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Ensuring that patients have a positive experince is important, but it's time-consuming to refuse inappropriate requests, says Aleksandra Zgierska, MD, PhD. "Then all the other patients waiting are dissatisfied. It's a vicious cycle." Photo by David Stluka / AP Images for American Medical News
Patient satisfaction: When a doctor's judgment risks a poor rating
■ Patients sometimes demand inappropriate care. Saying no could lead to unhappy patients, bad survey scores and even financial penalties. Some doctors see an ethical conundrum.
By — Posted Nov. 26, 2012
WITH THIS STORY:
» The sickest patients give the highest ratings
» 9 cases when primary care doctors should just say no
» 6 reasons to refuse patient requests
» External links
Family physician and addiction medicine specialist Aleksandra Zgierska, MD, PhD, often treats patients referred to her by primary care colleagues concerned about their patients' growing reliance on opioid analgesics. Caring for these patients raises clinical questions that even the most skilled physicians have trouble answering.
But recently, Dr. Zgierska has considered another question as she wonders how to proceed with treatment: Will using her best medical judgment harm her patient-satisfaction rating?
"If I feel the patient is not an appropriate candidate for opioids, I should say no," she says. "But in the back of my mind, the question can arise, 'What will the patient do with that?' Especially since the No. 1 question on our patient-satisfaction survey is, 'Are you happy with the way the physician treated your pain?' "
This is not just a matter of receiving a lousy review on one of the many consumer rating websites that have become popular in recent years. More physicians, no matter their specialty or practice setting, are finding their care graded on patient-satisfaction surveys that are used to determine pay.
A daily dilemma
Several surveys are in use, but they typically ask about areas such as nursing care, staff friendliness, test results follow-up and waiting times. They also ask patients about how well physicians communicated and whether doctors listened to their concerns, answered questions and explained things clearly.
Patients who do not get what they expect — even if it is medically inappropriate — can feel as though their doctors did not listen. The response: bad ratings.
"This is my day-to-day conundrum," says Dr. Zgierska, assistant professor in the Dept. of Family Medicine at the University of Wisconsin School of Medicine and Public Health in Madison. "The challenge is how do we discuss this with the patient so the patient doesn't leave unhappy. & Saying yes is easy. I know from firsthand experience that it's very tempting."
Dr. Zgierska is designing a study to examine the relationship between opioid prescribing and patient-satisfaction ratings. The ethical tension created by the challenge of trying to satisfy patients while refusing inappropriate care requests goes beyond the controversy over proper use of opioids, she and other physicians say. Any time patients request care that will not help — common examples are antibiotics for a cold or imaging for uncomplicated low-back pain — doctors are placed in an unenviable position.
Many doctors already have trouble turning down patient requests. For example, 36% of physicians told researchers they would yield to a patient who asks for a clinically unwarranted magnetic resonance imaging exam, according to a Dec. 4, 2007, Annals of Internal Medicine study.
"For all that doctors carry on about science and professionalism, the fact of the matter is that we want to please our patients," says Howard A. Brody, MD, PhD, a retired family physician who is director of the Institute for Medical Humanities at the University of Texas Medical Branch in Galveston. "And patients are likelier to appear to be pleased when we do something, rather than nothing."
Paying for satisfaction
For Dr. Zgierska and a growing number of physicians, saying no could carry a price tag. The University of Wisconsin Medical Foundation, the clinical practice organization for UW faculty physicians, recently created a new compensation plan for its primary care doctors. They can receive a 5% increase in their base pay if they meet benchmarks on certain performance measures, including patient-satisfaction metrics.
UW is far from alone. Nearly two-thirds of hospitals, health systems and large physician groups have annual incentive plans for doctors, said an October 2011 report from the Hay Group, a Philadelphia-based management consulting firm. Sixty-two percent of those use patient-satisfaction metrics as a factor, up from 43% in 2010, said the survey of 182 health care organizations covering physicians in 144 medical specialties. Many set base pay lower and require doctors to meet performance metrics to earn hefty incentive pay.
"Bonuses of less than 5% don't get anybody's attention. Make it 5% or 10% or 15%, and that's a sufficient financial opportunity to get your attention," says Ron Seifert, vice president of the Hay Group. "We're going to see more of this."
Medicare also is paying for and publicly reporting on patient satisfaction. Starting in October, the Centers for Medicare & Medicaid Services is withholding 1% in pay to hospitals and using the money to provide incentives to those with the highest performance-measure scores. Patient-satisfaction metrics account for 30% of the score. The percentage of pay withheld will rise to 2% in 2017.
In the proposed 2013 Medicare physician fee schedule, CMS outlined plans to include patient-satisfaction survey results for group practices participating in the Physician Quality Reporting System on the Physician Compare website "no sooner than 2014." Starting in 2013, physicians who do not report enough quality metrics to CMS will see a 1.5% Medicare pay cut in 2015, which will rise to 2% in 2016 and beyond.
The impact of unhappy patients
With physicians' reputations and pay riding on patient-satisfaction surveys, some doctors say a few angry patients can skew the ratings.
William P. Sullivan, DO, directed a hospital emergency department in suburban Chicago for several years. The department scored an overall 86.3 out of 100 on patient-satisfaction scores, as measured on surveys conducted by Press-Ganey Associates in 2010. Comparable small EDs averaged an 86.6 score.
Despite the tight bunching of scores, Sullivan's department fared worse than 58% of other EDs. A handful of bad grades seemed to make the difference, Dr. Sullivan argues. Only 4.1% of the 90 patients surveyed in a three-month period marked their care as poor or very poor.
Patients unhappy about not getting the care they wanted may have been among those handing out bad grades, Dr. Sullivan says. There is no way to know definitively, as most surveys are completed anonymously. There was one patient, for example, who asked Dr. Sullivan to write a note to excuse her from work because of an unsightly pimple on her nose. He asked the woman why she couldn't work.
"Maybe I can't work because I've been up all night crying about it," the patient said. Dr. Sullivan refused the request, but he wonders whether she was among those who gave his department a poor rating.
"People get mad and you think, 'Great. There goes another bad score,' " he says.
Press-Ganey tells hospitals to use at least 50 patient surveys for a small ED before judging its patient satisfaction compared with other EDs. The company says its research shows that unhappy patients are not likelier to complete patient-satisfaction surveys.
Perfect ratings not the goal
While patient-satisfaction surveys are inherently subjective, some experts argue that a small number of demanding patients should not make much of a dent on overall scores of individual doctors, clinics or hospitals.
"Don't worry too much about that," says Mark Friedberg, MD, a researcher at the Boston office of the nonprofit RAND Corp. who has helped develop patient-satisfaction surveys. "This is not about getting a perfect rating with all patients. It's to compare you to other physicians and to other practices. Everybody's going to have some patients who, when you give them the best care, won't be satisfied with it."
Yet other experts see a troubling link on the push for patient satisfaction, an unwillingness to say no to patients and greater health care utilization. A March 12 Archives of Internal Medicine study of more than 50,000 U.S. adults found that those giving the highest patient-satisfaction scores also were likelier to land in the hospital and rack up more health care spending than the least-satisfied patients. The most satisfied patients also had a 44% higher mortality rate, even after adjusting for illness severity, researchers found.The study has its critics. They argue that its lack of illness severity measurement produced a spurious association among higher patient satisfaction, more spending and worse outcomes. But the study's lead author, Joshua J. Fenton, MD, MPH, says the research raises key questions about how the drive to satisfy patients is shaping medical care.
"Our study suggests that these patient-satisfaction measures have a pretty strong correlation with utilization overall," says Dr. Fenton, associate professor of family and community medicine at the University of California, Davis, School of Medicine. "It seems like we need to understand that association, and the reasons for that association, a little bit better. & I think there's a great deal of uncertainty about the extent to which patient experience measures are related to care quality."
In September 2010, the American College of Emergency Physicians adopted policy that methodologically and statistically sound patient-satisfaction surveys "can be a valid measure of the patient's perception of health care value." ACEP said such tools should be based on a statistically valid sample size free of selection bias, and transparently administered and analyzed, adding that unvalidated survey tools should not be used for financial incentive programs.
The American Medical Association has policy saying that as a counterbalance to financial incentive programs focused solely on cost reduction, physicians should advocate for incentives based on care quality and patient satisfaction. The AMA also favors improved measurement of patient satisfaction efforts to document the relationship between satisfaction and favorable health outcomes.
Customer service vs. medical care
Physicians still face the challenge of meeting patients' expectations while providing optimal care. Experts agree that saying no does not have to mean an unhappy patient. They say that listening with empathy to a patient's concerns, reviewing options in an evenhanded, nonjudgmental way, emphasizing the undue risks of nonbeneficial interventions, asking the patient to defer a decision, and even sitting down with the patient — instead of standing — can help.
Dr. Fenton, at UC Davis, recently secured federal funding for a study to test if certain patient-centered counseling techniques can aid physicians in reducing inappropriate or unnecessary tests. He believes that with the right training, physicians can steer patients clear of inappropriate care. But doing so requires a professional commitment, one that the patient-satisfaction push may undermine.
"If you make the incentive too strong to satisfy patients, it might really alter the way you view your job," Dr. Fenton says. "You start thinking of yourself less as a physician whose job it is to really partner with patients and dispense medical advice — whether it's easy to explain or something the patients want to hear or not — and you start thinking of yourself as a service provider. That's a very different role.
"We have some things to learn from customer service, the retail industry and so on," he adds. "But in medicine, we're more than just service providers."
The sickest patients give the highest ratings
A study of more than 50,000 U.S. adults found that patients who grade their care the highest are likelier to have worse health outcomes and rack up more medical expenses than the least-satisfied patients, even after adjusting for factors such as age, income, illness severity and insurance coverage.
Increase in percentages of highest raters over least-satisfied patients
Mortality risk: 44%
Any inpatient admission: 12%
Prescription drug spending: 9%
Health care spending: 8%
Source: "The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality," Archives of Internal Medicine, March 12 (link)
9 cases when primary care doctors should just say no
Refusing patient demands for nonbeneficial tests or treatments could result in low patient satisfaction scores. According to lists compiled by medical specialty societies as part of the American Board of Internal Medicine Foundation's Choosing Wisely initiative, there are some common clinical circumstances when saying no is the right thing to do:
Don't do imaging for low back pain within the first six weeks, unless red flags such as severe or progressive neurological deficits are present.
Don't routinely prescribe antibiotics for acute, mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
Don't obtain brain imaging studies in the evaluation of simple syncope where the neurological examination findings are normal.
Don't do imaging for uncomplicated headache.
Don't use dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
Don't order annual electrocardiograms or any other cardiac screening for low-risk patients without symptoms.
Don't perform Pap smears on women who are younger than 21 or who have had a hysterectomy for noncancer disease.
Don't obtain imaging studies as the initial diagnostic test in patients with low pretest probability of venous thromboembolism. Obtain a high-sensitive D-dimer measurement instead.
Don't recommend follow-up imaging for clinically inconsequential adnexal cysts.
Source: American Board of Internal Medicine Foundation; items come from lists provided by the American Academy of Family Physicians, American College of Physicians and American College of Radiology (link)
6 reasons to refuse patient requests
Saying no to patients can upset them, threaten the physician-patient relationship and contribute to lower patient-satisfaction ratings. Experts say there are important reasons why doctors should hold fast when appropriate.
Patient autonomy is essential, but that tenet does not oblige physicians to grant any specific patient demand for a test, medication, treatment or procedure.
The treatment request may be scientifically invalid, have no medical indication or offer no possible benefit to the patient.
Patients' subjective judgments of their medical needs may be incorrect, or the result of anxiety or some other personal concern.
Allowing patients' demands for unnecessary interventions to trump careful clinical reasoning can undermine clinical excellence.
Granting inappropriate care requests could lead to patient harm, such as a delay in beneficial testing or treatment, inconvenience or out-of-pocket expenses.
Interventions that are ineffective can be costly, contribute to higher taxes and insurance premiums, and strain scarce medical resources.
Sources: "Addressing Requests by Patients for Nonbeneficial Interventions," The Journal of the American Medical Association, Jan. 11; "Opinion 8.20 — Invalid Medical Treatment," American Medical Association Code of Medical Ethics, June 1998
"Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal," The Journal of the American Medical Association, July 11 (link)
"The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality," Archives of Internal Medicine, March 12 (link)
"Addressing Requests by Patients for Nonbeneficial Interventions," The Journal of the American Medical Association, Jan. 11 (link)
Lists of tests and procedures physicians and patients should question, American Board of Internal Medicine Foundation Choosing Wisely initiative (link)
"Professionalism in medicine: results of a national survey of physicians," Annals of Internal Medicine, Dec. 4, 2007 (link)
"Opinion 8.20 — Invalid Medical Treatment," American Medical Association Code of Medical Ethics, June 1998 (link)


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Israel upon- Avon
Bringing the wonders of Shakespeare to Jerusalem's high-school students.
By SHAINA OPPENHEIMER
Updated: JUNE 2, 2016 12:14
Campus Ankori's production of A Midsummer Night's Dream
(photo credit: YACHATZ)
On the evening of February 28, friends and family gathered in Beit Shmuel anxiously awaiting the start of Campus Ankori's production of A Midsummer Night's Dream.
There was a warm feeling in the room as families greeted each other and talked about whose kids were performing, and fellow students arrived with their clans to support their friends. The audience cheered, laughed and yelled as the curtains went up.
From the opening lines of the play, it was clear that this wasn't your normal high-school production.
Walk through the halls of Jerusalem's Campus Ankori and you'll immediately be greeted by students eager to ask you who you are.
"Watch out!" someone will yell, as you duck to avoid being hit by an electric guitar, only to turn around and see a group of students sitting and talking with their teacher as if he were a friend. The halls are buzzing with students and teachers, and here there seems to be a much smaller divide between the two. There is an apparent air of openness, creativity and passion.
Campus Ankori Jerusalem is one of seven private high schools associated with the Ankori Education Network. Established in 1948 by Hanoch Ankori, the network operates private secondary schools, publishes textbooks and provides exam preparation throughout Israel. The school endorses interactive learning through creativity, flexibility, personal attention and teacher-student relationships.
At the beginning of the year, teacher Na'ama Mass brought the works of Shakespeare to her advanced-level English class. In the middle of class, one of the students proposed the idea of doing a play, and just like that a five-month project began. Mass chose A Midsummer Night's Dream, hoping it would pose a fun challenge for her students. She sat down with each character, made sure they understood their lines and adapted the script to best fit the play.
"I put a lot of focus on trying to keep the music of these lines," Mass explains. Although condensed, the majority of the play preserved the original Shakespearean language.
Many of the students jumped into their roles, as Mass tried to cast based on similarities in the personalities of the characters and those of the students.
For student Rebekah Wagner, connecting to her role didn't come as naturally as it did to the others.
"To be someone really beggy and throwing herself at people is the total opposite of me," Wagner explains. Seeing how her fellow classmates naturally assimilated to their roles, it took Wagner some time to warm up to Helena.
"Although I've never been in a place where someone I loved so much didn't love me back, I was able to connect with her…. At some point I realized how sad it was. How could a girl come to get to a place where she's begging for someone to love her, and the guy can't even look at her?" Wagner remarks.
For Wagner, as with the majority of the other students, this was her first time acting.
Gabriela Korson, who played Hermia, explains, "It brought so many people out of their comfort zone and gave a lot of people a sense of confidence they might not have had before, myself included."
Only about four of the 18 students had previous theater experience.
One of those experienced students was David Roiterstein, who played Nick Bottom.
"I think this really taught me not to overestimate myself and make myself a big deal. I learned to really be a part of this group and to be humble," Roiterstein remarks.
Mass adds, "The easiest to work with were the people with no experience, because they were so thirsty to learn. I could ask them for anything and they'd just do it."
Although the play was not of professional caliber, it was rather impressive that a group of high-school students could pull off a play in English, let alone in the English of the Bard.
This play served beyond the purpose of honing the students' English skills. As Roiterstein explains: "I think this taught everyone in the play what they're willing to do with themselves. At first there were a lot of 'I can't's, but now I think we're all really open to trying new things."
The way the whole production was sparked, by a student simply shouting out an idea, speaks to the open-minded approach to learning at Campus Ankori. Student Samuel Carpenter explains: "At all my other schools, it's mostly about the teachers standing in front of the room talking. Here it's a lot more interactive. There's a lot of dialogue between the teacher and the students."
Roiterstein adds, "It feels like a family here; you know you can always go to the teachers. This school endorses creativity. They challenge you to challenge them."
With an internationally and locally diverse student population, most of them living in Jerusalem, the school naturally feeds off a very open learning environment. The openness of the educators and students gives a different approach to knowledge, where students are eager to learn and expand their minds.
Through the teaching methods instilled at Campus Ankori, students are opening meaningful dialogues between themselves and their teachers and learning valuable lessons that will serve them both in and outside the classroom.

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text:
British lawmaker links Le Mesurier death with Russia
Ex-intelligence officer made enemies in Syria, says UK House of Commons foreign affairs committee chairman Tom Tugendhat
A senior British parliamentarian said he was "deeply concerned" to hear about the death of a former intelligence officer in Istanbul. The remarks by Tom Tugendhat, chairman of the foreign affairs committee of the U.K.'s House of Commons, came a day after former MI6 officer James Gustaf Edward Le Mesurier was found dead in Beyoglu district on Monday.
"His heroic work in defence of human rights in Syria has sadly made him many enemies, and Russian officials have frequently accused him of links to terrorist organisations," Tugendhat was quoted by the Financial Times as saying.
He added that U.K. officials should be part of any investigation, according to the British daily.
Le Mesurier was also the founder of a Syrian civil defense agency, the White Helmets.
Britain's Foreign and Commonwealth Office also said it was "deeply saddened" by Le Mesurier's death.
Russia has long accused the White Helmets -- the informal name of the group known as the Syrian Civil Defence -- of being a project by western intelligence services to undermine its ally Bashar al-Assad's regime in Syria, according to the Financial Times.
"The intelligence services have warned against persistent Russian smears, of Mr le Mesurier over his support for the rescue group," The Telegraph reported.
Quoting an unnamed Syrian expert, the daily said Le Mesuriere had faced "unimaginable pressure and targeting as a result".
The body of Le Mesurier was found in Beyoglu district in the early hours of Monday by passersby, who were going to mosque for the morning prayer.
The police and paramedics arrived at the scene soon after they got the call and initially found nothing in his possession to identify the man, who was later found to be Le Mesurier.
While the police suspect the cause of death was falling from height, the investigation is still in progress.
Le Mesurier's wife said in her statement that her husband had recently started to take sleeping pills and psychiatric medications due to stress disorder and the incident took place early in the morning while she was sleeping.
RussiaBritish LawmakerTom Tugendhat
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UK police officer pleads guilty to dozens of sexual...


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Dan Gleason of Fredericton, N.B., has experienced bouts of loneliness. He called into Checkup to share how he copes with the social isolation he's felt since his wife's passing over six years ago.
For Dan Gleason of Fredericton, N.B., bouts of loneliness are a common thing. But the feeling of isolation, he said, is deepest at the dinner table.
"I turn on the TV in order to take my mind off of being alone when I'm eating," he said. "I used to like some type of interaction over food."
Gleason has two adult children who live in different cities. He's been living alone for over six years, since losing his wife in a traffic accident.
He said there are days when he doesn't have any social interactions. "I'm aware of my desire for social contact, but I'm also not really doing anything to change it."
Gleason told Checkup host Duncan McCue how he copes.
Duncan McCue: I understand you live alone, Dan.
Dan Gleason: Yes, I do. I've lived alone for over six years now. My wife was killed in a traffic accident here in Fredericton.
DM: I'm sorry to hear that.
DG: My two adult children, one lives in Halifax, one lives down in Washington, D.C., and I go to visit them, but I choose to live alone. I like it here very much. And I'm ambivalent. I'll put it like that. I am aware of my need for social contact. Today, I didn't have any social contact except that I went out snowshoeing and talked to a couple of people and then yesterday, I did some shopping, but I didn't have any contact with friends.
But I also see that there are some positive things about living alone. You have freedom, you have independence. You have, maybe, the lack of complications that you might have with a social interaction. So, I'm aware of my desire for social contact, but I'm also not really doing anything to change it.
DM: There are absolutely benefits to solitude as well, for sure. Being alone isn't necessarily equivalent to loneliness. But I wonder, do you ever experience that loneliness?
DG: I guess I'm aware of it when eating alone, for sure. Live alone means eating alone.
DM: Why eating alone? Why does that seem to exacerbate it?
DG: I used to like some type of interaction over food and well, I turn on the TV in order to take my mind off of being alone when I'm eating, that's for sure.
DM: And so here's the thing. You're not alone. The statistics for people living alone have just risen dramatically. I'm looking at them now. In 1951, there were 7 per cent of Canadian households were one person households, in 2016, 27 per cent—one in four are one person households. More and more people are living on their own and I wonder if that has something to do with the loneliness.
DG: Yeah, I think so. There are senior centres here in Fredericton—a couple. I have gone to both of them and there is one in particular that I have to say is very helpful to me. I've gotten involved in doing some woodworking and I don't have any background in that, but there's a project I'm doing and the places were very well equipped and the people who go there are very helpful. I tell them about my project, what I want to do and they tell me what machines I should be using and how to use it.
That's an involving, positive thing for me. I admit there are services that I do benefit from. I'd say one thing that I might benefit from is just some type of health counselling. You talk about government doing something, well maybe I should use some of that type of thing if it existed.
DM: So do you think the government should get involved as they have in the U.K.?
DG: I think that would be a helpful thing for me. I can define that as something that I think is probably a public service in a field of let's say mental health, as opposed to physical health, that the government could help out on.


text:
Purdue Pharma's $12B Tentative Settlement Faces Push Back from State AG's
Purdue Pharma reached a potential $12 billion settlement with 23 states and more than 2,000 individual cases accusing the company of driving the country's opioid crisis.
Under the details of the agreement, the company's owners — the Sacklers —would need to pay $3 billion of the total, apply Purdue for bankruptcy, and dissolve the company.
A new company would then form, continuing to sell the painkiller OxyContin while also donating addiction treatment and overdose reversal drugs.
Tentative $12B Settlement
Purdue Pharma tentatively reached a massive settlement with more than 2,000 local governments after being sued for propagating by the United States' opioid crisis, a move that will reportedly cost the company $12 billion dollars.
The settlement, agreed upon by 23 states, also stipulates that the owners of Purdue — the Sackler family — must relinquish their ownership and pay $3 billion of the grand total over a seven-year period.
Forbes estimates the Sacklers net worth at $13 billion, but the family's penalty might actually end up coming from the sale of their overseas pharmaceutical company Mundipharma. If, however, the Sacklers make more than $3 billion from the sale of Mundipharma, they could end up paying up to another $1.5 billion.
Purdue manufactures OxyContin, an opioid painkiller that many have claimed drove the opioid crisis the country currently faces. The conglomeration of lawsuits against Purdue seeks to hold the company accountable for hundreds of thousands of overdoses beginning in the mid-1990s.
Purdue would also be expected to file for Chapter 11 bankruptcy, effectively dissolving the company. That, in turn, would allow the formation of a new company that would continue to sell OxyContin and other medicine. Money made from those sales would then help pay alleged victims from the lawsuits.
Additionally, Purdue would donate addiction treatment and overdose reversal drugs.
"Purdue Pharma continues to work with all plaintiffs on reaching a comprehensive resolution to its opioid litigation that will deliver billions of dollars and vital opioid overdose rescue medicines to communities across the country impacted by the opioid crisis," the company said in a statement.
Notably, the settlement allows Purdue to avoid publishing an admission of wrongdoing.
The agreement, however, is not finalized. The company's board must still agree to the settlement, and a bankruptcy court judge must also approve it.
If the settlement goes through, Purdue will avoid an upcoming October trial in Cleveland, which would be the first federal trial involving a company potentially being held accountable for the opioid epidemic. Attorneys who support the agreement said it is a better solution than a long trial that might not yield better results.
In August, Johnson & Johnson became the first pharmaceutical company to lose a lawsuit concerning the opioid crisis when it was forced to pay $572 million to the state of Oklahoma. Purdue was also implicated in the same lawsuit, but it settled with Oklahoma to pay $270 million.
In 2007, the company and three executives were forced to shell out $635 million after pleading guilty to lying to doctors and the public about OxyContin's safety.
Response From States
While the settlement would push a large sum across the country, more than half of the states' attorneys general criticized the tentative settlement, arguing the amount to be paid does not offset the amount governments have spent and will need to spend to fight the opioid crisis.
It comes in spite of the executive committee of lawyers representing all of the cases recommended states accept the deal.
Because of their response, that has led some commentators to question whether or not a bankruptcy judge will accept the proposal. Now, some of those state attorneys general — including those for Virginia, North Carolina, and Delaware — said they will go after the Sacklers directly.
"These people are among the most responsible for the trail of death and destruction the opioid epidemic has left in its wake," North Carolina Attorney General Josh Stein said of the Sackler family.
Several Democratic presidential hopefuls have suggested taking criminal action against either the company or potentially the Sacklers through proposed legislation.
"If no Sacklers end up behind bars, an entire class of people will continue to feel that writing a check is the worst thing that will happen to them ever no [matter] what they do," Keith Humphreys, a drug policy expert at Stanford, said.
Don't forget criminal penalties. If no Sacklers end up behind bars, an entire class of people will continue to feel that writing a check is the worst thing that will happen to them ever no what they do.
— Keith Humphreys (@KeithNHumphreys) August 28, 2019
In a statement, the family said it "supports working toward a global resolution that directs resources to the patients, families and communities across the country who are suffering and need assistance. This is the most effective way to address the urgency of the current public health crisis and to fund real solutions, not endless litigation."
Other attorneys representing various states called the agreement a win and "historic."
"Sadly, this agreement cannot bring back those who have lost their lives to opioid abuse," Ashley Moody, the state attorney general for Florida, said, "but it will help Florida gain access to more life-saving resources and bolster our efforts to end this deadly epidemic."
See what others are saying: (New York Times) (CNN) (Washington Post)
Related Topics:DrugsFeaturedhealthjohnson & johnsonLawsuitmundipharmaOpioidOpioid CrisisOpioid EpidemicPurdue PharmaSacklersackler familySettlement
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The letter accused Spotify of "enabling its hosted media to damage public trust in scientific research."
Doctors and Medical Professionals Sign Letter to Spotify
A group of 270 doctors, scientists, and other medical workers signed an open letter to Spotify this week urging the audio platform to implement a misinformation policy, specifically citing false claims made on the "Joe Rogan Experience" podcast.
Rogan has faced no shortage of backlash over the last year for promoting vaccine misinformation on his show, which airs exclusively on Spotify. Most recently, he invited Dr. Robert Malone on a Dec. 31 episode that has since been widely criticized by health experts.
Dr. Malone was banned from Twitter for promoting COVID-19 misinformation. According to the medical experts who signed the letter, he "used the JRE platform to further promote numerous baseless claims, including several falsehoods about COVID-19 vaccines and an unfounded theory that societal leaders have 'hypnotized' the public."
"Notably, Dr. Malone is one of two recent JRE guests who has compared pandemic policies to the Holocaust," the letter continued. "These actions are not only objectionable and offensive, but also medically and culturally dangerous."
Joe Rogan's History of COVID-19 Misinformation
Rogan sparked swift criticism himself in the spring of 2021 when he discouraged young people from taking the COVID-19 vaccine. He also falsely equated mRNA vaccines to "gene therapy" and incorrectly stated that vaccines cause super mutations of the virus. He took ivermectin after testing positive for the virus in September, despite the fact that the drug is not approved as a treatment for COVID.
"By allowing the propagation of false and societally harmful assertions, Spotify is enabling its hosted media to damage public trust in scientific research and sow doubt in the credibility of data-driven guidance offered by medical professionals," the doctors and medical workers wrote.
"We are calling on Spotify to take action against the mass-misinformation events which continue to occur on its platform," they continued. "With an estimated 11 million listeners per episode, JRE is the world's largest podcast and has tremendous influence. Though Spotify has a responsibility to mitigate the spread of misinformation on its platform, the company presently has no misinformation policy."
Rolling Stone was the first outlet to report on the letter from the medical professionals. Dr. Katrine Wallace, an epidemiologist at the University of Illinois Chicago, was among the signees. She told the magazine that Rogan is "a menace to public health."
"These are fringe ideas not backed in science, and having it on a huge platform makes it seem there are two sides to this issue," she said. "And there are really not."
Spotify had not responded to the letter as of Thursday.
See what others are saying: (Rolling Stone) (Deadline) (Insider)
Lili Stenn
In some cities that were first hit by the surge, new cases are starting to flatten and decline.
New Cases Flattening
After weeks of recording-breaking cases driven by the highly infectious omicron variant, public health officials say that new COVID infections seem to be slowing in the parts of the country that were hit the hardest earlier on.
Following a more than twentyfold rise in December, cases in New York City have flattened out in recent days.
New infections have even begun to fall slightly in some states, like Maryland and New Jersey. In Boston, the levels of COVID in wastewater — which has been a top indicator of case trends in the past — have dropped by nearly 40% since the first of the year.
Overall, federal data has shown a steep decline in COVID-related emergency room visits in the Northeast, and the rest of the country appears to be following a similar track.
Data from other countries signals the potential for a steep decline in cases following the swift and unprecedented surge.
According to figures from South Africa, where the variant was first detected, cases rose at an incredibly shocking rate for about a month but peaked quickly in mid-December. Since then, new infections have plummeted by around 70%.
In the U.K., which has typically been a map for how U.S. cases will trend, infections are also beginning to fall after peaking around New Year's and then flattening for about a week.
Concerns Remain
Despite these recent trends, experts say it is still too early to say if cases in the U.S. will decline as rapidly as they did in South Africa and the parts of the U.K. that were first hit.
While new infections may seem to be peaking in the cities that saw the first surges, caseloads continue to climb in most parts of the country.
Meanwhile, hospitals are overwhelmed and health resources are still strained because of the high volume of cases hitting all at once.
See what others are saying: (The New York Times) (The Washington Post) (The Wall Street Journal)
While some districts have implemented protective measures, many teachers say they fall short.
Schools Respond to Omicron Surge
U.S. COVID cases, driven by the omicron variant, are continuously topping new record highs, posing difficult questions for schools resuming after winter break.
According to Burbio, a data firm that tracks school closures, at least 5,409 public schools canceled classes or moved to remote learning by the end of last week due to COVID — more than triple the number at the end of December.
That is still only a fraction of the nation's 130,000 schools, and many of the biggest school districts in the country are still insisting that students come into the classroom.
Los Angeles, which is home to the second-biggest district, is requiring that students at least test negative before they return to school this week.
In the biggest district of New York City, classes have already resumed following winter break. Although the city has said it will double random tests and send home more kits, students were not required to provide negative results.
Teachers Protest In-Person Learning
Teachers in other major districts have protested the local government's decisions to stay open.
One of the most closely watched battles is in Chicago, where students on Monday missed their fourth consecutive day of school due to a feud between the Chicago Teachers Union and Mayor Lori Lightfoot (D).
Last week, the union voted to return to remote learning in defiance of a city-wide order mandating they teach in-person, citing inadequate COVID-19 protections. Lightfoot claimed the conditions were fine and that students were safe, despite record surges, instead opting to cancel classes altogether while the fight plays out.
On Sunday, the union said it was "still far apart" from making any kind of agreement with public school officials after Lightfoot rejected their demands.
Lightfoot, for her part, has said she remains "hopeful" a deal could be reached, but she also stirred up the union by accusing teachers of staging an "illegal walkout" and claiming they "abandoned their posts and they abandoned kids and their families."
Meanwhile, teachers in other school districts have begun to emulate the tactics in Chicago.
On Friday, teachers in Oakland, California staged a "sick-out," promoting 12 schools serving thousands of students to close.
See what others are saying: (The Chicago Tribune) (CNN) (The New York Times)


Hitting cinemas Thursday February 7 is Cold Pursuit, a crime thriller starring Liam Neeson as Nels Coxman, a father seeking revenge for his murdered son.
To celebrate the release of Cold Pursuit, we are giving away five lucky Beat readers the chance to win a double pass to check out the film once it premieres in Australia on Thursday February 7. To enter, simply fill out the form below.
Competition closes Friday February 1.


October 16, 2017 October 8, 2017 / Elizabeth T.
Autumn means it's officially sweater weather, and for one of my first sweaters of the season, I wanted to incorporate delicate and subtle details in to my ensemble to elevate the look for a more feminine outfit.
Although the breezes have been picking up, and it may be getting a bit chilly, LA is still warm enough for shorts. Rather than going for my usual denim cut-offs though, which were my go-to during the summer, I opted for white lace embroidered shorts to create a refined look that's perfect for an autumn lunch date.
While it may be fall already, I'm definitely not going to stop wearing white or lace (or both, actually)!
What I love about lace is that it instantly elevates just about any ensemble, since the delicate detailing is reminiscent of more regal, Victorian styles. The scalloped hem of these shorts also add an element of girlish charm to the overall ensemble, making for a look that's classy, but still fun!
I also wanted to give some more attention to the actual sweater itself. One of the key trends that I've been loving this year has been the lace-up trend. No matter what season, lace-up details seem to keep showing up, and I couldn't help but to pick out fall items that also incorporated this delicate little detail.
Love the detailing on every piece! The lace embroidered shorts did elevate the outfit to more of a date-feel look. The lace-back top added character to the basic sweater. I love my sweaters and to elevate the look, I would either add accessories to it (ie. wear a necklace, pin a broach or fun pins) or just wear a collared shirt underneath to give the sweater a different vibe!
that skirt is so so pretty!!
Nice! I love sweaters for this season!
Thanks love ❤ 🙂 You're too sweet! And me too!
You look so chic babe. Love the cut outs of your skirt and the string on the back.
Love the grey and white combo!
Love this outfit! It's so perfect for fall, not too cold or too warm. Love it.
You look like a porcelain doll! Seriously, please do a skincare post! Love this simple chic fall look babe.
Aww thanks Amy, you're too sweet ❤ 🙂 Heheh and yes, a skincare post will be coming soon, so stay tuned! Hope you had a great week, love!
I love little details that transform the look to something special. Lace is a material which is so perfect to dress up a very simple look. I love these shorts. Have a great week.
Yes, little details like lace and lace up are the best because they're subtle yet sweet 🙂 Thanks love ❤ 🙂 You're too sweet!
You look so lovely!!!!! Obsessed with those lace shorts!
Such a pretty skirt, loving it!
Loving this look! That skirt is so cute!
Love the detailing on every piece! The lace embroidered shorts did elevate the outfit to more of a date-feel look.
Thank you so much love ❤ 🙂 Glad you like the outfit!
I love how you styled the sweater with your lace skirt, very cute!
Thanks girl! ❤ 🙂 You're too sweet!
That laced back is a show stopper. Its simplicity and remarks to comfort are apparent. Your top and bottom colors are well incorporated resulting in a beautiful look.
Thank you so much love ❤ 🙂 Glad you liked the look!
Love the sweater, I'm thinking about getting some sweaters ready for this fall fashion season too. Thanks for the inspiration.
I totally support you wearing lace and white even in the Autumn! I plan on doing so as well! The trick is to style them in a way that's fall appropriate like you did with the sweater! White jeans with a dark sweater or a lacy number with a suede jacket or boots I think would also be great ways to incorporate white into the fall!
Love both the sweater and the shorts! You paired them together in such a perfect way!
Love how you put the sweater and the embroidered shorts together!
I absolutely love lace-up details on a sweater! I definitely feel like they make them look so much more feminine.
This outfit looks so classy! I love wearing light neutral colors. Looks great on you!
I love the simplicity in this outfit. It suites you very well and I love the whole outfit. Love the details.


If you can see how 'neat' my table is, that's what I can describe how's my brain is. After facing SAT in the great hall, added with arcane lexicon which is hardly to be understood, my brain becomes jammed. Furthermore, I have to finish space tunnel work, although I don't have a great role in it.
Having workload in university can be considered as a must for every student. I can't avoid this 'must-have stuff'. So, being a teenager who going to be a full-time adult have to think other than play and relax.
That's why I always remind myself not too feel burden if our lecturer give my friends and I bundles of assignment. Just look at them like my own friend. Besides, works will not arrive to the end once I will be graduated one day. If I want to stop working, be an animal. Being animal is easy;follow your instinct.
I hope you all can hear my morose voice and cry for me (haha). That's all. Just to release the steam in my head, so that the pressure inside can be reduced.
baru brape bulan masuk intec dh jadik camni!!
tahap gaban ko punye usaha!!
keep working hard..all the best!


An important need identified over time, to present who is FAC and what it does, not only produces and sells accessories, but also provides solutions. It ended on the occasion of the 45th anniversary with the opening of the new showroom / lab , a dedicated space for the technical explanation of our products, for the training of customers and installers, where touch the quality and usability of FAC products and Made in Italy solutions, to accompany the customer in the best choice and best suited to the needs of the market. This strong conviction has pushed us to realize this project, which will allow new meetings and new developments with an eye always attentive to innovation.


When an email from Lauren and Martin landed in my inbox, asking me to photograph their wedding at The Holford Estate I was pretty pleased. When they said they wanted photos of their dogs, it was a done deal.
I had met them when I photographed the wedding of Jo and Luke and it was a massive compliment that they got in touch wanting me to photograph their wedding.
As a Holford Estate wedding photographer it was easy for me to create just the kind of pictures Lauren and Martin were after. They knew that they wanted their photos to capture the natural beauty of the place, and be out and about in nature. As well as lots of green/trees/views/flowers – the estate provided us with all of this.
My style of photo taking also suited them both as in Lauren's words, 'I hate formal stuff. I hate having to look a certain way. Or act a certain way. I hate posing seriously for photos and having everyone stare at me.' So I kept things nice and relaxed and didn't set anything up. I just captured what was happening naturally.
Some of these moments included a beautiful outdoor ceremony, dogs eating ice-cream, quite a serious game of rounders and Lauren and Martin having five minutes out together to enjoy the last of the sun.
Lauren looked amazing in her Ivory and Co wedding dress and the stunning flowers by Green Earth Flowers, all made it a day to remember.
This was my first time photographing a wedding at the Holford Estate and I'm hoping it won't be my last!


In a late Friday night tweet, Senate Judiciary Committee Chairman Chuck Grassley extended the deadline originally given to Christine Blasey Ford, the woman who has accused Brett Kavanaugh of sexually assaulting her in high school, to testify before the committee.
"Judge Kavanaugh I just granted another extension to Dr Ford to decide if she wants to proceed w the statement she made last week to testify to the senate She shld decide so we can move on I want to hear her. I hope u understand. It's not my normal approach to b indecisive."
The backdrop: Ford said Thursday that she "would be prepared to testify next week," as long as the committee offers "terms that are fair and which ensure her safety." Grassley originally stated Ford must decide whether she plans to testify by Friday at 5 p.m., then extended it to 10 p.m., and has now extended it once again.
According to CNN, one of Ford's lawyers responded to the 10 p.m. extension in a letter to the committee saying, this has been "cavalier treatment of a sexual assault survivor who has been doing her best to cooperate with the Committee is completely inappropriate."
Kavanaugh has maintained throughout this process that he would like to testify as early as possible regarding the allegation.


text:
PERFORM AUSTRALIA
CLASSES - START HERE
What is an 'acting school'?
What is an acting school?
There are various names for institutions running acting classes. You may have heard some of the following:
Drama school
Acting studio
Theatre school
Screen acting academy
Acting academy
Acting school
Performing arts academy
These are all generic terms and mean roughly the same thing, and tend to be interchangeable, depending on where you come from.
Perform Australia could be happily described as any of these things. Needless to say, there are some nuances to the titles. For instance, a "drama school" generally trains actors for work in the industry; "drama school" implies that classical actor training is taught. A "theatre school" may tend to specialise in theatre over film, while a "screen academy" may focus only on film and television without any reference to theatre. An "acting conservatory" usually means the school thinks of itself as providing practical, workshop-style training attending to the body, voice and mind. Meanwhile, a "performing arts academy" might branch out beyond acting into music and dance. So if you are thinking of going to acting school, make sure you find one which is going to deliver what you are looking for, and doesn't exclude one aspect of acting at the expense of another that you're interested in.
One of the most important things to consider in actor training is the quality of the teachers concerned. Be wary of those who set themselves up as self-styled 'acting gurus', but who really have little or no professional experience to speak of. Make sure you see through the bold claims they make. It's easy to claim their work is "hugely successful" or "highly respected" without any evidence to support it. Take a good look at the teachers' acting CVs – have they trained at a recognised institution? If not, they may have little professional knowledge to draw on, and little of substance to teach. And the awards they list in their resumé – do they come from amateur competitions and settings, or are they industry awards? While the arts landscape has plenty of room for both amateur and professional endeavour, there is a huge difference between the two. You can see some of our teachers and their credentials here.
But what do you do at an acting school? You'll expect to receive "drama training" or "actor training" – that is, lessons on how to act - which may include things like:
Voice training: how to increase your vocal capacity, range and resonance. How to project in a large theatre space. How to improve your articulation. How to work with accents. Singing.
Movement training: how to develop new ways of moving, beyond your existing habits. How to improve posture. How to adopt physical traits to convey character. How to use your body as a communicative tool in storytelling, and how to increase your physical vocabulary. Dance.
Acting technique: how to create believable performances. How to use the techniques of a range of master acting teachers to develop a remarkable performance.
Acting in theatre: how to act in a theatrical environment. How to use space. How to use theatrical devices and explore theatricality. How to rehearse for a stage play.
Acting for camera: how to act for single and multiple cameras. How to adapt performance to the screen environment. How to operate on set. How to apply acting technique to screen performance.
Script analysis: how to mine a script for clues. How to develop a character from a script and bring it to life. How to understand the author's intentions. How to interpret a script for performance.
Auditions: how to maximise your audition opportunities. How to find auditions. How to prepare for auditions. How to deal with audition success and failure. How to manage nerves and put your best foot forward at auditions.
History of theatre, film and television: how to understand a work in its historical, social and political context. How to apply knowledge of other works to your current performance project.
Professional etiquette: how to behave in a theatrical or screen setting. How to meet industry expectations. How to prepare for a role. How to work with others effectively. How to find and apply for work.
Behind each of these things are tremendous fields of academic research, so it's important you choose a school that is up-to-date with the latest learning.
At Perform Australia, we teach all these things – and more! If you are looking for a qualification in acting, which gives you a thorough grounding in all of these things, start with our 10197NAT Certificate IV in Acting for Stage and Screen and you can later move onto the 10295NAT Advanced Diploma of Performance. If musical theatre is more your style, with singing, dancing and acting included, look to the CUA40513 Certificate IV in Musical Theatre as your starting point.
But if you're more after a short acting course, there are a range of courses on offer every term at Perform Australia. Just check out our short courses page, where we have a range of topical courses.
Writers from Perform Australia contribute to these posts
Perform Australia National Headquarters:
11 Whyalla St, Fyshwick ACT 2609 Australia
RTO Number 40859
Launching passion-driven actors
Acting classes and courses for children and adults, acting qualifications, musical theatre courses, singing lessons, corporate training around Australia


text:
Q: How to format strings in Scala? I need to print a formatted string containing scala.Long.
java.lang.String.format() is incompatible with scala.Long (compile time) and RichLong (java.util.IllegalFormatConversionException)
Compiler warns about deprecation of Integer on the following working code:
val number:Long = 3243
String.format("%d", new java.lang.Long(number))

Should I change fomatter, data type or something else?

A: @Bruno's answer is what you should use in most cases.
If you must use a Java method to do the formatting, use
String.format("%d",number.asInstanceOf[AnyRef])

which will box the Long nicely for Java.

A: You can try something like:
val number: Long = 3243
"%d".format(number)

A: The format method in Scala exists directly on instances of String, so you don't need/want the static class method.  You also don't need to manually box the long primitive, let the compiler take care of all that for you!
String.format("%d", new java.lang.Integer(number))

is therefore better written as
"%d".format(number)

redpajama_set_name: RedPajamaStackExchange


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text:
Q: Openjpa mappedsuperclass in a separate jar We are trying to build some services with entities that have common fields between them. To handle this the approach we have taken is to define a base class with all the common fields and extend all the others from this.
The base class is defined as a mapped superclass and the derived classes are regular entities. At the class level, the entities extend the base class.
To keep it modular, we have defined the base class in a common project (maven based) and in the entities in separate projects with a dependency on this common project.
The problem is that it doesn't identify/parse the mappedsuperclass. It is unable to resolve the common mappings.
So, my question is, whatever I am trying to do here, does it conform to the JPA rules/spec.
If I define the mappedsuperclass in the same mappings xml as the concrete one, it works fine. But then I have to repeat that for each project, which I want to avoid.
Here are some code snippets for the classes and mappings.
Also note here that the common mapped super class also defines a common primary key viz. ID.
The base class:
public class BaseEntity {
    String id;
    String status;
    Date createdDate;
    String createdBy;
    Integer versionNumber;

    //getters and setters for these fields
}

Mapping xml for the base class
<entity-mappings>
    <package>mypackage</package>
    <mapped-superclass class="mypackage.BaseEntity">
        <attributes>
            <id name="id">
                <column name="ID" />
            </id>
            <basic name="status">
                <column name="STATUS"/>
            </basic>
            <basic name="createdDate">
                <column name="CREATED_DT" />
            </basic>
            <basic name="createdBy">
                <column name="CREATED_BY" />
            </basic>
            <version name="versionNumber">
                <column name="VERSION_NUMBER" />
            </version>
        </attributes>
    </mapped-superclass>
</entity-mappings>

The persistence xml for this
<persistence>
    <persistence-unit name="test" transaction-type="RESOURCE_LOCAL">
        <provider>org.apache.openjpa.persistence.PersistenceProviderImpl</provider>
        <mapping-file>META-INF/jpa/CommonMappings.xml</mapping-file>
        <properties>
            <property name="openjpa.RuntimeUnenhancedClasses" value="supported"/>
        </properties>
    </persistence-unit>
</persistence>

These are packaged in a separate jar.
The concrete entity
public class MyEntity extends BaseEntity {

    String name;
    String address;

    //getters and setters
}

mappings for concrete entity
<entity-mappings>
    <package>mypkg2</package>

    <entity class="mypkg2.MyEntity" name="MyEntity">
        <table name="MYENTITY"/>

        <attributes>
            <basic name="name">
                <column name="NAME"/>
            </basic>

            <basic name="address">
                <column name="ADDRESS"/>
            </basic>
        </attributes>
    </entity>

</entity-mappings>

The persistence xml for the concrete entity
<persistence>
    <persistence-unit name="test" transaction-type="RESOURCE_LOCAL">
        <provider>org.apache.openjpa.persistence.PersistenceProviderImpl</provider>
        <mapping-file>META-INF/jpa/MyEntityMappings.xml</mapping-file>
        <properties>
            <property name="openjpa.RuntimeUnenhancedClasses" value="supported"/>
        </properties>
    </persistence-unit>
</persistence>

Edit: (based on dkaustubh's suggestion)

It works if I use annotations on my Base Entity. I have left the mappings for the derived entities in XML.
However, I want to keep the mappings consistent and would like to define it using XMLs. Why does it work with annotations but not with XML mapping?

A: You can keep the base class in separate jar but you need to define it in the same persistence.xml.
Now coming to your question of not repeating the mapping for each mapping xml, you can better use annotation on your base entity. Such a way you need not repeat your mapping xml.


text:
APDE
Conchi Paniagua Valiente
Director and founder of Centro "El Lucero"
"Whatever you can do or dream you can, begin it; Boldness has genius, power, and magic in it~ Goethe".
~ Goethe
Born in Madrid on October 9, 1974, the only child of Julia and Juan, Conchi grew up in the neighborhood of Villaverde Bajo (Madrid). Is in that neighborhood where she began what will culminate in Centro El Lucero, located in Cortes quarter in Madrid.
Conchi Paniagua was close, since her childhood, to the echoes of the flamenco coming from the gypsy villages of her native Villaverde. However, these flamenco echoes did not capture the attention of a restless and awake girl who seemed, in her eyes, to be always looking for something that only she knew it existed, but didn't know where to find it. Conchi, as our heading introduces, was born with the boldness that Goethe placed as the epicenter of great creative personalities.
She usually listened to copla from a cousin who was a cantaora (flamenco singer), and at weddings where her family took her there was always some flamenco as well. She didn't seem to be attracted to either jondo or Spanish singing, which in the Spain of the seventies were confused and alternated.
The flamenco "duende" (known as the magic some flamenco artists get to achieve on stage and convey to the public) is not key to flamenco itself but appears according to the environment, the moment, and how one is destined to participate in it. When Conchi was a child, she said that she did not like flamenco and when she did not say it, she thought of it but at the same time she was fascinated when her aunt Nati sang coplas of the Spanish singer Mari Fé de Triana. The love for her aunt woke up a "duende" in Conchi that she still could not recognize but that would mark her life.
During her youth, she met Raúl, a man who made her fall in love while listening to Rafael Farina and Grupo Barrio. From here, Conchi's life will always be entangled with flamenco and she will have a partner with whom to start a family. It will take a while for Conchi to recognize the "duende" as a true travel companion, but like that tickle that guides people destined to creativity of their own, she will not cease to provoke in her restlessness, to imbue her with projects, and to give her a push to carry them out.
While she felt deeply loved by her aunt, there was not much love in her home: neither between her mother and father nor for her. The lack of love in her childhood made her stronger and lead her to grow up with a fierce commitment to improve herself and to face adversity.She was a good student at school and high school but she didn't enter the university because she needed to find her own path. The world, for the time being, had lost a brilliant lawyer.
If we look at her formal education, Conchi studied Business Administration, Accounting, and computer science. From 1994 to 2004, she worked as a freelancer for the construction company of Raúl. They got married and together they started a specialized construction company managed by Raúl and in which, besides the purely administrative management, Conchi starts to be in charge of the human resources department.
At this point in our story, it could seem that Conchi's passion for flamenco had fallen asleep and hide behind her business activity, later on we will see that nothing could be further from the truth. Conchi, with Raul, is the mother of Daniel, María, and Elena.
María has inherited from her mother her love for flamenco and has grown up into an excellent flamenco dancer. Elena, the little sister, follows the path of María with her own dancing style and has a promising future in flamenco.
In 2017, Conchi became a partner of the "Centro Flamenco Foundation", later renamed Foundation Dolores Jiménez. One year later, Conchi embraces her passion for flamenco with all her love and determination by founding the School of Dance and Flamenco 'El Lucero', located in the street Marqués de Cubas 25, in Madrid.
Thus, since then, Conchi runs this center offering a wide range of workshops, flamenco and dance lessons, and wellness courses.
El Lucero smells of carnations because this was the first smell of flamenco that Conchi remembers. All El Lucero's rooms smell of orange and cinnamon because they are the natural essences that inspire Conchi as well as El Lucero's project. Anyone experiencing the tingling feeling of passion for arts is welcomed and expected at El Lucero.
Barrio de las Letras in Madrid (Madrid's literary quarter) June 5, 2020.
Luna Genovés,
Escritora de El Lucero
Cajón Flamenco
Danza estilizada
Meditación Chi Kung
Alquiler de salas para clases y grabación
Lunes a Sábado de 11:00 a 21:00 horas
© Copyright 2019 Centro El Lucero - Marqués de Cubas street 25. Madrid SPAIN. +34 918 448 080 info@centrolucero.com | Legal notice | Cookies policy


We are officially in February. The month of Love 💕 after January which will forever be known as the longest month in the history of the world, I think we are all in need of a little TLC.
With Valentine's Day just around the corner now is the time to have your outfit sorted. Especially if you plan to buy online. You are going to want time for delivery and any changes of mind.
Pink is definitely the new red this year and pink and red together is outfit goals.
We all seen Pippa O'Connor absolutely killing it in her pink suit for the Xpose and Benefit Awards and if you didn't you need to go check that out straight away. So I have added a cheaper , but still brilliant, River Island version of her outfit below too.
A lot of the clothing is from River Island , I am a huge fan and I love everything they have at the minute.
Remember if you order in pound it might work out cheaper for you. Always on the hunt for a good bargain. MissPap, Zara and Boohoo also make an appearance.


text:
Q: Question about kernel and homomorphism I was wondering is there any reason we take the identity e` for the kernel for ring homomorphism to be the additive identity instead of the multiplicative one?

A: Here's a line of reasoning that leads to this definition of kernel: among groups, one has the isomorphism $G/\text{ker}\varphi\cong \text{im}\varphi$, where $\varphi$ is any homomorphism out of $G$. This is a constantly useful theorem, so we'd like something equivalent for rings. And it's the usual definition of kernel as the inverse image of zero that gets us this theorem. As commenters have mentioned, this rests on the fact that the kernel is an ideal, so that $R/\text{ker}\varphi$ is at least a ring; in contrast the inverse image of the multiplicative identity is just some multiplicative submonoid of $R$, so that the best kind of isomorphism theorem you could get out such a "kernel" would be an isomorphism of monoids. And that's not very useful.

A: One reason is that the idea kernels in general works best with groups.
For a group homomorphism $f$ the kernel tells us something interesting about what happens to elements under $f$, namely that $f(a)=f(b)$ exactly when $ab^{-1}$ is in the kernel of $f$. This relation depends on taking the inverse of either $a$ or $b$, so it doesn't work well if we try to use it with something else than a group, where elements may not have inverses in general.
Kernels work for rings, vector spaces and so forth because these structures can all be described as an abelian group with some extra structure. In the case of a ring, the additive group is the only group structure in sight, so if we want to speak of kernels, it is the identity element of that group we want the preimage of.
If we're speaking of fields we almost have a multiplicative group -- but not quite; 0 is not a member of the multiplicative group. And speaking of kernels is not very relevant in the case of fields anyway, because a field homomorphism is necessarily injective, so having an object that tells us when $f(a)=f(b)$ is not really useful.


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Double doors feature 3 built-in steel shelves.
Heat- and scratch-resistant melamine top can hold a microwave, coffee machine or other breakroom equipment. 29 1/4"W x 20 1/2"D surface cleans with an easy wipe!
Double doors feature 3 built-in steel shelves. Each shelf has a lip to secure contents in place. Interior shelf measures 25"W x 11 3/4"D and is height adjustable.


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IJCY1-Is Jesus Calling You with Fr. Paul Hoesing episode 1 – Discerning Hearts podcast
https://media.blubrry.com/discerninghearts/p/discerninghearts.com/Hoesing/IJCY-1.mp3
Is Jesus Calling? A Spiritual Guide to Discerning Your Vocational Call with Fr. Paul Hoesing – episode 1: Introduction – Whether it's to the priesthood, religious life, married life…discerning what our vocation is can be a challenge, but it doesn't have to be. Fr. Hoesing discusses what discernment is, what the process is like, and what can help guide us along the way.
Based on "Is Jesus C alling You To Be A Catholic Priest: A helpful guide", published by National Conference of Diocesan Vocation Director.
Fr. Paul Hoesing serves at Kenrick-Glennon Seminary as Dean of Seminarians & Director of Human Formation
DWG6 – "What am I to do?" The Discernment of God's Will in Everyday Decisions w/Fr. Timothy Gallagher
Episode 6 "What am I to do?" The Discernment of God's Will in Everyday Decisions w/Fr. Timothy Gallagher
This episode offers Fr. Gallagher discusses the call to the marriage vocation and the call to the religious life. What are the differences found in each and how do we begin to discern our call.
https://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/Gallagher/DWG6.mp3
For other episodes in the series visit The Discerning Hearts "Discerning the Will of God" page
Father Timothy M. Gallagher, O.M.V., was ordained in 1979 as a member of the Oblates of the Virgin Mary, a religious community dedicated to retreats and spiritual formation according to the Spiritual Exercises of St. Ignatius. Fr. Gallagher is featured on the EWTN series "Living the Discerning Life: The Spiritual Teachings of St. Ignatius of Loyola".
For more information on how to obtain copies of Fr. Gallaghers's various books and audio which are available for purchase, please visit his website: frtimothygallagher.org
For the other episodes in this series check out Fr. Timothy Gallagher's "Discerning Hearts" page
Spousal Prayer – A Way to Marital Happiness Talk 1 with Fr. Paul Hoesing
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/Hoesing/Spousal-Prayer-Fr.-Hoesing.mp3
This is talk 1 of a 2-part presentation on "Spousal Prayer – A Way to Marital Happiness" based on the book by Deacon James Keating Ph.D. as offered by the Family Life Office of the Archdiocese of Omaha.
Fr. Paul Hoesing offers the first reflection on this subject. He discusses the value of silence and receptivity in our prayer. Then he moves on to the fundamental elements of "Spousal Prayer": Beholding, Listening, Forgiving.
Here are the images Fr. Hoesing references in this talk:
Fr. Paul Hoesing serves as the Vocation Director for the Archdiocese of Omaha, NE. He also serves as the President of the The National Conference of Diocesan Vocation Directors which promotes diocesan priesthood, providing resources for the formation, support, and advocacy of diocesan vocation directors as they work within the Catholic Church to foster a culture of vocations, raising up new priests for the Body of Christ.
You can purchase the book here
IP#250 Dr. Christopher Kaczor – 7 Big Myths about Marriage on Inside the Pages with Kris McGregor
In"The Seven Big Myths about Marriage: What Science, Faith and Philosophy Teach Us about Love and Happiness", Dr. Christopher Kaczor,
along with his wife Jennifer, shines an important light of truth on one of the most important issues of our day. Beginning with basic foundational principals and understandings, Dr. Kaczor rationally examines key issues in the marriage debate and carefully, and quite thoroughly, debunks the leading "myths" about marriage. An excellent resource and HIGHLY recommended for all who care about and engage in the discussions on marriage.
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/interviews/Inside_the_Pages-Dr._Christopher_Kaczor_7-Big-Myths-Marriage.mp3
If I were a pastor, I would make this book required reading for engaged couples in all my marriage classes. —Peter Kreeft, Ph.D., Author, Jacob s Ladder: Ten Steps to Truth
The media portrayals of the public debates over marriage and its meaning often generate more heat than light. In this carefully crafted and accessible book, Professor Kaczor provides just the sort of illumination that is absent from those portrayals. I cannot think of a better book that offers such a clear and winsome account of marriage and its meaning, and what that tells us about human dignity and happiness. —Francis J. Beckwith, Professor of Philosophy, Baylor University
'Don't miss:
IP#182 Dr. Christopher Kaczor – The Seven Big Myths About the Catholic Church on Inside the Pages
RN28 – Regnum Novum – "The Family, the Vital Cell of Society" in the Compendium of Social Doctrine Chap 5
Episode 28- Regnum Novum: Bringing forth the New Evangelization through Catholic Social Teaching with Omar Gutierrez
– We continue the study of the "Compendium of the Social Doctrine of the Church" Chapter 5
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/Omar/RN-28.mp3
THE FAMILY, THE VITAL CELL OF SOCIETY
I. THE FAMILY, THE FIRST NATURAL SOCIETY
a. Importance of the family for the person
b. Importance of the family for society
II. MARRIAGE, THE FOUNDATION OF THE FAMILY
a. The value of marriage
b. The sacrament of marriage
We live at a very special time. The confluence of many things has brought forth the clear need to be able to articulate the Social Teaching of the Catholic Church in a way that is accessible and applicable. This is not to be an effort where high-minded theories are to be bandied about. Rather, this is a time of opportunity wherein we can apply the Social Doctrine to the concrete so as to bring about a New Kingdom, a Revolution. – Omar G.
Also visit Omar's "Discerning Hearts" page Catholic Social Teaching 101
RN29 – Regnum Novum – "Marriage, the foundation of the family" in the Compendium of Social Doctrine Chap 5
– We continue the study of the "Compendium of the Social Doctrine of the Church" Chapter 5 – What is marriage?
Podcast: Play in new window | Download (53.3MB) | Embed
III. THE SOCIAL SUBJECTIVITY OF THE FAMILY
a. Love and the formation of a community of persons
b. The family is the sanctuary of life
c. The task of educating
d. The dignity and rights of children
IV. THE FAMILY AS ACTIVE PARTICIPANT IN SOCIAL LIFE
a. Solidarity in the family
b. The family, economic life and work
V. SOCIETY AT THE SERVICE OF THE FAMILY
USCCA23 – The Sacrament of Marriage Part 1 – U. S. Catholic Catechism for Adults w/ Arch. George Lucas
USCCA23 Chapter 21 The Sacrament of Marriage Part 1
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/archbishoplucas/USCCA-21-part-1.mp3
Archbishop Lucas offers insights on the US Catholic Catechism for Adults Chapter21:
The first effect of the Sacrament of Matrimony is the gift of the bond between the spouses. "The consent by which the spouses mutually give and receive one another is sealed by God himself" (CCC, no. 1639). "The marriage bond has been established by God himself in such a way that a marriage concluded and consummated between baptized persons can never be dissolved" (CCC, no. 1640).
United States Conference of Catholic Bishops (USCCB)
The Most Reverend George J. Lucas leads the Archdiocese of Omaha.
For other episodes in the visit our Archbishop George Lucas page
This programs is based on:
We wish to thank the USCCB for the permissions granted for use of relevant material used in this series.
Also we wish to thank Matt Willkomb for his vocal talents in this episode.
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USCCA38 – The 6th Commandment: Marital Fidelity Part 1 – U. S. Catholic Catechism for Adults w/ Arch. George Lucas
USCCA38 Chapter 30 – Marital Fidelity pt 1
Archbishop Lucas offers insights on the US Catholic Catechism for Adults Chapter 30:
The Catechism states that sexuality involves the whole person. "Sexuality affects all aspects of the human person in the unity of his body and soul. It especially concerns affectivity, the capacity to love and to procreate, and in a more general way the aptitude for forming bonds of communion with others" (CCC, no. 2332).
The Sixth Commandment summons spouses to practice permanent and exclusive fidelity to one another. Emotional and sexual fidelity are essential to the commitment made in the marriage covenant. God established marriage as a reflection of his fidelity to us. The vows made by the spouses at their wedding to be faithful to one another forever should witness the very covenant God has made with us.
United States Conference of Catholic Bishops (USCCB) (2012-04-02). United States Catholic Catechism for Adults (Kindle Locations 5856-5861). United States Conference of Catholic Bishops (USCCB). Kindle Edition.
God's Plan for Marriage
IP#188 Dr. Robert George – What Is Marriage? Man and Woman: A Defense on Inside the Pages
Dr. Robert George, Princeton professor of Philosophy, discusses why we must first answer the question of what marriage really is
before we can begin to defend the institution of marriage. He, and his co-authors, contend that marriage is a comprehensive union of mind and body, a conjugal union, ordered to family life, which unites a man and a woman as husband and wife. They document the social value of applying this principle in law.
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/interviews/Inside-the-Pages-Robert-George-What-is-Marriage.mp3
What Is Marriage? decisively answers common objections: that the historic view is rooted in bigotry, like laws forbidding interracial marriage; that it is callous to people's needs; that it can't show the harm of recognizing same-sex couplings, or the point of recognizing infertile ones; and that it treats a mere "social construct" as if it were natural, or an unreasoned religious view as if it were rational.
"With many countries on the verge of redefining a basic social institution, What Is Marriage? issues an urgent call for full deliberation of what is at stake. The authors make a compelling secular case for marriage as a partnership between a man and a woman, whose special status is based on society's interest in the nurture and education of children."
— Mary Ann Glendon, Learned Hand Professor of Law, Harvard University
MIL#1 Marriage in the Lord w/ Deacon James Keating – Episode 1
Episode 1 -Marriage in the Lord with Deacon James Keating –
Deacon James Keating, PhD, explores the theological and spiritual meaning of the Sacrament of Marriage. Using the Catechism of the Catholic Church as a touchstone, Deacon Keating challenges listeners to go to the depths of what it means to be married in the Lord.
http://media.blubrry.com/discerninghearts/p/www.discerninghearts.com/Keating/MIL1.mp3
From the Catechism of the Catholic Church:
2364 The married couple forms "the intimate partnership of life and love established by the Creator and governed by his laws; it is rooted in the conjugal covenant, that is, in their irrevocable personal consent." Both give themselves definitively and totally to one another. They are no longer two; from now on they form one flesh. The covenant they freely contracted imposes on the spouses the obligation to preserve it as unique and indissoluble. "What therefore God has joined together, let not man put asunder."
Deacon James Keating, PhD, the director of Theological Formation for the Institute for Priestly Formation, located at Creighton University, in Omaha, is making available to "Discerning Hearts" and all who listen, his series of programs entitled "Marriage in the Lord"
For other episodes in this series visit here
For more information on the "Institute of Priestly Formation" and for other material available by Deacon Keating, just click here
Don't forget to pickup a copy of "Marriage in the Lord" ,it is one of the best audio sets on the Sacrament of Marriage…ever!
Check out Deacon Keating's "Discerning Heart" page
2331 "God is love and in himself he lives a mystery of personal loving communion. Creating the human race in his own image . . .. God inscribed in the humanity of man and woman the vocation, and thus the capacity and responsibility, of love and communion."115
In this episode, Deacon Keating reflects on the Sacrament of Marriage and the liturgy of the Church in which it is celebrated. Where the wedding occurs says much about how the couple perceives the gravitas of the marriage commitment. He then discusses the questions that are asked of the couple at the beginnings of the liturgy. Can they answer the questions with integrity.
In this episode, Deacon Keating continues to reflect on the Sacrament of Marriage and the liturgy of the Church in which it is celebrated. Where the wedding occurs says much about how the couple perceives the gravitas of the marriage commitment. He then discusses the questions that are asked of the couple at the beginnings of the liturgy. Can they answer the questions with integrity. He also addresses the question of cohabitation and sex outside of marriage.
In this episode, Deacon Keating continues to reflect on the Sacrament of Marriage and the liturgy of the Church in which it is celebrated. The area of the vows given one to the other is explored. The covenant relationship as opposed to the contract nature of marriage.
In this episode, Deacon Keating continues to reflect on the Sacrament of Marriage and the liturgy of the Church in which it is celebrated. The blessings of rings as signs of love and fidelity. The importance of having the mass celebrated in the celebration of marriage is also discussed.
IP#133 Greg and Julie Alexander – Marriage 911 on Inside the Pages
In "Marriage 911: How God Saved Our Marriage (and can save yours, too!)", we meet
Greg and Julie Alexander, a great and courageous couple. They candidly share the trials of what they felt was a lifeless, loveless marriage on the verge of divorce. Married in the Church, they began the process of seeking a way out of their union. Unexpectedly they encountered a faithful caring priest, who shared with them the Church's understanding of marriage, and through incoporating those truths, revived and revitalized their sacramental relationship and their family as well. Now married over 20 years, they offer emergency hope and guidance to couples struggling in a similar conditions through their "Alexander House" non-profit marriage and family life enrichment apostolate. Visit their outstanding website http://www.thealexanderhouse.org/
http://media.blubrry.com/discerninghearts/p/discerninghearts.com/interviews/Inside_the_Pages-Greg_and_Julie_Alexander.mp3
Their breakthrough work in marriage has been featured on EWTN and talk radio, as well as in many publications, including Patrick Madrid s Surprised by Truth 3, Envoy, Catholic Herald, Denver Catholic Register, and Our Sunday Visitor.
Francis Cardinal Arinze speaking on Marriage, Family Life and the Challenge of Infertility
Cardinal Arinze spoke with
couples struggling with the challenge of infertility in Omaha on September 20, 2011.
http://media.blubrry.com/discerninghearts/p/discerninghearts.com/interviews/Cardinal_Arinze_on_Marriage_and_Infertility.mp3
We apologize for some of the noise in the recording. The microphone was inadvertently attached to a file on the podium and was jostled during the talk…it's not that bad and the talk is fantastic!
Francis Cardinal Arinze discussed the value of the marriage relationship and it's contribution to the personal growth of the couple, it's activity in the community and in the life of the Church. Cardinal Arinze goes on to talk about motherhood and fatherhood even when a couple do not have natural children of their own. The joy of giving, as opposed to grabbing…the gift of joy. He speaks of the example of priesthood and of St. Teresa of Calcutta (" The Smile of God"). "Sacrificing yourself for others the sun begins to shine".
Event sponsored by the Pro Sanctity Movement


Festival della Dieta Mediterranea | Pollica, Vivere Mediterraneo.
Meetings, tastings, excursions, theatrical performances, even for smaller, and musicals, wine tasting laboratories, book presentations and other initiatives dedicated to the food and life model theorized right at Poplars, where he lived for 40 years by the American scientist Ancel Keys and his wife Margareth. A unique opportunity to learn about the Mediterranean diet at 360 degrees, from food and wine to everyday habits, with benefits for health and quality of life; Learn, thanks to the wisdom of the homemakers of Pollica, how to prepare traditional dishes; Discover, through guided tours along the paths, the beauties of the Territory. Why, as Ancel Keys observed, the Mediterranean diet is first and foremost sharing and conviviality, in a word of life.


Snack food consisting of small pieces of crunchy noodles (called Murmur in i-taukei local Fijian language) made from chickpea pea flour paste. A wonderful addition to Raita for dinner or side dish for your afternoon tea.
* May contain traces of peanuts and or tree nuts.