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01.12.2017 | Research article | Ausgabe 1/2017 Open Access
Prescription of secondary preventive drugs after ischemic stroke: results from the Malaysian National Stroke Registry
BMC Neurology > Ausgabe 1/2017
Wen Yea Hwong, Zariah Abdul Aziz, Norsima Nazifah Sidek, Michiel L. Bots, Sharmini Selvarajah, L. Jaap Kappelle, Sheamini Sivasampu, Ilonca Vaartjes
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The online version of this article (https://doi.org/10.1186/s12883-017-0984-1) contains supplementary material, which is available to authorized users.
Anatomical Therapeutic Chemical
Computed tomographic
Disability-adjusted-life-years
LMIC
Low and middle-income countries
Modified Rankin Scale
Transient ischemic attack
There is a substantial geographical variation for stroke burden between countries of different income levels. The bulk of stroke burden comes from low and middle-income countries (LMIC), accounting for 69% of total incident strokes and 71% of stroke deaths in 2010. The number of disability-adjusted life years (DALYs) for stroke survivors aged below 75 years was 5-times higher in these regions compared to high-income countries [ 1 ].
The burden of stroke in LMIC is largely attributable to poor prevention and control of cardiovascular risk factors [ 2 ]. Besides primary prevention, part of the burden is potentially modifiable with effective secondary prevention. Stroke patients have a 30% estimated 5-year risk of a recurrent stroke [ 3 ]. Regular clinical audits are established to assess control of cardiovascular risk factors for secondary prevention [ 4 ] but such structures are particularly lacking in LMIC. Nevertheless, this information is essential because the implementation and uptake of secondary prevention in LMIC is likely to differ from high-income countries, owing to the disparity in terms of access to health care, average education level and availability of drugs between countries of different income statuses [ 5 ].
This study was therefore aimed at evaluating the prescription of secondary preventive drugs upon hospital discharge among ischemic stroke patients in Malaysia, an upper middle-income country. Furthermore, we sought to identify possible factors that influence the likelihood of patients being prescribed with these drugs.
Participant selection
Participants for this study were selected from cases that were registered in Malaysian National Stroke Registry, a database established under the National Neurology Registry [ 6 ]. This database recorded a total of 7592 patients from 14 public hospitals between July 2009 and December 2014. Although the coverage of this registry does not include stroke admissions from private hospitals, this database is the best available representation of the Malaysian stroke population. Moreover, public hospitals cover 66.2% of total hospital admissions for the country in 2014 [ 7 ].
For the present study, we included patients who had a diagnosis of non-fatal ischemic stroke upon discharge.
We kept to recommendations of the 2012 Malaysian Clinical Practice Guidelines for Management of Ischemic Stroke [ 8 ]. The contents are largely similar to the 2011 stroke guidelines published by American Stroke Association [ 9 ]. We did not account for evidence from an updated publication for the latter guidelines in 2014. This is to establish a consistency in terms of time frame between dissemination of information from the guidelines and selection of patients for this study.
Prescriptions of three types of drugs were assessed: 1) antithrombotic drugs comprising antiplatelet and anticoagulants; 2) antihypertensive drugs; and 3) lipid-lowering drugs. Indications for long-term anticoagulants in the present analysis included prior history of atrial fibrillation, electrocardiogram showing atrial fibrillation during admission or patients with cardioembolic stroke. Drugs were prescribed upon hospital discharge by treating physicians. Data for the prescription were obtained from medical records. These drugs were coded following the Anatomical Therapeutic Chemical (ATC) Classification, an international classification under the World Health Organization of which drugs are coded based on their active ingredients [ 10 ].
Determinant measures
Potential patient-level factors that were studied included 1) demographic characteristics: age, sex, ethnicity and education level; 2) comorbidities and prescriptions recorded prior to the stroke event: previous hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, ischemic heart disease, previous stroke or transient ischemic attack (TIA) events and prior prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs; 3) lifestyle factors: obesity and smoking status and 4) status of disability upon discharge that was assessed with Modified Rankin Scale (mRS). A hospital level variable that categorizes hospitals into state and non-state hospitals was also included. State hospitals are classified as hospitals with up to 45 resident specialties or subspecialties and are normally main referral centers for each state. Detailed operationalization of these factors are summarized in Additional file 1: Table S1.
Collection of data for this registry followed local routine clinical practice where it involved collection of existing data that were readily available as part of routine practice. Information on demographic characteristics with the exception of education level was obtained from patient identification cards. Education level was assessed via patient interview. Depending on availability, information on prior co-morbidities, lifestyle factors and drug prescriptions obtained during patient interviews were verified with patients' past medical records from respective general practitioners or availability of drug strips from patients. Clinical diagnosis of an ischemic stroke was confirmed via computed tomographic (CT) imaging where a visible infarct seen on scan confirmed an ischemic stroke. As for disability status, it was measured prior to discharge with mRS. This is a commonly used scale that incorporates both mental and physical adaptations to neurological deficits experienced after a stroke [ 11 , 12 ]. For the purpose of this study, a score of <3 was considered no or minor disability and a score of > = 3 as moderate or severe disability.
Proportion of missing data ranged from 0.06% (variable: ischemic heart diseases) to 39% (variable: smoking status). Details on the extent of missingness for each variable are summarized in Additional file 1: Table S1. Missing data were assumed to be missing-at-random and thus, we conducted multiple imputation with m = 10 prior to the inclusion of patients for analysis to reduce the extent of bias resulting from missing data [ 13 ]. Subsequently, patients who did not fulfil the inclusion criteria were removed from analysis.
As stroke patients were selected within clusters of hospitals, the variable 'Hospital ID' that defines each participating hospital was included as a random effect, to account for variations within and between hospitals. In that respect, multi-level logistic regressions were performed to identify factors that were associated with the likelihood of an ischemic stroke patient being prescribed antiplatelet, antihypertensive drugs and lipid-lowering drugs, respectively. All potential factors were fitted into regression models for the three drugs. Factors with p-value <0.05 were considered significant. For anticoagulants, a slightly different model fitting approach was taken as the number of prescriptions (events) were small (n = 128). Univariable analysis for each factor was first conducted to assess its possible relation to the outcome. Factors with p-value < 0.25 were chosen and subsequently included in a multivariable analysis.
Multiple imputation was conducted with package 'mice' in R version 3.1.1 [ 14 ]. Multi-level regression analyses were performed with Stata SE Version 14.3 [ 15 ]. Odds ratios with their corresponding 95% confidence intervals were reported.
Of 5292 patients, 43% were 60 years old or younger. A majority were of Malay ethnicity and nearly half of the patients had primary education. Table 1 shows that presence of atherosclerotic risk factors was common; 72% had prior hypertension, 47% diabetes mellitus and 32% dyslipidemia. Only 7% had atrial fibrillation. Prior to their hospital admission for ischemic stroke, 40% of patients were receiving antihypertensive drugs, 24% antiplatelet, 28% lipid-lowering drugs and 2%, anticoagulants. Among those with hypertension, 52% (n = 1960) were taking antihypertensive drugs. Upon hospital discharge, 62% had moderate to severe disability.
Patients Included (N = 5292)
n (%)
Age category (years)
< =50
> 70
Non-Malay
Co-morbidities prior to admission
Dyslipidemia
Atrial fibrillationa
Previous stroke/TIAb events
Life-style factors
Never smoked
Previous smoker (quit >30 days)
Current smoker
Drug use prior to admission
Antiplatelet
Anticoagulants
Lipid-lowering drugs
Disability scale at discharge (mRSb)
< 3
> =3
aincludes patients with documented history of atrial fibrillation and patients with electrocardiogram showing atrial fibrillation during admission for ischemic stroke
bTIA = transient ischemic attack; mRS = Modified Rankin Scale
Prescription of secondary preventive drugs
Figure 1 shows that 88.9% (95% CI: 88–90%) were discharged with antiplatelet. Similarly, 88.7% (95% CI: 88–90%) of patients received lipid-lowering drugs. Forty-eight percent (95% CI: 47–49%, n = 2543) of patients were discharged with antihypertensive drugs. Of those, 62% of them were on monotherapy. Angiotensin-converting-enzymes inhibitors (ACEIs) recorded the highest number of prescriptions (65%) whereas ACEIs and calcium channel blockers were the most commonly prescribed dual combination.
Prescription of secondary preventive drugs. *for ischemic stroke patients with indications to receive anticoagulants (n = 391)
Among ischemic stroke patients with an indication for long-term anticoagulants (n = 391), 33% (95% CI: 28–38%) received it. Figure 2 illustrates the types of antithrombotic drugs prescribed. More than half (52%, 95% CI: 47–57%) were discharged with a single antiplatelet and 4% (95% CI: 2–5%), more than one antiplatelet. There were 12% (95% CI: 8–15%) of the indicated patients who did not receive any antithrombotic drugs.
Types of antithrombotic drugs prescribed among ischemic stroke patients with indications for anticoagulation. (n = 391). *exploded slice from the pie chart indicates the proportion of patients who were not prescribed with any antithrombotic drugs
Factors associated with the prescription of secondary preventive drugs (Fig. 3a–d and Additional file 2: Table S2)
Increasing age was associated with less odds of receiving secondary preventive drugs (Fig. 3a–d). Patients above 70 years old were less likely to be discharged with secondary preventive drugs when compared to those aged 50 years and below; an odds ratio of 0.72 (95% CI: 0.50–1.03) for antiplatelet, 0.66 (95% CI: 0.45–0.95) for lipid-lowering drugs and 0.27 (95% CI:0.09–0.83) for anticoagulants. Contrastingly, this association was not observed for the prescription of antihypertensive drugs.
Factors related to the prescription of secondary preventive drugs among ischemic stroke patients. (Fig. 3 a–d are results from multivariable analyses, ref. = reference groups, TIA = transient ischemic attack, mRS = Modified Rankin Scale, − = factors were not included in multivariable analysis). *atrial fibrillation includes patients with documented history of atrial fibrillation and patients with electrocardiogram showing atrial fibrillation during admission for ischemic stroke. †state hospitals refer to hospitals with up to 45 resident specialties or subspecialties and are normally main referral centers for each state
Figure 3a–d displays no differences in the odds of receiving secondary preventive drugs between men and women or their ethnicities. In contrast, patients with moderate to severe disability (mRS > =3) were less likely to be discharged with antiplatelet (OR: 0.57, 95% CI: 0.45–0.71), antihypertensive drugs (OR: 0.86, 95% CI: 0.75–0.98) and lipid-lowering drugs (OR: 0.78, 95% CI: 0.63–0.97) in comparison to those with minor disability (mRS < 3). This observation was also noted for the prescription of anticoagulants although the association was not significant (OR: 0.61, 95% CI: 0.32–1.16).
Some factors were found to be associated with specific to respective drug prescriptions. Patients with secondary and tertiary education were more likely to be prescribed antihypertensive drugs when compared to those who completed primary education (OR: 1.21, 95% CI: 1.01–1.45 for the former and OR: 1.67, 95% CI: 1.12–2.48 for the latter). There was a 2.4-fold increase (95% CI: 2.05–2.79) in the prescription of antihypertensive drugs in patients with prior hypertension and similarly in those with previous TIA or ischemic stroke, a 19% increase (95% CI: 1.02–1.38) was noted (Fig. 3c).
Patients with dyslipidemia had significantly higher odds of receiving antiplatelet (OR: 1.40, 95% CI: 1.10–1.79) and lipid-lowering drugs (OR: 1.28, 95% CI: 1.00–1.63). Likewise, patients who were obese at admission were also more likely to be prescribed these drugs; an odds ratio of 1.56 (95% CI: 1.00–2.42) for antiplatelet and OR: 1.77 (95% CI: 1.15–2.73) for lipid-lowering drugs. Besides, our findings revealed a 9.7-fold increase (95% CI: 2.05–46.05) in the odds of being discharged with anticoagulants among ischemic stroke patients with atrial fibrillation. Figure 3a–d shows that the odds of receiving secondary preventive drugs significantly increased between 2 to 4-fold with prior respective drug prescription.
In addition, we found a 16% decrease (95% CI: 0.73–0.96) in the odds of receiving antihypertensive drugs in patients with dyslipidemia and similarly, a 28% decrease (95% CI: 0.58–0.89) in the odds of receiving lipid-lowering drugs in diabetic patients. Patients with prior antithrombotic drugs were also less likely to be prescribed with lipid-lowering drugs.
Prescription of antihypertensive drugs and anticoagulants upon hospital discharge among ischemic stroke patients in Malaysia were suboptimal. Less than half of the ischemic stroke patients were prescribed antihypertensive drugs and only 1 out of 3 ischemic stroke patients with an indication for long-term anticoagulants received the drug. Increasing age and poorer disability status consistently decreased the odds of receiving secondary preventive drugs upon hospital discharge whereas patients with specific comorbidities prior to admission and who were previously taking the respective drugs were more likely to be treated for secondary prevention. Importantly, prescription of these secondary preventive drugs was not influenced by different sexes and ethnicities.
The high proportion of patients receiving antiplatelet was consistent with previous studies [ 16 – 19 ]. In contrast, a majority of studies reported low prescriptions of lipid-lowering drugs with a range between 31 and 45% [ 16 , 17 , 19 ], with the exception of Thailand [ 18 ]. Inclusion of statin prescription as a key performance indicator for stroke management in the country and similarly, in Thailand may explain the larger proportions observed [ 8 , 18 ].
The low rate of in-hospital initiation of antihypertensive drugs after an ischemic stroke event however, warrants crucial attention. Comparatively, the proportion of antihypertensive drugs received varied within LMIC regions; from 31% in Thailand [ 18 ] to 63% in China [ 19 ] whereas a higher range between 69 and 77% were observed in high-income countries [ 17 , 20 ]. While fluctuations in the measurement of blood pressure during hospital admission may had possibly led to a delay in prescription among some patients, there were potentially other contributing factors to the fact that more than half of the patients in our cohort were discharged without an antihypertensive drug. Of importance is the uncertainty to prescribe these drugs to normotensive patients after an ischemic stroke and the extent of lowering their blood pressure levels [ 21 ]. Despite this contentious issue, the local guidelines, supported by the international guidelines on secondary stroke prevention in 2011 have recommended the use of antihypertensive drugs, in particular ACE inhibitors as part of secondary preventive therapy in both hypertensive and normotensive patients [ 8 , 9 ]. Moreover, Thompson et al. [ 22 ] showed a significant reduction in the risk of recurrent stroke for non-hypertensive patients who were prescribed antihypertensive drugs (RR: 0.77; 95%CI: 0.61–0.98). It is essential to be aware that initiation of secondary stroke prevention goes beyond solely treating specific risk factors. In addition, despite an increase in the prevalence of hypertension in Malaysia, treatment, awareness and control of the condition remains alarmingly low [ 23 ]. This is clearly observed from our findings where only half of the hypertensive patients received antihypertensive drugs prior to admission.
Besides that, the influence of education level on the likelihood of being prescribed antihypertensive drugs upon hospital discharge is of particular interest. The decision to prescribe is often a complex interplay between the prescriber, patient and resources available. Used as a proxy for socioeconomic status and literacy level, patients of higher education levels are more likely to understand the benefits attained with secondary prevention and thus, showed more acceptance towards treatment [ 24 ].
Parallel to our findings, a range between 19 and 40% for the prescription of anticoagulants was reported among Asian cohorts in LMIC [ 18 , 25 ]. Fear of intracranial bleeding as well as difficulties in achieving optimal anticoagulation with warfarin especially among elderly Asians might play a role in the suboptimal prescription of long-term anticoagulants [ 26 ]. This is reflected in our findings where younger patients with lower risk of bleeding and those who received the drugs before, were more likely to receive anticoagulants. Locally, the current delivery of stroke care is fragmented, in particular between the points of transfer of care. Besides a lack of post-discharge stroke care guidelines in primary care, resources are restricted especially in rural areas. Follow-up services for post-stroke patients therefore, largely remain within the settings of tertiary centres that are located in the main cities [ 27 ]. Nonetheless, this poses several challenges in terms of distance, logistics and convenience for patients. Initiation of treatment such as warfarin that requires frequent monitoring of prothrombin time and dose readjustments are often not possible.
Increase in age and higher mRS score are predictors of recurrent vascular events [ 28 ]. While rightfully patients with higher risks of stroke recurrence should be more optimally treated, we found that older patients and those with worse disability were less likely to receive secondary preventive drugs. Although previous studies reported conflicting results on prescription of secondary preventive drugs in older patients, under prescription in older patients could be attributed to issues on increased adverse effects [ 16 ]. Comparatively, findings on the relation between disability status and drug prescription were similar to other studies [ 19 , 25 ]. Restrictions in drug availability within some LMIC may explain such practice but more importantly, this is a reflection of the difficulties faced by physicians in providing the best 'do no harm' care to patients. Patients with poor independence status are generally those with a higher number of comorbidities. Pill burden may cause non-adherence and an increase risk of adverse drug reactions [ 29 ]. Moreover, secondary prevention is perhaps viewed as of little value for these patients because they are perceived to have less to lose with future recurrent events.
Furthermore, we found no differences in the odds of receiving secondary preventive drugs between sexes and ethnicities of the patients. In developing countries where issues of gender and ethnic discriminations ranging from job choices, societal expectations to limited access to education and healthcare are often raised [ 30 ], absence of such associations are reassuring facts that these social determinants do not influence a prescriber's decision to treat.
Exact reasons remain to be ascertained so as to why there were less odds in prescribing antihypertensive drugs among patients with prior dyslipidemia and similarly, lipid-lowering drugs for diabetic patients and patients with prior antithrombotic drugs. We postulate the probability of variations in blood pressure and lipid levels after an acute ischemic stroke that can potentially delay the prescription of antihypertensive drugs [ 31 ]. Statin precautions such as fear of increased risk for intracranial bleed or raised liver enzymes in diabetic patients with fatty liver disease are among possible reasons [ 32 , 33 ] Nevertheless, recent evidences are increasingly proving the greater benefits of these drugs over their minimal risks [ 34 ]. Thus, unless for absolute contraindications, there is no reason to withhold secondary preventive drugs from these indicated patients.
To the best of our knowledge, we are among the few LMIC regions within Southeast Asia to initiate evaluation of secondary stroke prevention. Our large study sample is of advantage. In addition, we performed multiple imputations to reduce possible bias from missing data. It was not possible, however to identify patients with absolute contraindications to the drugs because reasons for non-prescription were unknown. Comorbidities upon hospital discharge or its proxy measurements were unavailable. Besides, this study is not designed to be nationally representative. Caution should be taken when generalizing the findings to the whole Malaysian stroke population.
Fundamentally, this study sets a benchmark of the current status of secondary stroke care among ischemic stroke patients in Malaysia. These findings imply that it is timely to establish regular assessment on the uptake and effectiveness of these preventive strategies. Establishing collaborations with other countries will allow initiation of such evaluation to be carried out. Among the few examples are the conduct of EUROASPIRE and Survey of Risk Factors audit (SURF) where a standardized method of assessing secondary prevention for cardiovascular diseases is implemented across participating countries to enable comparisons and benchmarking [ 4 , 35 ]. Findings from the assessment should subsequently be put into use by initiating a continuous feedback system to relevant healthcare professionals and stakeholders. Besides, the need for an improved stroke care model in the country with an emphasis on continuity of care for post-stroke patients at various levels of care should be made a priority. Other targeted plans include organizing regular continuous medical updates to increase prescribers' awareness on the impact of in-hospital initiation of secondary preventive drugs on subsequent improvement in patient adherence and overall survival [ 36 ].
In summary, the prescription of antihypertensive drugs and anticoagulants upon hospital discharge among ischemic stroke patients in Malaysia were suboptimal. Our findings revealed a treatment pattern that was influenced by age, disability upon discharge, specific comorbidities and prior drug prescriptions. No differences were found between sexes and ethnicities. Continuous efforts from relevant aspects of healthcare stakeholders are essential to allow better cardiovascular preventive actions to be put into place.
We thank the Director General of Health, Ministry of Health, Malaysia for his permission to publish this manuscript. Our sincere thanks also go to personnel from all participating hospitals for their contribution in the data collection.
The registry is funded by Ministry of Health Malaysia. Ministry of Health Malaysia had no role in the study design, analysis and preparation of the manuscript. WYH is funded by Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht under the Netherlands Organization for Scientific Research grant (Grant number: 022.005.021). IV is funded by the Dutch Heart Foundation for project Facts and Figures. The Julius Center and the Dutch Heart Foundation had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The data that support the findings of this study are available from the Malaysian Stroke Registry established under the National Neurology Registry but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available upon reasonable request with approval from the principal investigator of the data source: Dr. Zariah Abdul Aziz @ zaraziz_ayie@yahoo.com
Duplicate publication
The abstract of this manuscript was presented as a poster in EuroPrevent 2017 conference [ 37 ].
Ethical approval was obtained from Medical Research and Ethics Committee, Ministry of Health Malaysia (ID: NMRR 08–1631-3189). The approval includes data collection and use of data for secondary analysis. With a waiver of informed consent, a public notice is displayed at all participating sites and participants have the option to opt out.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Additional file 1: Table S1. Operationalization and proportion of missingness for determinants. This table shows definitions for each variable included in the regression analysis, the types of variables and its proportion of missingness in the dataset. (DOCX 19 kb)
12883_2017_984_MOESM1_ESM.docx
Additional file 2: Table S2. Factors related to the prescription of secondary preventive drugs among ischemic stroke patients by types of drugs (multivariable analysis). This table is similar to Fig. 3a–d but the estimates are provided in a table format. (DOCX 21 kb)
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Wen Yea Hwong
Zariah Abdul Aziz
Norsima Nazifah Sidek
Michiel L. Bots
Sharmini Selvarajah
L. Jaap Kappelle
Sheamini Sivasampu
Ilonca Vaartjes
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Das Buch schildert Ereignisse im Rahmen der Neuromedizin, die während der Diagnostik und Therapie neurologischer Erkrankungen und Symptome auftreten können. Die Fallbeispiele sensibilisieren Sie für mögliche Risikofaktoren, um das Auftreten solcher Komplikationen zu vermeiden.
Frank Block
Facharztwissen Psychiatrie, Psychosomatik und Psychotherapie
Leitsymptome, Untersuchungsmethoden, Krankheitsbilder, Notfälle & Co. – mit der Neuauflage des "Facharztwissens" sind Sie auf die Facharztprüfung in Psychiatrie und Psychotherapie optimal vorbereitet. In dieser 2. Auflage sind die Kapitel zu psychosomatischen Störungen deutlich ausgebaut.
Prof. Dr. Dr. Frank Schneider
Kompendium der Psychotherapie
Für Ärzte und Psychologen
Dieses Werk wendet sich an Ärzte und Psychologen, die an psychiatrischen und psychosomatischen Kliniken oder an Psychotherapeutischen Ausbildungsinstituten arbeiten und in den vorhandenen Lehrbüchern der Psychotherapie den Brückenschlag zur …
Tilo Kircher
» zur Themenseite Neurologie rotated-square
» zur Themenseite Psychiatrie rotated-square


text:
Home>>Disco>>Disco Lights And The New Nightclub Designs
Disco lights that are introduced as dance club structure parts have different styles. They are without a doubt more exceptional than they were a couple of decades prior. There was not the decision in those circumstances such as there is presently. As a general rule, the change is so observable, benefactors can't resist the urge to see them. These days, these lights use LED lighting boards that are, generally, introduced on the dividers of the club. There is additionally programming that is introduced for the lights. Whoever is turning the records can control how the lights are actuated.
Dance club structure parts like disco lights are intriguing a direct result of their novel plan. Supporters appreciate to see various sorts of style once they go to a club. With the lighting that is applied today, it very well may be synchronized where it tends to be in a state of harmony with the sound beats. This as well, is turned on by the man or lady who is turning the records. Once upon a time, these plans arrangements were not advertised. The clubs simply had the typical recessed lights and the strobe light, which was a globe situated in the move floor area and fixated on by a white laser shaft. Despite the fact that benefactors became accustomed to the strobe light, they were costly to do. Dance club proprietors found without anyone else paying significantly more cash to work this than what they needed to dish out.
These days, LED lighting has had this spot. Truly, there might be numerous dance club that are as yet retro and utilize the strobe light, yet they are rare. Dance club plans which incorporate LED lighting are extremely worth, basically on the grounds that they don't use as a lot of vitality and they are financially savvy. Dance club proprietors can find some extremely unmistakable plan thoughts with these lights. Item plans like LED Disco Panel Bubble come in different hues, similar to gold and silver. Remember that regardless of what the shading is, these dance club items must coordinate the other style of the dance club. Remember about having lighting on the move floor with the goal that people can see.
Dance club structure items are a fundamental segment of the dance club's stylistic theme. In all honesty, benefactors do see how the foundation is set up. They despise going to various clubs and seeing a similar sort of plan. To them, that is unexciting. They search for wide assortment and various styles. Likewise with the lights, it's basic to be imaginative and inventive. Utilize assorted shades, yet ensure that they blend in with each other. Along these lines, it's fundamental that dance club proprietors change with the occasions and supplant their stylistic theme to mirror that.

redpajama_set_name: RedPajamaCommonCrawl


A new parliamentary report shows that the number of migrants living in a Paris suburb may be nearing 400,000, according to Paris Vox.
The report of the deputies François Cornut-Gentille and Rodrigue Kokouendo says that the French Republic is failing in the Seine-Saint-Denis suburb, which is north east of Paris.
Between 150,000 and 400,000 illegal immigrants live in the Paris suburb under bad conditions. The poverty rate is 28% while the unemployment rate stands at 12.7%, well above national averages.
French newspaper Le Figaro says the report describes the situation as: "the incredible deterioration of social, economic and security conditions" in the area.
The very high numbers of poor and unemployed illegals also causes problematic behaviour, such as trafficking and forms of delinquency.
The illegals now make up a fifth of the population of the Seine-Saint-Denis and are severely straining public services and creating social tensions, according to the parliamentary report.
After the clearance of the jungle camp in Calais, several migrants moved to Paris and near 550 migrants a day are still arriving in the city. Many of them come from Italy, as there are no structural border checks between the countries.


Stuffing vegetables with a filling is such a simple and budget friendly meal. Many of the filling items are things you might have in your pantry. Want some other ideas for similar meals? Try this Spaghetti Squash Burrito Bowl or these Southwestern Pepper Cups.
Steam the squash, skin side down, in a small amount of water in a fry pan or skillet until slightly tender (but not mushy).
Scoop out a good amount of pulp (1 cup). Place in a bowl and mix with rest of ingredients, except Parmesan.
Place the squash shells in a baking dish. Stuff the squash with the stuffing mixture.


text:
Robo-pets give veterinary students hands-on experience in new simulation center
Robo-pets give veterinary stud...
Students at Cornell University's College of Veterinary Medicine can train in a simulation center to get realistic, hands-on experience of veterinary care
Assistant professor of emergency and critical care Daniel Fletcher has led the creation of the simulation vet care center at Cornell University
The center evolved from the use of a pioneering robotic dog simulator back in 2010
Medical students have been honing their skills on human simulations for years and Cornell University's College of Veterinary Medicine has been using the world's first robotic dog simulator Robo-Jerry II and Robo-Fluffy, his feline counterpart, to give aspiring vets experience since 2010. The robo-pets now have a new home in the form of a new robotic simulation center the University claims is the first of its kind in the world, with work underway on a more advanced robotic dog called "Butch" that will boast more realistic features and which will run on cheap, standard components.
The new simulation center features fully equipped exam rooms, two rooms for video-feed observation as well as space for storage and the development of new robotic cat and dog models. The simulations run for 10 minutes and give students the opportunity to collect data from the robo-pets before deciding on the best course of treatment. A range of equipment is available to the students, including a full crash cart, medical supplies, defibrillator and other tools to take the robo-pet's pulse, listen to heart and lung sounds, insert catheters and hook up monitoring devices.
The center evolved from the use of a pioneering robotic dog simulator back in 2010 and was developed by assistant professor of emergency and critical care Daniel Fletcher. While first-year students perform more basic functions, such as listening to heart and lung sounds, second and third-year students use the center to perform scenarios involving actors filling the roles of technicians, clients and other clinicians.
"Our model can enhance CPR (cardiopulmonary resuscitation) scenarios and can simulate a slew of other conditions, and we've seen interest in it growing. We're gathering evidence and tools to help bring the simulation capability and teaching model outside Cornell," said Fletcher.
Fletcher is also building a more advanced robotic dog called "Butch" that he says will boast a more realistic airway, a soft abdomen compartment, articulating joints, more areas for catheters, more space inside the body and a more realistic overall feel. Later this year, he also intends to release a simulation toolkit that includes an open-source software platform and affordable hardware to be shared with other institutions interested in simulation teaching.
"No other schools are using this kind of simulation yet," said Fletcher. "Our model can enhance CPR scenarios and can simulate a slew of other conditions, and we've seen interest in it growing. We're gathering evidence and tools to help bring the simulation capability and teaching model outside Cornell."
Source: Cornell University
MedicalPetsRoboticSimulatorCornell University
mooseman February 6, 2013 01:54 AM
Heh.... they mention a defibrillator. I can just imagine using one of those on this robot...... ;) "Ok - *clear!*" ZAP. ( Blue smoke.... ) "GAH! Short-circuit!"
j-stroy February 6, 2013 09:09 PM
Reminds me of a book by Phillip K. Dick called "Do androids dream of electric sheep?" which became "Blade Runner". Most animal life was dead, and people had robotic pets. That is why the Android snake referenced in the movie. The tinkerer who took in the replicants was a robotic pet repairman.
Gregg Eshelman February 6, 2013 11:22 PM
Is it named Muffit II? http://en.battlestarwiki.org/wiki/Muffit
"Super-human red blood cells" hide drugs from immune system attack
Edible fluro tags light up prescription drugs to ensure their safety
Pig study sheds new light on sugar's addictive impacts on the brain
Specific gut bacteria may reduce severity of Parkinson's disease


text:
Award-Winning Breakfast, Brunch and Lunch Franchise Hatches in Mount Pleasant
Source: Moultrie News
Another Broken Egg Cafe, an award-winning breakfast, brunch and lunch franchise celebrated for its charming atmosphere and diversified menu options, announced it will be opening its newest location at 608 A Long Point Rd. on Monday, Nov. 2, boosting the local economy by creating up to 40 new jobs.
Another Broken Egg Cafe shines in the crowded restaurant sector thanks to a universally-appealing menu of 130 fresh and nutritious dishes that includes the likes of Bananas Foster, Huevos Rancheros and six Signature Benedicts, as well as popular lunch offerings ranging from gourmet burgers to Lobster and Shrimp Sliders, and a Healthy Side menu with lighter food options. Driven by attention to detail - everything from its French country décor, hand-made stoneware coffee mugs, warm color schemes, and original artwork - the upscale cafe offers patrons the opportunity to 'vacation' in an inviting atmosphere equipped with casual elegance.
Guests can also enjoy breakfast cocktails including house-infused bloody marys, mimosas and more from the full bar, as well as locally brewed beer from Holy City Brewery.
In addition to the award-winning dishes and charming ambiance, Another Broken Egg Cafe uses each grand opening to raise anywhere from $5K - $10K in donations for local charities. As the first Mount Pleasant location settles into the community, it looks forward to partnering with two local organizations prior to the official grand opening, the National Alliance on Mental Illness (NAMI) on Friday, Oct. 30 from 9 a.m. until noon and the Low Country Firefighters Support Team on Saturday, Oct. 31 from 9 a.m. until 1 p.m. There is no charge for the public to attend these separate fundraising events and donations can be made via cash or check and will be accepted for the featured nonprofits. Those wishing to support the ABEC Mount Pleasant pre-opening events are encouraged to call 843-352-9833 for reservations as seating is limited.
Bringing the ultimate dose of Southern hospitality to Mount Pleasant, the newest Another Broken Egg Cafe is owned and operated by Double R Restaurant Group, led by President Stuart Ottinger, who started his restaurant career as a co-founder of Nashville-based fast casual chicken concept, Otter's Chicken. Now, Ottinger looks forward to spreading the great taste of Another Broken Egg Cafe throughout the South Carolina region. As the company's largest franchisee, with a current portfolio of 23 cafes throughout the Southeast, Double R looks forward to expanding into the South Carolina market.
"Mount Pleasant residents will quickly discover that our southern-inspired cuisine and vacation-like atmosphere is truly a one-of-a-kind experience," said Ottinger. "Another Broken Egg Cafe is unlike any other restaurant in the region, and we are confident that it will become an instant favorite in the community, as well as the regional standard for quality breakfast, brunch and lunch throughout South Carolina."
The 3,479 square foot Mount Pleasant location comfortably seats up to 124 guests and will operate daily from 7 a.m. to 2 p.m. For more information about Another Broken Egg Cafe, call 843-352-9833 or visit www.anotherbrokenegg.com.
About Another Broken Egg Cafe
Founded by Ron E. Green in 1996, the Destin, Florida based Another Broken Egg Cafe is an upscale breakfast, brunch, and lunch restaurant that provides an extensive, diversified menu at an affordable price. With 52 locations throughout the US, the company has plans to have 100 restaurants open and operating by 2017. http://www.anotherbrokenegg.com/franchising.


Christy Grimsley brings 21 years of experience in facilitation, training, curricula development, and project management to the EnCompass team. As a trainer, she specializes in team building and organizational development, leadership and management training, and workshop planning and facilitation. As a curriculum designer, she has engaged in efforts to plan, develop, and roll out trainings, manuals and e-learning solutions for audiences around the world for the private sector, USAID, and the Peace Corps. She has deep knowledge of USAID programming through her facilitation of the Programming Foreign Assistance and Project Design and Management courses, as well as her design work for the Budget and Resource Management course.
Before joining EnCompass, Ms. Grimsley was the Director of Programming and Training for Peace Corps Mongolia where she led Peace Corps staff in developing strategies for program and training enhancement for volunteers, and provided volunteer mentoring and support. From 2007 to 2011, she served as a Senior Manager in the Training and Development Department at Chemonics International Inc., where she oversaw the Management and Leadership curriculum, assisted departments and region divisions with team development and facilitation needs domestically and overseas. Ms. Grimsley served as a Peace Corps Health Volunteer in Moldova and as an HIV Prevention Education Advisor with American Red Cross in Sri Lanka and the Maldives. She holds an MS in Kinesiology from the California State University.


fact that Jesus saw when He had compassion on the multitude.
leads us. He makes us conscious of "the still sad music of humanity."
is ours if we can behold suffering, however caused, without pity.
object of compassion rather than of vengeance?
With no rare art of speech or song.
She knew that she must be like Him.
For she had given all she had.
And staining tears, the Stranger wore.


text:
from bambou import NURESTFetcher

class NUPTranslationMapsFetcher(NURESTFetcher):
    """ Represents a NUPTranslationMaps fetcher

        Notes:
            This fetcher enables to fetch NUPTranslationMap objects.

        See:
            bambou.NURESTFetcher
    """

    @classmethod
    def managed_class(cls):
        """ Return NUPTranslationMap class that is managed.

            Returns:
                .NUPTranslationMap: the managed class
        """

        from .. import NUPTranslationMap
        return NUPTranslationMap

redpajama_set_name: RedPajamaGithub


text:
Q: Adjust nomogram ticks with (splines) transformation, rms package [R] I'm using a Cox regression model considering my variable trough splines transformation. All is working nice until the subsequent nomogram... as expected, the scale of my variable is also transformed but I'd like to add some custom ticks inside the region between values 0 and 2 (I guess is the transformed one). Any idea, if you please?
Here's my code...
data <- source("https://pastebin.com/raw/rGtUSTLz")$value
ddist <- datadist(data)
options(datadist = "ddist")

fit <- cph(Surv(time, event) ~ rcs(var, 3), data = data, surv = T, x = T, y = T)
surv <- Survival(fit)

plot(nomogram(fit,
              fun = list(function(x) surv(times = 10, lp = x),
                         function(x) surv(times = 30, lp = x),
                         function(x) surv(times = 60, lp = x)),
              funlabel = paste("c", 1:3), lp = T))

... and these are the real and the desired outputs.

Thanks in advance for your help!

A: I have had this issue too. My answer is a work around using another package, regplot. Alternatively, if you know what the point values are at the tick marks you want plotted, then you can supply those instead of using the output from regplot. Basically, you need to modify the tick marks and points that are output from the nomogram function and supplied to plot the nomogram.
This method also provides a way to remove points / tick marks by editing the nomogram output.
data <- source("https://pastebin.com/raw/rGtUSTLz")$value
ddist <- datadist(data)
options(datadist = "ddist")

fit <- cph(Surv(time, event) ~ rcs(var, 3), data = data, surv = T, x = T, y = T)
surv <- Survival(fit)
nom1 <- nomogram(fit, fun = list(function(x) surv(times = 10, lp = x),
                         function(x) surv(times = 30, lp = x),
                         function(x) surv(times = 60, lp = x)),
              funlabel = paste("c", 1:3), lp = T)

library(regplot)
# call regplot with points = TRUE to get output
regplot(fit, fun = list(function(x) surv(times = 10, lp = x),
                         function(x) surv(times = 30, lp = x),
                         function(x) surv(times = 60, lp = x)),
              funlabel = paste("c", 1:3), points = TRUE)
# look at the points supplied through regplot and take those.
nom1_edit <- nom1
# now we edit the ticks supplied for var and their corresponding point value
nom1_edit[[1]][1] <- list(c(0, 0.06, 0.15, 0.3, 2,4,6,8,10,12,14,16))
nom1_edit[[1]][2] <- list(c(0, 10, 21, 32, 42.41191, 50.63878, 58.86565,
                       67.09252, 75.31939, 83.54626, 91.77313, 100.00000))

nom1_edit$var$points <- c(0, 10, 21, 32, 42.41191, 50.63878, 58.86565,
                       67.09252, 75.31939, 83.54626, 91.77313, 100.00000)
# plot the edited nomogram with new points
plot(nom1_edit)

redpajama_set_name: RedPajamaStackExchange


An iPhone user can use the Apple wired headphone switch to perform several actions, including ending a phone call. This project makes an electrical breakout, allowing another switch or a programmatically controlled relay to perform these actions. This can be used for automated testing of iOS apps that make phone calls.
The project could use an actual headphone or a fake headphone. I prefer an actual headphone, the earphones and microphone can still function. Also it may be more compatible with phone hardware and software.
Please note if you do this you could accidentally damage the phone or yourself. If you are careful I think the risks are low, but no warranty!
The headphone plug has 4 contacts.
The phone interprets a resistance of roughly 5 kohms between the microphone input and ground as a microphone. Clicking the center switch on the headphone cord momentarily shorts the microphone input to ground.
First I pried and cut into a headphone switch, thinking to splice directly into the switch. This exposed a thin circuit board.
The top was covered with metal strip, insulating film and thin metal domes. I didn't expose switch contacts.
The bottom was covered with a thin black strip of something(!) and a metal strip. I didn't expose switch contacts.
I felt even if I did get to the contacts, they would be too small to solder to easily. So I tried another approach.
I got a headphone extension cord, cut off one end and attempted to solder some of the wires. The wires were very fine and it was difficult to mechanically strip the insulation. Soldering didn't work, too contaminated. I made a fake headphone using a screw terminal strip and a 5 kohm resistor from microphone input to ground.
After starting a phone call, manually shorting the microphone input to ground ended the call.
Finally I realized the switch can go between the headphone plug and the phone jack. The switch box connects an Apple wired headphone to a 4 conductor headphone extension cable. No need to cut into the headphone. Much easier! The switch box breaks out the microphone contact (farthest from the headphone plug tip) and the ground contact (second farthest from the headphone plug tip) to a coaxial jack. An external switch or programmatically controlled relay may plug in to this jack.


193. VIII. THAT THE WOMAN IS FORMED INTO [THE MAN'S] WIFE ACTUALLY ACCORDING TO THE DESCRIPTION IN THE BOOK OF CREATION. It is said in that Book, that the woman was created out of the rib of the man, and that when she was brought to him, the man said, This is bone of my bones, and flesh of my flesh; and she shall be called Ishah (woman), because she was taken out of Ish (man). Gen. 2:22, 23.
In the Word in its spiritual sense, by a rib of the breast nothing else is signified than natural truth. This is signified by the ribs which the bear carried between his teeth (Daniel 7:5), by bears, being signified those who read the Word in its natural sense and see truths therein without understanding. By the breast of a man is signified that essential and characteristic thing which is distinct from the breast of a woman. This is wisdom, as may be seen above (no. 187); for truth supports wisdom as a rib supports the breast. These are the significations because the breast is the region in which everything belonging to the man is present as in its center.
 From the above it is evident, that woman was created out of man by the transcription of his proprial wisdom, which is wisdom from natural truth; and that the love of this wisdom was transferred from man into woman that it might become conjugial love; also that this was done, to the end that in the man there may be, not self love but love of his wife, and she from her innate disposition cannot do otherwise than convert the self love with the man into his love to her. Moreover, I have heard that this is effected by the wife's love, neither the man nor the wife being conscious of it. Hence it is that no man can ever truly love his partner conjugially if he is in the pride of self- intelligence from love of self.
 When this arcanum of the creation of woman out of man is understood, it can be seen that in marriage woman is likewise created, as it were, that is, is formed from man; and that this is effected by the wife, or rather through the wife, by the Lord, it being the Lord who infuses into women the inclination so to act; for the wife receives the man's image into herself by appropriating to herself his affections (see above, no. 183); also by conjoining the man's internal will to her own will, of which hereafter; and, moreover, by appropriating to herself the propagations of his soul, of which likewise hereafter. From this it is evident, that in accordance with the description in the Book of Creation interiorly understood, a woman is formed into a wife by means of such things as she takes from her husband and from his breast and inscribes on herself.


text:
Q: How to add elements from a dictonary of lists in python given a dictionary of lists
vd = {'A': [1,0,1], 'B':[-1,0,1], 'C':[0,1,1]}

I want to add the lists element wise. So I want to add first element from list A to first element of list B vice versa
the complexity is that you cannot rely on the labels being A, B, C. It can be anything. second the length of the dictionary is also variable. here it is 3. but it could be 30.
The result i need is a list [0, 1, 3]

A: So you just want to add up all the values elementwise?
[sum(l) for l in zip(*vd.values())]

A: In short:
>>> map(sum, zip(*vd.values()))
[0, 1, 3]

Explanation
Given a dictionary:
>>> vd = {'A': [1,0,1], 'B': [-1,0,1], 'C': [0,1,1]}

We can get the values:
>>> values = vd.values()
>>> values
[[1, 0, 1], [-1, 0, 1], [0, 1, 1]]

Then zip them up:
>>> zipped = zip(*values)
>>> zipped
[(1, -1, 0), (0, 0, 1), (1, 1, 1)]

Note that zip zips up each argument; it doesn't take a list of things to zip up. Therefore, we need the * to unpack the list into arguments.
If we had just one list, we could sum them:
>>> sum([1, 2, 3])
6

However, we have multiple, so we can map over it:
>>> map(sum, zipped)
[0, 1, 3]

All together:
>>> map(sum, zip(*vd.values()))
[0, 1, 3]

Extending to an average rather than a sum
This approach is also easily extensible; for example, we could quite easily make it average the elements rather than sum them. To do that, we'd first make an average function:
def average(numbers):
    # We have to do the float(...) so it doesn't do an integer division.
    # In Python 3, it is not necessary.
    return sum(numbers) / float(len(numbers))

Then just replace sum with average:
>>> map(average, zip(*vd.values()))
[0.0, 0.3333, 1.0]

A: vd = {'A': [1,0,1], 'B':[-1,0,1], 'C':[0,1,1]}
vd_keys = list(vd.keys())
rt = vd[vd_keys.pop()].copy() # copy otherwise rt and vd[vd_keys.pop()] will get synced
for k in vd_keys:
    for i in range(len(rt)):
        rt[i] += vd[k][i]

print(rt)


text:
"Keep The Real Ones Close": Yuzvendra Chahal Posts Pic With Family
Sports Home Cricket News "Keep The Real Ones Close": Yuzvendra Chahal Posts Pic With Family
Yuzvendra Chahal's picture with his family on Instagram garnered heartwarming replies from fans.
Yuzvendra Chahal was all smiles in a picture where he was clicked with his family.© Instagram
Yuzvendra Chahal posted a picture with his family on Instagram
Fans flooded the comments box with heart-warming replies
Chahal's wife Dhanashree revealed that his parents tested Covid positive
Yuzvendra Chahal took to Instagram on Saturday to share a picture with his family, saying "keep the real ones close". Chahal's post comes days after his wife Dhanashree Verma broke the news, via an Instagram story, that the cricketer's parents had tested positive for coronavirus. On Thursday, Dhanashree, in her Instagram story, had mentioned that while Chahal's mother was being treated at home his father had to be hospitalised with "severe symptoms" after testing positive for COVID-19.
Soon after Chahal posted the pictures, fans flooded the comments section with heartwarming replies.
A post shared by Yuzvendra Chahal (@yuzi_chahal23)
"My parents in law have tested positive with severe symptoms. My father in law is admitted and my mother in law is being treated at home," Dhanashree had written in her Instagram story.
Dhanashree also revealed that when she was in the IPL bio-bubble, her mother and brother tested positive for Covid but they recovered. However, she lost her aunt and uncle due to the coronavirus.
Chahal was part of the Royal Challengers Bangaloresetup during the Indian Premier League (IPL) 2021 season.
The 14th edition of the IPL was postponed after several players and support staff tested positive for the virus within the IPL bio-secure bubble.
After two players from Kolkata Knight Riders and one each from SunRisers Hyderabad and Delhi Capitals returned positive for Covid, the IPL Governing Council and the Board of Control for Cricket in India (BCCI) unanimously decided to postpone the T20 tournament indefinitely.
While it is still not clear as to when the remaining season of the IPL will be played, BCCI president Sourav Ganguly said that the remaining part of the T20 tournament will not be played in India due to the "organisational hazards."
Yuzvendra Chahal Cricket India Cricket Team Rajasthan Royals Royal Challengers Bangalore
Kevin Pietersen Not Surprised By Virat Kohli's Decision To Quit Captaincy
Delhi High Court Refuses To Stay Legends League Cricket


text:
namespace Microsoft.IdentityModel.Protocols.Tests
{
    public class MessageComparer
    {
        public static bool AreEqual(AuthenticationProtocolMessage authenticationProtocolMessage1, AuthenticationProtocolMessage authenticationProtocolMessage2)
        {
            if (!DoObjectsHaveSameNullState(authenticationProtocolMessage1, authenticationProtocolMessage2))
            {
                return false;
            }

            if (authenticationProtocolMessage1 == null)
            {
                return true;
            }

            if (!DoObjectsHaveSameNullState(authenticationProtocolMessage1.IssuerAddress, authenticationProtocolMessage2.IssuerAddress))
            {
                return false;
            }

            if (authenticationProtocolMessage1.IssuerAddress != null && authenticationProtocolMessage1.IssuerAddress != authenticationProtocolMessage2.IssuerAddress)
            {
                return false;
            }

            if (authenticationProtocolMessage1.Parameters.Count != authenticationProtocolMessage2.Parameters.Count)
            {
                return false;
            }

            return true;
        }

#if SAML
        public static bool AreEqual(WsFederationMessage wsFederationMessage1, WsFederationMessage wsFederationMessage2)
        {
            if (!MessageComparer.AreEqual(wsFederationMessage1 as AuthenticationProtocolMessage, wsFederationMessage2 as AuthenticationProtocolMessage))
            {
                return false;
            }

            return true;
        }
#endif
        static bool DoObjectsHaveSameNullState(object object1, object object2)
        {
            if ((object1 == null && object2 != null) || (object1 != null && object2 == null))
            {
                return false;
            }

            return true;
        }
    }
}


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text:
Words I Needed Last Week 8/15
The right people were always going to find you.
Photo shot by Nneka Julia on 35mm in Oaxaca, Mexico (2022).
Words I saved, read, wrote down, and savored last week. From making uncomfortable art, to the right people finding you, to enduring the "thing" without wordplay, to finding your invincible summer.
Happy Monday, friends.
—Nneka
"My belief is that art should not be comforting; for comfort, we have mass entertainment and one another. Art should provoke, disturb, arouse our emotions, expand our sympathies in directions we may not anticipate and may not even wish."
―Joyce Carol Oates
"The right person will know how to hold your love. The right person will choose you just as deeply as you choose them. You will not have to quiet the way you care, you will never feel like you are too much. You will not have to beg for the love you deserve. One day, you will be met where you are. One day, you will be someone's favorite thing, and you will not be confused you will not feel like you are fighting for someone who isn't fighting for you. One day, you will understand that it never mattered how tightly you held on to the wrong people, how intensely you tried, because the right people were always going to find you. The right people were always going to stay."
—Bianca Sparacino
Ms. Howe: But it seems that everything in the Western world is trying to tell us this now, even as we're speeding up, and speeding up, and speeding up, and staring into our screens. It hurts to be present, though. I ask my students every week to write 10 observations of the actual world. It's very hard for them.
Ms. Tippett: Really?
Ms. Howe: They really find it hard.
Ms. Tippett: What do you mean? What is the assignment? 10 observations of their actual world?
Ms. Howe: Just tell me what you saw this morning like in two lines. I saw a water glass on a brown tablecloth, and the light came through it in three places. No metaphor. And to resist metaphor is very difficult because you have to actually endure the thing itself, which hurts us for some reason.
Ms. Tippett: It does.
Ms. Howe: It hurts us.
Ms. Tippett: You naming something.
Ms. Howe: We want to say, "It was like this; it was like that." We want to look away. And to be with a glass of water or to be with anything — and then they say, "Well, there's nothing important enough." And that's whole thing. It's the point.
Ms. Howe: It's the this, right?
Ms. Howe: Right, the this, whatever. And then they say, "Oh, I saw a lot of people who really want" — and, "No, no, no. No abstractions, no interpretations." But then this amazing thing happens, Krista. The fourth week or so, they come in and clinkety, clank, clank, clank, onto the table pours all this stuff. And it so thrilling. I mean, it is thrilling. Everybody can feel it. Everyone is just like, "Wow." The slice of apple, and then that gleam of the knife, and the sound of the trashcan closing, and the maple tree outside, and the blue jay. I mean, it almost comes clanking into the room. And it's just amazing.
Ms. Tippett: In some basic level, what they've done is just engage with their senses.
Ms. Howe: Yeah, and have been present out of their minds and just noticing what's around them, which is — we don't do. And again, not to compare it to anything. They're not allowed. And that's very hard for them. And then on the fifth or sixth week, I say, "OK, use metaphors." And they don't want to. They don't know how. They're like, "Why would I? Why would I compare that to anything when it's itself?" Exactly. Good question.
So then you think, why the necessity of a metaphor? Why do you have to use a metaphor now? Not just to do it to avoid it, but to do it to make it more there. And it's very interesting.
Excerpt from an episode of On Being, a conversation between Krista Tippett and Marie Howe.
"That's what dries a writer up…not listening. That is where it all comes from. Seeing, listening. You see well enough. But you stop listening… For Christ sake write and don't worry about what the boys will say nor whether it will be a masterpiece nor what. I write one page of masterpiece to ninety one pages of shit. I try to put the shit in the wastebasket. You feel you have to publish crap to make money to live and let live. All right but if you write enough and as well as you can there will be the same amount of masterpiece material. You can't think well enough to sit down and write a deliberate masterpiece… Forget your personal tragedy. We are all bitched from the start and you especially have to hurt like hell before you can write seriously. But when you get the damned hurt use it…don't cheat with it… All you need to do is write truly and not care about what the fate of it is. Go on and write."
"No person is your friend who demands your silence, or denies your right to grow."
"We are kept from our goal not by obstacles but by a clear path to a lesser goal."
—Robert Brault
"In the depths of winter, I finally learned that within me there lay an invincible summer."


text:
KU Jayhawks
MU Tigers
KSU Wildcats
Quick links... Chiefs Royals Sporting KC KU Jayhawks MU Tigers KSU Wildcats High Schools
United States shuts down South Korea, awaits Japan in gold medal game
Imagn
United States pitcher Joe Ryan celebrates against South Korea in a baseball semifinal match during the Tokyo 2020 Olympic Games at Yokohama Baseball Stadium.
By: NBC Olympics
The United States has clinched a medal in the Olympic return of its national pastime, beating South Korea 7-2 to advance to the gold medal game against Japan.
After taking a 2-1 lead through five innings, the Americans belted out five runs in the bottom of the sixth. After a walk to Todd Frazier and a strikeout by Eric Filia, Jamie Westbrook and Mark Kolozsvary hit back-to-back singles, with Frazier scoring on the second. Nick Allen walked to load the bases, and Jack Lopez drove home Westbrook with a single.
Eddy Alvarez, now assured of joining the exclusive club of U.S. athletes with medals in both the Winter and Summer Olympics thanks to his short-track speedskating relay silver in 2014, got an RBI groundout. Then Tyler Austin picked up two RBI with a single to center.
South Korea got one back in the seventh but gave up its lone baserunner to a double play in the eighth against U.S. reliever Anthony Gose. In the ninth, the Korean team sent up three straight pinch hitters, but Anthony Carter struck out the first two and snagged a line drive hit straight at him to end it.
Lopez also had an RBI single in the second to give the USA the lead, and Westbrook hit a solo home run in the fourth.
Joe Ryan gave up one run in 4 1/3 innings. Ryder Ryan replaced him to pick up the win.


text:
ACCEPTED

#### According to
The Catalogue of Life, 3rd January 2011

#### Published in
Stud. Mycol. 9: 44 (1975)

#### Original name
Peresiopsis carludovicae Bat., 1960

### Remarks
null


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text:
L'article marketing è una forma di marketing con la quale un'azienda promuove il suo marchio o i suoi prodotti attraverso la pubblicazione di articoli redazionali.
La comunicazione di informazioni sui diversi canali della rete, corredate dai riferimenti e dall'indirizzo telematico della redazione, ha lo scopo di:

 Generare traffico diretto al sito web;
 Gestire la propria reputazione online;
 Incrementare la propria link popularity.

La pubblicazione degli articoli può avvenire attraverso segnalazione ai siti nati esclusivamente per l'article marketing, oppure la partecipazione a blog e a riviste online specializzate nel proprio settore . L'obiettivo di una campagna di article marketing è aumentare la disponibilità in rete di documenti che possano tornare utili alla causa aziendale.

Molte delle risorse in cui si fa segnalazione per la pubblicazione dei propri articoli vengono indicizzate dai motori di ricerca. Una buona percentuale del traffico che questi siti otterranno dalle query degli utenti convertirà in visite a favore dell'azienda attraverso i link presenti tra i riferimenti degli articoli.

Inoltre, gli articoli indicizzati saranno utili per gestire la propria brand reputation nei motori di ricerca. Oggi gli utenti hanno a disposizione strumenti sempre più semplici per versare in rete nuove informazioni, commenti ed esperienze. Si tratta di dati su cui le aziende non hanno controllo e che una volta metabolizzati dai motori di ricerca andranno a soddisfare le query degli utenti. L'article marketing permette anche di aumentare e gestire ciò che si dice in rete del proprio prodotto o azienda.
Infine, grazie ai collegamenti ipertestuali inseriti nei riferimenti degli articoli, la campagna di article marketing è diventata un'attività fondamentale per l'incremento della link popularity dei siti web di cui si cura la visibilità nei motori di ricerca.

È importante tuttavia, mantenere una buona qualità dei contenuti e prediligere, per le proprie campagne di article marketing, siti che applicano un filtro sui contenuti pubblicati dagli utenti, per prevenire lo spam. Inoltre è importante che i contenuti siano nella stessa lingua del sito che si vuole promuovere quindi, per esempio, in Italia è opportuno  scegliere solo siti che facciano article marketing in italiano.

Note

Link esterni
 Nellanotizia.net divulgazione article marketing

Tecniche di marketing

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