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Health impact assessment (HIA) is defined as "a combination of procedures, methods, and tools by
which a policy, program, or project may be judged as to its potential effects on the
health of a population, and the distribution of those effects within the population."

Overview
HIA is intended to produce a set of evidence-based recommendations to inform decision-making . HIA seeks to maximise the positive health impacts and minimise the negative health impacts of proposed policies, programs or projects.

The procedures of HIA are similar to those used in other forms of impact assessment, such as environmental impact assessment or social impact assessment. HIA is usually described as following the steps listed, though many practitioners break these into sub-steps or label them differently:

 Screening - determining if an HIA is warranted/required
 Scoping - determining which impacts will be considered and the plan for the HIA
 Identification and assessment of impacts - determining the magnitude, nature, extent and likelihood of potential health impacts, using a variety of different methods and types of information
 Decision-making and recommendations - making explicit the trade-offs to be made in decision-making and formulating evidence-informed recommendations
 Evaluation, monitoring and follow-up - process and impact evaluation of the HIA and the monitoring and management of health impacts

The main objective of HIA is to apply existing knowledge and evidence about health impacts, to specific social and community contexts, to develop evidence-based recommendations that inform decision-making in order to protect and improve community health and wellbeing. Because of financial and time constraints, HIAs do not generally involve new research or the generation of original scientific knowledge. However, the findings of HIAs, especially where these have been monitored and evaluated over time, can be used to inform other HIAs in contexts that are similar. An HIA's recommendations may focus on both design and operational aspects of a proposal.

HIA has also been identified as a mechanism by which potential health inequalities can be identified and redressed prior to the implementation of proposed policy, program or project .

A number of manuals and guidelines for HIA's use have been developed (see further reading).

Determinants of health
The proposition that policies, programs and projects have the potential to change the determinants of health underpins HIA's use. Changes to health determinants then leads to changes in health outcomes or the health status of individuals and communities. The determinants of health are largely environmental and social, so that there are many overlaps with environmental impact assessment and social impact assessment.

Levels of HIA
Three forms of HIA exist:

 Desk-based HIA, which takes 2–6 weeks for one assessor to complete and provides a broad overview of potential health impacts;
 Rapid HIA, which takes approximately 12 weeks for one assessor to complete and provides more detailed information on potential health impacts; and
 Comprehensive HIA, which takes approximately 6 months for one assessor and provides a in-depth assessment of potential health impacts.

It has been suggested that HIAs can be prospective (done before a proposal is implemented), concurrent (done while the proposal is being implemented) or retrospective (done after a proposal has been implemented) . This remains controversial, however, with a number of HIA practitioners suggesting that concurrent HIA is better regarded as a monitoring activity and that retrospective HIA is more akin to evaluation with a health focus, rather than being assessment per se . Prospective HIA is preferred as it allows the maximum practical opportunity to influence decision-making and subsequent health impacts.

HIA practitioners
HIA practitioners can be found in the private and public sectors, but are relatively few in number. There are no universally accepted competency frameworks or certification processes. It is suggested that a lead practitioner should have extensive education and training in a health related field, experience of participating in HIAs, and have attended an HIA training course. It has been suggested and widely accepted that merely having a medical or health degree should not be regarded as an indication of competency.

The International Association for Impact Assessment has an active health section.

A HIA People Directory can be found on the HIA GATEWAY.

HIA worldwide
HIA used around the world, most notably in Europe, North America, Australia, New Zealand, Africa and Thailand .

The safeguard policies and standards of the International Finance Corporation (IFC), part of the World Bank, were established in 2006. These contain a requirement for health impact assessment in large projects. The standards have been accepted by most of the leading lending banks who are parties to the Equator Principles. Health impact assessments are becoming routine in many large development projects in both public and private sectors of developing countries. There is also a long history of health impact assessment in the water resource development sector - large dams and irrigation systems.

See also
Impact Assessment
Environmental impact assessment
Equality Impact Assessment
Four-Step Impact Assessment
Healthy development measurement tool
Risk assessment
Social impact assessment
Health promotion
Jakarta Declaration
Ottawa Charter for Health Promotion
Health protection
Environmental health
List of environmental health hazards
Precautionary principle
Risk assessment
Population health
Public health
Social determinants of health

References
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 .
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This page uses Harvard referencing. References are sorted alphabetically by author surname.

Further reading

Books and edited book chapters
 .
 .
 .
 .
 .
 . Includes several chapters on HIA.

Journal articles
 .

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 .
 .
 .

 .
 .

Journal special issues
 .
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Manuals and guidelines
 .
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This page uses Harvard referencing. Further reading categories are sorted alphabetically; citations are sorted by year (newest to oldest), then alphabetically by author surname within years. If citations are included in the references section they are not listed in the further reading section.

HIA resource websites
 Health Impact Project - Funding for HIA and resources
 HIA Connect
 HIA Gateway
 IMPACT - International Health Impact Assessment Consortium
 RIVM HIA Database
 World Health Organization HIA Site

Government HIA websites
 Environmental Health Branch, New South Wales Health (Australia)
 European Centre for Health Policy (Belgium)
 HPP-HIA Program (Thailand)
 Institute for Public Health in Ireland (Ireland)
 Planning for Healthy Places with Health Impact Assessments (United States)
 San Francisco Department of Public Health (United States)
 Centers for Disease Control and Prevention (United States)
US Environmental Protection Agency (United States)

University HIA websites
 Monash University, SHIA@Monash (Melbourne, Australia)
 University of Birmingham, HIA Research Unit (Birmingham, UK)
 University of California, Berkeley, Health Impact Group, School of Public Health (Berkeley, USA)
 University of California, Los Angeles, HIA Project (Los Angeles, USA)
 University of California, Los Angeles, Health Impact Assessment Clearinghouse Learning and Information Center (Los Angeles, USA)
 University of Liverpool, IMPACT - International Health Impact Assessment Consortium Department of Public Health and Policy.(Liverpool, UK)
 University of New South Wales, HIA Connect, Health Inequalities, Health Impact Assessment and Healthy Public Policy Program (CHETRE), Research Centre for Primary Health Care and Equity, Faculty of Medicine (Sydney, Australia)
 University of Otago, Health, Wellbeing and Equity Impact Assessment Unit, Wellington School of Medicine and Health Sciences (Wellington, New Zealand)

Professional associations
 IAIA
 Society for Practitioners of Health Impact Assessment (SOPHIA)

Other HIA websites
 Health Impact Assessment - International (Email Discussion Group)
 HIA Blog
 HIA Blog on Twitter

This page uses Harvard referencing. External links are sorted alphabetically.

Public health
Human geography
Impact assessment
Health care quality
Health economics


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Fed research lab reportedly mandated race-segregated 'reeducation' training to deconstruct 'white male culture'
August 13, 2020 | Frieda Powers | Print Article
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A research laboratory that designs America's nuclear weapons hosted a taxpayer-funded training for its white male executives on deconstructing "white male culture."
Filmmaker and policy researcher Christopher Rufo shared screenshots of leaked documents from a three-day reeducation camp last year hosted by Sandia National Laboratories. The infuriating thread showed training materials from the "race-segregated, taxpayer-funded session" held at the La Posada luxury resort.
(Image: Sandia National Lab/YouTube screenshot)
The mandatory training held over three days and paid for by American taxpayers was called "White Men's Caucus on Eliminating Racism, Sexism, and Homophobia in Organizations."
Last year, Sandia National Laboratories—which designs America's nuclear weapons—sent its white male executives to the La Posada luxury resort to undergo a mandatory training called "White Men's Caucus on Eliminating Racism, Sexism, and Homophobia in Organizations." pic.twitter.com/fcxlWrKD4d
— Christopher F. Rufo (@realchrisrufo) August 12, 2020
A screenshot of a whiteboard reportedly used during an opening brain-storming session apparently had the men list words associated with white male culture. Some of the words seen in the photo included "KKK," "Aryan Nation," "privileged," and "mass killings." Other notable words, including "MAGA hat," referring to President Trump's campaign slogan as well as "patriotic," "hard worker" and even "football" were also listed as phrases associated with white male culture.
In the opening thought-work session, the trainers demand that the men make a list of associations about white male culture. The trainers write "white supremacists," "KKK," "Aryan Nation," "MAGA hat," "privileged," and "mass killings." pic.twitter.com/TUKARqvoar
Another screenshot from the training materials that Rufo posted showed that the camp trainers insisted that white males must "work hard to understand" their "white privilege," their"male privilege," and "heterosexual privilege.
The trainers insist that white males must "work hard to understand" their "white privilege," "male privilege," and "heterosexual privilege." They claim that white men benefit from positive stereotypes that "far outweigh the Tim McVeighs and Ted Kaczynskis of white maleness." pic.twitter.com/FyKW1ynz4G
The trainees, apparently the lab's white male executives, were also called on to expose the "roots of white male culture," which is apparently made up of "rugged individualism," "a can-do attitude," "hard work," and "striving towards success," traits that the trainers obviously thought were negative.
Next, the white male employees must expose the "roots of white male culture," which consists of "rugged individualism," "a can-do attitude," "hard work," and "striving towards success"—which sound good, but are in fact "devastating" to women and POCs. pic.twitter.com/saVYdG6bHJ
The trainers gave outrageous examples of the negative effects of simply being successful, asserting that this "white male culture" forces a "white male standard" on women and minorities.
In fact, the trainers claim that "white male culture" leads to "lowered quality of life at work and home, reduced life expectancy, unproductive relationships, and high stress." It also forces this "white male standard" on women and minorities. pic.twitter.com/xVIkMXwbBG
Subsequent posts from Rufo unveiled even more eyebrow-raising training points, including "white privilege statements" and "male privilege statements" that the employees were forced to recite.
In a subsequent session, the white males must publicly recite a series of "white privilege statements" and "male privilege statements." They must accept their complicity in the white male system and their role in creating oppressions. pic.twitter.com/egIchSLwWd
Adding insult to injury, the conclusion of the three-day reeducation required the men to write letters "directed to white women, people of color, and other groups regarding the meaning of this Caucus experience."
Finally, as the reeducation camp concludes, the white males must write letters "directed to white women, people of color, and other groups regarding the meaning of this Caucus experience." They apologize for their "privilege" and pledge to become "better [allies]." pic.twitter.com/LZIB22CpYc
Insisting that it is "no joke," Rufo noted that the training was provided by a company called "White Men As Full Diversity Partners" which specializes in "confronting those who 'typically hold all the power': namely, 'white males,'" he wrote.
Who is leading the struggle session? A company called "White Men As Full Diversity Partners." This is no joke—their company is literally called White Men As Full Diversity Partners and they specialize in confronting those who "typically hold all the power": namely, "white males." pic.twitter.com/dMNu8XHZYw
Rufo also provided a link to see all of the leaked documents from the training.
"It's time to expose this taxpayer-funded pseudoscience and rally the White House and legislators to stop these deeply divisive training sessions," he wrote in a tweet concluding the thread.
"My goal is simple: we must pass legislation to 'abolish critical race theory' in the federal government. Let's push as far as we can," he added.
In response to one Twitter user, Rufo explained that he would "like to see an executive order and then a debate in Congress, where progressives have to defend this on the merits and vote on it in front of the public."
Frieda Powers
Originally from New York, Powers graduated from New York University and eventually made her way to sunny South Florida where she has been writing for the BizPacReview team since 2015.
Latest posts by Frieda Powers (see all)
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I think anything will work, straps, wire, rope, tape shock cord etc. There was one builder's site that used rope. He just notched the deck overhang at each rope wrap to avoid bending the deck up in the middle.


This very large home is under construction.
These photos show how just two men are required for the setting of DAC-ART architectural blocks.
These next photos can hopefully will give you a sense of the size of this large residence.
As you can see from these photos, the blocks made for you for a DAC-ART project come to you clearly labeled as to their position on your plans and additional manufacturing information.


West Valley: Here's a great coupon for the highly reviewed Shiro Kum Snow Cream that will save you 48% off!
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Yes, we're talking about Utica, New York. An online post is going around claiming the star was involved in a bar brawl in our city.
What would Justin Bieber be doing in Utica last night?
Multiple news outlets from the Utica, New York area are reporting that pop superstar Justin Bieber was involved in a bar fight in Utica late last night. Witnesses are reporting that the pop star was attacked by two men and was able to fend them off until others came to his aid and restrained the two assailants until police arrived.
First of all, "multiple news outlets from the Utica, New York area are reporting..." - We don't know about you, but we saw NOTHING in the media about a bar fight involving Justin Bieber in Utica. Who are these "news outlets" they're getting their information from?
Second, Justin Bieber isn't even in America right now. He's on the European leg of his "Purpose World Tour." There is no way he could have possibly been in the states last night, let alone Utica.
And Justin "...attacked by two men and able to fend them off..." - That's just hard to believe. His crew fighting off two men seems more realistic. Just saying.
Don't believe everything you read online! This story was written by "Baldwin Post" - which is a "satirical news site" meaning they post fake news stories for humor purposes. The problem is, people start sharing these posts without looking at where the information is coming from.
Although... If Justin Bieber was in Utica, he probably would end up getting into a bar fight.


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Passaloecus longiceps is een vliesvleugelig insect uit de familie van de graafwespen (Crabronidae). De wetenschappelijke naam van de soort is voor het eerst geldig gepubliceerd in 1973 door Merisuo.

Graafwespen

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El período legislativo de 2018 a 2022 de Costa Rica fue el período que abarcó del 1 de mayo de 2018 al 30 de abril de 2022 en la Asamblea Legislativa, siendo su decimoctava () legislación desde 1948. El Presidente de Costa Rica durante este período fue Carlos Alvarado Quesada del Partido Acción Ciudadana.

Tras las elecciones legislativas del mismo año el Partido Liberación Nacional mantuvo la mayoría parlamentaria de la que goza desde 2006 aunque perdió un diputado respecto al proceso anterior. Este será el primer período en el cual el partido evangélico Restauración Nacional tendrá más de un diputado, originalmente 14. Por un tiempo fue también la primera vez en la historia en que el partido oficialista no solo no es la primera mayoría, sino que tampoco es la segunda, ya que el oficialista PAC tendrá 10 diputados, de los cuales uno de ellos es la primera persona abiertamente gay en ser electa diputado de la República; Enrique Sánchez, aunque tras la división de Restauración Nacional en dos bancadas el PAC retomó el puesto de segunda mayoría, seguido por el PUSC que pasó a ser la tercera (9).

En esta elección el Partido Integración Nacional logró regresar al Parlamento tras una ausencia de 20 años y con 4 diputados, sin embargo uno de ellos se declaró independiente previo incluso a iniciar funciones. El Partido Republicano Social Cristiano, escisión del PUSC obtiene diputados (2) por primera vez en las primeras justas parlamentarias en las que participa. La izquierda por su parte está representada por la fracción unipersonal del diputado José María Villalta quien repite por segunda vez diputación, si bien su partido redujo considerablemente su bancada respecto al período anterior pasando de nueve a uno.

Es también la primera ocasión en que el Movimiento Libertario no tiene representación legislativa desde que fue fundado.

A partir de noviembre de 2018 la mayor parte de la fracción electa por el Partido Restauración Nacional renunció al mismo siguiendo al excandidato Fabricio Alvarado en la fundación de un nuevo partido llamado Nueva República.

Leyes

Durante este período una de las leyes más mediáticas y controversiales aprobadas fue la Ley de Fortalecimiento de las Finanzas Públicas o Plan Fiscal, esto a pesar de que la oposición a dicha reforma tributaria generó una huelga general en el sector público. También se reformó por primera vez en 60 años el Reglamento Legislativo con el voto favorable de 41 diputados, reforma que buscaba desentrabar la tramitación de leyes, uso de tiempos y limitar las posibilidades de filibusterismo parlamentario.

También se realizó en el primer año legislativo la primera reforma integral al Reglamento Legislativo en 60 años y que requería dos tercios de los votos, agilizando los procedimientos para la aprobación de leyes y limitando las posibilidades de filibusterismo.

A mediados de 2019 se aprobó la Ley de Educación Dual con 48 votos a favor y dos en contra, a pesar de que dicha iniciativa generó las protestas estudiantiles de Costa Rica de 2019. En noviembre de 2019 se aprueba el mayor recorte que ha hecho a las controversiales «pensiones de lujo» con 40 votos a favor y ninguno en contra de los diputados presentes, después de que la Corte Suprema (principal afectado por el recorte) asegurara que el voto debía ser con mayoría calificada por afectar el funcionamiento de otro poder del estado. El proyecto grava hasta con un 35% toda pensión de montos millonarios. Se aprobó un proyecto de ley que revive la polémica «pesca de arrastre» a la que se oponen grupos ambientalistas y expertos técnicos, con 26 votos a favor de la mitad del PLN y la totalidad de las bancadas cristianas y el PUSC, pero el voto en contra de la bacanda del PAC en pleno, parte del PLN y el Frente Amplio. Sin embargo el PAC anunció que someterá a consulta constitucional la ley aprobada. En enero de 2020 se aprobó la controversial Ley para Brindar Seguridad Jurídica y Sus Procedimientos propuesta por el presidente legislativo Carlos Ricardo Benavides Jiménez después de haber sido refrendada tras una consulta ante la Sala Constitucional y a la cual se oponían los sindicatos del país. El proyecto fue aprobado con 35 votos a favor, 13 en contra y 9 ausentes distribuidos entre todas las bancadas salvo Restauración Nacional (que votó en bloque a favor) y la bancada unipersonal del Frente Amplio que votó en contra. La ley reforma el Código de Trabajo y entre otras cosas; prohíbe las huelgas en servicios considerados como esenciales (salud, educación, seguridad, recolección de basura, etc.), obliga a los sindicatos a tener un correo electrónico para notificaciones, permite al patrono no pagar los salarios durante el período en huelga a menos que la huelga sea declarada legal por un Juzgado de Trabajo, prohíbe las huelgas por razones políticas (como oposición a proyectos de ley que no afecten directamente la relación empleado-patrono), permite en el caso de las huelgas por oposición a leyes que están sean por un máximo de 48 horas y en el caso de la educación considerada un "servicio estratégico" se permiten las huelgas por un máximo de 21 días consecutivos o 10 días no concecutivos y acorta los plazos para dictar sentencia de los Tribunales de Trabajo.

Durante este período el país vivió la crisis por la pandemia del COVID-19 por lo cual el plenario de la Asamblea se trasladó temporalmente al auditorio del Centro Costarricense de la Ciencia y la Cultura en San José. También se legisló para atender la crisis con distintos proyectos de ley convocados por el Ejecutivo incluyendo un presupuesto extraordinario para atender la crisis y ayudas especiales para familias afectadas económicamente, la mayoría aprobados casi unánimemente.

Durante la discusión del presupuesto 2021 la Asamblea Legislativa realizó polémicos recortes a múltiples instituciones incluyendo la Contraloría General de la República, la Defensoría de los Habitantes de la República, la Dirección de Inteligencia y Seguridad, la Comisión Nacional de Emergencias, Comercio Exterior y el Ministerio de Cultura y Juventud que muchos acusaron de generar «cierres técnicos». Los diputados a favor de los recortes argumentaron que el país afronta una peligrosa crisis fiscal. Los recortes al sector cultura generaron protestas y manifestaciones por parte de los profesionales del área así como el uso de proyectores en la fachada principal del recién estrenado Edificio legislativo. Una moción para recortar el presupuesto de la propia Asamblea Legislativa no fue aprobada por los diputados.

En octubre de 2020 también se aprobó por 28 votos a favor y 16 en contra la controversial ley que re-legalizó la pesca de arrastre. La controversia a raíz de esta aprobación también generó un rechazo en redes sociales y la condena por parte de grupos ambientalistas que se reunieron con el gobierno (la fracción oficialista junto con el diputado Villalta votaron en contra) solicitando al presidente Carlos Alvarado que vete la ley, como efectivamente lo hizo el 30 de octubre de 2020 por lo que de acuerdo con la Constitución de Costa Rica para que la ley quede en firme requiere ahora de mayoría califiada (38 votos). A raíz de esto el expresidente legislativo y líder de la bancada liberacionista en el Congreso Carlos Ricardo Benavides Jiménez quien votó a favor, aseguró que no veía posibilidades de que la ley fuera resellada.

En junio de 2021 la Comisión Plena Tercera con potestad plenaria aprobó convertir al perezoso en símbolo nacional, autorizando así su uso en publicidad turística y obligando a instituciones como el Instituto Costarricense de Electricidad y el Ministerio de Obras Públicas y Transportes a tomar medidas de protección de estos animales al construir infraestructura.

A inicios de julio de 2021 se aprobó en primer debate el Acuerdo Costa Rica-Fondo Monetario Internacional con el voto a favor de la mayoría de fracciones, y el voto en contra de los diputados José María Villalta Flórez-Estrada, Dragos Dolanescu Valenciano, Walter Muñoz Céspedes y Patricia Villegas.

Controversias
Durante este período la diputada del extraoficial «Bloque fabricista», así apodado por ser leales al excandidato Fabricio Alvarado, protagonizó una polémica protesta de más de una semana manteniéndose en vigilia en el plenario legislativo ininterrumpidamente. Céspedes protestaba contra la aprobación del aborto en Costa Rica, aun cuando ningún proyecto de ley se discute al respecto en la corriente legislativa ni tiene el aval de ninguna fracción. Durante esta misma fecha su compañera de bloque Marulín Azofeifa fue grabada en video amenazando a un oficial de tránsito por ponerle una multa a su chofer asegurando que ella como diputada tenía «foro» parlamentario (fuero). Azofeifa se disculparía luego con el oficial.

También en este perídio la Procuraduría de la Ética determinó que el diputado Jonathan Prendas, también fabricista incurrió en ilícito al aceptar dádivas de una empresa española.

Visitas narco a la Asamblea Legislativa
Durante el 2021 se descubrió que desde el 2015 un presunto grupo organizado de narcotráfico habría tenido reuniones en la sede legislativa con unos trece legisladores y exlegisladores en sus oficinas. Los legisladores actuales visitados fueron Ivonne Acuña, independiente (electa por RN, luego adherente de Nueva República); Mileyde Alvarado y Eduardo Cruickshank, de Restauración Nacional; Óscar Cascante y Erwen Masís, del PUSC; y Zoila Volio, independiente (electa por el PIN), son los legisladores actuales que habría tenido contacto con los supuestos antisociales. Los de la legislatura anterior fueron Johnny Leiva, Humberto Vargas, Gerardo Vargas y William Alvarado, del PUSC; Olivier Jiménez, del PLN; Natalia Díaz, del Movimiento Libertario (hoy Unidos Podemos); y Gerardo Vargas Varela, del Frente Amplio.

El diputado socialcristiano Óscar Cascante renunció a la Comisión de Investigación del Narcotráfico y se separó temporalmente de su fracción a raíz de las investigaciones.

Gastos de combustible
Una investigación a 32 diputados por presunto mal uso de los tiquetes de combustible gratuito, uno de los beneficios que obtienen los legisladores, se abrió tras el escándalo que descubrió que la diputada Ivonne Acuña (independiente, originalmente electa por Restauración Nacional y temporalmente parte de Nueva República) recibió salario tras ausentarse por meses y utilizó los tiquetes de gasolina. La investigación involucra incluso a excandidatos presidenciales como Fabricio Alvarado y José María Villalta.

Nuevo edificio

Durante este período se estrenó el recién construido edificio de la Asamblea Legislativa que serviría como nueva sede del congreso. El edificio fue criticado por sus costos especialmente durante tiempos de crisis fiscal donde sólo las sillas de los diputados costaban más de un millón de colones.

Fracciones

Presidentes Legislativos

Durante la primera elección de Directorio Legislativo el 1 de mayo de 2018 la candidata oficialista Carolina Hidalgo fue apoyada por las bancadas de Liberación Nacional, Unidad Social Cristiana y la diputada Zoila Rosa Volio Pacheco, mientras que la candidatura alternativa de la entonces bancada unificada de Restauración Nacional fracasó en obtener la presidencia. Restauración se dividiría algunos meses después. La siguiente elección del 1 de mayo de 2019 vio la alianza entre el PAC y el PLN para impulsar la candidatura de Ricardo Benavides con el apoyo de Volio y el diputado republicano Otto Vargas. Sorpresivamente el PUSC sale del bloque y se alía con Nueva República, el sector que emergió de Restauración y siguió al excandidato Fabricio Alvarado en su nuevo partido. Restauración Nacional, ahora con la mitad de su membresía, apoyó la candidatura de Benavides que fue la exitosa. Para el 1 de mayo de 2020 estas lealtades se mantienen, el bloque PLN-PAC-PRN y algunos aliados independientes apoyan la candidatura del restauracionista Eduardo Cruickshank mientras que la alianza PUSC-NR presenta su propio candidato en Pablo Heriberto Abarca sin obtener suficientes votos. Sorpresivamente el PAC renuncia a tener cargos en el Directorio y cede el puesto que se le había prometido a la diputada del PUSC María Vita Monge quien fue elegida sin el respaldo de la mayor parte de su fracción, generando una fractura dentro del PUSC.

Notas

Referencias

Política de Costa Rica
2018
Años 2010 en Costa Rica


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Q: Azure Mobile Services - Custom Authentication Claims Issue I've implemented custom authentication in my mobile services, but the claims that I add to my ClaimsIdentity object don't appear to be saved.
I create my ClaimsIdentity object, and then pass it to the CreateLoginResult method, as follows:
public IServiceTokenHandler Handler { get; set; }

...

ClaimsIdentity claimsIdentity = new ClaimsIdentity();
claimsIdentity.AddClaim(new Claim(ClaimTypes.NameIdentifier, "username"));
claimsIdentity.AddClaim(new Claim(ClaimTypes.GivenName, "FirstName"));
claimsIdentity.AddClaim(new Claim(ClaimTypes.Surname, "LastName"));

LoginResult login = new CustomLoginProvider(Handler).CreateLoginResult(claimsIdentity, "masterkey");

If I call another method with the returned authorization token and try to retrieve the GivenName or Surname claims, they aren't available.
var identity = (ClaimsIdentity)User.Identity;
// 'claim' will be null
Claim claim = identity.FindFirst(ClaimTypes.GivenName);

Is this expected behaviour or am I doing something wrong? I'm making an assumption that the Claims in the ClaimsIdentity object being sent to CreateLoginResult are being saved against that authenticated user.

A: The ClaimsIdentity passed into this method does not get used fully unless you act on it in an overload of CreateCredentials(). First you should create a child class of ProviderCredentials with the fields you want. CreateCredentials() will be called by CreateLoginResult(), and it will get the same ClaimsIdentity as a parameter.
The returned ProviderCredentials gets stored, and you can always retrieve it again in your server code with a call to ServiceUser.GetIdentitiesAsync().

redpajama_set_name: RedPajamaStackExchange


text:
[CfP] Language Documentation Collections: Assessment and Recognition
Hugh Paterson III <[log in to unmask]>
Thu, 1 Apr 2021 13:33:39 +0200
Call for Papers for Language Documentation Collections: Assessment and
***Overview***
Language Documentation is an interdisciplinary approach to creating
multi-purpose collections that exhibit and support language use—often for
languages used by ethno-linguistic minorities. These collections are often
made as part of linguistic work and often contain audio and video
materials, representing speech, music, and cultural events. However, many
ethno-linguistic collections are created by people outside of linguistics.
We are seeking papers which address issues on how these collections should
be assessed as part of scholarly work and how recognition should be given
for the curation of these collections as part of scholarly work.  See the
linked full call for a list of specific issues.
We are interested in presenting a broad range of perspectives in this
collection of papers. We are particularly interested in insights that
archivists, curators, and librarians can provide to this discussion.
*** Details***
Deadline: July 1st, 2021
Full call: https://l.linklyhq.com/l/NW3J
Journal announcement:
https://openhumanitiesdata.metajnl.com/announcement/#:~:text=Language%20Documentation%20Collections
*** Venue***
Accepted papers will be published in a special collection within the
Journal of Open Humanities Data
*** About the Guest Editors ***
Richard Griscom is a researcher at Leiden University Centre for
Linguistics. His research focuses on the documentation and description of
endangered languages, with an emphasis on the languages of East Africa, and
the development of digital data collection and processing methods for
researchers working in resource-constrained environments.
Lauren B. Collister is a faculty librarian and the Director of the Office
of Scholarly Communication and Publishing for the University of Pittsburgh
Library System. Her research background in sociolinguistics focuses on
language change, identity, and online communication. Her current work
focuses on reproducibility, open scholarship, data management, and
intellectual property in linguistics research.
Hugh J. Paterson III is an unaffiliated collaborative researcher with a
background in language documentation in Nigeria and Mexico. He has worked
in accessions and digitization at a language archive, and as a user
interaction designer for digital experiences. He is interested in
leveraging language technology for the benefit of language communities and
in the ways they desire to see their language used.


text:
Joe Rosenthal
Joseph John Rosenthal was born in Washington. His parents were immigrants from Russia. He had a strong interest in photography and after finishing college joined the Newspaper Enterprise Association in San Francisco before becoming a staff photographer with the San Francisco Examiner.
On the outbreak of the Second World War Rosenthal applied to join the US Army as a military photographer. Rejected because of his poor eyesight, Rosenthal was eventually sent to cover the Pacific War by the Associated Press. In March 1944 he photographed the American progress toward Japan, including the invasions of Guam, New Guinea and Guadalcanal.
Rosenthal was at Iwo Jima and took some very dramatic pictures of the invasion. On February 23, 1945, while on the top of Mount Suribachi, Rosenthal took one of the most famous photographs of the war: Raising of the Flag on Iwo Jima. Of the six soldiers, three were killed within the next few days.
The Raising of the Flag on Iwo Jima, was published throughout the world. Rosenthal was later accused of staging the photograph. In fact, this was untrue. "On February 23, having captured Surabachi, a small volcanic hill and the highest point on the island, some marines raised a small flag at its summit. They were photographed by Sergeant Louis Lowery for the marine magazine, Leatherneck. Rosenthal, having talked with Lowery, decided to get a shot of the flag himself. When he arrived, he found the marines raising a larger flag, attached to a pole so heavy it took six men to lever it into place in a small mound of rocks. He stepped just inside the volcano's crater and snapped the photo with his Speed Graphic."
After the war Rosenthal became chief photographer and manager of Times Wide World Photos. Later he worked for the San Francisco Chronicle.
www.spartacus.schoolnet.co.uk
Image courtesy of Doug Mills/Associated Press
Joe Rosenthal, Flag Raising on Iwo Jima, February 23, 1945, Framed poster, 35 x 43in. (88.9 x 109.2cm), Collection of the Embassy


Hello, so I finally finished Chapter 11 of "NSA"! OMG, I read over and over it again, changed things, deleted parts, found mistakes and I think now it is ready. It would have been a long chapter so I divided it into two parts! I hope you will enjoy it! I think it is good chapter because it shows more of Ariana and Jason and definitely brings them a lot closer! Hope you will like it and let me know please! Thanks for reading!


text:
Columns Nutrition Probiotics — Pros, No Cons
Probiotics — Pros, No Cons
By Gabriella Boston
Wednesday, October 23, 2013 at 8:00 pm | י"ט חשון תשע"ד
We hear about them everywhere — how they clear up everything from a bloated gut to a depressed mind. How they boost the immune system and improve skin health. How they delay allergies in children and prevent urinary tract infections in women. The list is truly impressive. But what are probiotics? And do they deserve all the attention and accolades?
"Probiotics can impact just about everything in the body," says Meagan McCusker, a University of Connecticut dermatologist who uses probiotics to treat a wide variety of conditions including acne and psoriasis. "They really can't and shouldn't be overlooked when it comes to overall health maintenance."
So what, exactly, are they?
By way of the National Institutes of Health: "Probiotics are live microorganisms that are similar to beneficial microorganisms found in the human gut. They are also called 'friendly bacteria' or 'good bacteria.'"
The idea is that the "friendly bacteria" will help fight the good fight along with gut-dwelling bacteria to scare off pathogens, improve immune function and aid digestion, among other things, McCusker says.
"In some patients I have seen rapid improvement of digestive distress like gas and bloating after they have started taking probiotics," says local nutritionist Jared Rice, who started taking the supplement for his own health maintenance seven or eight years ago.
"I can definitely say that it's been a very positive experience for me since I started taking probiotics. And I have never experienced any downsides," he says.
It was around that time, in 2006, that Dannon introduced its Activia yogurt with live cultures to the U.S. market. That's when many Americans picked up on probiotics, says Mary Ellen Sanders, executive director of the International Scientific Association for Probiotics and Prebiotics.
"We've been tracking this topic for more than 20 years, and it really was doing nothing until Activia. And now it's super-hot," Sanders says.
Probiotics come in many forms, and they don't need to be delivered through yogurt — particularly important for the dairy-intolerant. Probiotics can be found as fresh, refrigerated supplements at some health food stores, as well as dried and preserved.
For health maintenance, McCusker says, try starting with no more than 5 billion units of active probiotic cultures — preferably a mix of cultures that include strains of Lactobacillius and Bifidobacterium.
Ebeth Johnson, a Washington nutritionist and chef, says to look for the following foods to provide that probiotic benefit: unpasteurized miso, live cultured pickles, tempeh, unsweetened kefir and yogurt, as well as kombucha teas.
"Blue algae are also a great source of probiotics," Johnson says. "Get them at your local health food store and blend them into your morning fruit and greens smoothie."
Rice cautions that, when buying probiotic food products, you should check nutrition labels, just as you would with any food, to be sure they are healthful beyond their probiotic content and don't have too much sugar or fat.
On the other hand, if you take probiotics as a supplement, don't look at that as a silver bullet, because benefits will be experienced only if the probiotic is combined with a healthful diet on the whole, he says. "You can't continue to eat fast food and pop some probiotic supplements and expect a great outcome."
In fact, the probiotics thrive best when prebiotics are present. Prebiotics, which are found in such foods as whole grains, bananas and onions, are non-digestible carbohydrates that create a probiotic-friendly gut environment.
The appropriate probiotic dosage, according to McCusker, is about 5 billion units for daily health maintenance and 15-20 billion when you are treating a specific condition. (Note: The Food and Drug Administration has not approved any health claims for probiotics.)
Before you get to the higher dosages, Rice says, you should talk with a nutritionist or doctor with particular expertise in the area of probiotics about side effects, though they are rare.
So, is this all a fad that will disappear once the next nutrition celebrity makes a splash?
Sanders doesn't think so.
"Unlike multivitamins, for example, many people who take probiotics actually feel much better," she says, and that's enough of a reason for many to keep taking them.
Rice says he's excited about the therapeutic possibilities for probiotics in the future as nutritionists and doctors get a better handle on targeting certain conditions with certain strains and combinations of probiotics.
"It's an evolving topic. But I can see how probiotics at some point will be used more like a prescription," he says. "I don't think the concept of bacterial balance will fade. I think it will grow."
Gabriella Boston is a fitness trainer and freelance writer.


text:
You are here: Home » Artist Spotlight » Review: Color of Light, "Memory"
Review: Color of Light, "Memory"
No Comments 11 January 2015
"This album is best served in one long dose; a full listen reveals a great deal of sophisticated nuance and an interconnectivity that would potentially be lost listening to one track at a time. Neuse is working in a soundscape of his own creation, one that values the instrumentation, melody and breadth of sound…"
Artist: Color of Light
Album: Memory
Genre: Shoegaze / Dream Pop
RIYL: My Bloody Valentine, Altered States, The Jesus and Mary Chain
When I think South Carolina-born artists, I don't necessarily go straight to ambient dream pop; roots rock, sure. But while the dark, lush soundscapes may remind a bit of the wilder, untamed spots of the Low Country, Color of Light's Sean Neuse is creating a place for himself in time and space that reaches much further out than the water's edge. Memory is an interesting and hypnotic collection of songs that teems with life and natural rhythm.
This hasn't always been my genre of choice as a fan; but I must be softening to it because I was transfixed at several points while listening to Memory. There is something almost meditative in the song structures and tone. Neuse's vocals are used just as the other instruments, as a medium for sound rather than a vessel for spoken lyrics. But that doesn't detract from the overall lyricism present; in fact, it enhances a sumptuous and warm, hazy style.
"Window" is a highlight, there's a hopefulness hidden in the spaces between the notes and Neuse's vocals that's incredibly appealing. The ebb and flow of this track just feels right on the money, a perfect blend of soft edges that moves really beautifully. Using that term - "ebb and flow" - seems even more appropriate when paired with "Dying," a sparse but effective instrumental that samples the surf. The title track and "Fading" also put a strong foot forward. But it's difficult to choose highlights from an album of this style as each track fades and weaves into the next.
This album is best served in one long dose; a full listen reveals a great deal of sophisticated nuance and an interconnectivity that would potentially be lost listening to one track at a time. Neuse is working in a soundscape of his own creation, one that values the instrumentation, melody and breadth of sound more than lyrical content; and it's an interesting choice in a business full of two-minute, bite-sized, easily digestible verse-chorus-verse tunes. Memory is, without question, a unique and pleasing record that sits right in the pocket and provides a different kind of listening experience for the senses.
Memory by Color of Light
Color of Light website: http://www.imerarecords.com/
« Review: Jack Lover, "Humour, Love and Health"
Review: Tapebenders, "Chasing Ghosts" »


They're back! Rediscover the zaniest characters you've ever met in this bestselling series which has sold millions worldwide. Bright and charming, with easily recognizable characters, Mr. Men audiobooks are easy enough for young listeners, witty enough for humor-prone adults, and highly collectible for one and all.
Similarly to its Little Miss audiobook companion, my daughter ADORES this audiobook. We are huge fans of Roger Hargreaves, and becoming quite fond of Mr Jim Dale and his renditions of the cute Mr Men stories. We just can't get enough, my daughter is simply taken in the Mr Men world and forgets about the boredom of traveling strapped to her seat at the back of the car. Magic, bring on volume 2!
Little Miss Late as you can imagine, is late for everything. If you ask her round for dinner, she probably won't arrive until next week, and that's if you're lucky!


text:
CME/MOC
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www.clevelandclinic.org
To scan or not to scan? DXA in postmenopausal women
Kristi Tough DeSapri, MD, CCD, NCMP and Rachel Brook, MD
Cleveland Clinic Journal of Medicine April 2020, 87 (4) 205-210; DOI: https://doi.org/10.3949/ccjm.87a.18136
Kristi Tough DeSapri
Assistant Professor of Obstetrics and Gynecology and Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
For correspondence: kristi.toughdesapri@nm.org
Assistant Professor, Hospitalist, Department of Medicine, Iris Cantor UCLA Women's Health Center, University of California, Los Angeles
Fracture is a major cause of morbidity and death in postmenopausal women. Dual-energy x-ray absorptiometry (DXA) measures bone mineral density, which helps in estimating fracture risk and in identifying those who may benefit from treatment. Although screening guidelines differ somewhat for postmenopausal women under age 65, in general, DXA is indicated if the patient has a high risk for fracture.
Bone is lost with aging and declining estrogen and testosterone levels, particularly after menopause.
Advanced age, prior fragility fracture, and low T scores (< –3.0) are the greatest risks factors for fracture.
DXA is considered the therapeutic standard for measuring bone mineral density.
In younger postmenopausal women, guidelines recommend DXA only in those who have a substantial risk of fracture based on clinical factors.
A 56-year-old woman presents for a routine physical examination. Her last menstrual period was at age 51. She takes hydrochlorothiazide for hypertension and a multivitamin containing 400 mg of calcium carbonate plus 1,000 IU vitamin D3 daily. On most days, she eats 2 servings of calcium-rich foods (6 oz yogurt and 1 or 2 servings of cheese). She has no personal or family history of osteoporosis or fracture. She exercises 3 times a week and has had no falls or imbalance. She drinks about 5 alcoholic beverages per week. Her weight is 140 lb (63.5 kg) and height is 5 ft 2 in (157.5 cm), giving her a body mass index of 25.6 kg/m2, stable from last year. She asks whether she should get a dual-energy x-ray absorptiometry (DXA) scan to check her bone mineral density (BMD) because many of her postmenopausal friends have done so.
Is DXA screening indicated in this patient?
BONE MINERAL DENSITY DECLINES WITH AGE AND MENOPAUSE
Most women achieve peak bone mass in their second or third decade of life, depending on skeletal site, with the most active bone formation occurring during childhood, adolescence, and young adulthood. Bone is lost with age and with declining levels of estrogen and testosterone, particularly after menopause, and low bone mineral density is associated with an increased risk of fracture.
Estrogen plays a key role in maintaining the balance between bone formation and resorption. Estrogen deficiency disrupts this balance, resulting in decreased bone formation and increased bone resorption.
The Study of Women Across Nations found that women may lose 5% to 10% of bone mineral density in both cortical and trabecular bones during late perimenopause and the first postmenopausal years.1 As women age, this bone loss slows but continues at an average rate of about 0.5% to 1% per year.
Women with premature ovarian insufficiency or early menopause from natural or surgical causes experience more profound bone loss and are at higher risk of fracture during their life.2
Several other medical, genetic, and surgical conditions also either decrease peak bone mass or accelerate bone loss. These include medications such as glucocorticoids (> 5 mg for > 3 months) and lifestyle factors such as smoking and being underweight (ie, body mass index < 18 kg/m2). Rheumatoid arthritis and diabetes, particularly type 1 diabetes, also contribute to bone loss and increase the risk of fracture.3
The National Osteoporosis Foundation has published an extensive list of risk factors that can be shared with patients.4 Advancing age, prior fragility fracture, and a T score below –3.0 are the strongest risk factors predicting future fracture.
OSTEOPOROSIS IS COMMON
According to data from the third National Health and Nutrition Examination Survey, more than 9.9 million Americans have osteoporosis (defined as a T score ≤ −2.5), and an additional 43.1 million have osteopenia (a T score between −1.0 and −2.5), leading to more than 2 million fractures per year.5,6 These osteoporosis-related fractures are a major cause of morbidity and death in postmenopausal women.
DXA SCREENING
DXA measures a patient's bone mineral density. Other screening tools exist, but DXA is considered the technical standard. Results are reported in absolute terms in g/cm2 and also as a T score (the difference, in standard deviations, between the patient's value and the mean value for healthy 30-year-olds of the same sex) and a Z score (the difference between the patient's value and the mean value of people the same age, race, and sex).
The clinical purpose of a DXA scan is to screen patients for low bone mass and osteoporosis. It also provides a surrogate measure of bone strength to help estimate fracture risk.
For example, a 10% loss of bone mass (equivalent to a 1 standard deviation decrease in the T score) in the vertebrae can double the risk of vertebral fractures. In the hip, a 10% loss of bone mass can cause a 2.5 times greater risk of hip fracture.7,8
For DXA to be an appropriate screening test, it must be able to detect disease (osteoporosis or osteopenia) at a stage when treatment (medication or lifestyle modification) can effectively reduce the serious consequences of the disease (eg, fracture). It must also be safe (this applies to both the test and the treatment), widely available, and inexpensive.
RECOMMENDATIONS FOR DXA SCREENING IN POSTMENOPAUSAL WOMEN
Several major medical societies strongly recommend DXA testing for women age 65 and older,3,9,10 but the recommendations are not as clear for younger postmenopausal women, such as our patient. In general, however, women under age 65 should be screened if they have clinical risk factors for bone loss or fracture.
The US Preventive Services Task Force (USPSTF)9 recommends DXA of the hip and spine if the 10-year predicted risk of major osteoporotic fracture according to the Fracture Risk Assessment Tool (FRAX)11 without bone mineral density is 8.4% or greater. This is equal to the fracture risk of a 65-year-old white woman of mean height and weight without major risk factors for fracture.
The National Osteoporosis Foundation4 and the International Society of Clinical Densitometry10 both recommend DXA for postmenopausal women under age 65 and those in the menopausal transition who have clinical risk factors for fracture such as:
Low body weight
Prior fracture
A disease or condition associated with bone loss
Use of medications that cause bone loss, such as glucocorticoids.
DXA is also recommended in women being considered for pharmacologic treatment and to monitor treatment response.
WHY NOT SCREEN ALL YOUNGER POSTMENOPAUSAL WOMEN?
Because recommendations differ regarding DXA screening of postmenopausal women under age 65, patients are selected on the basis of their clinical risk factors other than bone mineral density. The USPSTF, as noted above, recommends basing the decision on the FRAX score without bone mineral density.
If a postmenopausal woman has a low clinical risk of fracture based on the FRAX score and the clinician's determination, DXA will not add any information to determine if she needs treatment. Therefore, women who recently went through menopause who are at low risk do not need DXA screening.
In addition, anyone who has already had a fragility or low-trauma fracture (eg, fracture from falling from a standing height or less) as an adult should be evaluated for treatment of clinical osteoporosis. These patients do not need DXA screening because their risk of a subsequent fracture is 85%, regardless of bone mineral density.12
Does DXA have side effects?
The USPSTF found only minimal harms from DXA screening.9 They reported that patients had no increased anxiety or decreased quality of life associated with screening.
Radiation exposure from a DXA scan is low (typically 0.001 mSv, equivalent to 3 hours of background radiation). In comparison, a mammogram releases 0.4 mSv.13
Overall, DXA is a low-cost screening test for those who meet the criteria to be screened, but it should not be done in all early postmenopausal women.
FRAX IS A VALIDATED TOOL
FRAX11 is a computer-based equation that uses clinical risk factors (and, if available, bone mineral density information) to estimate a patient's 10-year fracture probability. Although it has been validated in the general population, it has some limitations that may cause it to underestimate the fracture risk in postmenopausal women. Its use of yes-or-no responses can limit its clinical application. For example, a patient who smoked cigarettes for 10 years but has quit is considered a nonsmoker in FRAX, even though their smoking history could have a substantial effect on their peak bone deposition and rate of bone loss.
Some experts suggest using one of the alternate risk calculators that include other variables to determine the risk of fracture.14 Table 1 lists the risk variables used in each tool.
Osteoporosis risk assessment calculators
The Simple Calculated Osteoporosis Risk Estimate (SCORE) tool, for example, accounts for hormone therapy and race in its calculation, whereas FRAX does not. In addition, FRAX does not account for falls, which are a major contributor to fractures. Of note, except for FRAX, most of these risk calculators have not been validated in diverse populations and are not in widespread use. We recommend FRAX because it is an easy-to-use clinical tool and is used around the world, but with caveats, as mentioned above.
SHOULD OUR PATIENT UNDERGO DXA?
Our patient is a postmenopausal woman who went through menopause at an average age, does not smoke, has a normal body mass index, and has no personal or family history of osteoporosis or fracture. She consumes adequate calcium and vitamin D through supplements and diet. Based on her history and physical examination, we assume she achieved a normal peak bone mass before menopause and, thus, has a low risk for fracture. Her FRAX score, calculated without DXA screening, shows a 6% 10-year risk of major osteoporotic fracture, which does not meet the 8.4% threshold for DXA screening.
If she continues to get enough calcium, vitamin D, and exercise, and without any offending agents or conditions that accelerate bone loss, she has a low risk of fracture and a very low probability of needing treatment. If her clinical situation remains the same, she should undergo DXA screening at age 65.
In summary, clinicians can accurately assess the fracture risk in younger postmenopausal women (ie, before age 65) by performing a comprehensive history and physical examination and combining it with the FRAX tool without a DXA scan.
MANAGING LOW BONE MASS
More fractures occur in women with osteopenia than in those with osteoporosis because many more women have osteopenia, even though their fracture rate is lower.15 Therefore, it is important to judiciously treat low bone mass in patients who meet the criteria for treatment based on their FRAX score and the practitioners' clinical judgment.
The trabecular bone score is an indirect measure of trabecular microarchitecture derived from DXA images of the lumbar spine. It provides information about bone quality. A score below 1.200 indicates degraded microarchitecture.
Using a trabecular bone score independently or in conjunction with a DXA scan or FRAX score can improve fracture prediction.16,17 Also, FRAX can be adjusted for this score. More accurate evaluations of bone density and bone quality can help determine which patients with low bone mineral density need treatment.
The efficacy of treatment to reduce fracture rates in women at high risk of fracture but without a low T score (−2.5 or below) has not been established. Most FDA-approved therapies are indicated for treatment based on bone mineral density.
EFFECTIVE AND EMERGING THERAPIES
For postmenopausal women who are candidates for pharmacologic treatment based on their fracture risk assessment, there are safe and effective FDA-approved options.
Hormone therapy has been proven in the large Women's Health Initiative18 and the Postmenopausal Estrogen/Progestone Interventions trial19 to both prevent osteoporosis and reduce the incidence of fractures (such as vertebral and hip) compared with placebo. In the Million Women Study,20 women who received hormone therapy had a significantly lower risk of any fracture than women who did not. Despite those results, hormone therapy is FDA-approved only for prevention of osteoporosis, not treatment. It is also recommended for menopause-related vasomotor symptoms and the genitourinary syndrome of menopause.
Candidates for hormone therapy are primarily women under age 60 who are fewer than 10 years past menopause; the risk-benefit ratio for older women is less favorable because of higher risks of heart disease and stroke.21 It is important to engage the patient in an accurate, evidence-based discussion of the risks and benefits of hormone therapy.
Tissue-selective estrogen complexes can be appropriate options to reduce the fracture risk and prevent osteoporosis. These pair estrogens with selective estrogen-receptor antagonists or agonists, such as conjugated estrogen and bazedoxifene.
Selective estrogen-receptor modulators, such as raloxifene, are available in generic form. They may play a dual role of reducing risk of breast cancer and preventing or treating osteoporosis.
Antiresorptives
The antiresorptive class of medications includes bisphosphonates (oral or intravenous) and denosumab, a subcutaneous monoclonal antibody; both are considered first-line treatment for women with osteoporosis. Denosumab is indicated for women (and men) with a history of fracture or who are at increased risk of fracture and cannot tolerate other therapies.
Although effective at reducing the incidence of fractures, antiresorptive therapies may increase the risk of osteonecrosis of the jaw and atypical femoral fractures, especially with prolonged use. Fortunately, these are rare: the incidence rate with 10 years of denosumab use is 0.05%,22 and only 0.001% to 0.01% with more than 4 years of oral bisphosphonate use.23,24
Anabolic drugs
The anabolic drugs such as teriparatide, abaloparatide, and romosozumab build bone mass by stimulating osteoblasts more than osteoclasts. Abaloparatide was studied head-to-head against placebo and teriparatide for 18 months, after which patients received alendronate for 2 years; sequential treatment with abaloparatide followed by alendronate reduced the risk of vertebral, nonvertrbral, clinical, and major osteoporotic fractures and increased bone mineral density.25 Romosozumab, a humanized monoclonal antibody to sclerostin, is FDA-approved to treat women at high risk of fracture. It has a dual effect, stimulating bone formation and reducing bone resorption.
CLINICAL BOTTOM LINE
Osteoporosis and osteopenia leading to fracture are major causes of morbidity and mortality in postmenopausal women. A DXA scan is considered the best tool to measure bone mass, which can be used to determine the risk of fracture and who may benefit from treatment.
For younger postmenopausal women (age 50 to 65), the need for a DXA scan is determined by a thorough history and physical examination, noting any risk factors that contribute to bone loss. A DXA scan is indicated if their fracture risk is high (ie, equivalent to that of a woman age 65 or older) based on a FRAX calculation without a bone mineral density measurement. If DXA is not indicated, clinicians should counsel women on ways to prevent bone loss and reduce fracture risks.
Conversely, women at the highest risk of fracture are those with a prior adult fragility fracture, regardless of T score. Evaluation and pharmacologic therapy should be strongly recommended in these cases.
Dr. Tough DeSapri has disclosed membership on advisory committees or review panels and teaching and speaking for Amgen, and consulting for Radius Health, Inc.
Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.
Finkelstein JS,
Brockwell SE,
Mehta V, et al
. Bone mineral density changes during the menopause transition in a multiethnic cohort of women. J Clin Endocrinol Metab 2008; 93(3):861–868. doi:10.1210/jc.2007-1876
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Curry SJ,
Krist AH,
Owens DK, et al
. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 319(24):2521–2531. doi:10.1001/jama.2018.7498
The International Society for Clinical Densitometry
. 2015 ISCD official positions—adult. http://www.iscd.org/official-positions/2015-iscd-official-positions-adult/. Accessed October 18, 2019.
Centre for Metabolic Bone Diseases, University of Sheffield, UK
. FRAX Fracture Risk Assessment Tool. https://www.sheffield.ac.uk/FRAX/. Accessed October 18, 2019.
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With only weeks left to live, we sit down with long time Drinkin' Bro Patrick Gordon as he talks about his life, dealing with terminal cancer, and what he's learned during his short time here on this earth. This is the first time our audience has unanimously voted for the same individual for Brosman Of The Year and we couldn't have imagined a more deserving person. Patrick is an inspiring guy with an amazing spirit.


text:
Christoph Riegler (* 30. März 1992 in Ybbs an der Donau) ist ein österreichischer Fußballtorwart.

Karriere

Karrierebeginn beim ASK Ybbs
Riegler begann seine aktive Karriere als Fußballtorwart im Alter von acht Jahren im Mai 2000 beim damals bereits finanziell angeschlagenen ASK Ybbs aus der niederösterreichischen Stadtgemeinde Ybbs an der Donau. Beim heute noch immer im unterklassigen Fußball agierenden Klub durchging der junge Torwart die verschiedensten Jugendspielklassen, ehe er im Jahre 2006 ein Angebot des SK Rapid Wien erhielt, der ihn zu sich in den Vereinsnachwuchs holen wollte. Bei den Wienern genoss Riegler allerdings nur eine kurze, wenn auch lehrreiche Ausbildung und kam bereits mit Ende März 2007, exakt an seinem 15. Geburtstag, wieder nach Niederösterreich zurück.

Dort wurde er sogleich in die AKA St. Pölten aufgenommen, in der er fortan für die verschiedenen Akademiemannschaften zum Einsatz kam. Obgleich seines Talentes kam Riegler in der Saison 2008/09 nicht für die U-19-Mannschaft in der von Toto gesponserten U-19-Jugendliga zum Einsatz, die im weiteren Saisonverlauf mit einem passablen Vorsprung auf ihre Verfolger den Meistertitel holte. Weiters gehörte er in dieser Spielzeit auch dem Kader des sehr erfolgreichen U-18-Jugendteams an, das in einer kleinen niederösterreichischen Nachwuchsliga zum Einsatz kam. Ohne einen Einsatz des ehemaligen Rapid-Nachwuchsspielers erreichte die klar dominierende St. Pöltner Mannschaft den Meistertitel in dieser Liga und das mit einer Tordifferenz von +112 und 18 Siegen und einem Remis aus 20 absolvierten Partie. Derweil spielte Riegler vorwiegend im U-17-Akademieteam mit Spielbetrieb in der Toto-U-17-Jugendliga und agierte dort großteils als Stammtorhüter. Mit der Mannschaft erreichte er in der Saison 2008/09 den Vizemeistertitel hinter dem U-17-Team aus Linz.

Ebenfalls in derselben Saison absolvierte Riegler zwei Spiele für die zweite U-17-Akademiemannschaft mit Spielbetrieb in einer niederösterreichischen U-17-Nachwuchsliga und saß in einigen weiteren Partien einsatzlos auf der Ersatzbank. Zum Saisonabschluss holte sich die von Saisonbeginn an dominierende Mannschaft mit einer Tordifferenz von +145 und 24 Siegen sowie einem Remis aus 26 Spielen den Meistertitel. In seinem Abschlussjahr an der Akademie kam Riegler vorwiegend in der Toto-U-19-Jugendliga zum Einsatz und erreichte mit dem Team einen vierten Platz im Endklassement. Daneben sicherte sich der zu diesem Zeitpunkt bereits 18-Jährige mit der U-18-Akademiemannschaft in der kleinen niederösterreichischen U-18-Nachwuchsliga zum wiederholten Male den Meistertitel. Riegler brachte es dabei auf sieben Meisterschaftseinsätze, in weiteren Partien saß er auf der Bank.

Landesliga- und Profidebüt
Nach einer durchaus erfolgreichen Zeit in der Akademie der niederösterreichischen Landeshauptstadt schaffte der junge Torwart vor der Spielzeit 2010/11 den Sprung in den Herrenfußball, wo er vom SKN St. Pölten zuerst in deren zweite Mannschaft mit Spielbetrieb in der 1. Niederösterreichischen Landesliga aufgenommen wurde und es dann auch in den Profikader schaffte. Bis zu seinem eigentlichen Ligadebüt im Herrenfußball dauerte es schließlich bis August 2010. Nachdem er bereits in einigen Freundschaftsspielen zum Einsatz gekommen war, gab Riegler am 21. August 2010 sein Herrendebüt, als er für das Landesligateam bei einer 1:2-Heimniederlage gegen den ASK Bad Vöslau über die volle Spieldauer das Tor der St. Pöltner hütete.

Nicht einmal zwei Monate nach seinem Debüt im Herrenfußball gab Riegler bereits sein Debüt im Profifußball, als er am 15. Oktober 2010 beim 1:0-Erfolg über den SC Austria Lustenau über die vollen 90 Minuten im Tor seiner Mannschaft stand und dabei den verletzten Stammtorhüter Thomas "Tommy" Vollnhofer ersetzte. Gleich bei seinem zweiten Profieinsatz am darauffolgenden Spieltag gab Riegler beim 4:3-Auswärtssieg über die Vienna per weitem Abschlag eine Torlage für Florian Zellhofers 1:0-Führungstreffer in der 17. Spielminute. Mitte Mai 2019 verlängerte er seinen Vertrag bis zum Sommer 2022.

2016 konnte er mit dem SKN St. Pölten in die Bundesliga aufsteigen. In fünf Spielzeiten in der Bundesliga, in denen er zumeist als Einsertormann gesetzt war (ab 2018/19 war er zudem Kapitän), kam er zu 145 Einsätzen in der höchsten Spielklasse. Am Ende der Saison 2020/21 stieg er allerdings mit dem SKN wieder in die 2. Liga ab. Nach internen Problemen spielte er in der 2. Liga allerdings keine Rolle mehr und war nur noch vierter Tormann und stand so bis zur Winterpause 2021/22 gar nie mehr im Spieltagskader. Daraufhin verließ er den SKN nach elfeinhalb Jahren im Jänner 2022 und wechselte zum Bundesligisten SCR Altach, bei dem er einen bis Juni 2022 laufenden Vertrag erhielt. Noch vor Beginn der Rückrunde verletzte sich Riegler jedoch schwer an der Schulter und fiel bis Saisonende aus. Sein Vertrag wurde nicht verlängert und so verließ er Altach ohne Einsatz nach der Saison 2021/22 wieder.

Im Amateurfußball
Nach einem halben Jahr ohne Klub wechselte Riegler dann im Jänner 2023 zum Regionalligisten Kremser SC.

Erfolge
AKA St. Pölten
 1× Vizemeister mit der U-17 (Toto-Liga): 2008/09
 1× Meister mit der U-17 (NÖ-Nachwuchsliga): 2008/09
 1× Meister mit der U-18 (NÖ-Nachwuchsliga): 2009/10

Weblinks

Einzelnachweise

Fußballtorhüter (SKN St. Pölten)
Fußballtorhüter (SCR Altach)
Fußballtorhüter (Kremser SC)
Sportler (Ybbs an der Donau)
Österreicher
Geboren 1992
Mann


Do GERB Party's Elected Officials Boost a Stray Dog Removal Industry?
Two fatal dog attacks occurred within just eleven weeks in Sofia. After death of Professor Botjo Tachkov who was mauled by a dozen strays, another elderly man - 88 year old - was severely injured by two unmanaged dogs. He died on 17th June 2012 in hospital.
"Municipality will open new animal shelters in three monts. 4000 strays will be impounded in one year. I will urge lawmakers to approve euthanizing unowned dogs," Mayor Fandykova of GERB Party told media the same day. Recently she reiterated intentions to increase the dog catchers teams number "to at least 10".
During the past 30 months in office, Fandykova failed to take any adequate step to curb overbreeding in local dog population. Owned dogs are estimated 200,000 and annual dog population increase is at least 10,000.
Bulgarian Animal Programs Foundation remains the only proponent of the humane and comprehensive pet population management at local and national level. Solutions proposed in written public comments and letters to the Prime Minister and Sofia Mayor include registration and monitoring of neighborhood dogs; animal shelter accountability on intake and disposition of strays; appointing animal control officers instead of dog catchers teams in order to promote responsible pet ownership rather than simply serve the animal shelter system; and subsidizing low-cost neutering schemes for cats and dogs that involve private veterinary clinics.
Fandykova's team just inserts the "free surgery" item in the 2012-2016 Curbing Stray Dog Population Program approved by City Council in early May 2012. However, neither budget quantities, nor targeted sub-population and number of provided sterilizations are specified in this paper.
So far, Fandykova has poured over 4 million leva in false animal birth control and adoptions outside Bulgaria. The only comprehensible outcome was a total of about 12,200 dogs impounded according to the municipal officials' media announcements. Yet dog catching is routinely presented to the public as a part of an unreported City Hall's "catch-neuter-release program".
Big pet population dynamics, big dog pound capacity, and big money provided by GERB Party's elected officials may satisfy the illegal dog dealers' interests only. Behind the rulers' talk about either catch-neuter-release or "final" stray dog removal, it can be seen tens of thousands unwanted and lost animals impounded over the years and an intention to move the dog farming industry from public spaces to increased animal shelter system.
Roaming dogs loaded in Sofia on Orthodox St. George's Day, 6th May 2012, Sunday. The Sofia municipal animal control enterprise routinely collects strays by shooting darts filled with tranquillizer.


This level of intolerance is not good; for that to come down, we must, as a nation, mature, the All India Majlis-e-Ittehadul Muslimeen chief says. If there is one thing that rankles, it is being branded as the BJP's "B-Team", says All India Majlis-e-Ittehadul Muslimeen (AIMIM) chief Asaduddin Owaisi, saying the party is contesting only three seats countrywide.
Are you looking at a pan-India expansion of your party?
Naturally, every party wants to expand. This is why we are contesting in Aurangabad and Kishangunj.
Despite contesting only three seats, I am being branded a "vote cutter", the 'B-Team' of the BJP. I would request them to make it 'A-Team' as 'B-Team' sounds a bit demeaning.
So, what is your view on the government led by Modi?
As far as performance of Mr. Modi is concerned, you see in 2014, he used to address public meetings in which he spoke about achhe din. He hardly utters it now. He never talks about demonetisation. At the time, the message was about black money, depositing ₹15 lakh, employment for youth. He would say 'my foreign policy is different'. It is not. It is the same. We are still dithering on China.
There is no Pakistan policy. Our influence has been reduced in our own neighbourhood. There is a great danger now with the Americans leaving Afghanistan, we don't know what will happen at our western borders. This is why PM is sticking to security, terrorism, Muslims, Pakistan.
ALSO READ: Why PM Modi 'Tightlipped' On The Controversy Of 'Jinnah Photograph In Aligarh Muslim University'?
What are the issues in the current elections?
I feel this is an open election. There is no wave as such. That is why, out of the 135 seats in south India, they will get a few seats, may be here or there. I don't think the BJP can even retain the two seats in Andhra Pradesh, one in Telangana and one in Tamil Nadu.
What do you think the people are looking for?
One thing is for sure, that this government has not lived up to its promises. There was talk of a strong leadership, supreme leader. That is not there any more. Every State has its issues and even every constituency has different issues.
So Pulwama and Balakot will not make much of a difference?
Why should it make a difference? If you talk about Pulwama, then BJP has no place to hide because it is an intelligence failure. When Balakot happened, I said we believe the statement of the Foreign Secretary. But now, PM says Pakistan is counting corpses. Amit Shah says 250. The Agriculture Minister says 350. Ahluwalia says our intention was not to kill. So who should we believe?
Is this election also bereft of the Ram Mandir issue?
In the first phase, Mr. Modi would be lying low. Come second or third phase, qabrastan-shamshan will begin.
What are your views on mediation on the Ayodhya issue?
We have no problem with mediation and will abide by it. My personal objection is about Mr. [Sri Sri] Ravishankar because he is close to subject matter and parties. But I hope that he lives up to the expectation of a mediator, wherein you are completely unbiased. You don't carry baggage, and listen to all parties.
ALSO READ: Is BJP's Game Plan To Defeat MP Asaduddin Owaisi In His 'Hyderabad' Constituency?
You have been talking about KCR (Telangana Chief Minister K. Chandrasekhar Rao) as a person of PM calibre. Do you think the proposed federal front could be a reality post-polls?
Why not? I think the country requires a non-Congress, non-BJP government. This is not only to represent political diversity, but to give a new economic path. Most important points are: in these five years, institutions of democracy have been weakened. The hatred that has been created against the minorities and Dalits. I have my doubts that even if the government changes, the level of hatred will not decrease. This is scary. The government of the day tried to weaken institutions of democracy.
How would you de-institutionalise this 'hatred' you speak of?
This level of intolerance is not good. For that to come down, we must, as a nation, mature. These are no more 'fringe elements'. The fringe are the main players now. They should be controlled. That can happen only when governance is done by rule of law and not favouritism. Democracy demands that you have rule of law, not rule by law.
Sections of media have reported that a judge stated that important evidence in the Samjhauta blast case was not brought on record. What is your opinion of the investigation agency?
If they have any self-respect left, the National Investigation Agency investigation officers' team should be suspended. The Home Minister should apologise, the government should apologise. Why don't you appeal when judge himself is saying crucial evidence was not shown? Whether it is Mecca Masjid, Ajmer blast, you don't appeal. This is complete favouritism. There is an Urdu saying, baarah khoon maaf. If you are close to chowkidar, everything is forgiven.
What are the electoral prospects in Telangana?
I feel 16 seats will be won by the TRS. One, Hyderabad, would be won by my party (Telangana has 17 seats). Congress has lost perception and narrative battle. BJP, again, the same.
What about your foray into AP with YSRC's Jaganmohan Reddy?
The objective is that he [Jaganmohan Reddy] wins 20-plus Parliament seats. I feel that he is on the path to this. We are in touch through different people. If, and when, he wants, I will go. Otherwise, I am happy here.
How do you intend to replicate the Maharashtra model of Muslim-Dalit alliance across the country as the dynamics is different States are different?
I accept that it is not going to be easy. But there is a churning, a realisation on the ground. It is not a wrong statement to make, but Prakash Ambedkar is now the undisputed leader of the Dalit community.


In order to do well in the TOEFL reading section, you need an array of skills. The four most important skills are listed below.
Detailed knowledge of the question types.
Language awareness has two key aspects: vocabulary and grammar.
It is vital that test-takers develop rich knowledge of vocabulary for the TOEFL test as a whole, but for the reading section, knowing more words will greatly help you to score well. As well as general academic vocabulary, you also need some awareness of topic specific vocabulary.
TOEFL reading passages are formed using a variety of phrases and clauses; therefore, the sentences are complex which makes comprehension difficult for many test-takers. Understanding different forms of sentences (i.e. compound and complex) and how they are formed using various phrases (prepositional, adverbial, etc) and clauses (independent and dependent) will help the test-taker to comprehend the reading passages.
Academic English has two key aspects: writing structure and pattern of organization.
TOEFL passages (in all sections of the test) follow the same top-down approach. This means that the first or the second sentence of a paragraph is the topic sentence, which broadly describes the main idea of the paragraph, and the rest of the paragraph describes the details that support the main idea in the topic sentence. You are also expected to adopt this structure in your speaking and writing responses.
Take a look at the following example paragraph.
"In the modern world, everyone should be able to speak another language. Being able to speak another language may help you to find jobs as more and more businesses work with partners around the world. Also, being able to speak another language allows you better understand other cultures, helping you to become more tolerant of differences between cultures.
The topic sentence contains the main idea 'everyone should be able to speak another language' and its supporting details are 1) helps to find jobs and 2) better understand other cultures. This kind of structure is what you will find in TOEFL passages, though the pattern of organization may affect this structure at times.
Pattern of organization will greatly affect the organization of ideas of a passage. Passages tend to have one main pattern of organization and other minor patterns of organization. For instance, a passage on American Civil War may have 'time order' as the main pattern of organization to explain the sequence of events, but it may also have 'cause and effect' as a minor pattern of organization to explain the cause of events during the war. Pattern of organization can be seen through the use of transitions. Below are patterns of organization.
Skimming and scanning are key reading skills for the TOEFL test. These skills will enable you to be time-efficient during the reading section.
Skimming is a way of reading to understand the overview of a passage rather than the small details. The aim is to read quickly understand only the gist of the reading passage as a whole.
Since the TOEFL passages have a top-down structure, you should be able to find the main idea of each paragraph in the first couple of sentences. Therefore, focus on reading these sentences carefully and skim through the rest of the paragraph very quickly.
Scanning is a technique of reading where you are looking for a specific detail. One you have skimmed the reading passage, you should have an awareness of the reading passage's overview. Then, when a particular question asks you to find a specific detail, you should scan the reading passage looking for that specific detail.
Therefore skimming and scanning are reading techniques which go hand in hand. The purpose of skimming and scanning can be best explained by most people's experience of going to a buffet.
When we go to a buffet, we may first SKIM the restaurant finding out what foods the restaurant has. There may be a barbecue section, Chinese food section, Italian food section and finally a dessert section. Then, when we want to eat pizza, we know that we are going to find this in the Italian section, so rather than wasting time in other sections, we go straight over there and SCAN for pizza. We look carefully around the Italian section looking for what we ant. This analogy of going to a buffet best describes the technique of skimming and scanning.
It is vital that you have an in-depth understanding of all the different question types. This will help you to know the processes involved in finding the correct answer which ultimately helps you to use your time more efficiently and, of course, achieve a high score. The TOEFL reading section has 10 question types.
After gaining an understanding of the processes involved in answering these questions, you must also practice answering them in TOEFL reading passages.


So much news, so little time. But fear not, as MMA Journalist has condensed current events into easily-digestible Japanese poem form!
Jay Hieron signs with / Bellator. Wait, what? You mean / Jay Hieron still fights?
Josh Gross leaves S.I. / for ESPN. Guess what? / Dana White still hates him.
Machida trained with / Steven Seagal. Won't help, though. / Rampage has A-Team.
Roy Nelson's career / is on hold. Something about / new McRib, I bet.
Strikeforce cut Roxy. / That's fine, though. There will always / be a Moosin show.


What will happen to the British immigration policy after Britain's exit from the European Union? Even if the free movement between UK and EU looks like it's coming to an end, we still don't know exactly what the UK plans in order to control the immigration level.
After all the pressure, it looks like the British government has finally made a call regarding the immigration rule and said that an urgent review will be made. Since there are lots of working immigrants in the UK, if this problem will not be fixed soon, it will surely damage some important UK firms.
Since the government faced big problems even before the negotiation between the UK and the European Union began, this process seems like it will last forever.
With all these things happening, you may be wondering about the outcomes of the Brexit and how they will influence you if you are an immigrant or a UK citizen.
In order to answer these questions, let's think about what the government said it wants. Well, it indicated that by March 2019, the free movement of people as it happens today will end. Therefore, until we reach that date, the government will negotiate a transitional period. This means that the free movement in and out of the UK will be more or less limited and it will soon end in a legal way. However, it will practically continue, but the people who are coming for the first time and need to register will have a disadvantage.
If you already are a worker or if you live in the UK, then you will be protected by a special system that will give you the chance to settle in the UK if you lived at least five years in this country.
Since the demand is high, the British government is trying to introduce a new immigration system that would please anyone.
Currently, in the UK, there is a points-based immigration system that was introduced in February 2008 by the Labour government. Before that, there were 80 different types of visas to be granted. This system was based on the Australian one, but there are certain differences between the two of them and further, we will try to focus on why the Australian system would be good for UK immigration, rather than the British system.
Tier 1-> Here we have the highly valuable people. We can include here a graduate entrepreneur or a very talented or skilled person.
Tier 2 -> This tier consists of skilled workers.
Tier 3 -> This tier was made for unskilled immigrants, but soon after the system was introduced, the government decided to delete it, because they believed the UK didn't need any unskilled immigrants.
Tier 4 -> This is the student's tier. It doesn't matter what kind of education they follow.
Tier 5 -> Migrants that are coming in the UK just for a temporary stay.
Being called a points-based system, it means that you have to earn the points somehow. Well, there are different criteria on how you can earn these points depending on the tier you fit in. The main criteria are the financial capacity to support yourself, your age, previous experience and how well you speak English.
However, there are special ways to enter into the first two tiers. Not everyone can be part of them because not everyone has an exceptional talent or a great job. The first tier gives you 1,000 points per year whereas the second tier earns you only 70 points.
Since the UK is still in the European Union, this system only applies to the immigrants from outside of EU, but after the Brexit process is complete, this system will apply to all the immigrants.
At the end of 2015, BBC estimated that almost 630,000 immigrants arrived in the UK with the objective of staying more than one year. 270,000 of them were from the European Union and no more than 83,000 of them were British citizens.
Therefore, that's why the United Kingdom needs to update its points-based system.
Australia's system is different than UK's because it consists of two immigration schemes. The first scheme is called the Migration Programme and it includes the economic immigrants, while the second one is called the Humanitarian Programme and it is for refugees.
Thinking about the numbers, Australia was quite active too, although not as visited as the UK. It capped 190,000 economic immigrants and no more than 20,000 humanitarian immigrants.
The points system in Australia was firstly introduced in 1972 but it was lastly updated in 2011. The Migration Programme is divided into two classes: employer-sponsored or skilled worker.
If employer-sponsored visas are not tested, the skilled-worker visas are. A person needs to meet at least 65 points in order to qualify for this visa. The points are given depending on recognised qualifications, previous working experience abroad and age.
A difference between UK's system and this one is the character test that is mandatory in Australia. This test aims to exclude anyone who can harm the Australian society.
Since we talked about Australia and UK's systems, we believe it is fair to at least mention Canada's points-based system that is the oldest one, being introduced in 1967.
This system also makes the difference between skilled workers and the other types of immigrants, but Canada's system is recognised to prioritise the desirable immigrants rather than the specific job offers.
So, in conclusion, the Australian or Canadian points-based systems would be a good influence on the UK's system after Brexit because they allow skilled and highly-skilled workers to come with more ease to the United Kingdom. Currently, there is an active points system in the UK, but it could do with some improvements because there are very limited quotas and even doctors are having trouble getting visas.