the April, we haven't been able to really get the data quite yet, because they're still looking at cases. So well, you know, we'll see that. But it's probably not going to be for another six months.
And there are two things that are going in what you are describing. One of them is, of course, have the cases of overdose increased? And what we have actually gotten reports of is that, yes, overall there appears to be across the United States, in most states, an increase in people overdosing. But what they are reporting, is that those people that are overdosing, are less likely to end up in the emergency department. For some of the reasons that you are describing.
But the other aspect about it, that is too very concerning, is for you to have an impact to administer Naloxone. Someone has to observe you. So, with social distancing, that becomes much less likely. So, the ability to revert someone from a overdose is much lower. And to what you were commenting has also influenced what happens to someone after a reversal, we always emphasize importance to link them with treatment. And emergency department was a great place to do that. But people are afraid.
So… And I know that you're coming up with a commentary where you're bringing up your own experiences and recommendations. As we're living the COVID alongside the opioid crisis. So, what are challenges and opportunities?
Okay, so really we have… There's lots of challenges. But as you said, we have an opportunity to initiate treatment. And so, the most important thing, because there's always this disconnect, should you have to transport a patient that's overdosed in the community to the ED. You know, will they be okay? Well they might not need another dose of Naloxone, but they certainly need the opportunity to access treatment. So, we're still going after that. We want people to do treatment.
And we're still public messaging about this isolation. That we're hoping that people are with somebody when they're using. We've done, you know, simple things, like telling people, just call someone and tell them that you are using and have them call you back in a few minutes or in a couple of minutes or whatever, and make sure that you're okay. So, all different types of harm reduction methods. So, you're not going to be alone when you do overdose, and not have that potential.
And, you know, in terms of the emergency departments, you know, it really is on us to make sure that people do get into treatment. And as I've said to you before, it's not optional, right? It is not… At best, it's not optional to see a patient that has such a life-threatening illness, see them, and then let them go. Not everyone will accept treatment. But you can have a conversation with them, express your concern. Tell them that you're ready to help them start treatment today.
But if not, where they could go if they needed that treatment, or even to come back. And to keep doing that. And, you know, we've talked about that before. There is nothing that is so life threatening than opiate use disorder, for example, than anything else that we see. And such life, you know, threatening in often a young population.
So, we talk about the quality issues here, and how important it is for emergency medicine to step forward, and to say, these are real quality and CMS quality measures. This has to be it. We do a lot of things for the other major, probably the largest thing we see is chest pain in an emergency department. And people that have acute myocardial infarctions have not much more of a mortality rate at one year, it's almost a little less than 6%, five point something.
And yet, in that we have all these quality measures that we do. All these time sensitive quality measures that we measure, and we measure, and we measure. The time to get to the CAP lab, the time to get the medication if your CAP lab isn't open. The time to transport people. It's on, yada, yada, yada. On and on and on. And we probably have somewhere, we're a huge hospital, so we might have 20 or 30 a month. Most places probably have ten a month.
And yet you to have that many people with substance use disorder a day that you see. And yet we have no specific guidelines that are required that we should do. And that is just not acceptable. It just isn't. We need to move on, we need to have better reforms, and better quality. Just like we do in any other aspect of emergency medicine. Whether it's sepsis, or it's MIs, or whatever, diabetes. We have protocols.
So we need to make sure that these protocols are in place and that we're following them. And we need to really have good quality control. And some of [overtalking]…
No, I resonate honestly with that recommendation that you have, that we need to have protocols with high quality control. And I think that as you highlight, more than 5% of people with an opioid use disorder that visited an emergency department will die.
And so you had them in the emergency department, did not do anything and the person die. And you are discussing about where we don't tolerate that for a myocardial infarction, so we have a protocol and we hospitalise. We have a protocol and we hospitalise. Here people are thrown out on the streets when there are medications that can protect them from overdose with a large effect size.
So, I think that that's why, very much, I mean in terms of where we are right now with this emergency with COVID and opioid epidemic is the opportunity to create those guidelines. So, what are the next steps? What would you like to happen? And how to make it happen?
Okay, so one is really clear. We need to have certain regulations made. One of the biggest things that we've seen during COVID that's been another silver lining is that we're now allowed to give the waiver courses over Zoom, which we couldn't do before. So, we have had these X Waivers in and my colleagues here, Doctor Hawk, myself, and Doctor Herring, we've done three now, and probably have trained over 200 emergency physicians, or providers in just the last month.
And I have… There's other emergency physicians doing this same similar thing. And that's a four month… A four-hour course. We really don't need that X Waiver as we've seen a lot of people talk about in the recent paper as well. You know, we need to axe the X Waiver, right? It's an incredible barrier that doesn't need to exist. Education does need to exist. And I would argue that that four hours was well used.
But in addition to that, they have to take four more hours. And then they have to be able to know how to navigate the whole system where you put all this information in. You send it along to, you know, the DA then you get your number back. It's just way too much. We find that we have to have a research assistant almost all the time walking through doctors, how they do that. They said I did the training, but I never got my X Waiver. And they said, well, did you do this, did you do this? Oh no, I didn't know I had to do that.
So it's taking time and time and energy. And we just don't need that. First of all, emergency physicians should be able to give out three days' worth without a problem, no matter what. We can give out 150 prescriptions for Oxycodone, we have an unlimited armitarium of medications, narcotics we can give out. So why can't we give this life-threatening medication?
And as I said, we do need education, but we don't need this long educational block. And we don't need all these regulations. But it does need to be incorporated into medical schools, in all residencies in education. Maybe a CME that people have to take. And that's one thing that needs to just go away.
So, one question, and I… It was intended actually in my prior question to you. Which was a notion is, is there need of more evidence, or based on the data that we currently have that shows such a large effect of medications like, Epinephrine [?], Methadone, Naltrexone. Is there anything else that is needed to document how powerful these treatments are? Specifically, in an emergency department setting.
In my opinion, no. But you often say that I quote you all the time when you say, okay, maybe 50% of our treatment at, you know, six months. But without it, only 5% are, right? So, what do you need to know? We already know that if you're not in treatment, you die. Right? We already know 5% are going to die in one year. We already know a huge amount are going to die within a month leaving a facility of some kind of controlled environment. Whether that's rehab or jail. We already have all that data.
We have the data that it works. I mean in terms of the ED, that's a venue where we're using it. But there's enough information opiate agonist treatment works. We don't need to replace that. So that's why I think we don't need to do anymore ED studies, except feasibility studies and implementation, how we implement it. Nothings easy to implement. But we don't need to know that it works. We know that it works.
I don't need to tell people that opiate agonist treatment works, because I just can give them a litany of proper reviews. I just need to tell them that, yes, you could do it, right. It's possible. I'll help you through it. Because even when people are waivered, they tend not to do it. You know, we published a study recently from one of our night at CTN baselines that is, that when we started doing our implementation and foresights, 80% of the emergency providers said they didn't feel comfortable doing it, they didn't feel ready to do it. And only 3% were waivered.
So we, hopefully, have fixed that because we certainly know that more people are waivered. We know that more people are getting education. But once they get waivered, they have this, they're not quite sure what to do. And they sometimes just need a champion. So we just say we're… Just call up somebody now. Everyone… And in emergency medicine, we're open 24 seven. So, I tell everyone, I used to give my phone number to everyone.
But now I just say, all of my doctors at Yale New Haven Hospital have a waiver. You can call up our ED 24 hours a day and get a doctor who knows what they're doing. And they'll just help you. So, you don't, you know, it doesn't have to be one or two of us anymore. There's lots of people. In every single city there's people. So, we're used to calling people all the time in the middle of the night. We have providers. So, let's start doing that, and just get the show on the road.
There's something else to that, you spoke about in your commentary that resonated very much with me. Because I actually had been at one point in visiting those shooting galleries where people go to inject heroine. And I was in one of such galleries in Puerto Rico. And the man that was manning the place, and it was actually a very, very poor area, and it was in a tent, it wasn't even a building, and people were sitting on the floors. And it wasn't even cement floors. It was very, very primitive.
And the man had a horrifically infected leg. And he himself was trying to inject himself, not in that leg, but someplace else. But I was horrified about the state of that leg. And I said, you know, I apologise for bringing this up, but I very strongly urge you to go to an emergency department to take care of that leg. And he said no, I don't want to go there, because they mistreat me. So… And that is where, again, the issue of the stigma, and discrimination against people with substance use disorder is interfering with them getting into treatment.
And you bring up that as one of the actions. So, yes, we need to have guidelines of evidence care, but you also address the issue of education and stigma. And I guess part of that education is against the stigma that persists. So, what are your thoughts and how are you dealing with it in your emergency department?
Well I think one of the things is you just have to address it, right? It's like racism that we're in the midst of now, you just have to address it and say, it exists. And highlight it when it does exist. And sometimes it's sort of not… It's really unbiased kind of stuff, people don't even know that they do it. So that when you hear someone saying a word, you just say, you know it might be better to use this other word.
And we stress this all the time, and we role model that we try not to say addicts, that they're people, they're people. We don't say that diabetic over there. We say that person with diabetes. And so we role model it. But it's really a climate change. It's not something that can easily be done. But I'll just tell you that I think behaviour in terms of quality has to happen. I don't ask a doctor how do they feel about giving out a tetanus shot, right? We don't see tetanus. I've never seen a case of tetanus.
But, you know, ten people will ask a patient about their tetanus status before they get out of the ED. I don't ask them how they feel about it. It's just evidence based treatment, and you do it. So I do believe that will… We can address stigma, and we should. But on the other hand, we just need to have great leadership. The leadership says you need to give out this medication regardless of, you know, any, any peoples' ability to pay, or whatever, or what they look like. And that's just the bottom line.
And so the leaders have to come out and say that. In my shop, you know, you don't work here if you don't have a waiver. It's expected. I'm trying to get all of my residents waivered. All of the students at Yale are… Have all received their training for waivers. All of the PA, all the medical students. We're doing most of the nursing school now. It's just expected. It's just part of the thing. So people… We need to just build up. And the residents are great. They're kind of teaching up.
When I go places, the residents are learning about this. And then they're saying to their attending, well why aren't you offering this, right? And they've all told me, you know, if I could just get a policy written, I could just show them that it's this policy over here. And emergency physicians follow, like, orders really well. So they said, okay, here's the order, go ahead and do it. But it's not something we can simply just turn over.
But I think though, Gail, in my perspective, in terms of… For that to work, of course you have to have the patients getting to the emergency department for which they need to have… Feel that they are welcome, that they are not rejected. And that were, again, I think that there are more actions that we could do, so that patients that may have substance use disorders.
That maybe African Americans with substance use disorders where they've been mistreated again and again can feel comfortable to end up… So, I mean, that's where… What are your thoughts on how to change that?
Well one of the things I could tell you that was done with California Bridge, which is this huge program that Doctor Herring's running, who's over 70 hospitals. He has, and I wish I had… He has this great card that's up, when patients walk into the ED, it's a sign. And the sign says, do you have a problem with heroine or prescription narcotics? We're here to help. Ask us. And that is so empowering right there. Like we're here, we can help you.
So, I'd like every ED to have that sign up, if you have a problem, if you want to talk about heroine, please let us know. If you need help, let us know. That's what we're here for. And we do those public health messages in our federally funded health centres. We call… We tell them what we can have be available here. We've told… We have a, you know, a great investigator here who works in the black churches who's trying to work with them, to know that we aren't as horrible as we may appear and give us another chance.
And here in New Haven, people do know that we have medication. I think what happens is people think, oh everybody's going to run to the emergency department. You put out these public health messages, I'm going to be overrun, like what's your problem Gail, you can't do that. And I'll tell you that they're already in your ED with their complications, like you said. Whether it's an injection abscess, or something else. They're already using your healthcare facility, so just identify the problem and start the treatment.
But, you know, stigma from the community. Getting patients with addictions to understand that we recognise their stigma, and we're trying to fix it is a huge problem. And it's got to be a lot of public health messaging out there. And it's got to be a lot of people changing their behaviours, and I don't have the total answer. But I know we can do better.
But like you were saying about… In your commentary, that we can create guidelines and metrics. I think that we can establish it and make every person accountable to them. Because that's what motivates behaviour. And you also had in your commentary something that I think is too, very, very important. And says give feedback to the providers of what happens to their patients. Because that is one of the most effective ways of changing practices.
Yes. We found that, actually, from doing a tremendous amount of focus groups in multiple cities, that one of the best things that we can do is to give that person a positive. Because remember, in emergency department always hear the bad things. We only see people coming back. We don't see people we don't see again. So the best thing you can do, and we try to do this, is to have somebody follow that person, and just ask whether they showed up at the referral site. Or if you can get permission to call the patient afterwards.
We, many of us have nurses that follow up patients for all kinds of problems. In COVID, for example, we call people all the time, if we sent them for testing, we just want to make sure that they're doing okay. This is the same thing, we can call up and ask somebody, did you get to your treatment? What were the problems? How can I help you? And we need to do that. And I see no reason why we can't expect that we do that.
And also the issue that you commented upon, which I think is an extraordinary opportunity to do the follow up is Telehealth. I mean provided, of course, that the patients have access to it. But if they do, that's an extraordinary resource that you have to actually follow their outcomes. Now we're almost off time.
But there's a question that has been burning in my brain, and I will feel bad if I don't ask you, because it's something that I'm very concerned. And that is the issue, as people are dying from overdoses. I mean it is clear in our brain that some of them may be intentional. We don't know exactly what's the level of intentionality. But we do know that some of them do qualify as suicides, even though they die by an opioid overdose. And they are… Though they are not scored as suicides. But…
So the concept is with COVID and the social distancing, we've also seen concerns of increases in depression, anxiety, hopelessness. That of course you mix in with opioid use disorders, and you really have a very, very bad combination. So what have you seen in the emergency department? And what are you doing to ensure that you're screening, and that you are doing this very difficult to treat situation, but crucial not to neglect?
Well you're right. It's… There's a huge overlap between severe depression and suicidality and using. And it's hard to take that all apart. And I think for emergency physicians, their biggest concern is that there's not enough providers out there for mental health. And this is true everywhere around the country that there aren't. Here in New Haven, I can just say about our hospital, we also had a pretty large drop in our people who are requesting help.
We have a… An emergency department for psychiatric illness right embedded in our main ED. And we have full time psychiatrists who are there. And they have reported that they've seen a marked drop, like almost 26% drop in patients that are coming through there.
And we're worried about that, because in the face of COVID where there is a lot of despair, and a lot of reasons to be worse off than two months ago, we're extremely nervous about that. We don't know where they're going, and we're kind of reaching out to the community to make sure they know we're open. And the ED, we do ask everyone some questions about suicide. At least we do here. We're part of the Zero Suicide group. And we will ask questions. Some people won't answer them accurately. And then some people will.
And then we're really lucky because we have psychiatry here to go through a bunch of questions with them to make sure that, do they need extra care? So they need to be hospitalized? Or do they… Can they go home with services. But it's really hard to find services. I just have to tell you that. Over all the country, it's not easy to find outpatients. It's even harder, by the way, when you have insurance here than when you don't have insurance.
And it's… The answer is really difficult. It's hard to tease that out from an emergency point of view. And then once you do, and you feel like, well, they could do with outpatient counselling and help, it's really hard to find that. I'm hoping with all this new technology, maybe we can do some more group things outside. Some Zoom things. Maybe we'll be able to come up with some innovations, and having more people access mental health treatment.
And indeed, that has happened. And certainly there is… I mean, for once it's much easier to get reimbursed if you're a physician and you're providing Telehealth, including behavioural intervention, or a psychiatric assessment and follow up. So there is another example about the changes that have helped medicine through COVID, by making Telehealth so much more accessible. It's relatively new. So we need to understand how to optimally utilise it.
But I… They've been flagging me that I basically been stealing your time. But I do want to give you an opportunity, Gail, to basically bring up something that you feel is important that I may have not asked, or that you want the message to transpire.
I think, really, in my final thing, is that it's not only, by the way, opiates that we're seeing. We are seeing a lot of alcohol use disorder, a tremendous amount. Both in the emergency department and patients that are getting admitted to the hospital with COVID-19. And it's really… That's been what some people are using to deal with stress. And accentuating other problems. So it's… The ED is there for recognizing all kinds of substance use disorder.
And it's on us to start with an initial treatment. And some of that is just the conversation that we have, we try to teach this to everybody. We have somebody to come brief negotiation interview, but it's just a conversation with our patients. Meeting them where they are, just asking them, first of all, permission to talk about it. Then what they think about it, what we, what our feedback is and then coming to some kind of a plan with them. And it's much better to do that.
And if you talk to people like they're real people, you can move on. And so this has to be part of our [inaudible], it just has to be incorporated into our care. And we hope that some of these new changes will persist. We hope we can get rid of that X Waiver, at least for emergency physicians. We hope that we will continue to have places to send people, and use Telemedicine.
We hope that methadone can be given more… And we really have to revise that whole system. Because for many people, this is working much better. They actually can have a job if they can. They can actually get to their places that they need to get to instead of spending the whole day trying to get their methadone. So we need to review that. And then just the general message is time is up, right? Time is up. We need to incorporate these quality measures into our care. And it's just not optional anymore.
Gail, I really thank you. Not just for being with us today, but the terrific work that you do. And for driving, actually you and the fill in medicine to other strategies for properly managing individuals with substance use disorder. Not just those with opioid use disorder. As well as the complexities medical situations that they find themselves right now in amidst COVID.
And I also think that as physicians, we also have a unique opportunity to actually upfront address the issues of discrimination and racism. So that every single patient that needs us will get the quality care that they deserve. So Gail, thanks very much for everything you so.
Yes. And let me just add one thing I forgot before we go, is that with all of this, we recognize that we're… That all of us we're addiction specialists are working 24 hours a day, and we need more. We just need more addiction medicine, and addiction psychiatry. And we've got to get that pipeline going, and we need the resources and funding to really increase the workforce. And nothing has shown up, we need it more than COVID-19. So thanks for having me.
No, thanks very much. And thanks to the audience for your attention to the program. Thanks a lot.


As our spring semester came to a close this past week, it was time for the annual MPA ball!
This year, it was held at the Grand Connaught Rooms with the after-party at Sway.
The evening included a speech from our Dean, several musical performances by classmates, and incoming/outgoing MPASA board members.
Plus, there were the token superlatives awarded to my graduating class.
It was a fun evening of dancing and sharing laughs before we all depart on our five week spring break! We've got one more term to go before we are done!


text:
CDC-funded study confirms flu shots linked to spontaneous abortions… vaccine experts rush to explain away the findings
A CDC-funded medical study being published by the medical journal Vaccine has confirmed a shocking link between flu shots and spontaneous abortions in pregnant women. The study was rejected by two previous medical journals before Vaccine agreed to publish it, further underscoring the tendency for medical journals to censor any science that doesn't agree with their pro-vaccine narratives.
"A study published today in Vaccine suggests a strong association between receiving repeated doses of the seasonal influenza vaccine and miscarriage," writes CIDRAP, the Center for Infectious Disease Research and Policy.
"A puzzling study of U.S. pregnancies found that women who had miscarriages between 2010 and 2012 were more likely to have had back-to-back annual flu shots that included protection against swine flu," reports Medical Xpress, a pro-vaccine news site that promotes vaccine industry interests. Notice that the opening paragraph of their study assumed the study couldn't possibly be true. It's "puzzling" that mercury in flu shots could cause spontaneous abortions, you see, because these people have no understanding of biochemistry and the laws of cause and effect.
"That study was conducted after the CDC made the recommendation 2004 that all pregnant woman in all trimesters get the seasonal flu shot," explains CIDRAP. That's because the CDC is primarily a vaccine propaganda front group that buries whatever science it doesn't like while promoting the interests of vaccine manufacturers.
400% increase in miscarriages among pregnant women who receive vaccines
The study found a more than 400% increase in spontaneous abortions / miscarriages among pregnant women who received flu shots vaccines in back-to-back years. As ABC News reports:
The study's authors, two of whom are CDC researchers, saw a big difference when they looked at women who had miscarried within 28 days of getting a shot that included protection against swine flu, but it was only when the women also had had a flu shot the previous season. They found 17 of 485 miscarriages they studied involved women whose vaccinations followed that pattern. Just four of a comparable 485 healthy pregnancies involved women who were vaccinated that way.
This new research confirms the truth about vaccines that Natural News has been courageously reporting for years: Flu shots cause spontaneous abortions and numerous other health problems. See the evidence yourself in this article entitled Why flu shots are the greatest medical fraud in history.
It has already been well established that women who receive flu shots in previous years have weakened antibody response to flu shots in the current year. This was documented in a study published in Vaccine entitled, Effects of prior influenza virus vaccination on maternal antibody responses: Implications for achieving protection in the newborns. That study abstract admitted, "Prior receipt of influenza vaccine can dampen antibody responses to subsequent vaccination." In other words, flu shots weaken your immune response to future flu shots.
We also know that flu shots contain mercury, a potent neurotoxin. Mercury is unsafe to inject into a human being at any level, yet my own laboratory research using mass-spec instrumentation confirmed that flu vaccines contain over 50,000 ppb mercury — more than 25,000 the EPA's legal limit of mercury in drinking water.
Vaccine propagandists begin to panic
Vaccine propagandists are already beginning to panic over the news of this new study linking spontaneous abortions with flu shot injections. The CDC — a pro-vaccine front group that's deeply involved in scientific fraud — is invoking desperate measures to try to control the narrative. Via ABC News:
The Centers for Disease Control and Prevention has reached out to a doctor's group, the American Congress of Obstetricians and Gynecologists, to warn them the study is coming out and help them prepare for a potential wave of worry from expectant moms, CDC officials said.
Watch for heavy industry pressure on the Vaccine journal to pull the study or fabricate an excuse to discredit it. Even the editor-in-chief who accepted the study for publication is already stating he doesn't believe the findings. Via Medical Xpress:
Dr. Gregory Poland, Vaccine's editor-in-chief, said it was a well-designed study that raised a question that shouldn't be ignored. But he doesn't believe flu shots caused the miscarriages. "Not at all," said Poland, who also is director of vaccine research at the Mayo Clinic.
Watch for a massive media effort over the next few weeks to assure pregnant women that flu shots don't cause spontaneous abortions. When it comes to vaccines, science and logic are thrown out the window and every effort is made to propagandize and misinform the public about the serious risks associated with vaccines.
Read more about vaccine injuries and side effects at Vaccines.news.
Tagged Under: Flu shots, mercury, miscarriage, scientific study, side effects, spontaneous abortions, toxic ingredients, vaccine risks, vaccines
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