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Erykah Badu releases a phone-themed mixtape
Inspired by her remix of Drake's "Hotline Bling," singer Erykah Badu's "But U Caint Use My Phone" is chock full of samples and phone references.
Jimmy Fallon pens Thanksgiving thank you notes
This year for Thanksgiving, Jimmy Fallon penned some thank you cards we all we wish we could write.
"Star Wars: The Force Awakens" shows new trailer
On Thursday, "Star Wars: The Force Awakens," released an all-new trailer on its Facebook page.
'NCIS''s Michael Weatherly reportedly arrested
TMZ reports the "NCIS" actor was "well above the legal limit" when officers allegedly pulled him over.
Thanksgiving Eve is special for Nathan Lane
The night before Thanksgiving is a special night for many people. But it holds a particularly vivid memory for actor Nathan Lane.
Jennifer Lawrence might take a shot at directing
Jennifer Lawrence has signed on to direct "Project Delirium," a film about mental warfare in the 1960s.
Going to the Show
2015 Detroit Auto Show DatesJanuary 12-13: Media Preview
January 14-15: Industry Preview
January 16: Charity Preview Gala
January 17-25: Open To Public!
January 23: WXYZ Family Day
2015 Detroit Auto Show HoursWed, January 14: Noon - 9 p.m.
Thu, January 15: 7 a.m. - 9 p.m.
Fri, January 16: 6 p.m. - 9 p.m. (Black-tie)
Sat, January 17 - Sat, January 24: 9 a.m. -10 p.m.
(no admittance after 9 p.m.)
Sun, January 25: 9 a.m. - 7 p.m.
(no admittance after 6 p.m.)
The show takes place at Detroit's Cobo Center. For parking information and to purchase tickets in advance, visit the official NAIAS website.


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Randomly, spontaneously, we decided to cook down the many gallons of maple sap that we've collected in the past few days. We've been cooking it slowly as we go (on the kitchen stove of all places) but Pete and Sage build a simple maple cooker out of a dozen cinder blocks today.
So we went for it.
We started cooking mid-afternoon, and the next thing I knew we had spent the day outside in the sunshine around the fire.
Not too shabby for a random Wednesday.
When we got hungry we had a perfectly balanced meal of hot maple sap, organic hot dogs, and last year's dilly beans from the cellar. (Yes, some days not going in to cook trumps a healthy meal.)
There was music, laughter, books, woodsmoke, and steam.
And then it was time to call it a night.
Long after bedtime might have been we wandered inside for warmed raw milk with ghee (to help little ones sleep and fill any empty spots left in tummies after our questionable dinner). Then – still laughing – everyone tucked in for the night.
Spring in the country. Maple sap. Woodsmoke. Steam. Bald eagles. Sandhill cranes. Music. Handknits. Magic. Stars. Peace.
More goodness than my heart can hold.

domain: food


Samsung to Use Sony Batteries in Galaxy S8 and Galaxy S8 Plus Phones
Friday, 17 February 2017 After two recalls, the discontinuation of a flagship phone, internal and independent investigations, we can safely say that Samsung won’t be taking any chances when it comes to the battery inside its upcoming Galaxy S8 and Galaxy S8 Plus phones. A recent report by the Wall Street Journal reveals that Samsung has selected Sony as the third battery supplier for the Galaxy S8. Samsung will be receiving lithium-ion batteries for the Galaxy S8 from Japan’s Sony Corporation. We don’t expect the two companies to confirm this information until the phone is launched. Sony will be third battery supplier for the Galaxy S8, the others are Japan’s Murata Manufacturing and Samsung SDI, the affiliate company that provided batteries for the Galaxy Note 7. There’s much controversy surrounding the South Korean giant’s division, considering that the first recalled...
Burning batteries has been a problem with Samsung recently, especially since last year's Galaxy Note 7 phone had defective batteries, prompting for a recall and discontinuation of the phone. According to Reuters on Wednesday, its sister company Samsung SDI was hit by a minor fire involving faulty...
Electronics giant Samsung will this week offer an unusually early software update for its newly- released Galaxy S8 phone, it said today after some consumers... DNA - Front PageAlso reported by •The Verge •Softpedia •betanews
Microsoft, the developer of Windows Phone/Windows 10 Mobile, is becoming more involved in the Android ecosystem, not only with apps developed to run on... Softpedia - TechnologyAlso reported by •The Verge
Today, Samsung announced the commercial launch of its Galaxy S8 and Galaxy S8+ flagships in select markets around the world, including the US, Canada, Puerto... Softpedia - TechnologyAlso reported by •BGR India
Samsung's new flagship Galaxy S8 and S8+ smartphones went on sale today in the U.S., Canada, Puerto Rico, and Korea, as the company looks to rebound from last... MacRumours.com - Computer IndustryAlso reported by •Softpedia


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A friend’s Facebook post was my first hint that Knoxville had a new Korean restaurant. Your photos were enticing enough for me to plan a dinner visit at Q Korean Steakhouse with The Grub Spouse.
We had viewed the menu online but the way it explained the food format left me with more questions than answers. It wasn’t until we interacted with our server that we understood how the menu was set up.
The à la carte area offers a variety of pork, beef and seafood dishes such as grated pork belly, boneless short ribs and shrimp. You can also start with an appetizer like the K seafood pancake (made from shrimp and squid) or a serving of japchae (fried noodles). There are also combo dinners, each serving a choice of seven to eleven different dishes. Price points range from $ 99 for a combination for two or three people to $ 139 for a combination for four to five people.
However, we decided to try what is obviously the most popular menu option, the unlimited dinner. For $ 29.99 per person (minimum two people), choose three types of meat from 17 chicken, pork, beef, and seafood dishes. When you’ve done this, you can order three more types of meat. (Everyone in your group must agree on the three types of meat you choose. For example, one person cannot order soy chicken, pork belly, and brisket, while another person orders three completely different dishes.)
You start with a common serving of salad and a choice of four side dishes. The menu includes spicy rice cakes, vegetable rice, kimchi, and beef soup, but the side dishes we were actually served that night included kimchi, a radish and jalapeño mix, another variety of radishes, and cucumbers. Like kimchi, the other vegetables were fermented and gave us plenty to eat while our meat was cooked.
And this is one of Q’s distinctions. Each table is essentially a gas grill. Your server places the meat on the removable metal grill surface (every party starts with a clean grill) and cooks them one at a time in the order you prefer. We started with the beef bulgogi, then moved on to teriyaki chicken and finally shrimp (two per person).
Once our waiter got the beef going, she moved around other tables and came back regularly to turn the meat and make sure it was thoroughly cooked. The beef didn’t take long and when it was ready our waiter said we could either eat it straight from the grill or transfer it to our plates. Each dinner is also given a bowl of rice. I decided to put pieces of beef on my plate along with rice and start the more traditional way. It’s not the leanest piece of beef, a bit stringy, but the grill flavor was wonderful.
Next came the chicken, which took a little longer to cook thoroughly. I had read reviews online complaining about waiters who undercook the chicken, but in this case customers can check for themselves and leave the meat on the grill until satisfied that it is fully cooked, just like at home. At this point, I got tired of plate transfers and started taking my chicken bites straight off the grill. This also resulted in additional cooking time.
That left us with four huge shrimp – heads, limbs, and everything – that we should leave on the grill until they turned from gray to pink. However, by the time it was cooked, they had shrunk to average size. My main complaint was that the clams and antennae were really difficult to peel. When I reached the scarce amount of cooked meat, it was hardly worth it.
Of course, between the side dishes (all you can eat) and the essential servings of beef and chicken, we were stuffed and couldn’t even consider another round of protein. But we found the flavors and experience to be more than satisfactory and our waiter took us very well through the process and helped us make sure our meat selections were thoroughly cooked.
Given that Knoxville doesn’t have a lot of Korean dishes and that table cooking is a fun element, I think Q Korean Steakhouse is at least worth adding to your restaurant queue.
Q Korean steakhouse
The atmosphere: 4th
All in all: 4th
Address: 8851 city and district
Full bar service
Hours: Monday to Sunday from 11 a.m. to 10 p.m.
Try this Korean grill restaurant where the dishes are actually cooked on the table.


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From this September, Széchenyi István University offers 35 programmes in English for its Hungarian and international students, including the newly launched Master of Business Administration (MBA) as well. The 2-year-long programme is the first MBA programme in English in Hungary that is accredited by the Association to Advance Collegiate Schools of Business (AACSB), the most prominent global accrediting body for business schools.
Barnabás Virág, the Deputy Governor of Hungarian National Bank said that that there are more than 16 000 MBA programmes in the world, of which only 5 per cent have received the accreditation of the prestigious association. In Central Europe, Széchenyi István University is the only institution who earned it.
The programme allows students to register at both universities and earn a degree issued at each institution. Upon successful completion, students can receive both an Executive MBA degree at Széchenyi István University and a Master of Business Administration at the University of Rhode Island at the same time. The fully online programme is taught by American instructors as well.
Dr Eszter Lukács, the Vice-Rector for Educational Affairs at Széchenyi István University also emphasized the significance of the newly launched programme and said that it is an outstanding opportunity for all professionals who want to work in management to acquire state-of-the-art American knowledge here in Hungary.
If you want to read more about the programme, visit the official website of Széchenyi István University.

domain: news


text: Just for fun... I've been looking at my flock and having a lot of fun trying to figure out what chicks from various rooster/hen combos would look like. I'm currently considering putting my Columbian Wyandotte rooster in with his hen and also a black Jersey Giant. Would I get dalmatian looking chickens? In looking at these chickens of mine, I'm thinking that I would get relatively large chickens that would probably be black & white splashes. Does the rooster carry dominate genes always? Where can I look to see what traits are dominate in different breeds?

domain: hobby


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The McPherson County Health Department is laying out its guidelines for reopening the economy following the COVID-19 shutdown.
After Kansas Gov. Laura Kelly’s Tuesday move to give individual counties authority on reopening, all 105 Kansas counties are now implementing whether or not they will have restrictions on mass gatherings.
McPherson County Health Officer, Shalei Shea, says as of Thursday that they are still encouraging residents to socially distance and follow the guidance of the Governor’s “Ad Astra” reopening plain, however, they will not be enforcing any restrictions by law–a change from which several other counties are doing.
Still, the county is discouraging mass gatherings of more than 15 individuals where six-fot social distance cannot be maintained between the individuals as well as encouraging residents to wear masks in public gatherings.
McPherson County is also continue to phase in reopenings as the next phase–Phase 3–is set for June 8.
More on the official reopening guidance from the McPherson County Health Department can be found here: McPherson County Reopen Plan 2020


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We examined the effects of an orally active inhibitor of converting enzyme, captopril (D-3-mercapto-2-methylpropanoyl-L-proline), in pentobarbital-anesthetized rats. Intravenous (i.v.) administration of captopril (0.1, 0.3, 1.0, 3.0 mg/kg) resulted in a dose-dependent inhibition of the pressor responses to angiotensin I (1.0 μg/kg, i.v.); at 1.0 mg/kg, captopril markedly potentiated the magnitude and duration of vasodepressor responses elicited by bradykinin (0.3 μg/kg, i.v.). Captopril effected a marked elevation of plasma renin activity by its blocking action on the angiotensin II-mediated negative feedback of renin release without markedly altering systemic blood pressure and heart rate. Propranolol (1.5 mg/kg, i.v.), at a dose which almost completely inhibited isoproterenol (0.15 μg/kg/min, i.a.)-induced renin release, tended to suppress the captopril-induced renin release. However, indomethacin (5.0 mg/kg, i.v.) failed to change the captopril-induced renin release. These findings suggest that captopril specifically inhibits converting enzyme and kininase II, and that captopril-induced renin release is partially associated with the beta-adrenergic system without mediation by prostaglandins.
|ジャーナル||Archives Internationales de Pharmacodynamie et de Therapie|
|出版ステータス||Published - 1981 12月 1|
ASJC Scopus subject areas

domain: biology


text:
Objective: To assess the effectiveness and safety of implementingan inpatient management and discharge strategy based onempiric antibiotic therapy with ceftriaxone sodium and a guidelineto promote timely discharge for clinically stable patients hospitalizedwith community-acquired pneumonia.
Study Design: A cluster randomized controlled clinical trialwith 30 days of patient follow-up at 8 teaching hospitals and 17nonteaching hospitals nationwide.
Methods: Participants included 240 intervention patients and209 control patients admitted by 85 physician groups betweenDecember 1998 and December 1999. Within each hospital,defined physician practice groups were randomized to the interventionarm (physician notification coupled with ceftriaxone sodiumas empiric therapy) or control arm (neither component).Physicians in the intervention arm were notified when theirpatients met guideline criteria for clinical stability; physicians inthe control arm were not contacted.
Results: The median length of stay was 4 days in both studyarms. The observed reduction in costs associated with the interventionwas not statistically significant when cost outliers wereexcluded. Mortality, serious adverse event, and rehospitalizationrates did not differ significantly across study arms.
Conclusions: Implementation of an inpatient management strategybased on physician reminders coupled with empiric use of ceftriaxonesodium did not reduce length of stay or associatedmedical care costs for patients hospitalized with community-acquiredpneumonia. These negative findings are most likely dueto insufficient potency of the intervention, inadequate guidelineimplementation, or imbalances in baseline patient characteristics.
(Am J Manag Care. 2005;11:491-499)
Community-acquired pneumonia (hereafter referredto as pneumonia) results in more than 1million hospitalizations annually in the UnitedStates, at a cost of $9 billion in 1994 dollars.1-3 Two keycomponents of the inpatient management of patientswith pneumonia are the initiation of appropriate empiricantibiotic therapy and the discharge decision.Observational studies4,5 demonstrate that appropriateempiric antibiotic therapy is associated with improvedsurvival for this illness. In addition, prior studies6-8demonstrate variation in length of stay that is unrelatedto severity of illness at presentation, suggesting thatpatients with pneumonia could be managed more efficientlywithout compromising their safety.
Observational data from the Pneumonia PatientOutcomes Research Team cohort study9 demonstratedthat most inpatients with pneumonia reached stabilityby hospital day 3 based on an objective definition ofclinical stability and that 77% stayed in the hospital atleast 1 day after reaching stability. Managing physiciansbelieved that only about one fifth of patients remainedhospitalized 1 or more days after reaching clinical stability.10 Therefore, physicians may not accurately determinewhen patients reach clinical stability and, despitethe high costs of hospital care, may not use this informationto guide the hospital discharge decision. A 1-dayreduction in length of stay is associated with an estimatedmean savings of $680 per patient.11
In prior studies12-23 to assess the effectiveness ofvarious strategies to reduce the length of stay of adultshospitalized for pneumonia, the clinical criteria usedto guide hospital discharge varied widely, and thereduction in length of stay ranged from 0 to 3 or moredays. Limitations of many of these studies include nonrandomizedstudy designs12,13,15-17,20-22 and the enrollmentof homogeneously low-risk patients15,21 or smallnumbers of patients, often from a single studysite.13,14,16,17,19,21,22 The Community-Acquired PneumoniaIntervention Trial Assessing Levofloxacin (CAPITAL)study,18 conducted in Canada, demonstrated thata critical pathway addressing the admission decision,empiric antibiotic therapy, and antibiotic conversionand discharge decisions could safely improve the efficiencyof care for patients with pneumonia. A prior trialof a multifaceted guideline implementation strategyshowed modest reductions in the duration of parenteral antibiotic use and nonsignificant reductions inlength of stay for patients with pneumonia managed at7 Pittsburgh hospitals.23
The primary aim of this multicenter randomizedcontrolled trial was to assess the effectiveness of implementingan inpatient management strategy involvingempiric antibiotic therapy with ceftriaxone sodium andphysician notification to promote timely discharge forclinically stable patients hospitalized with pneumonia.We also compared the associated total medical carecosts and the medical outcomes of patients managed byphysicians in the 2 study arms.
Inpatient Management Strategy
Empiric Antibiotic Therapy.
Patients in the interventionarm received parenteral ceftriaxone sodium astheir initial antibiotic therapy (1 g/d administered intravenouslyor intramuscularly), with or without concomitanttherapy with a macrolide. Ceftriaxone sodium is awidely used agent for the empiric treatment of pneumonia,because of its broad antimicrobial coverage ofgram-positive and gram-negative bacteria, once-dailydosing, and favorable safety profile.24 During the timeframe of this study, sole use of this agent was recommendedas appropriate empiric therapy by subspecialtypractice guidelines.25 All approved medications for thetreatment of pneumonia, except for ceftriaxone sodiumas empiric therapy, were allowed in the control arm. Allnecessary medications to treat medical comorbiditywere allowed in both arms.
Guideline for the Discharge of Clinically Stable
The discharge guideline was based on a reviewof the medical literature and empiric evidence on thetime to reach clinical stability.9 Each component of theguideline was discussed by a national panel of experts inpulmonary medicine, infectious diseases, and internalmedicine until consensus was reached. In contrast tomany prior guidelines,14,15,19,21,22 the guideline shown inTable 1 is based on the premise that patients with pneumoniareach clinical stability at different times duringthe course of treatment, rather than on a fixed day ofhospitalization.
Implementation of the Discharge Guideline
A case report form operationalized the daily assessmentof patient stability, which began on hospital day 2(the day after admission). Patients in both study armswere to be assessed daily by on-site medical personnelbetween 6:30 and 9:00 AM and again between 2:00 and4:30 PM if the morning assessment indicated potentialfor stability later that day. Each patient's stability statuswas recorded on the case report form but not in themedical chart. When a patient in the intervention armmet all of the guideline criteria for clinical stability, themanaging physician was notified that the patient wasstable for discharge. At all times, managing physiciansretained autonomy for the discharge decision.Physicians who were managing patients in the controlarm were not contacted regarding their patients' stabilitystatus.
To ensure that all providers began with the sameknowledge base, participating physicians in both studyarms attended an initial educational session in whichthe empiric evidence base for the discharge guidelinewas presented. Although it is possible that this 1-timeprestudy session influenced provider behavior duringthe trial, prior work has shown that education alone isnot an effective means of changing provider behavior.26
Study Sites and Identification of Physician andPatient Participants
A national sample of study hospitals was selectedbased on the interest of site investigators, an adequatevolume of inpatients with a discharge diagnosis of pneumonia,and site reviews performed by Medical andTechnical Research Associates, Inc. The principalinvestigator at each site identified participating physiciansand their associated medical groups. Usually,groups were defined as existing practices, individualphysicians, or teams of physicians who formally orinformally provided patient care coverage for eachother. Less frequently, groups were created for the purposeof this study. Before randomization, participatingphysicians agreed to be randomized to either study arm.The project statistician (RAS) randomized the physiciangroups within each study site, using generatedpseudorandom numbers balanced in blocks of size 2.Randomization of physician groups within each siteminimized contamination of the physician-level interventionbetween physicians caring for the same patientand provided a control for hospital-level characteristics.Because of the nature of the intervention, physicianscould not be blinded to their study arm assignments.Although patients were not aware of their physician'sassigned study arm, the antibiotics were open-label.Screening of potentially eligible patients occurred at 31study sites in 17 states in the United States betweenDecember 1998 and December 1999. Patients wererecruited at the time of presentation to a study siteemergency department and followed up for 30 days.
Patient Eligibility Criteria
Patients with a working diagnosis of pneumonia anda chest radiograph positive for a new pulmonary infiltrate consistent with pneumonia were eligible for thestudy if they were at least 18 years of age and admittedfor care by a participating physician. At presentation,patients were classified according to their estimated riskof mortality using the Pneumonia Severity Index (PSI).27
We excluded patients who (1) were in PSI risk classV; (2) required mechanical ventilation or had activeunderlying pulmonary disease; (3) had serious comorbidillness; (4) required admission to a critical care unit;(5) were immunocompromised; (6) had a metastaticconcomitant infection; (7) were hospitalized for palliativecare only; (8) resided in a skilled nursing facility orwere homeless; (9) were pregnant, nursing, or of childbearingpotential and not using reliable contraception;(10) currently used illicit drugs; (11) had been in anacute care hospital within the past 10 days or had beenhospitalized for an established diagnosis of pneumoniawithin the past 30 days; or (12) had a known or suspectedhypersensitivity to ceftriaxone sodium,cephalosporins, or penicillins.
For patients who met all eligibility criteria, thepatient or legal representative was approached forinformed consent to participate in the study. This studywas conducted in full compliance with the principles ofthe Declaration of Helsinki28 or with the laws and regulationsof the United States, whichever afforded thegreater protection of the patient, and was approved byall relevant institutional review boards.
The study population was defined as all enrolledpatients except (1) inadvertently enrolled patientswhose physicians had an unconfirmed study armassignment at the time of patient enrollment and (2)patients who had at least 1 exclusion criterion presentat the time of enrollment that was identified after enrollment.Patients who did not receive a parenteral dose ofan antibiotic or who withdrew consent during the indexhospitalization were excluded after enrollment.
Study Assessments and Procedures
Baseline characteristics, processes of care, and medicaloutcomes were assessed for patients in both arms.Within 24 hours of admission, the medical record wasreviewed for the patient's medical history, use of previousantibiotics or concomitant medications, and resultsof laboratory tests used in the PSI. Demographic datawere obtained by patient interview. Vital signs wereassessed daily, and antibiotic treatment was recordedthroughout the hospital stay. Guideline discharge criteriawere monitored from hospital day 2 through the dayof discharge, and serious adverse events and mortalitywere monitored throughout the 30-day study period.Length of stay for the index hospitalization was definedas the day of discharge minus the day of admission. Inaddition, the 2 components of length of stay wereassessed separately, namely, time to stability (the day onwhich clinical stability was first documented minus theday of admission) and poststability length of stay (theday of discharge minus the day on which stability wasfirst reached). Through a retrospective review of thecase report forms, we ascertained whether the empiricantibiotic therapy, daily assessment, and physiciannotification components of the protocol appeared to beappropriately applied for each patient. Because pneumoniaguidelines have been revised since this study wasconducted, with the most recent guidelines recommendinga second- or third-generation cephalosporinplus a macrolide or a fluoroquinolone alone for wardpatients similar to the participants in this study,29,30 wealso assessed whether antibiotic therapy within 24hours was consistent with the most recent InfectiousDiseases Society of America (IDSA) guidelines.29
Hospital bills for all hospitalizations at study siteswere collected for the 30-day study period. Index hospitalizationcosts were estimated by adjusting the chargeson the UB-92 bills by the Medicare hospital cost-tochargeratios.31 The total cost of medical care for 30days included costs for the index hospital admissionand the postdischarge events of rehospitalization, outpatientphysician visits, emergency department visits,chest radiographs, antibiotic therapy, home health visits,and postacute care. The cost of the intervention wasnot quantified in this study, given prior data demonstratingthat the cost of such an intervention is low($3.20 per patient assessment) relative to the total costof inpatient care.23
This study was designed with 80% power to detect a0.7-day decrease in length of stay from an assumedbaseline of 5 days, using a 1-sided .05-level test. Thiscorresponds to a 14% to 15% decrement in total medicalcare costs. The sample size was adjusted for the clusteringof patients within physician groups,32 assuming amean of 2 patients per cluster and an intraclass correlationof 0.1. The target sample size was increased by 5%to allow for potential loss to follow-up.
Length of stay was considered as a time-to-event outcome,in which the event was hospital discharge.Patients still hospitalized for the index hospitalizationwere censored at hospital day 30. The primary samplingunit was the physician group. To account for the manytied event times and the correlation between patientswithin the same physician group, discrete proportionalhazards models were estimated using SUDAAN, release8.0.33 Preliminary analysis indicated significant nonproportionalityof the hazards with respect to PSI riskclass (< .001) but not treatment arm (= .14) or site(= .75). Subsequent analyses were stratified on PSIrisk class, with covariate adjustment for the site effects.
The same approach was used to analyze time to stabilityand poststability length of stay. Patients who weredischarged before reaching stability were censored on theday of discharge in the analysis of time to stability andwere excluded from the analysis of poststability lengthof stay. All of these time-to-event analyses were rerunto take into account compliance of the empiric antibioticregimen with the most recent IDSA guidelines.29
Except for descriptive purposes, costs were naturallog transformed; log costs were analyzed using a generalizedestimating equation approach with a robustvariance estimate.33,34 These analyses were adjustedfor PSI risk class and site. To assess sensitivity toextremely high costs for some patients, this analysiswas repeated with cost outliers excluded. Additionalsensitivity analyses included adjustment for thosepatient-level baseline characteristics that were imbalancedbetween the study arms at the .10 level basedon c2 statistics.
All-cause mortality was compared for patients in the2 treatment arms using an exact permutation test that acommon odds ratio is 1 across the 4 PSI risk class strata.35 Rehospitalization rates were compared using theSTRATE command in Stata.36 For the length of stay andcost outcomes, treatment effects were assessed using 1-sided .05-level tests. Two-sided tests were used for allother comparisons.
Five hundred thirty-six patients were enrolled at 28study sites. Of these, 20 patients were excluded becauseof unconfirmed randomization assignments of theenrolling physicians; 33 intervention patients and 30control patients were excluded because of discovery ofan exclusion criterion after enrollment; and 2 patientsin each arm withdrew their consent during the indexhospitalization. Therefore, the final study populationcomprised 449 patients from 25 sites in 11 states, ofwhom 53.5% were in the intervention arm (Table 2).Imbalances in patient enrollment by study armoccurred at some sites.
These 449 patients were enrolled by 201 physiciansin 85 physician groups (Table 2). More than 90% ofphysicians in each arm were attending physicians ingeneral internal medicine (55% overall), an internalmedicine specialty (27% overall), or family practice(11% overall) (data not shown). All but 2 of the participatinghospitals were designated as urban, and 17 werenonteaching community hospitals.
Baseline Patient Characteristics
Of the 240 patients in the intervention arm, 54.6%were 65 years or older, 46.7% were male, and 83.8%were white (Table 3). More intervention patients thancontrol patients were admitted from emergency departments.Except for current smoking, each comorbid conditionlisted in Table 3 was more prevalent amongintervention patients, particularly diabetes mellitus andthe presence of 2 or more comorbid conditions. The PSIrisk class distributions of the intervention and controlpatients were similar.
Almost all (99.6%) of the patients in the interventionarm received parenteral ceftriaxone sodium, and45.0% received a macrolide within the first 24 hours;4.2% started macrolide therapy between 24 and 48hours after admission. In the control arm, the most frequentlyused parenteral agents were cephalosporinsother than ceftriaxone sodium (56.0%), fluoroquinolones(31.1%), and penicillins (24.9%); 5.7%received ceftriaxone sodium. Among control patients,58.4% received a macrolide within the first 24 hours,and 1.4% started macrolide therapy between 24 and 48hours after admission. The median time from presentationto initiation of parenteral antibiotic therapy was3.8 hours for intervention patients and 4.3 hours forcontrol patients (= .005). In this study, 46.7% of interventionpatients and 79.4% of control patients receivedempiric therapy within 24 hours of presentation thatwas compliant with the most recent IDSA guidelines.29
Length of Stay, Time to Reach Stability, andPoststability Length of Stay
The median length of stay was 4 days for patients inboth study arms (Table 4). Compared with controlpatients of the same PSI risk class at the same studysite, intervention patients were less likely to be dischargedon a given day of hospitalization (relative risk ofdischarge, 0.88; = .90). Overall, 88patients were discharged before reachingstability (approximately 20% in eacharm), and 1 patient was dischargedbefore any stability assessment. Amongthe 353 remaining patients, 101 interventionpatients (54.0%) and 73 controlpatients (44.0%) were dischargedwithin 1 day of reaching stability.Compared with control patients,intervention patients took longer toreach clinical stability (relative risk ofreaching stability on a given day, 0.79;= .02) and were discharged morequickly once they became stable (relativerisk of discharge, 1.26; = .006).
We reran these analyses with adjustmentfor whether or not patientsreceived antibiotic therapy within 24hours that was compliant with the mostrecent IDSA guidelines.29 The hazardratios associated with the interventionwere virtually unchanged for length ofstay, time to reach stability, and poststabilitylength of stay. For each ofthese outcomes, the hazard ratio forpatients who received IDSA-complianttherapy within 24 hours rangedbetween 0.94 and 0.96 (> .61 foreach), indicating that within eachstudy arm the time to these events wasonly slightly shorter for patients whoreceived the currently recommendedempiric antibiotic therapy.
Total Costs of Medical Care
The estimated median total costs ofmedical care were $4686 per patient inthe intervention arm and $4517 perpatient in the control arm (Table 5).Log costs were lower for patients in theintervention arm whenthe analysis was adjustedfor PSI risk class and studysite (= .09) and were significantlylower whenalso adjusted for observedbaseline imbalances(= .03) (Table 6).Five of the 6 identifiedcost outliers were in thecontrol arm, including 4low-risk control patients.Log costs were not significantlylower in the interventionarm when thecost outliers were excluded(> .64).
Five intervention patientsand 3 control patientsdied within 30 days.No statistically significant differences were observedbetween intervention and control patients with respectto 30-day mortality (2.1% vs 1.4%, = .73), occurrenceof serious adverse events (15.8% vs 11.0%, = .10), orrates of rehospitalization (8.5% vs 7.6%, = .21).
Study Protocol Implementation
The protocol was implemented as planned for 184intervention patients (76.7%) and 181 control patients(86.6%). In the intervention arm, 9 patients received anempiric antibiotic agent other than ceftriaxone sodium;the discharge strategy was not implemented as intendedfor 38 patients (including no physician notificationfor 17 stable patients and incorrect notification regarding20 patients who were not stable); and neither componentwas implemented for 9 patients. In the controlarm, 6 patients received ceftriaxone sodium as empiricantibiotic therapy; the physician was notified incorrectlyof stability regarding 18 patients; and both ofthese events occurred for 4 patients.
In this large multicenter randomized controlled trialof patients hospitalized for pneumonia, implementationof an inpatient management strategy (empiricantibiotic therapy with ceftriaxone sodium and physiciannotification when patients met guideline criteriafor discharge) did not reduce overall length of stay. Weraise the following 4 possible explanations for thesenegative findings: (1) insufficient potency of the interventionto modify provider behavior, (2) inadequateguideline implementation, (3) imbalances in baselinepatient characteristics, and (4) systematic differencesin the empiric antibiotic therapies that affected thetime to reach clinical stability. Prior research conductedas part of the Cochrane collaborative review ofprovider behavior change has demonstrated thatreminders, including electronic and paper formats, areeffective means to change provider behavior.37 Priorwork also shows that telephone delivery of suchreminders by nursing staff, similar to the interventionused in this study, is an effective means of changingprovider behavior.38 However, such an approach byitself may not have been sufficient to promote earlierhospital discharge. A more potent multifaceted implementationstrategy may be necessary to ensure timelyphysician notification that a patient has reached clinicalstability. The fact that the study protocol was notimplemented as planned for almost one quarter ofintervention patients, primarily because of errors inthe physician notification process, suggests that therigor of this guideline implementation may have contributedto the observed null effect of the intervention.In addition, randomizing physician groups does notguarantee balance at the patient level, even theoretically.In this study, intervention patients were morelikely to have multiple comorbid illnesses. Althoughlength of stay and cost results were somewhat morefavorable to the intervention when the treatment comparisonswere adjusted for baseline imbalances, theseobserved imbalances did not account fully for thelonger time to stability observed in the interventionarm. Finally, the choice of empiric antibiotic may havedifferentially affected the time to clinical stability in the2 study arms. Although the empiric antibiotic regimenswere consistent with existing pneumonia guidelinesat the time this study was conducted,25,39 the use of ab-lactam alone in the intervention arm is not consistentwith current pneumonia guidelines.29,30 In this study,almost one third of control patients received fluoroquinolonesas empiric therapy; therefore, more controlpatients than intervention patients received empiricantibiotic therapy that was consistent with currentIDSA pneumonia guideline recommendations29; however,time to clinical stability and length of stay were notassociated with thereceipt of IDSA-recommendedtherapy. Oneprior study40 demonstratedthat treatmentwith empiric antibiotictherapy within 4 hours ofpresentation was associatedwith a reducedlength of hospital stay,with no clear associationbetween guideline-recommendedantibiotic therapyand length of stay.
In this study, clinicallystable patients in theintervention arm weresignificantly more likelyto be discharged on agiven day than comparablestable patients in thecontrol arm. The hospitaldischarge criteria inthe present study are virtuallyidentical to thosein a 2003 study of a multifacetedguideline implementationstrategy.23Although poststabilitylength of stay was notassessed in the 2003study, the relative risk ofdischarge for stableintervention patients inthe present study issomewhat higher thanthat of interventionpatients in the 2003study. Together, thesestudies provide some evidence that interventions tomonitor hospitalized patients with pneumonia for stabilityand notify their physicians when they are clinicallystable can facilitate discharge withoutcompromising patient outcomes. These findings areconsistent with a recent meta-analysis41 showing that,although modest reductions in length of stay are possible,the overall reductions are not statistically significantacross well-designed studies.
This study has limitations that are important toacknowledge. First, the exclusion of patients who wereseverely ill (PSI risk class V), were admitted fromnursing homes, or had severe comorbid illnesses limitsthe generalizability of the study findings. Second,we estimated costs indirectly, by adjusting charges onthe hospital bills by the Medicare hospital-specific cost-to-charge ratios. This imperfect approach is used toadjust for between-hospital differences in the markupover costs in hospitals that do not have state-of-the-artaccounting systems31 and should not bias our within-hospitalcomparisons. Third, like the CAPITAL study,18this study was not designed to assess the separateeffects of the empiric therapy and discharge guidelinecomponents of the proposed inpatient managementstrategy; unlike other studies,18,23 the conversion decisionwas not explicitly addressed. Fourth, we do notknow why some intervention physicians were not notifiedwhen their patients reached clinical stability;unfortunately, we did not collect data on the barriersand facilitators of guideline implementation.
In conclusion, our implementation of an inpatientmanagement strategy based on physician reminderscoupled with empiric use of ceftriaxone sodium did notreduce overall length of stay or associated medical carecosts for patients hospitalized with pneumonia. Thesenegative findings are most likely due to insufficientpotency of the intervention, inadequate guidelineimplementation, or imbalances in baseline patientcharacteristics.
We acknowledge the contributions of the study site investigators, whowere responsible for facilitating the initiation and conduct of this trial atthe participating sites. We also acknowledge the assistance of AntoinetteKlein, MS, and D. Scott Obrosky, MS, in the preparation of the manuscript.
From the Departments of Biostatistics (RAS, MKM) and Health Policy and Management(JRL), Graduate School of Public Health, Division of General Medicine, Department ofMedicine (LJH, MJF), and Center for Research on Health Care (RAS, JRL, LJH, MJF),University of Pittsburgh; and VA Center for Health Equity Research and Promotion and VAPittsburgh Healthcare System (RAS, MKM, JRL, MJF); Pittsburgh, Pa.
This research was funded by protocol NR15534/M44119 from Roche Laboratories,Inc., Nutley, NJ. The investigators from the University of Pittsburgh were responsible for thedesign, analysis, and reporting of this study. Under a separate contract with RocheLaboratories, Inc, an external clinical research organization, Medical and TechnicalResearch Associates, Inc, Natick, Mass, was responsible for the recruitment of sites andinvestigators, data collection, oversight of the conduct of the study at the sites, and provisionof a final database to the University of Pittsburgh investigators.
Address correspondence to: Roslyn A. Stone, PhD, Department of Biostatistics,Graduate School of Public Health, University of Pittsburgh, 304 Parran Hall, Pittsburgh, PA15261. E-mail: email@example.com.
1. Niederman MS, McCombs JI, Unger AN, Kumar A, Popovian R. The cost oftreating community-acquired pneumonia. 1998;20:820-837.
Vital Health Stat 13.
2. Kozak LJ, Lawrence L. National Hospital Discharge Survey: annual summary,1997. 1999;No. 144:i-iv, 1-46.
Semin Respir Crit Care Med.
3. Lave JR, Lin CC, Hughes-Cromick P, Fine MJ. The cost of treating patients withcommunity-acquired pneumonia. 1999;20:189-198.
Arch Intern Med.
4. Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ. Associations betweeninitial antimicrobial therapy and medical outcomes for hospitalized elderlypatients with pneumonia. 1999;159:2562-2572.
5. Houck PM, MacLehose RF, Niederman MS, Lowery JK. Empiric antibiotic therapyand mortality among Medicare pneumonia inpatients in 10 western states:1993, 1995, and 1997. 2001;119:1420-1426.
Am J Med.
6. McCormick D, Fine MJ, Coley CM, et al. Variation in length of hospital stay inpatients with community-acquired pneumonia: are shorter stays associated withworse medical outcomes? 1999;107:5-12.
J Gen Intern Med.
7. Lave JR, Fine MJ, Sankey SS, Hanusa BH, Weissfeld LA, Kapoor WN.Hospitalized pneumonia cases in Pennsylvania: outcomes, treatment patterns, andcosts in urban and rural areas. 1996;11:415-421.
8. Fine MJ, Singer DE, Phelps AL, Hanusa BH, Kapoor WN. Differences in lengthof hospital stay in patients with community-acquired pneumonia: a prospectivefour-hospital study. 1993;31:371-380.
9. Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalizedwith community-acquired pneumonia: implications for practice guidelines.1998;279:1452-1457.
Arch Intern Med.
10. Fine MJ, Medsger AR, Stone RA, et al. The hospital discharge decision forpatients with community-acquired pneumonia: results from the Pneumonia PatientOutcomes Research Team cohort study. 1997;157:47-56.
11. Fine MJ, Pratt HM, Obrosky DS, et al. Relationship of length of hospital stayand the costs of care for patients with community-acquired pneumonia. 2000;109:378-385.
Infect Control Hosp Epidemiol.
12. Ehrenkranz NJ, Nerenberg DE, Shultz JM, Slater KC. Intervention to discontinueparenteral antimicrobial therapy in patients hospitalized with pulmonaryinfections: effect on shortening patient stay. 1992;13:21-32.
Arch Intern Med.
13. Ramirez JA, Srinath L, Ahkee S, Huang A, Raff M. Early switch from intravenousto oral cephalosporins in the treatment of hospitalized patients with pneumonia.1995;155:1273-1276.
14. Siegel RE, Halpern NA, Almenoff PL, Lee A, Cashin R, Greene JG. Aprospective randomized study of inpatient IV antibiotics for community-acquiredpneumonia: the optimal duration of therapy. 1996;10:965-971.
15. Rhew DC, Riedinger MS, Sandhu M, Bowers C, Greengold N, WeingartenSR. A prospective, multicenter study of a pneumonia practice guideline. 1998;114:115-119.
Arch Intern Med.
16. Ramirez JA, Vargas S, Ritter GW, et al. Early switch from intravenous to oralantibiotics and early hospital discharge: a prospective observational study of 200consecutive patients with community-acquired pneumonia. 1999;159:2449-2454.
17. Ramirez JA. Switch therapy with β-lactam/β-lactamase inhibitors in patientswith community-acquired pneumonia. 1998;32:S22-S26.
18. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG;CAPITAL Study Investigators. A controlled trial of a critical pathway for treatmentof community-acquired pneumonia: Community-Acquired PneumoniaIntervention Trial Assessing Levofloxacin. 2000;283:749-755.
19. Omidvari K, de Boisblanc BP, Karam G, Nelson S, Haponik E, Summer W.Early transition to oral antibiotic therapy for community-acquired pneumonia:duration of therapy, clinical outcomes, and cost analysis. 1998;92:1032-1039.
J Healthc Qual.
20. Ross G, Johnson D, Kobernick M, Pokriefka R. Evaluation of a critical pathwayfor pneumonia. 1997;19:22-29, 36.
Am J Respir Crit Care Med.
21. Weingarten SR, Riedinger MS, Hobson P, et al. Evaluation of a pneumoniapractice guideline in an interventional trial. 1996;152:1110-1115.
22. Hendrickson JR, North DS. Pharmacoeconomic benefit of antibiotic stepdowntherapy: converting patients from intravenous ceftriaxone to oral cefpodoximeproxetil. 1995;29:561-565.
Am J Med.
23. Fine MJ, Stone RA, Lave JR, Obrosky DS, Hough LJ, Kapoor WN.Randomized trial of a practice guideline to reduce length of stay for patients withpneumonia. 2003;115:343-351.
Infect Dis Clin
24. Brown RB. Ceftriaxone intervention in an inpatient setting. 1996;9(suppl):S1-S6.
Am Rev Respir Dis.
25. Niederman MS, Bass JB Jr, Campbell GD, et al. Guidelines for the initialmanagement of adults with community-acquired pneumonia: diagnosis, assessmentof severity, and initial antimicrobial therapy: American Thoracic Society:Medical Section of the American Lung Association. 1993;148:1418-1426.
26. Davis D, O'Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops,rounds, and other traditional continuing education activities changephysician behavior or health care outcomes? 1999;282:867-874.
N Engl J Med.
27. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-riskpatients with community-acquired pneumonia. 1997;336:243-250.
Declaration of Helsinki.
28. World Medical Association. Rev ed. Hong Kong:41st World Medical Assembly; 1989.
Clin Infect Dis.
29. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C;Infectious Diseases Society of America. Update of practice guidelines for themanagement of community-acquired pneumonia in immunocompetent adults.2003;37:1405-1433.
Respir Crit Care Med.
30. Niederman MS, Mandell LA, Anzueto A; American Thoracic Society.Guidelines for the management of adults with community-acquired pneumonia:diagnosis, assessment of severity, antimicrobial therapy, and prevention. 2001;163:1730-1754.
31. Lave JR, Pashos CL, Anderson GF, et al. Costing medical care: usingMedicare administrative data. 1994;32(suppl):JS77-JS89.
Am J Epidemiol.
32. Donner A, Birkett N, Buck C. Randomization by cluster: sample size requirementsand analysis. 1981;114:906-914.
SUDAAN User's Manual, Release 8.0.
33. Research Triangle Institute. ResearchTriangle Park, NC: Research Triangle Institute; 2001.
34. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuousoutcomes. 1986;42:121-130.
StatXact 4 Windows.
35. Mehta C, Patel N. Cambridge, Mass: Cytel SoftwareCorp; 1998.
Stata Statistical Software, Release 7.0.
36. StataCorp LP. College Station, Tex:StataCorp LP; 2001.
37. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA;Cochrane Effective Practice and Organization of Care Review Group. Closing thegap between research and practice: an overview of systematic reviews of interventionsto promote the implementation of research findings. 1998;317:465-468.
Arch Intern Med.
38. Davidson R, Fletcher S, Retchen S, Duh S. A nurse-initiated reminder systemfor the periodic health examination. 1984;144:2167-2170.
Clin Infect Dis.
39. Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumoniain adults: guidelines for management. The Infectious Diseases Society ofAmerica. 1998;26:811-838.
Arch Intern Med.
40. Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. The timing of antibioticadministration and outcomes for Medicare patients hospitalized with community-acquiredpneumonia. 2004;164:637-644.
41. Rhew DC, Tu GS, Ofman J, et al. Early switch and early discharge strategiesin patients with community-acquired pneumonia: a meta-analysis. 2001;161:722-727.

domain: literature


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text:
Alfred Cannan has apologised for the Summerland fire, in a statement made to Tynwald.
It comes a week before the 50th anniversary since the fire.
The Chief Minister said: 'In little over a week the Isle of Man will be remembering its worst peacetime tragedy and loss of life.
'On August 2 we will remember the 50 people who lost their lives as fire ravaged the Summerland complex, hosting thousands of visitors looking forward to an evening of family entertainment.
'Also Mr President, in the forefront of our minds will be those who survived the tragedy and those who were bereaved; both groups left carrying a lifetime’s burden of hurt and suffering.'
'I have heard, first-hand, how those affected endure ongoing physical and mental pain caused by the events of that night. I am aware that feelings of loss and anger caused by what happened half a century ago often do not fade or diminish as the years pass.
'The images of the inferno are not something one can easily forget. They are part of our national consciousness. They are deeply ingrained in our culture, our community, and it is vital that we acknowledge and remember that.'
He said that it is clear that there were failures found which were identified in a commission into the Summerland fire.
'The Commission of Inquiry into the fire identified the two most important causes: a “delayed, unorganised and difficult evacuation” from the building; and faults in its design and construction, in particular the use of materials that could not prevent the spread of the fire.
'It is clear Mr President that there were inadequacies, failings and lapses identified by the Commission, and that had matters been addressed differently, some of the loss of life at Summerland may have been prevented.
He said: 'I am sorry. Sorry for the pain and suffering felt by everyone affected by the fire and sorry for the failings that could have prevented such a tragedy.'
He added that it is his genuine hope that this apology that he has offered today helps to restore trust and build more positive relationships for the future.


text:
On Friday's episode of The Ezra Levant Show, Ezra Levant breaks down a video from Microsoft Ignite.
Nothing is more absurd than turning humans into nothing but race and sex and gender — and hairstyle and height and sleeves on or off.
On this weird clip from Microsoft, Ezra says:
I don’t know what that is. Because my head is being filled with things that would make a first year grievance studies class at university think: you guys are going too far.
I’m pretty sure that in Huawei’s tech labs, in Lenovo’s headquarters, they don’t identify themselves by their height or hair colour or ethnicity. Then again, there really isn’t a lot of diversity in those companies — not even other Chinese ethnicities like Uygur Muslims.
To watch the full episode become a RebelNews+ subscriber.


text:
April 4, 2022
This Week in Health Policy for April 4
This Week (April 4-8)
The Senate Health, Education, Labor & Pensions Committee will hold a hearing on “FDA User Fee Agreements: Advancing Medical Product Regulation and Innovation for the Benefit of Patients.”
The Senate Finance Committee will hold a hearing on the “The President’s Fiscal Year 2023 Health and Human Services Budget.”
The House Energy and Commerce Committee’s Subcommittee on Health will hold a hearing on “Communities in Need: Legislation to Support Mental Health and Well-being.”
The House Ways and Means Committee will hold a hearing on the “Proposed Fiscal Year 2023 Budget with Health & Human Services Secretary Becerra.”
The House Budget Committee will hold a hearing on the “Department of Health and Human Services FY 2023 Budget.”
Last Week (March 28-April 1)
Health Care Highlights
House passes bill to cap insulin costs. On Thursday (March 31), the House voted 232-193 to pass a bill (HR 6833) that would cap monthly out-of-pocket insulin costs at $35 for people with health insurance. The Congressional Budget Office on Wednesday (March 30) said the bill would increase government spending by $6.6 billion over a decade and reduce government revenues by $4.8 billion. AHIP has come out against the bill, saying instead of lowering the price of insulin the bill shifts costs to others. The bill’s prospects in the Senate are unclear as Sens. Jeanne Shaheen (D-NH) and Susan Collins (R-ME) are working on a separate insulin cost cap bill that could include other provisions aimed at reducing drug list prices.
Biden unveils FY 2023 budget request. On Monday (March 28), President Joe Biden released his fiscal year (FY) 2023 budget, requesting $127.3 billion in discretionary funding for the Department of Health and Human Services (HHS), a $26.8% increase from the 2021 enacted level. The National Institutes of Health (NIH) would get $49 billion, which includes a $5 billion investment in the Advanced Research Projects Agency for Health (ARPA-H). The Food and Drug Administration (FDA) would receive a $2.1 billion increase over FY 2022 appropriations to total $8.4 billion. The Centers for Disease Control and Prevention (CDC) budget would increase by $2.3 billion over FY 2022 appropriations to total $10.675 billion.
Biden’s budget request also includes investments across multiple agencies to support several priority initiatives, including preparing for future pandemics and other biological threats ($81.7 billion), improving public health infrastructure and domestic and global threat surveillance ($28 billion), increasing public health capacity at CDC and state and local levels ($9.9 billion), addressing the nation’s mental health ($51.7 billion) and opioid ($10.4 billion) epidemics, reducing new cases of HIV/AIDS ($850 million), and reducing maternal mortality and race-based disparities ($470 million). In addition, the budget includes $92 million to support the president’s goal of reducing the cancer death rate by 50% over the next 25 years.
CMS expects health spending to slowdown. On Tuesday (March 28), the Centers for Medicare and Medicaid Services’ (CMS) Office of the Actuary’s projected that national health spending grew by 4.2% to $4.3 trillion in 2021, down from 9.7% in 2020 as federal supplemental funding for the COVID-19 pandemic declined. CMS said hospital spending, which accounted for the largest percentage of national health spending in 2021, grew 5.7% to $1.3 trillion in 2021, while pharmaceutical spending increased 4.7%, Medicare spending grew 11.3%, and Medicaid spending grew 10.4%. CMS projected Medicaid enrollment grew 8.2% in 2021, up from 5.1% in 2020. However, CMS said health care use is expected to normalize between 2020 and 2024, and health insurance enrollment will decline to more closely reflect pre-pandemic distributions.
Congress working toward COVID-19 relief. A bipartisan group of senators has been working on a new COVID-19 relief package after the House lawmakers pulled a $15.6 billion package from the omnibus bill earlier this month over disagreements about the offsets. Details of the new bill are still unclear, but the latest reports indicate the package now includes about $10 billion in funding for vaccines and treatments. The senators are still working out disagreements over funding offsets, but House Majority Leader Steny Hoyer (D-MD) on Wednesday (March 30) said he is optimistic a new package will pass before Congress leaves for Easter recess next week. The White House has warned without additional funds it will not be able to purchase more COVID-19 vaccines in the event of another surge in cases, and HHS’ Health Resources and Services Administration (HRSA) as of March 22 stopped accepting COVID-19 claims for testing, treatment, and vaccine administration for the uninsured due to insufficient funds. In related news, the White House on Wednesday (March 30) announced the launch of a new website, COVID.gov, where people can access information on where to find COVID-19 vaccines, tests, treatments, masks, and more.
HHS wants $100M in PRF money back. Earlier this month, HRSA sent notices to certain round one Provider Relief Funding (PRF) recipients, giving them 30 days to return the funds for not complying with federal reporting requirements. The Medical Group Management Association (MGMA) said some providers were unaware of the reporting requirements and reminder emails were lost in spam folders or sent to employees who no longer worked at the practices. As such, MGMA is asking HRSA to re-open the reporting portal and give providers 60 days to comply before taking enforcement action. The American Medical Association also has asked HHS for a delay to give providers more time to comply with reporting requirements. The move comes as provider groups have asked for additional PRF relief to cover care costs from the omicron COVID-19 variant.
CMS issues FY 2023 proposed rule for hospice payment. On Wednesday (March 30), CMS published a proposed rule that would increase payment rates for hospices in FY 2023 by 2.7%, or $580 million. The proposed rule would put in place a permanent solution to limit annual changes in the hospice wage index. CMS also proposed updates to the Hospice Quality Reporting Program (HQRP). Hospices that do not meet quality reporting requirements will see a 2-percentage point reduction in payments for FY 2023. CMS in the proposed rule noted that under statutory requirements the penalty is slated to rise to 4% in FY 2024. CMS also included a request for information on equity-based hiring and retention strategies; barriers to care and hospices’ localized solutions; and methodologies for collecting demographic data. CMS will accept public comments until May 31.
CMS issues FY 2023 proposed rule for inpatient psychiatric facilities. On Thursday (March 31), CMS published a proposed rule that would increase payment rates for inpatient psychiatric facilities (IPFs) by 1.5%, or $50 million, for FY 2023. CMS included requests for comments on ways to update the IPF prospective payment system, which is still based on adjustment factors created in 2005, as well as ways to measure health care quality disparities through the IPF Quality Reporting Program. CMS will accept public comments until May 31.
CMS issues FY 2023 proposed rule for inpatient rehabilitation facilities. On Thursday (March 31), CMS published a proposed rule that would increase payment rates for inpatient rehabilitation facilities (IRFs) by 2%, or $170 million, for FY 2023. The proposed rule would put in place a permanent solution to limit annual changes in the IRF wage index. In addition, CMS proposed expanding IRF quality data reporting requirements to include all IRF residents, not just those with traditional Medicare and Medicare Advantage plans. CMS also included requests for comments on ways to track the development of a new C. difficile infection among IRF patients, ways to track health equity initiatives at IRFs, and ways to implement a health equity measure to the quality reporting program. CMS will accept public comments until May 31.
CMS announces new funding for Money Follows the Person Program. On Thursday (March 31), CMS announced more than $110 million in grants to encourage more states to participate in Medicaid’s Money Follows the Person Program. The program enables Medicaid beneficiaries to receive care in their homes and local communities.
CDC recommends fourth COVID shot. On Tuesday (March 29), the Centers for Disease Control and Prevention (CDC) recommended people ages 50 and older and immunocompromised adults receive a fourth COVID-19 vaccine. CDC said immunocompromised teens could get an additional dose of the Pfizer vaccine. The recommendation came after the FDA authorized an additional booster shot for those 50 and older and immunocompromised patients age 12 and older.
Hospital groups ask for PHE renewal. On March 28, a group of hospital associations sent a letter asking HHS Secretary Xavier Becerra to renew the public health emergency, which is currently set to expire April 16. The Biden administration has promised to give at least 60-days’ notice before allowing the PHE to lapse, meaning it’s likely the PHE will continue at least through July.
House Oversight and Reform Committee Hearing on Examining Pathways to Universal Health Coverage. On Tuesday (March 29), the House Oversight and Reform Committee held a hearing entitled, “Examining Pathways to Universal Health Coverage.” During the hearing, Democrats discussed proposals to build on the Affordable Care Act (ACA) and achieve universal health coverage in the United States, as well as legislation to create a single-payer health insurance program in the United States. Republicans during the hearing lambasted such proposals, saying they would increase federal spending without addressing core inefficiencies of the current system and called on Democrats to consider market-based competitive policy solutions.
Senate Finance Committee Hearing on Behavioral Health Care When Americans Need It: Ensuring Parity and Care Integration. On Wednesday (March 30), the Senate Finance Committee held a hearing entitled, “Behavioral Health Care When Americans Need It: Ensuring Parity and Care Integration.” During the hearing, lawmakers and witnesses discussed health insurer compliance with mental health parity laws and models to integrate behavioral and primary care. Lawmakers asked specific questions on ways to improve parity enforcement and remove barriers to integrated care models, while witnesses provided examples of successful models and policy solutions to improve parity enforcement, such as centralizing enforcement authority. The hearing is one in a series the Senate Finance Committee plans to have as it works on bipartisan legislation to improve access to mental health care and substance use disorder treatment. As part of that effort, the Committee on Tuesday (March 29) released bipartisan report on mental health care, “Mental Health Care in the United States: The Case for Federal Action.”
House Committee on Energy and Commerce Hearing on FDA User Fee Reauthorization: Ensuring Safe and Effective Medical Devices. On Wednesday (March 30), the House Committee on Energy and Commerce held a hearing entitled “FDA User Fee Reauthorization: Ensuring Safe and Effective Medical Devices.” The Medical Device User Fee Amendments (MDUFA) authorizes the Food and Drug Administration (FDA) to collect user fees from companies producing medical devices and must be reauthorized by Congress every five years. The most recent MDUFA reauthorization expires on September 30, 2022. During the hearing, committee members expressed dismay that the Department of Health and Human Services has missed the statutory deadline for transmitting a final performance goals letter for MDUFA V, emphasizing the role of MDUFA in enabling access to innovative medical devices and stressing the importance of authorizing MDUFA V by the September 30 deadline. Center for Devices and Radiological Health Food and Drug Administration (CDRH) witness Dr. Jeff Shuren apologized for the delay, citing the significant burden that the COVID-19 pandemic had placed on his team and noting that the MDUFA V draft agreement would substantially improve their ability to meet these challenges and ensure patient access moving forward.
House Appropriations Committee Hearing on FY 2023 Budget Request for the Department of Health and Human Services. During the hearing, HHS Secretary Xavier Becerra asked committee members to advance President Biden’s budget request of $127.3 billion in discretionary funding and $1.7 trillion in mandatory budget authority for HHS. During the hearing, Becerra informed lawmakers that the Advanced Research Projects Agency for Health (ARPA-H) will be housed within the National Institutes of Health, rather than create an independent agency within HHS – a decision that drew criticism from both Democrats and Republicans on the committee. Becerra also asked lawmakers to pass legislation to allow medical professionals to obtain interstate licensing to facilitate telehealth visits across state lines when the pandemic ends.
Reports, Studies, and Journals
CDC’s Morbidity and Mortality Weekly Report: Adolescent Behaviors and Experiences Survey —United States, January–June 2021. A new CDC report found 44.2% of U.S. high school students reported “persistent feelings of sadness or hopelessness” during the pandemic, while 19.9% reported “seriously contemplating suicide” and 9% reported attempting suicide. According to the report, LGBTQ youth were more likely than heterosexual youth to report poorer mental health and suicide attempts.
JAMA. Racial Disparities in COVID-19 Outcomes Among Black and White Patients With Cancer. A new cohort study of 3,506 patients with cancer and COVID-19, found black patients were more likely to experience more severe COVID-19 outcomes, than white patients. The study also found the all-cause mortality rate for black cancer patients was 19%, compared with 17% among white cancer patients.
Health Affairs. The Effectiveness of Government Masking Mandates On COVID-19 County-Level Case Incidence Across The United States, 2020. In this observational cohort study, the researchers examined data from 394 U.S. counties between March 21, 2020 an October 20, 2020 and found the daily COVID-19 case incidence per100,000 people in masked counties declined by an average of 23% at four weeks, compared with non-masked counties. The researchers said the benefit of masking varied across regions by population density and political leanings.


text:
It’s Narcissist Friday!
Escaping from the dragon can be an exhausting ordeal. You enter the new territory drained, confused, and upset. Everything in your life seemed to revolve around the dragon. Now, you have a chance to breath again.
Shortly into your new journey, you meet someone walking your path. Almost immediately, you are impressed with his gentleness and kindness. He offers to help you as you learn about the new land. He listens to your story and sympathizes with your suffering. He says just the right things to make you feel good about yourself again. He also has suffered. It is good to have someone to walk with.
Until you discover that he is very much like the dragon you thought you left behind.
Through this short series of posts I often use the terms “dragon” and “narcissist” almost interchangeably. Dealing with a narcissist feels like fighting a dragon. You never knew when he/she was going to strike next. Sometimes the attacks were intense and personal. His/her presence loomed over almost every part of your life. It was easy to be confused and afraid.
But after you leave the narcissist, the dragon remains. The dragon doesn’t die or even sleep. You know this. There are dangers in this new life you are entering. Even though you feel used up, weary from the battle, you cannot afford to let your guard down.
But you want to. You want to trust someone. You want a friend. You want someone who will support you, listen to you, walk with you. So, when the new charmer comes to you, the praise and kindness feels good. You want to rest in the relationship.
When it happens to you again, you blame yourself for being gullible. You shame yourself for being stupid. How could you be deceived again?
To be gullible is to desire truth from a relationship. In other words, you want to trust the person. You accept the lie in order to continue or enhance the relationship. To question a person’s honesty is to doubt the person and threaten the relationship. Because you are naturally kind and welcoming, you expect that others are truthful.
But the dragon whispers sweet talk, words designed to touch your heart. The dragon knows that you are vulnerable. He knows what you want to see and hear.
It may not be another lover. Perhaps it is a friend, someone who senses your need to be valued. Maybe it will be a person with a “ministry” to help people like you. Sometimes the next narcissist you meet will not be overt, but a needy user we refer to as “covert.” That person will seem loving and helpful, but you will find yourself used again. The dragon whispers the right things to open your heart to the abuse again.
In our culture, people think of gullibility as being stupid. Fool me once, etc. But the only people who say that are those who don’t know the dragon. They may not have grown up in a family like yours or lived a marriage like yours. They don’t understand. Or they are already so bound to the dragon that they speak his whispers.
Listen: it isn’t your mind and thinking that has opened you again. It’s your heart. And that’s not a bad thing. You want to trust people. You want a good relationship. That’s who you are. It isn’t bad, but it explains why you get hurt.
So, pray for wisdom. Pray that your relationship with Jesus would be so fulfilling that you are not attracted to the dragon’s whispers. Pray that your heart needs are met by Jesus Himself. Then, when your mind and heart are clear, let Him lead you into a good relationship again.


The Obama administration has asked the CIA to deliver options on possible retaliatory cyber attacks on Russia designed to "embarrass" the country's leadership, NBC News reports.
Unnamed sources who NBC says have direct knowledge of the conversations say no decisions have been made on the style and scope of any attack, but the CIA has "reams of documents that could expose unsavory tactics by Russian President Vladimir Putin."
Any such attack, covert or otherwise, would be in response to Russia's alleged meddling in the American presidential election, with numerous damaging leaks in recent months from hacks on Democratic Party organizations and alleged attempts to break into state voting systems. In just the past week, Wikileaks has been publishing emails that were hacked from the account of John Podesta, Hillary Clinton's campaign chairman. The U.S. government has publicly named Russia as the culprit, saying "based on the scope and sensitivity of these efforts, that only Russia's senior-most officials could have authorized these activities. These thefts and disclosures are intended to interfere with the U.S. election process."
Vice President Joe Biden also stoked speculation with an interview on NBC in which he declared that "we're sending a message" to the Russian leadership. “We have the capacity to do it," he said, according to the New York Times. “He’ll know it. And it will be at the time of our choosing. And under the circumstances that have the greatest impact.” The vice president also seemed to suggest that any such action would be covert, replying "hope not," when asked if the general public would know such a message was sent.
If covert action was taken, President Obama would have to authorize a "finding," which would allow the U.S. to utilize its arsenal of cyberweapons under the control of the N.S.A., military's Cyber Command and CIA, the Times reports.
Intelligence sources say there are many methods available to the U.S., including hitting Russia's internal internet controls that allow censorship or exposing the financial affairs of Putin and his cronies, NBC reports.
However, intelligence sources are split on whether an American response should be public or covert. Retired Admiral James G. Stavridis believes the government should publicly reveal "the names of the officials who authorized the cyberattacks against the United States," which would "put Moscow in an extremely uncomfortable position," the Times reports. Former CIA deputy director Michael Morell told NBC he doesn't favor attacks against Russia's computer networks but does believe any response should be overt, "for everybody to see."
Intelligence sources recently told Newsweek's Jeff Stein that Russia's cyber meddling reveals attempts to sway public opinion based on disinformation, with obvious fabrications among the hacked documents released recently by Wikileaks. "The purpose of developing black propaganda is not to throw a whole slew of fake documents into the stream, but to insert or delete words or phrases into the record which are damaging but [can only] later be disapproved,” said Malcolm Nance, a career U.S. intelligence officer and author of The Plot to Hack America.
The hacks and subsequent leaks have become a campaign issue, with Republican presidential candidate Donald Trump repeatedly expressing doubt about Russia's complicity in the attacks while Clinton, her surrogates and President Obama condemn Russian involvement. Trump, of course, also has spoken warmly about Putin and expressed hope that the U.S. and Russia will be "friends" under a Trump administration.


The social survey of the Corruption Prevention and Combating Bureau (KNAB) shows that 85% of residents and 73% of entrepreneurs are not prepared to give a bribe to a public official to resolve a problem. The most common considerations by residents and entrepreneurs in favour of possible giving of bribes is greater certainty that the problem will be addressed at all.
Compared to the public opinion poll conducted by KNAB in January 2021, the attitude of both surveyed groups towards bribery has changed this year – negative attitude has risen among residents, whereas tolerance has increased among entrepreneurs, which may possibly be linked to the business restrictions caused by the Covid-19 pandemic. Although greater certainty about the problem being resolved has been noted in both surveys as the most common reason for the giving of bribes, the 2022 survey has shown a percentage increase in favour of the specific reason among both groups of respondents.
Survey data reveals that in the last two years, 20% i.e. one in five residents have used informal methods to resolve various situations. This most commonly occurred in health care and for gaining employment in state or municipal institutions. Informal methods were more widely used by entrepreneurs – 31% i.e. nearly every third entrepreneur. It was most often done for resolving construction related issues and participating in state and municipal procurements. Personal contacts have remained the most commonly used informal method among both groups of respondents.
Citizens continue to cite the need for greater disclosure of information in relation to those persons and organizations that influence decision-making, and stricter controls on public procurements as important solutions in the fight against corruption. Meanwhile, the opinion among entrepreneurs that harsh and real penalties should be imposed on offenders, and that officials should be recruited through open competition remains unchanged.
Along with the growing public rejection of bribery, the number of people who would be willing to report corruption has also increased. Namely, the majority or 61% of the population would report it, of which 19% would be willing to do so by revealing their identity. In situations where a bribe is requested or an official violates their authority, 38% of respondents would report to KNAB, and the highest reporting activity is observed among the youngest population.
1040 residents over the age of 18 and 400 companies operating in Latvia participated in the public opinion poll. The survey was conducted by the Market and Social Research Centre "Latvijas Fakti" on behalf of KNAB in the period from 7 January 2009 to 14 February 2022.
The survey conducted within the framework of the project “Support for the establishment of a whistle-blowing system in Latvia”, where KNAB receives grants from grants from Iceland, Liechtenstein and Norway in the European Economic Area. The aim of the project is to promote public involvement in reporting corruption and other latent crimes, while providing the population with a secure and convenient reporting channel, as well as improving KNAB competence in detecting and investigating corruption crimes.


text:
Dance Magazine Awards 2007
(Dance Magazine Website)
50 Years of Dance Magazine Awards
Awardees: Wendy Whelan, Bettie De Jong
Bebe Neuwirth, Desmond Richardson
Welcome: Karla Johnson, McFadden Performing Arts Media
Introduction: Wendy Perron, Editor in Chief, Dance Magazine
Stage Manager: Abigail Epprecht
Awards Coordinators: Janelle Abbott, Katy Malone
Presented at Florence Gould Hall
(Gould Hall Website)
55 East 59th Street
Press: Katy Malone
Dr. Roberta E. Zlokower
November 5, 2007
The 2007 Dance Magazine Awards have been presented since 1954 to such renowned artists and choreographers as Moira Shearer (1955), Gene Kelly (1958), Margot Fonteyn (1962), Rudolf Nureyev (1973), Antony Tudor (1974), Paul Taylor (1980), Tommy Tune (1984), Mark Morris (1991), Savion Glover (1996), Julio Bocca (1998), Terese Capucilli (2001), Chita Rivera (2004), and the dance critic, Clive Barnes (2006). The evening began with a black-white slide show of portraits in still or motion of probably all Dance Magazine recipients since 1954 (There were no awards in 1970 and 1971). This put lighting designer, Jennifer Tipton, on a scale with choreographer, Susan Stroman, with dancer, Damian Woetzel, with impresario, Sol Hurok, and with the early TV shows, “Omnibus” (CBS). There was much class, much nostalgia, and obviously much detail and organization.
In fact, I found the Dance Magazine Awards ceremony to be a model, on which to design future such tributes in one dance form and across many genres and roles. Speeches were tight, humorous, and charismatic. And, all renowned dance stars in the audience were applauded, individually. The Post-Awards reception was elegant and attended by the glitterati of New York’s dance community.
Wendy Whelan: An Excerpt from “Wendy: A Home Movie”, a Short Film by David Michalek and Wendy Whelan, 2003, Super 8 Footage by Rick and Kay Whelan, Music: Fratres by Arvo Pärt, Presentation by Jock Soto.
Wendy Whelan, a principal dancer with NYC Ballet, has been reviewed in dozens of ballets in this magazine. She was noted in tonight’s program for mastering the “leotard” repertoire, early on, and shining in classical and lyrical story ballets and shorter set pieces, such as Swan Lake, La Sonnambula, and The Cage. She was noted also for her ethereal and mesmerizing dances by Christopher Wheeldon, like After the Rain. Whelan dances with Wheeldon’s new Company, Morphoses, now, as well. For Jock Soto’s Farewell City Ballet Gala, Wendy Whelan was his featured partner.
Jock returned the favor tonight with a heartfelt speech, as he presented Wendy her award, after an excerpt of a film made at home by Whelan and her husband, David Michalek. In this film, Whelan moves to the stark music of Arvo Pärt, even with her cuddly cat. There’s also a brief childhood dance film. Whelan was quite gracious and moved, as this was her “first award”.
Bettie De Jong: An Excerpt from Cloven Kingdom (1976), “Man is a Social Animal” (Spinoza), Choreography by Paul Taylor, Music by Malloy Miller, Men’s Formalwear courtesy of After Six, Original Lighting by Jennifer Tipton, Performed by Orion Duckstein, Robert Kleinendorst, James Samson, and Sean Mahoney, Presentation by Carolyn Adams.
Bettie De Jong, of Dutch and Indonesian roots, was Paul Taylor’s dance partner for many years, and since 1985 his Rehearsal Director and invaluable colleague. Ms. De Jong revitalizes the repertoire, so that the Taylor “classics”, such as Aureole and Esplanade, remain vital and engaging. Ms. De Jong met Taylor at the Martha Graham school, and she has worked at his side on and off stage ever since. Carolyn Adams, also a former Taylor dancer and the founder of the Harlem Dance Foundation, reminisced about the cheap motels, where the Taylor dancers used to stay, during travel engagements, and about Ms. De Jong’s ability to dance in the toughest of physical and logistical difficulties.
The prior performance, by a quartet of Taylor male dancers, Cloven Kingdom, was superbly athletic, masterful, and highly entertaining. This was gymnastics and mime, all in black tuxedoes.
Bebe Neuwirth: An Excerpt from the Video of Chicago, Performed at the 1997 Tony Awards, Presentation by Ann Reinking. Bebe Neuwirth, who recently won the 2007 Career Transitions Rolex Award, was honored with an excerpt of a video from the 1997 Tonys, showing her in her Tony Award-winning role, dancing and singing in Chicago. Ms. Neuwirth also appeared on Broadway in A Chorus Line, Sweet Charity, Damn Yankees, and Fosse. On TV, she had a long-time role in Cheers and Frasier. In film, Ms. Neuwirth starred in Le Divorce.
The filmed excerpt of Chicago, part of the 1997 Tonys, was dynamic, driven, and dazzling. This is one of the longest-running Broadway shows, and Ms. Neuwirth made an indelible mark with her talent and charm on its history and success. The speech by Tony winner Ann Reinking, who choreographed the revival of Chicago, and who danced in the original musical, was personal and lots of fun. She praised Ms. Neuwirth as a real “Fosse dancer”, and Ms. Neuwirth thanked Ms. Reinking, the late Bob Fosse, and all her mentors.
Desmond Richardson: An Excerpt from Dear Frédéric (2006), Choreography by Dwight Rhoden, Music by Frédéric Chopin, Original Lighting by Michael Korsch, Costumes by DM Design, Performed by Members of Complexions Contemporary Ballet, Presentation by Judith Jamison. A film of a recent Desmond Richardson solo performance highlighted Mr. Richardson’s muscularity and momentous presence. Mr. Richardson danced with the Alvin Ailey American Dance Theater for eight years, briefly appeared with Ballett Frankfurt, and danced in a Principal role with American Ballet Theatre. In 1994, he co-founded Complexions Contemporary Ballet with Dwight Rhoden, and he has appeared in numerous dance galas.
Judith Jamison, Artistic Director of the Alvin Ailey American Dance Theater, lauded Mr. Richardson, and Mr. Richardson thanked her and Alvin Ailey for his inspiration and success. Kudos to Dance Magazine and all the award recipients and presenters for a memorable and first class Dance Magazine Awards 2007.
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domain: artistic


text:
This article serves as reference material for candidates preparing for the Paper P6 (MYS), Advanced Taxation.
This article aims to pull together various laws and successive development in the relevant laws relating to Labuan entities to provide an up-to-date picture.
Labuan is an island in the South China Sea off the coast of Sabah in East Malaysia. In 1990, Labuan was established as an international offshore financial centre (IOFC) in a bid to attract international financial activities.
Right from the start, the Malaysian Government had taken pains to avoid the label 'tax haven' for Labuan, and had been vigilant against being used for international money laundering. However, its fixed tax rate of 3% capped at RM20,000 per year clearly calls to mind 'low-tax regime' and inevitably, Labuan was viewed as a tax haven. Some among the double tax treaty partners of Malaysia formally, through protocols or re-negotiated treaties, introduced limitation of benefits (LoB) with regard to Labuan structures.
In response to this development, the Malaysian Government put in laws to facilitate a Labuan entity to irrevocably elect to come under the purview of the mainstream Malaysian tax system rather than enjoy the tax goodies available under the Labuan tax regime.
Consequently, the last few years saw Labuan IOFC being rebranded as IBFC (international business financial centre), involving the renaming Labuan legislations, terms and nomenclatures to omit the word 'offshore' which arguably carries the pejorative 'tax haven' connotations and associations.
Apart from the Labuan Business Activity Tax Act 1990 (LBATA), there are parallel Labuan legislations for Companies Act, Trusts Act. In 2010, a slew of legislations governing foundations, limited liability partnerships, financial services and securities and Islamic financial services and securities have been put in place.
In this article, the focus is on the provisions of the LBATA 1990, as amended.
Labuan means the Federal Territory of Labuan
'Labuan company' means a Labuan company incorporated under the Labuan Companies Act 1990 and include a foreign Labuan company registered under the said Act.
This term includes:
Preceding year basis of assessment
Tax under the LBATA is levied on the preceding year basis e.g. The year of assessment 2013 has its basis period ending in 2012. This is in contrast to the current year basis practised in the mainstream tax system under the Income Tax Act 1967.
'Labuan business activities'
It means activities carried on by a Labuan entity in a foreign currency with non-residents or with another Labuan entity.
Nevertheless, the Minister of Finance may designate any activity to be a Labuan business activity, which then may enable the carrying out of activities with residents or in the Malaysian currency.
Labuan non-trading activities mean activities relating to the holding of investments in securities, stocks, shares, loans, deposits or any other properties by a Labuan entity on its own behalf.
Scope of charge [s3]
A Labuan entity is subject to tax under the LBATA in respect of its Labuan business activity – ie in foreign currency with non-residents or other Labuan entities, or in respect of any designated Labuan business activities which then may be transacted with residents or in the Malaysian currency.
Net profit per audited accounts for Labuan trading activities
Tax is chargeable only on the net profits per audited accounts in respect of Labuan trading activities (– ie banking, insurance, trading, management, licensing, shipping operations and any other activity (other than the holding of investments in securities, stocks, shares, loans, deposits or other properties).
The tax rate is 3% upon the chargeable income from only the Labuan trading activities. This means the income from the Labuan non-trading activities (– ie the holding of investments in securities, stocks, shares, loans, deposits or other properties) of a Labuan entity is not subject to tax at all.
Tax return and statutory declaration
A Labuan entity carrying on Labuan business activities which are Labuan trading activities must file an annual statutory declaration and tax return within three months from the commencement of the year of assessment – ie by 31 March of the following calendar year.
Election for tax of RM20,000
A Labuan entity may elect (within three months of the start of the year of assessment, in a prescribed form) to be charged to tax of RM20,000 instead of the 3% of net profits. This means that the Labuan entity will not be required to submit a tax return for that year of assessment.
In a nutshell, a Labuan entity with an accounting net profit of up toRM666,667 a year should file a tax return and be taxed at 3%. If the income exceeds RM666,667, the Labuan entity should elect to be taxed at the fixed sum of RM20,000 and thereby avoid having to file a tax return as well.
Zakat paid to a Labuan Islamic religious authority (and evidenced by a receipt) up to the amount of tax charged (whether at 3% or at fixed amount of RM20,000) may be given as a rebate. No refund is available if the Zakat paid exceeds the tax charged.
Non-trading activities not chargeable to tax
A Labuan entity carrying on a Labuan business activity which is a Labuan non-trading activity is not chargeable to tax. A statutory declaration in a prescribed form is all that is required compliance-wise.
To date, 11 countries have specifically excluded Labuan from treaty benefits in their double tax agreements with Malaysia. They are Japan, Netherlands, United Kingdom, Australia, Sweden, Luxembourg, Republic of Seychelles, Chile, Indonesia, South Africa and South Korea.
In an attempt to facilitate Labuan companies in accessing treaty benefits, the laws have been amended to allow a Labuan company to elect to be treated under the Income Tax Act 1967 rather than the Labuan Business Activities Tax Act 1990.
The election is irrevocable.
No indirect taxes
Labuan enjoys free-port status. Hence indirect taxes are not applicable here.
Stamp duty is exempted on all instruments executed by a Labuan entity in connection with its Labuan business activity.
Labuan entities are also not subject to exchange control restrictions.
Payments by Labuan entities
The following exemptions are available to recipients of income from Labuan entities:
In addition, the following payments made by Labuan entities to non-residents are exempted in the hands of the non-resident recipients, and hence are not subject to withholding provisions:
Individuals working in Labuan for Luan entities
418 of 2011
The Minister exempts any person from the payment of income tax on 65% of the statutory income from a source consisting of the provision of qualifying professional service rendered in Labuan by that company to a Labuan entity.
'qualifying professional service' means legal, accounting, financial or secretarial service.
419 of 2011
Exemption for non-citizens in respect of
100% of director’s fees from Labuan entities.
420 of 2011
|Exemption of 50% of employment income in managerial capacity with Labuan entity in Labuan, or in a co-located office of marketing office which may be located elsewhere in Malaysia to facilitate business meetings, but cannot be for exercising trading activities on behalf of Labuan entities.|
421 of 2011
Exemption for Malaysian citizens in respect of
50% of gross housing allowance and gross Labuan Territory Allowance received in respect of exercising employment in Labuan with Labuan entity.
209 of 2012
|With effect |
|The Minister exempts from tax any gains or profit falling under section 4(f) of the Act received by a non-resident from a Labuan entity.|
Written by a member of the Paper P6 examining team

domain: finance


Clare, a parent in the Bronx:
“My children go to the library everyday after school to do their homework with classmates, Whenever it rains a lot, the library gets flooded, especially in the children’s section. When this happens, arriving families are turned away and this always makes them frustrated and sad. It would be so nice to have funds to make the necessary upgrades for flood prevention.”
This story was originally a nomination for the NYC Neighborhood Library Awards. It has been generously provided by the Charles H. Revson Foundation.


text:
Inscribed and initialled by André Breton: "peut-être pour illustrer l’article de Calas, ainsi que les 2 dessins de Masson" (maybe to illustrate (Nicolas) Calas article, with 2 drawings by Masson).
This early semi-glossy silver print has a light fold near the lower left corner visible under raking light only. The print verso shows some traces of a former mounting.
By helping to distort this nude in 1933, the mirror is here the first assistant of André Kertész. The Hungarian reporter-photographer gets a distorting mirror at the flea market, similar to those he saw at the Jardin d'Acclimatation, and makes about two hundred Distortions in a few weeks. The curves of his models are confronted with those of the mirror and generate an abyss in which our eyes try to find their bearings.
In the artist’s own words: "I purchased two deforming mirrors at the flea market – the type of thing that is found in amusement parks. With the existing light and an old lens invented by Hugo Meyer, I have realised amusing impressions. Some images resemble sculptures, whereas others became grotesque and frightening."
André Kertész moves to Paris at the age of 31 and starts working as a press photographer. The history of art will retain a pillar of surrealism and a great master of photography. Contacted in 1932 by Aimé-Paul Barancy to illustrate the magazine Le Sourire with a series of nudes, Kertész is inspired by a child's play to produce what remains one of the most surrealist works he ever produced. The original title Déformation gives way to the one we know today, Distortion. This series was published for the first time in the US by the magazine Photography (n°46) in 1936. The name, comprehensible both in France and in the United States, will remain.
The mirror of Distorsion # 82 does not think about the information in the center and duplicates the model's body while reversing it. This unexpected, unidentified, sinuous body lets us see a fan-shaped radiator supposed to warm women throughout their session. In the manner of a cubist painting, the twist of the image cuts the subject, duplicates and reshuffles it on a flat surface. Usually an accomplice in figuration and the reproduction of reality, photography is the first to stand up to the unusual. Each surface reflecting another reality becomes a doorway to a strange world that Kertész tries to show us.
All of Kertész's work has been fashioned from nature. From August 1917, he spotted the magic of the world around him with his Nageur sous l’eau. Since that day, the distorted perception of the human body has an important place in the work of the artist. A series made in 1927, of which only one portrait survives, and a portrait of Carlo Rim in 1930 indicates that this vision continues to inhabit the photographer. It is really when Le Sourire is published, on March 2nd, 1933, that we can measure the originality of his gaze and the universe in which he lures us. Aberrations, exaggerations, shortcuts and enlargements highlight or erase body parts while inviting us to reflect. Although humorous, this nude approach is highly aesthetic for the surrealists. The artist goes beyond the object and produces a work literally of another dimension, related to his time and close to the nudes without form by Pablo Picasso or Salvador Dali’s melted clocks.
Aesthetically, Distortions stands apart from the work of Kertész and makes forget the melancholy character of the photographer. Recognized for his right lines and his significant framing, André Kertész signs a work that upsets his oeuvre but especially that leaves its mark on the photography of the inter-war period. His treatment of the nude is an avant-garde within the avant-garde. Under the influence of photography, painting and sculpture have freed themselves from the figurative representation for a long time. Here, in this mise en abîme, photography frees itself by representing the inexistent.
The initial publication of Distortions did not see the day despite an advanced model, and it was not until the work of Nicolas Ducrot in 1972 that it finally reaches a legitimate international recognition.
André Kertész was a one of the most influential Hungarian photographers. He is best known for his contributions to photojournalism, with distinctive and dynamic compositions in his photo ...Continuez à lire
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