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|Year : 2020 | Volume
| Issue : 1 | Page : 87-92
Preoperative anxiety in adult patients undergoing day care surgery: Prevalence and associated factors
Meghna Jiwanmall1, Stephen A Jiwanmall2, Aparna Williams1, S Kamakshi3, Lovisal Sugirtharaj3, K Poornima4, Kuruthukulangara S Jacob2
1 Department of Anaesthesiology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
4 Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||09-Apr-2019|
|Date of Decision||01-May-2019|
|Date of Acceptance||04-Aug-2019|
|Date of Web Publication||6-Jan-2020|
Dr. Stephen A Jiwanmall
Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There is a paucity of data related to anxiety levels in patients undergoing day care surgery in India.Methods: Preoperative anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS) 1 day before surgery and on the day of surgery, and the patients were categorized as cases (APAIS score ≥13) and controls (APAIS score <13). Sociodemographic characteristics, clinical features, and fears associated with anesthesia and surgery were also noted. Results: Out of the 399 patients recruited, 58.1% experienced significant preoperative anxiety. The fear of needles (P = 0.002), fear of waking up during the surgery (P < 0.001), and the patient's need of additional information regarding anesthesia and surgery (P < 0.001) were significantly associated with preoperative anxiety. Conclusion: A significant proportion of patients scheduled for day care surgery have preoperative anxiety. A preanesthetic workup of a patient with adequate clarification about their doubts and fears related to anesthesia and surgery is recommended to bring down the level of anxiety.
Keywords: Anxiety, risk factors, day care surgery, preoperative
Key messages:(1) Preoperative anxiety does exist in a significant proportion of patients scheduled for day care surgery. (2) The factors significantly associated with preoperative anxiety were fear of injection or needles, fear of waking up during the surgery, and the patient's need for additional preoperative information regarding anesthesia and surgery. (3) A preanesthetic workup of a patient with adequate clarification about their doubts and fears related to anesthesia and surgery is recommended to bring down the level of anxiety.
|How to cite this article:|
Jiwanmall M, Jiwanmall SA, Williams A, Kamakshi S, Sugirtharaj L, Poornima K, Jacob KS. Preoperative anxiety in adult patients undergoing day care surgery: Prevalence and associated factors. Indian J Psychol Med 2020;42:87-92
|How to cite this URL:|
Jiwanmall M, Jiwanmall SA, Williams A, Kamakshi S, Sugirtharaj L, Poornima K, Jacob KS. Preoperative anxiety in adult patients undergoing day care surgery: Prevalence and associated factors. Indian J Psychol Med [serial online] 2020 [cited 2020 Jan 26];42:87-92. Available from: http://www.ijpm.info/text.asp?2020/42/1/87/273393
Day care surgery has witnessed an exponential increase both globally and in India over the past few years., Numerous patients, with multiple comorbidities, previously deemed unfit for day care surgery, are now undergoing day care surgical procedures. The advantages of day care surgery include shorter hospitalization times, shorter waiting time, decreased risk of infections, early mobilization, lower costs, and reduced bed occupancy. The other presumed advantages include less stress for the patients due to avoidance of prolonged hospital stay and decreased time of separation from the family and home environment.
Day care surgery seems to be an attractive option for many patients, but recent studies have shown that preoperative anxiety is observed more frequently in day care patients when compared with in-patients undergoing fast-track surgery. Some authors recommend that anxious patients and those who wish strongly for inpatient treatment should be excluded from day care surgical procedures., Wetsch et al. have reported that day care surgery also has additional stress and that all patients may not be fit for shortened hospitalization.
Preoperative anxiety is a real concern for many patients undergoing anesthesia and surgery., Literature reports that 60%–92% of patients experience significant preoperative anxiety. Autonomic response associated with increased anxiety may cause tachycardia, hypertension, and arrhythmias and increase the risk of intraoperative hypothermia. Preoperative patient anxiety in the day care setup is especially relevant as sedative premedication is often omitted. Other factors contributing to patient stress and anxiety may include time pressures associated with the surgery in 1 day's time, waiting time in the ward prior to surgery, interaction with the hospital staff (nurses, anesthetists), and arranging an accompanying person and monetary resources. In addition, patients may have fears regarding anesthesia, surgery, and adverse events in the recovery period. There is a dearth of data from India in this field. Therefore, this study attempted to examine the prevalence and factors associated with preoperative anxiety in patients undergoing day care surgical procedures.
| Methodology|| |
This was a cross-sectional study to evaluate the prevalence of anxiety in patients posted for day care surgery. However, a case–control framework was used to assess the factors associated with preoperative anxiety.
The study was conducted in a medical college with tertiary and specialist surgical departments.
Consecutive patients posted for day care surgery were recruited for the study after obtaining informed written consent. The inclusion criteria were as follows: (i) adults within the age group of 18–70 years, (ii) with or without a history of previous surgery, and (iii) American Society of Anaesthesiologists (ASA) Class 1–2, scheduled for elective surgery.
The exclusion criteria were as follows: (i) patients with a known history of anxiety or depressive disorders, (ii) people with mental retardation or with difficulties in speech and hearing, resulting in impaired communication, and (iii) patients who had taken an anxiolytic medication within 24 h prior to surgery.
The following instruments were used to evaluate the patients:
- Amsterdam Preoperative Anxiety and Information Scale (APAIS): The scale has been specifically developed to evaluate preoperative anxiety. It is a six-item questionnaire with a 5-point Likert scale for each item. It has been validated against standard measures of anxiety. It has good psychometric properties. The instrument has been translated into many languages and has been validated for use across countries. In this study, we used its English version. Patients with an anxiety score of ≥13 on the scale are considered to have clinically significant preoperative anxiety
- A specially designed proforma to collect sociodemographic characteristics, clinical details, information regarding proposed surgery, and previously known factors associated with preoperative anxiety.
Since the APAIS questionnaire did not distinguish well between the fear of anesthesia and fear of surgery, a list of some selected variables from previous studies that were associated with preoperative anxiety was included in the proforma.
Patients who presented to the ward for day care surgery were invited to take part in the study. Details of the study were explained, and written consent was obtained. The APAIS was administered on the day prior to the surgery and repeated on the morning of the surgery. Details of the time taken from admission to the day care ward to the induction of anesthesia and waiting time were also documented.
The recommended APAIS threshold of ≥13 was used to divide the sample into cases with preoperative anxiety; patients who scored <13 were not anxious and consequently considered controls. The mean and standard deviation were used to describe continuous variables, while frequency distributions were obtained for categorical data. The Chi-squared test and Student's t-test were used to assess the significance of bivariate associations for the categorical and continuous variables, respectively. Variables that were significant on bivariate statistical tests were entered into multiple logistic regression analysis. Odds ratio and 95% confidence interval were calculated. SPSS version 16 was used to analyze the data.
The sample size was calculated using the Epi Info program using the following assumptions:
(i) For the prevalence component, with a precision of 5%, confidence interval of 95%, and a 25% prevalence, the sample size calculated was 323. (ii) For the factors associated with preoperative anxiety component, assuming exposure among cases being 25% and among controls being 10%, power of study 80%, and error of 5%, the sample size required was 224, with 112 cases and 112 controls.
Approval was obtained for the research protocol from the Institutional Review Board (IRB Min. No. 10909) of Christian Medical College, Vellore, prior to the recruitment of patients.
| Results|| |
A total of 399 people were recruited for the study. The sociodemographic and clinical characteristics of the total study population are documented in [Table 1] and [Table 2], respectively. The majority were middle-aged men (72.2%), literate (86.5%), married (79.2%), with a previous history of surgery (59.4%) and without health insurance (97.2%), coming from places which are outside Tamil Nadu (65.2%), and undergoing procedures under general anesthesia (58.6%). Different types of day care surgeries were included under a broad heading of general surgery, orthopedics, ear–nose–throat, urology, and epidural steroid injections.
The majority of patients who were found to be anxious gave history of surgery in the past (56%). They were from other states outside Tamil Nadu (56.5%) and were scheduled for only general anesthesia (56%). The anxiety score taken a day before the surgery (APAIS A1) for cases and controls was 14.22 ± 2.25 and 11.23 ± 2.81, respectively, which was significant (P< 0.001). Similarly, the anxiety score taken on the day of surgery (APAIS A2) for cases and controls was 16.09 ± 1.89 and 10.60 ± 2.73, respectively, with P < 0.001.
The factors significantly associated with preoperative anxiety were patient's fear of needles/injections (P = 0.002), fear of waking up during the surgery (P< 0.001), and the need for additional information regarding anesthesia and surgery, which is generally given during the preanesthetic clearance for surgery (P< 0.001). Multiple logistic regression analysis showed that factors associated with preoperative anxiety remained statistically significant (P< 0.05) [Table 3].
|Table 3: Multiple logistic regression analysis showing factors associated with preoperative anxiety|
Click here to view
| Discussion|| |
This study attempted to examine the prevalence and factors associated with preoperative anxiety. Its strengths included the fact that it recruited consecutive patients, had a large sample size, used a standard instrument to evaluate anxiety, and used multivariate statistics.
The prevalence of preoperative anxiety in our study, using the APAIS, was 58.1%. Studies from different parts of the world have reported varying prevalence rates, from 23.4% to 76%. A Sri Lankan study reported a prevalence of preoperative anxiety of 23.4%, whereas a Mexican study showed a much higher prevalence of 76%.
A study reported 42.2% prevalence and concluded that the preoperative anxiety is a multifactorial issue which needs reduction strategies. Lichtor et al. showed the prevalence of preoperative anxiety as 59% and stated that anxiety seen at the preoperative holding bay could be predicted from the anxiety seen in the afternoon before the surgery. Our study found this similar association between the anxiety score on the day of surgery and anxiety score taken a day before the surgery, where both the values were not very different from each other. Gangadharan et al. reported a 60% prevalence, with the important associated factors being age, gender, marital status, previous surgical experience, and different types of surgeries. Wetsch et al. reported 38.3% prevalence of preoperative anxiety in day care surgery patients.
More than half of the patients admitted to day care surgery wards are anxious. This finding is of significance because according to standard day care anesthesia protocols, generally, premedication is usually avoided and therefore, such patients are likely to have more preoperative anxiety. The awareness about the prevalence also points out toward the scope of further research to find out the means to allay the anxiety.
Many factors associated with preoperative anxiety have been mentioned in the literature, namely, gender, marital status, fear of complications, apprehensions, previous surgical experience, socioeconomic status, postoperative pain, type of anesthesia, lack of preoperative information, cigarette and alcohol usage, education, and occupation., We have taken selected variables to examine their association with preoperative anxiety. The majority of patients who were anxious gave a history of previous experience of surgery in our study, but this finding varied from other study. This may be attributed to the previous unpleasant experience they would have had, or related to surgery or anesthesia. While some studies reported that anxiety is more common in women, we found that males had more anxiety than females.,
We found a close association between anxiety and the need for additional information. As in the APAIS study, patients who had a high anxiety score were the ones who needed additional or more information than the patients who had low anxiety score.,, This finding may strengthen the recommendation for a good preoperative workup of patients before surgery, where additional information can be provided and problems can be addressed. Fear of complications during surgery has been reported to have an association with preoperative anxiety. Out of the selected variables that were studied, the fear of needles or injections and fear of waking up during the operation were found to be significant and commonly associated with the preoperative anxiety, in our day care population.
During the preanesthetic check-up, information regarding the type of anesthesia is generally explained to all patients by the examining anesthesiologist. But, due to time constraints, complexity of the disease process, or language barrier, there might be a deficiency in the explanation of the related information of anesthetics and surgery. In some studies, it has been found that the patients who received better preanesthetic information showed low scores on the anxiety scale when compared with those who did not receive any explanation. However, an association was found in our study where the anxious patient had a higher need for additional information. Our study did not show any significant association between the level of anxiety and educational status or occupational status.
Other factors such as age, sex, socioeconomic status, marital status, body mass index, previous experience of surgery, presence or absence of health insurance, duration of waiting period prior to administration of anesthesia, type of anesthesia, and residential status were not significantly associated with preoperative anxiety. In our institutional practice, the surgical waiting period ranges from 2 to 3 months; hence, patients may not mind waiting for 6 h preoperatively on the day of surgery. Therefore, this did not have an association with anxiety in our patients, unlike some study where prolonged waiting time was shown to cause distress among patients. But even then, support strategies are recommended by the authors, to be implemented by the nursing staff during the waiting period in day care centres to reduce anxiety. There was no significant difference found in relation to the type of anesthesia, but patients who were planned for general anesthesia were more anxious than the ones who were planned for regional or local anesthesia, which was similar to the results of a recently published study. This may point toward a limited knowledge about the types of anesthesia available, the risks associated with each, and previous surgical experience. This can also help us in planning future studies to assess the awareness about anesthesia among patients and thereby improving the quality of care. Incidentally, we also found that patients who were anxious belonged mainly from states outside Tamil Nadu, even though this did not reach statistical significance. This might imply that most of the patients who come from far off places need more flexibility in their treatment plans and facilities to reduce their anxiety.
There have been some limitations to our study. The pediatric and geriatric populations have been excluded from the study, even though they constitute a good number in the daycare surgery patient pool. Different types of surgeries were included in the study and they were not divided according to their duration and nature.
| Conclusion|| |
A considerable number of patients scheduled for day care surgery were found to have a significant amount of preoperative anxiety. In our study, the factors associated with preoperative anxiety that were significant were the fear of injections or needles, fear of waking up during the surgery, and the need for additional information that the patients require regarding anesthesia and surgery. Hence, a good preanesthetic workup of patients, with adequate clarification about their doubts and fears related to anesthesia and surgery, is recommended to bring down the level of anxiety.
Amsterdam preoperative anxiety and information scale (APAIS)
- I am worried about the anesthetic
- The anesthetic is on my mind continually
- The procedure is on my mind continually
- I am worried about the procedure
- I would like to know as much as possible about the anesthetic
- I would like to know as much as possible about the procedure.
(The measure of agreement with these statements should be graded on a 5-point Likert scale from 1 = not at all to 5 = extremely).
The anxiety scale (APAIS A) consists of four items (questions 1, 2, 3, 4), each of which could be scored from 1 to 5. The score of the anxiety scale is the sum of these four questions, with a scoring range from 4 to 20. The cut-off score is 13. Score ≥13 defines significant anxiety, whereas <13 defines mild anxiety.
The need-for-information scale (APAIS N) consists of two items (questions 5 and 6), each of which could be scored from 1 to 5. The sum of the need-for-information scale is the sum of these two questions, with a scoring range from 2 to 10. Cut-off being 5. Score ≤5 needs no excessive information, whereas score >5 needs more information than the legal explanation about the procedure.
Financial support and sponsorship
The project was funded by the FLUID research grant of Christian Medical College and Hospital, Vellore, Tamil Nadu, India.
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery. Br J Anaesth 2009;103:199-205.
Kakande I, Nassali G, Kituuka GO. Day care surgery: The norm for elective surgery. East Cent Afr J Surg 2005 1;10:1-4-4.
McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthesia 1990;45:153-5.
Nigussie S, Belachew T, Wolancho W. Predictors of preoperative anxiety among surgical patients in Jimma University Specialized Teaching Hospital, South Western Ethiopia. BMC Surg 2014;14:67.
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Prathapan S, Wanigabandu LU, Silva DD, Serasinghe V, Dadigamuwa N, Rajakaruna M, et al.
Anxiety of adult patients undergoing general anaesthesia and their myths and beliefs. Sri Lankan J Anaesthesiol 2013;22:11-4.
Valenzuela Millán J, Barrera Serrano JR, Ornelas Aguirre JM. Anxiety in preoperative anesthetic procedures. Cir Cir 2010;78:147-51.
Cevik B. The evaluation of anxiety levels and determinant factors in preoperative patients. Int J Med Res Health Sci 2018;7:135-43.
Lichtor JL, Johanson CE, Mhoon D, Faure EA, Hassan SZ, Roizen MF. Preoperative anxiety: Does anxiety level the afternoon before surgery predict anxiety level just before surgery? Anesthesiol J Am Soc Anesthesiol 1987;67:595-8.
Gangadharan P, Assiri RA, Assiri FA. Evaluating the level of anxiety among pre-operative patients before elective surgery at selected hospitals in the kingdom of Saudi Arabia. IJCRR 2014;6:37.
Mulugeta H, Ayana M, Sintayehu M, Dessie G, Zewdu T. Preoperative anxiety and associated factors among adult surgical patients in Debre Markos and Felege Hiwot referral hospitals, Northwest Ethiopia. BMC Anesthesiol 2018;18:155.
Matthias AT, Samarasekera DN. Preoperative anxiety in surgical patients – Experience of a single unit. Acta Anaesthesiol Taiwanica Off J Taiwan Soc Anesthesiol 2012;50:3-6.
Pokharel K, Bhattarai B, Tripathi M, Khatiwada S, Subedi A. Nepalese patients' anxiety and concerns before surgery. J Clin Anesth 2011;23:372-8.
Kiyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, Ogawa NY, et al.
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Carr T, Teucher U, Mann J, Casson AG. Waiting for surgery from the patient perspective. Psychol Res Behav Manag 2009;2:107-19.
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[Table 1], [Table 2], [Table 3]

domain: psychology


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Parris Campbell breakout Candidate Film Room
The Indianapolis Colts Wide Receiver Parris Campbell turns 24 today, and to celebrate, we break down the All-22 of why if he can stay healthy, he could dominate the field.
I mainly talk about the Indianapolis Colts Professional Football team. I do get into the rest of the NFL, and also talk about the Indy Express professional basketball team (Part of The Basketball League 'TBL'), which I am the broadcast coordinator, and in-game commentator/announcer. If it has to do with Indiana, I have an opinion.

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Biden is skeptical Russia is scaling back operations in Kyiv
WASHINGTON (AP) — President Joe Biden says he’s not yet convinced that Russia’s announcement that it will scale back military operations near the Ukrainian capital of Kyiv will lead to a fundamental shift in the war.
Biden said during an appearance before reporters with Singapore Prime Minister Lee Hsien Loong at the White House on Tuesday that he was waiting to see what Russia offers in ongoing talks with Ukraine and how Moscow readjusts its troop presence.
Biden says of the latest development, “We’ll see" he said “I don’t read anything into it until I see what their actions are.”
The Democratic president says he doesn’t read anything into it until he sees what Russia’s actions are. Lee says “the war in Ukraine has implications for the Asia Pacific” region.
As for the negotiations between Russia and Ukraine, Biden said the consensus of Western allies is to “see what they have to offer.”
Meanwhile, the U.S. will likely need to add more permanent or rotational forces in Europe in the wake of the Russian invasion of Ukraine, the U.S. European Command leader told Congress Tuesday, without detailing when or how many.
Gen. Tod Wolters, who also serves as NATO’s supreme allied commander, said decisions will be based on what European nations do, particularly in response to the need to build four additional NATO battlegroups, which are being set up in Hungary, Slovakia, Romania and Bulgaria. The groups are an effort to protect and reassure nations on Europe’s eastern flank.
“My suspicion is we’re going to still need more,” Wolters told the Senate Armed Services Committee.
Questioned about early U.S. intelligence that suggested Russia would overwhelm Ukraine quickly, Wolters said that there may have been an “intel gap.” He said broader reviews of the U.S. response to the war will consider that element.
On Russia’s use of hypersonic weapons in Ukraine, Wolters said there have been “multiple” launches that appeared to be an attempt by Putin to demonstrate his military’s capabilities..
“I don’t think they were successful,” he said.

domain: news


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I bought abridged versions of the Three Musketeers and the Adventures of Robin Hood when I was eight. Both I ended up putting aside with a queasy feeling after reading them, because they were so obviously not children’s books (being influenced by Disney). The Three Musketeers ends with murder, a trial by peers and a gruesome execution. Robin Hood ends, not with a fox marrying his lady love, but with an old, wounded outlaw begging sanctuary from a convent, bled to death in the night by a vengeful prioress.
So it time to revisit d’Artagnan, Athos, Porthos, and Aramis as an adult. The Penguin Classic Deluxe edition was the obvious choice as 1) it was attractive with a marvelous cover by Tom Gauld and 2) it was translated by Richard Pevear who is one half of my favorite translating team (he and his wife Lara Volokhonsky translated Tolstoy’s Anna Karenina, along with many other works by Tolstoy, Dostoyevsky and Dumas.)
Thanks to the frequent cinematic adaptations, nearly everyone knows the plot without having read the books. In a time of shifting loyalties and political intrigue of seventeenth century France, a young impressionable, hot-headed provincial, d’Artagnan, comes to Paris with the ambition of becoming a musketeer. After – what else? – a duel or two, our young quixotic hero befriends three musketeers: Athos, the silent deep-thinker sunk into a pervasive mysterious melancholy; Porthos, larger than life, lover of finery and women; and Aramis, the dreamy, poetic temporary musketeer longing to join the priesthood. Of course the novel is called the Three Musketeers not Four, and it is the three friends, their motivations, secret histories and mythic natures, which exert a strong fascination upon both d’Artagnan and the reader. The four friends fight for the King, defend themselves against the Cardinal, attempt to rescue damsels in distress, survive wars and assassinations, and generally run around the countryside in a great hurry.
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Category: plein air painters
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When Lauren and I were first married we used to spend most of a day walking from the distant eucalyptus groves, out over the bluffs, around the slough, through IV and UCSB, down the bike trail, out on More Mesa, through the horse trails in Hope Ranch, through westside and finally downtown. There we’d sit our tired legs down at a cafe, eat a big meal and take the bus all the way back home. It was our favorite date… so simple but so full of interesting people watching, nature exploration and places to appreciate the many sides of our town.
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Gelato Ice Cream
5000 Unit/Units per Year
Packaging & Delivery
220V 50Hz/60Hz, 380V 50Hz
Regulates the entire refrigeration process and maintains consistent product viscosity, adjustable through modifying viscosity between level 1 and level 5 on the front panel,thereby allowing users to fine-tune optimal serving temperature and viscosity.
Shuts down for self protection when motor overload or compressor overheat occurs due to power surge or abnormal voltage from power supply.
Water nozzle available on the front panel for easycleaning of machine surface.
Adjustable Discharge Speed
Product discharge speed can be manipulated through adjusting parameters of the phase converter (Only for 60Hz).
Stainless Steel Shell & Word class spare parts
For being durable and reliable.
Upgrade cylinder is optional which could shorten the cooling time at least 30%.
Large Cylinder Freezing
Packing & Delivery
1. Guarantee Time: 12 months
2. Professional production of ice cream machine since 1998
3. Direct manufactures
4. Extra spare parts are attached with order for stock accessories
5. Specialized after-sales teams offer technology support
6. The punctual delivery of goods, quality and quantity guaranteed
7. Fast delivery and good quality control teams to ensure timely delivery.
As the leader and the only one Chinese manufacturer which can both produce ice cream machine and ice cream powder, Oceanpower have got over 20 patent technologies since 1998.
Began manufacturing and exporting soft serve freezers;
Initiated R&D partnership with industrial experts in China and Sweden.
Began to manufacture ice cream powder mixes and cones automated production lines imported from Italy and Austria.
Over 20 patents for company's proprietary technologies filed and approved.
Drafted China National Ice Cream Machine and Ice Cream Powder Mix Standards Manufacturing facility approved by SGS for ISO-9001, ISO-14001, and OHSAS-18001 compliance.
Selected soft serve freezers granted UL, ETL and NSF certification.
New 44,000 square meter manufacturing facility in Heyuan opened for business.
Export sales surpassed USD 10 million.
We had participated many famous show, such as NAR Show, NAFEM Show, America Food & Beverage Show, DJAZAGRO Show, SIGEP Show, China-ASEAN Expo, HOTEL Shanghai Expo Finefood, China Import & Export FairHOFEX Show.etc.


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Join us for our guest dance party! Open to the public. Don’t miss this fun event full of dancing and music.
You can also join us for our group class before the dance party. Country Western Swing at 6:45pm.


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Background: Mobile phones with operating systems and capable of running applications (smartphones) are increasingly being used in clinical settings. Medical calculating applications are popular mhealth apps for smartphones. These include, for example, apps that calculate the severity or likelihood of disease-based clinical scoring systems, such as determining the severity of liver disease, the likelihood of having a pulmonary embolism, and risk stratification in acute coronary syndrome. However, the accuracy of these apps has not been assessed.
Objective: The objective of this study was to evaluate the accuracy of smartphone-based medical calculation apps.
Methods: A broad search on Google Play, BlackBerry World, and the iTunes App Store was conducted to find medical calculation apps for smartphones. The list of apps was narrowed down based on inclusion and exclusion criteria focusing on functions thought to be relevant by a panel of general internists (number of functions =13). Ten case values were inputted for each function and were compared to manual calculations. For each case, the correct answer was assigned a score of 1. A score for the 10 cases was calculated based on the accuracy of the results for each function on each app.
Results: We tested 14 apps and 13 functions for each app if that function was available. We conducted 10 cases for each function for a total of 1240 tests. Most functions tested on the apps were accurate in their results with an overall accuracy of 98.6% (17 errors in 1240 tests). In all, 6 of 14 (43%) apps had 100% accuracy. Although 11 of 13 (85%) functions had perfect accuracy, there were issues with 2 functions: the Child-Pugh scores and Model for End-Stage Liver Disease (MELD) scores on 8 apps. Approximately half of the errors were clinically significant resulting in a significant change in prognosis (8/17, 47%).
Conclusions: The results suggest that most medical calculating apps provide accurate and reliable results. The free apps that were 100% accurate and contained the most functions desired by internists were CliniCalc, Calculate by QxMD, and Medscape. When using medical calculating apps, the answers will likely be accurate; however, it is important to be careful when calculating MELD scores or Child-Pugh scores on some apps. Despite the few errors found, greater scrutiny is warranted to ensure full accuracy of smartphone medical calculator apps.
Keywords: cellular phone; computers, handheld; medical informatics applications; mhealth; mobile phone; software.

domain: medical


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The LEGO Ideas Typewriter (21327) is now available for purchase for VIPs on the LEGO Shop. This long-awaited set has 2,079 pieces and retails for $199.99. First conceived by fan designer Steve Guinness on LEGO Ideas, the set is a great representation of the old school typewriters down to the color scheme. As an added bonus, each set will include a booklet with a letter by LEGO Chairman Thomas Kirk Kristiansen that is translated into 43 languages. You can check out my review of the set here.
When you make a purchase or, sometimes, carry out some other action as direct result of clicking on a link at The Brick Fan, we will receive a small commission.
The Brick Fan is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. As an Amazon Associate I earn from qualifying purchases.

domain: hobby


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Book by Catherine Bush & Music and Lyrics by Dax Dupuy
Directed by Sarah Sutliff
Produced by Rebel Playhouse
Nominations: Outstanding Choreography / Movement, Sarah Sutliff; Outstanding Production of a Musical
|Photos by Theik Smith Photography|
About the Company: Rebel Playhouse is a non-profit, educational theater company that produces shows for children and families based on stories that break traditions and challenge normative thinking, and offers classes designed to foster creative development.
About the Show: Old Turtle and the Broken Truth was an interactive musical for all audiences based on the children's book of the same name by Douglas Wood. The production included dance, puppetry, and audience participation. In Old Turtle and the Broken Truth, a truth falls like a star from the sky and breaks into two pieces. When the villagers discover only half of the truth, it causes so many problems that Little One, a brave young girl, decides to search for the missing half. With the help of Old Turtle, and many animal friends, Little One is able to mend the broken truth and make it whole again creating a better world for everyone. Old Turtle and the Broken Truth is a powerful allegory about accepting and welcoming differences.
Producer Clara Kundin and Director/Choreographer Sarah Sutliff talk about staging this innovative morality tale.
What first attracted you to this project?
Sarah: My connection to this production is twofold: first as the Artistic Director of the Rebel Playhouse I knew I had to select an inaugural production that would pack a punch and show that children's theatre could be deeper and darker than what many think of in regards to Theatre for Young Audiences. The message of Old Turtle... can be challenging, but I felt that it was particularly relevant and important in light of our current national climate of distrust and miscommunication. As soon as I selected the piece to serve as our season opener, I knew that I wanted to be the one to tackle it as Director and Choreographer.
Clara: Rebel Playhouse wanted to present an inaugural production that was outside of the norm of the typical stories presented in theatre for children, and would be appealing to both child and adult audiences. Old Turtle and the Broken Truth tackled challenging themes of war, religious belief, communication, discrimination, and morality in a delightful package of a one hour musical with dance and live instrumental performances. It permitted our younger audience members to reflect on issues that effect our current world, and showed adults how deep and complex theatre for young audiences can truly be.
What was your favorite part of working on this production?
Sarah: I had the most talented, authentic, and passionate team of performers and artists. They made every day working on Old Turtle... an exploration and a joy. They made my job easy, and they dove into every suggestion, every musing, with 110%.
Clara: The best part of working on this production was seeing how truly universal the themes and messages the piece explores truly are. They moved our actors, they moved our production team, and they moved our audiences, young and old. Listening to the audience feedback after each show was profound, particularly realizing just how much our younger audience members were able to comprehend of some very challenging moments in the piece. They were able to speak about and reflect on Old Turtle and the Broken Truth in a very conscious and honest way.
What was the most challenging part of working on this production?
Sarah: We put on a 13 person musical with live music and full choreography in a very small black box theatre. The greatest challenge was definitely making the best use of the space without allowing the staging and choreography to leave the audience feeling cramped or overwhelmed.
Clara: We realized at the offset what a lofty undertaking this production was. To have a 13 person cast in which all performers had to play instruments and sing and dance and had devising experience seemed a daunting task... but shockingly that was the easy part! The greatest difficulty was finding a performance space. As a brand new company with limited funding, trying to find a performance space that was in our budget, could accommodate us for the full duration of our run, and was large enough to serve our staging and choreography was quite a challenge. The Dorothy Strelsin Theatre wound up being a magical space for us to call home for our three week run, but it came after many weeks of searching and inquiring.
What did you want the audience to walk away with after watching Old Turtle...?
Clara: We wanted audiences to leave our production with greater expectations for the quality and content in theatre for children, and a new appreciation of what musical theatre can look like. There is so much more range to the genre than the huge big budget dance musicals you see on Broadway.
What was one of the most notable elements of this production for you?
Sarah: I took inspiration for a great deal of the choreography from the tradition of the Haka; a Maori war dance/cry. The New Zealand All Blacks Rugby team is notorious for their pre-game Hakas, and I must have watched about 3 dozen Haka videos compiling the physical vocabulary of a dance that would suggest intimidation and battle. The climactic fight/dance in Old Turtle... was the first number I choreographed, and although I feared it may intimidate younger viewers, the feedback from the children in our audiences was overwhelmingly positive.
Clara: We were so lucky to have our incredible composer Dax Dupuy not only serve as our Musical Director, but she was also the production's pianist and she played Old Turtle herself! How's that for range!? Dax was onstage playing piano for the whole show, and she emerged from behind the piano in a great reveal to "enter" as Old Turtle. We loved the magic of the ever-present pianist turning out to be the wise Old Turtle, so in our programs we listed Dax as "The Pianist" so her appearance as Old Turtle would be a complete surprise to our audiences. We adored that in almost every show a child in the audience would exclaim "Old Turtle was playing the piano this whole time!!!"
Did you learn anything from your experience of working on this production?
Sarah: I learned so much. I guess my biggest take away is that regardless of how many curveballs may be sent your way, you never have to settle. Old Turtle... wound up being all I could have wished for, and more. As a brand new company presenting a new work, there is a great potential for roadblocks. We just never accepted them as absolutes and pushed through them all.
What was it like working with Rebel Playhouse?
Sarah: Well, I am a bit biased because Rebel Playhouse is my baby. Clara Kundin, Greer Samuels and I founded Rebel Playhouse in the Fall of 2016 in the hopes of promoting stories that challenged traditional thinking, advocating for truly non-biased and non gender/age/or race specific casting, and encouraging children's theatre as a whole to dive deeper and push harder. I like to think that we accomplished all of these things in our first production.
What was it like working with Sara Sutliff?
Clara: Sarah Sutliff is a force to be reckoned with in all that she does. The choreography of this show didn't end with each song. With a cast of 13 actors onstage at almost all moments and a small theater, each scene was a delicately choreographed ballet. She made a tight space feel open and inviting. As a person, her enthusiasm, talent, and professionalism set a high bar for those she works with, and we are all the better for it.
Make sure to check out Rebel Playhouse on Twitter and Instagram @rebelplayhouse


Eagles cornerback Ron Brooks suffered a ruptured quadriceps tendon in Sunday’s win over the Vikings, a source tells Les Bowen of the Philadelphia Inquirer. Brooks will require surgery and he likely will not be fully healthy until training camp in July. Needless to say, the corner will be shut down for the season and placed on IR.
Brooks, 28, joined the Eagles as a free agent in March, following defensive coordinator Jim Schwartz from Buffalo along with Nigel Bradham and Leodis McKelvin. Prior to this season, Brooks started just three games in his career. This year, he started in five of six games as the team’s slot cornerback.
Meanwhile, the Eagles are meeting with cornerback Aaron Grymes today, according to Geoff Mosher of 97.5 The Fanatic (on Twitter). Grymes was a standout for the Eagles over the summer but was waived after suffering a shoulder injury. Grymes will take a physical at the team’s Novacare Complex and, if everything checks out, he could rejoin the team this week.
Brooks is in the first year of a three-year, $5.5MM deal, though the pact only includes $1.55MM guaranteed.
Photo courtesy of USA Today Sports Images.


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A report looking into the potential for nuclear power in Australia is expected to be released later this week.
The parliamentary environment and energy committee was tasked by Energy Minister Angus Taylor in August to examine the potential for nuclear power.
Mr Taylor told the committee the moratorium on nuclear energy would remain, but he wanted some "sensible" advice on economic, environmental and safety implications.
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The inquiry received evidence on the potential for micro-reactors - some as small as five megawatts - and even floating nuclear power stations which are being developed in Russia.
Former federal minister and now Queensland Resources Council boss Ian Macfarlane told the committee the existing ban on mining uranium was purely "ideological", and ignored the fact it could be a $10 billion industry for the state.
He said nuclear power could lower emissions from the electricity sector without detracting from economic growth, however it needed national policy.
Environment groups said there were huge health, environmental and financial risks from a nuclear industry, which would also need massive taxpayer subsidies.
They warned suggestions of small modular reactors were a pipedream and the nuclear waste storage problem had not yet been solved.
Previous studies have identified at least 19 sites in Queensland, NSW, Victoria and South Australia which could be suitable for nuclear power plants, including Bundaberg, Port Stephens, South Gippsland and Port Adelaide.
It is understood the committee is aiming to table the report in parliament by the end of the week, but no formal release date has been set.

domain: politics


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The Virtual Cuban, That's All!
sequel to Cuban, That's All! - Candid Voices of a Spanglish Existence!
The beloved original
set of monologues detailing the Cuban exile experience from 1959 to present day (Large Print - para los viejos!)
Hernandez's Profile | Create Your Badge
revised edition of the original set of monologues, published as a companion piece to More Cuban, That's All!
Coming in 2010!


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West Tower Wedding Photographer, Aughton Weddings with Laura and Felix. West Tower seems to be one of my more popular venues this year and yet again really nice to photograph a wedding right on my doorstep.
Laura got ready at Birches Brow which is a beautiful boutique hotel right round the corner of West Tower in Aughton. The atmosphere on the wedding morning, from the girls, was a mixture of excitement and fluttering nerves. Around midday we headed to West Tower to finish off bridal prep along with more bubblies. Brides maids ready and boom now time to dress Laura. It wasn’t long before Laura was walking up the aisle to marry Felix. They had some fantastic readings, one read by Laura’s cousin, and to finish a beautiful song sung by Laura’s eldest cousin, Rachel.
The weather was stunning, either side of the wedding the weather had been horrible but by some miracle we had gorgeous sunshine. So with out further due we cracked on with some groups leading into Mr and Mrs photos around the gardens. Once we had got back the ceremony room had been transformed into an absolutely breathtaking room with loads and very pretty rustic details. Everybody tucked into a lovely meal, me included, before the brilliant speeches began and the happy couple joyfully cut the cake to lead us into the evening reception.
I left after the first dance as the party was in full swing and everybody seemed to be having a great time – I heard the following day that people barely left the dance floor!
What a brilliant day and a great party, huge congratulations to the lovely Mr and Mrs Watson.
More West Tower Weddings click here


text: The Top 5 Free -to-Play Games for Xbox One Despite the gradual pace of the game, there's plenty of fun to be had and strategy to uncover. Top 5 F2P games. Top 5 Free to Play Games on Xbox one. Beanz. Loading Unsubscribe from Beanz. Let's take a look at the Upcoming Free To Play Xbox One games. but the whole 1v4 pvp aspect really. I have each game you have stated that you are unable to play and i am able to play them all wothout my xbox one live so i have no live and am still playing games like neverwinter and warframe on my xbox do YOU even internet. The Best Free Games on the Xbox One By Grant Brunner on March 8, at This is the Grand Cru Classe of knocking metal balls about with flippers. By GamesRadar Staff News. See, Hawken uses a 'free-to-not-grind' system - you can choose to unlock all the game's content for a fee, or you can play for hours to unlock it for nothing. Which has more uptime? Try to look at it with an open mind. I personally enjoy the Xbox as most of my friends do as well and it has good quality. Harmonix macht's noch einmal. As i stated quite clearly my playstation was at risk. What people need to complain about is the nickel and dime DLC tactics by developers. Have you ever heard of the google play store getting hacked? Especially when it comes to tanks. Finally a comment i can agree with. Underground Expansion We Happy Few ID Xbox Indie-Programm Abstimmen. Because a lot of the aesthetic skins in the game are locked behind a paywall.


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This was a stop on a food tasting tour in Old Scottsdale. We were served a refreshing summer shandy beer with a mango flavor. Then came slices of the Fico pizza, which tastes amazing with the truffle oil and fig jam.
We would certainly come back for a full meak.
Own or manage this property? Claim your listing for free to respond to reviews, update your profile and much more.

domain: food


Stand-up comedian Kunal Kamra's new video for The New York Times has sparked a new controversy. He has laid in to Prime Minister Narendra Modi and his Bharatiya Janata Party (BJP) government for not being able to manage the crisis that led to what he describes as "a state-orchestrated COVID-19 massacre".
The video begins with Kamra's sarcastic assessment of the Modi government as he asks viewers: "Did you know India was the first country in the world to beat the coronavirus in January 2021?" This is followed by a video clip of Modi's speech, where the Prime Minister claims: "This country, by effectively controlling the coronavirus, has saved the world and mankind from tragedy."
Kamra accuses Modi of “blatantly lying" and states that during the second wave of the COVID-19 pandemic in May 2021, India witnessed more than 400,000 cases per day as well as 4,000 daily deaths - a figure which experts describe as a gross underestimation.
“My people are needlessly dying. Our government has blood on its hands. No world leader can compete with Modi. He runs India on a cocktail of bizarre lies and high-octane hypocrisy. And boy, can he act,” Kamra says, referring to a recent speech where Prime Minister Modi got emotional while lamenting the deaths caused by COVID-19.
From criticising the government for permitting Kumbh Mela (a Hindu festival which involves mass pilgrimages to four riverbanks) to go ahead and holding election rallies ahead of the West Bengal state elections, to taking a swipe at the shortcomings of the vaccinations and Modi’s claim that India is the “pharmacy of the world”, Kamra blames the government for nothing less than a state-orchestrated COVID-19 massacre.
“We produced more than 60 million doses for other countries, but we didn’t make enough vaccines for ourselves. So, what’s our government doing about this tragedy?”
Resonating with Kamra's thoughts, many netizens are lauding him for calling out Modi and criticising him for allegedly "lying".
— Harbinder Kaur 🚜 (@harbspeak) June 24, 2021
— JI SARDAARJI (@ji_sardaarji) June 24, 2021
— Priyam Jain (@priyam_jainn) June 24, 2021
— Legalman2 (@Legalman21) June 24, 2021
— Aneri Thakkar (@AneriThakkar6) June 24, 2021
Kamra is also facing a backlash from several netizens who suspect that he downplayed Modi to get into the "limelight" and is being "paid" by the anti-Modi group.
— Vaibhav Vyas (@vaibhav_260797) June 24, 2021
— Radheshyam (@_radhe_shyam__) June 24, 2021


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MemberJune 1, 2023 at 9:48 pm::
Ah, relationships and friendships! They are truly special bonds that make our lives richer and more meaningful. For me, there are a few key elements that define these connections and make them extraordinary. Let’s explore them together in a more personal and relatable way:
Trust is the foundation upon which all strong relationships are built.
It’s about having faith and confidence in each other. When you trust
someone, you feel safe opening up and sharing your thoughts, dreams, and
fears. It’s like having a secret keeper who you know will always have your
back.Imagine having a friend who has always been there for you, who has proven time and again that they can be relied upon. They keep your secrets and never judge you for your mistakes. You trust them with your deepest fears and know that they will provide a listening ear and unwavering support. That’s the power of trust in a friendship.
Effective communication is the lifeblood of any relationship. It’s about
truly listening, understanding, and expressing ourselves honestly. When we
communicate well, we build a bridge of connection and create a safe space
for open and authentic conversations.
Think about a friend with whom you can have long chats about anything and everything. They listen attentively, ask thoughtful questions, and provide meaningful responses. They understand the importance of communication and make an effort to truly connect with you. Such conversations deepen the bond and make the friendship even more special.
Values and Interests: Shared values and interests act as magnets, drawing
us closer to certain individuals. When we find common ground, it creates a
sense of belonging and strengthens the connection. It’s like discovering a
kindred spirit who shares our passions and understands us on a deeper
Consider a friend who shares your love for a particular hobby or interest, whether it’s playing a musical instrument, hiking, or a specific sport. You spend hours together pursuing that shared passion, exploring new avenues, and creating lasting memories. This shared enthusiasm becomes the glue that binds your friendship.
and Empathy: Relationships are about being there for one another through
thick and thin. True friends provide a shoulder to lean on, offer a
comforting presence, and show empathy during both joyous and challenging
times. They celebrate your successes and lend a hand when you stumble.
Picture a friend who was there for you during a difficult period in your life. They listened without judgment, offered a warm hug when you needed it, and provided words of encouragement. Their unwavering support and genuine empathy helped you overcome obstacles and grow stronger together.
and Effort: Building and nurturing relationships takes time and effort.
It’s about showing up, being present, and investing in the connection.
It’s the little things like reaching out, spending quality time, and
making each other feel valued that make all the difference.
Think about a friend who always makes time for you despite their busy schedule. They prioritize your friendship and ensure that you feel important and cherished. They remember your birthdays, plan outings, and create beautiful memories together. This effort and dedication make your bond unbreakable.
In the end, relationships and friendships are unique and personal, shaped by our experiences and the people we meet along the way 😇.


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Soldier Bug Nymph
4. Predatory Bugs, including minute pirate bugs, ambush bugs and assassin bugs (soldier bugs, big-eyed bugs)
These bugs prey on many insects, including tomato hornworms, thrips, spider mites, many insects' eggs, leafhopper nymphs, corn earworms and other small caterpillars. Pirate bugs are attracted by willows, buckwheat, corn and nectar and pollen from many flowers. Predatory bugs are attracted to bunch grasses, shrubs and other permanent plantings that provide them shelter. A unique lure is available to attract emerging soldier bugs to gardens.
Big eyed bug: Bradley Higbee, Paramount Farming, Bugwood.org
Ambush bug: David Cappaert, Michigan State University, Bugwood.org
Soldier bug nymph: Russ Ottens, University of Georgia, Bugwood.org
5. Ground beetles
Large, long-legged, shiny blue-black or brown beetles that hide under rocks and logs during the day, and are fast-moving when disturbed. They feed on slugs, snails, cutworms, root maggots, and Colorado potato beetle larvae. Attract them by providing perennial ground covers, stones, or logs. Rove beetles resemble earwigs without pincers, and feed on many insect pests and like similar conditions to ground beetles.

domain: agronomy


Winter Storm Warning for Tri-Cities area
Tue, 18 Feb 2014 00:30:34 GMT —
The National Weather Service has issued a Winter Storm Warning for Midland, Bay, Saginaw, Tuscola, and Huron counties until 4:00am (image 1).
We've been forecasting 4-7" of snow for most of the NBC25 viewing area tonight, but isolated 8" totals are possible in the new warning area with the potential for a few heavy bands of snow setting up.
The rest of the NBC25 viewing area remains in a Winter Weather Advisory until 4:00am (image 2).
For more information on the new warning, click here.
For a look at your long-range forecast that includes a February thaw, click on the video!


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Location: Philippines > Luzon > Bicol Region > Albay Province > Naga
Bar / Lounge Free High Speed Internet ( WiFi ) Free Parking Pets Allowed ( Dog / Pet Friendly ) Restaurant Room Service
Price Range (Based on Average Rates): $
- Official Description (provided by the hotel):
- Our Bed & Breakfast is right in the middle of Naga City but is enclosed in a beautiful garden -- you can do bird watching, feed the kois by the pond with hanging bridge, hang out by the Gazebo in the middle of the pond or a tree house. Rooms are are fully-air conditioned with hot/cold shower. It’s near every hot spot and a few minutes away from CamSur Watersports Complex, airport, the beach and hot springs. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Asiatravel.com Holdings so you can book your Fishcove Garden reservations with confidence. We help millions of travelers each month to find the perfect hotel for both vacation and business trips, always with the best discounts and special offers.

domain: travel


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Kinistin Saulteaux Nation opens new daycare
from Parkland Review
A new building means a new start for the Kinistin Saulteaux Nation's daycare and early childhood education programs. "It brings pride and joy and recognition to our community to get such a great facility for our community and it just shows we're moving forward our community, getting these new venues and replacing the old," said Coun. Ivan Severight. "It's a positive step forward for our community."
7701 Las Colinas Blvd., Ste. 800, Irving, TX 75063

domain: sociology


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ONE PALESTINE, COMPLETE: Jews and Arabs Under the British Mandate, by Tom Segev. (Owl/Holt, $18.) Relying on personal histories and anecdotes as well as his own wry insights, Segev (at right), a newspaper journalist, tells the complex story of the period when Britain ruled the Holy Land (1917-48) from all three perspectives: British, Arab and Jewish. His "enormously important book," which was chosen by the editors of the Book Review as one of the best books of 2000, is "perhaps the best single account of Palestine under the British mandate," Omer Bartov wrote here.
September 30, 2001

domain: history


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I recently returned from spending a week in Somalia, where I saw first-hand the catastrophic effects that today’s famine is having on its people, and how drought has devastated the land they depend on.
Agriculture is the country’s largest employer, with two-thirds of Somalia’s workforce traditionally relying on farming to scratch a living. But no longer, however, for years of drought have reduced fields to parched scrubland that cannot be farmed or used to sustain livestock, leading to the deaths of many thousands of cattle, sheep and goats. As a result, some 6.5 million people – half the population of Somalia – have had to leave their barren farmlands in search of food and water.
The number of people affected by the combination of drought and famine is unprecedented, with women, children and older people suffering the most – more than 800,000 children under the age of five are severely malnourished.
Since March, Islamic Relief has worked to highlight the urgent need for funds to help the 16 million people in Ethiopia, Kenya, Somalia and South Sudan who are on the brink of starvation and in immediate need of food, water and medical treatment. Firstly, in collaboration with the Disasters Emergency Committee (DEC), through our joint East Africa Crisis Appeal, and then later through our own independent campaign.
Thankfully, the response from the British public has been phenomenal, with the DEC crisis appeal raising an incredible £50 million to enable its member charities to step up their response and provide more food, water and medical care to these millions of people. Most are women and children who walk 30km in excruciating heat in search of some food and water.
During the 2011 famine, 260,000 people died in Somalia. History looks set to repeat itself unless we act now to prevent a similar situation from happening again.
I visited three camps in Somalia for people who have been internally displaced. At one of the camps I met two dear people who shared their stories with me – stories that I believe captures the pain and grief that millions of people are experiencing there on a daily basis.
Fatouma, from the town of Burhakaba in the south western Bay region, around 250km from Mogadishu, told me:
“We are farmers and our lives depend on our livestock and farming. With no rain there was no food for our cattle to eat and 30 of our cattle very quickly died. We weren’t able to grow anything, and we were forced to leave home in search of food and water.”
With her husband and their six malnourished children, the family left their village with only the clothes on their backs. Their journey on foot was an arduous one. “Walking in this heat was almost unbearable, but we had no choice,” she said. “My children were sick because we couldn’t feed them. The bodies of my three youngest started to badly swell.”
Unknown to Fatouma, the swelling was an indicator of kwashiorkor, a serious form of malnutrition due to a diet lacking in protein and other essential nutrients. Too much fluid in the body’s tissues causes swelling under the skin and results in an enlarged “pot-belly” stomach, leaving children very vulnerable to infections.
Sadly, one by one, her three youngest children Nooratu, Khadiju and Usman, died on the journey to Mogadishu. Fatouma and her husband could not afford to bury their children but local villagers en route raised the money for the three funerals.
It took the rest of the family 10 days to reach Mogadishu. They arrived at a camp with little sanitation, where the only food is that which is donated by local people, who are themselves struggling to get by. Camps like these are filling up fast. Over two days the numbers had swelled by over 200.
We did not speak the same language, but from looking into Fatouma’s eyes it was clear that she was still in a deep state of shock, her pain palpable from her body language.
Then there is Mohammad Ali Abdullah, who lost his wife to acute watery diarrhoea. When you are thirsty, and there is no clean water but puddles of mud, you become so desperate that you drink that. She contracted diarrhoea and, as a result, passed away.
I met Mohammad and his five children when they had just arrived at the camp, desperately looking for shelter from the sun and the intense heat. They were a sad sight, having lost their mother on top of walking for days without food or water.
This is a crisis upon a crisis. It is the reality for millions of people in Somalia and now across much of East Africa. Unless we continue to act by donating to Islamic Relief’s East Africa Crisis Appeal or any of the aid agencies already working on the ground, we could be facing another catastrophic humanitarian disaster in the region that will overshadow the 2011 famine.
Donations to Islamic Relief’s East Africa Crisis Appeal can be made here.
Follow Tufail Hussain on Twitter: www.twitter.com/TufailH
Funding al-Shabaab: How aid money ends up in terror group’s hands
Baidoa, Somalia (CNN)The murderous al Qaeda affiliate al-Shabaab is making millions of dollars each year by exploiting foreign aid money sent to Somalia by the very western nations who are trying to eliminate the terror group.
A CNN investigation has revealed how money given directly by the United Nations to people displaced by conflict and famine is ending up in the hands of Africa’s oldest terrorist organization.
Former members of al-Shabaab and Somali intelligence agents said the terror group is extorting thousands of dollars per day through road blocks and taxes on merchants attempting to transport food and supplies to sell to internally displaced people in towns where they are concentrated.
People who have fled their homes and are living in a sprawling camp in the central Somali city of Baidoa are screened by the UN and issued cash cards that the UN tops up with around $80 to $90 each month, enabling them to buy essentials from local merchants.
UN officials say this direct payment system will avoid distorting local markets by flooding them with free food, and relieve the UN of the burden of running food convoys that are vulnerable to attacks and theft.
Businessmen now truck food bought on the open market to places like Baidoa, where internally displaced people (IDPs) arrive every day. But they must pay al-Shabaab, which controls the main road into the town, to move their goods.
Former members of the terror group and Somali intelligence agents said that tolls taken from trucks and other vehicles at just two al-Shabaab roadblocks on Somalia’s busiest road raked in thousands every day. The UN has estimated that a single roadblock generated about $5,000 per day on the road to Baidoa.
Speaking at a secret location on the outskirts of Baidoa, a former zaqat (tax) collector for al-Shabaab, who was captured in a recent raid by agents from Somalia’s National Intelligence and Security Agency, confirmed that the extraction of tolls at roadblocks was one of the biggest sources of money for al-Shabaab.
The two biggest sources were the road to Baidoa and the main artery which connects the capital Mogadishu with the agriculturally-rich Lower Shabelle region.
The gouging is more subtle today than it was in the early 1990s, when local warlords deliberately starved hundreds of thousands of Somalis in order to profit from international aid money. Scenes of mass death on the streets of Baidoa in 1992 provoked the United States to lead a multinational UN-backed military intervention in the same year.
In Baidoa back then, a truck known as the Death Bus collected around 100 bodies a day, all of them skeletal from starvation, from the dusty streets of the town every morning.
Aid organizations were so desperate to help that they paid warlords to permit access to starving victims. Until Western nations intervened, the warlords worked to sustain the famine in order to keep the aid money flowing into their coffers — effectively exploiting desperate people to turn a profit.
Back then, organizations like the International Committee of the Red Cross had to pay for armed guards — the ICRC spent $100,000 a week on protection in Mogadishu.
The money went into the hands of mere gangsters — not international terrorist organizations, who are less forgiving when their debts go unpaid.
In 2018, if local merchants don’t pay up, “they’re captured and killed,” said a former al-Shabaab fighter who collected tax for eight years and now works with Somalia’s National Intelligence and Security Agency.
Speaking in a secret location in Baidoa, he explained how for every sack of rice delivered to the city by private merchants, al-Shabaab would cream off about $3 in tolls, taking nearly half the difference in the price of a sack that sells for $18 in Mogadishu and $26 in Baidoa.
On top of that the merchants are then forced to pay an annual tax to al-Shabaab — even in towns and cities that are not under the group’s control, like Baidoa and Mogadishu.
These allegations have been confirmed by the regional government and the president of the South West State of Somalia, Hssan Sheikh Ada.
Michael Keating, the UN’s head of country, acknowledged the scam but said that most of the foreign aid still reached its intended destination.
“Unfortunately those in need, and those who are going to be targeted by humanitarian organizations to receive assistance, do become attractive for those trying to make money, and there will be all sorts of scams going on,” said Keating, a veteran UN official with years of experience in Afghanistan and the Middle East.
“To deny it is happening would be wrong, but I think to take examples of it happening, and to say the whole response is like this, would be a gross misrepresentation of what is going on.”
Forced to flee
The paying of “zaqat” isn’t confined to road tolls and taxes on businessmen. Ordinary Somalis have to pay an annual tax to the al Qaeda group which was behind terror attacks on the US embassies in Kenya and Tanzania in 1998, and the massacre at Nairobi’s Westgate Mall four years ago.
Fatima Ali Hassan used to own dozens of goats and cows. Driven out of her home by drought and demands for money by al-Shabaab, the mother of seven now lives in a tent made out of rags in Baidoa. She’s one of tens of thousands who have made their way to this hungry city.
But even here, she’s an asset to the terror group, like the other 270,000 displaced people living in the city — and more are pouring in every day. The UN fears that the ongoing drought will once again threaten Somalia with famine and provide al-Shabaab with even greater opportunities to make money from foreign aid — particularly if the group maintains control of the main routes through the interior of the country.
Somalia’s national army is a patchwork quilt of rival militias sewn together by thin threads of hope that one day it will be able to prevail against the extremists.
For now, the country’s primary fighting force is a 22,000-strong African Union (AU) contingent that has been protecting the country’s fledgling government in Mogadishu, and working to wrest control of south back from al-Shabaab. But it’s withdrawing slowly and is expected to be out of the country in two year’s time.
The African Union military leadership admits that it can’t push al-Shabaab off the major roads that provide it with so much income.
“Instead of reducing [AU forces], it should have been increased,” said Lt. Colonel Chris Ogwal. “We are now overstretched, we are just conducting minor offensive operations.”
Ogwal commands the Ugandan contingent which controls the road between Mogadishu and the small town of Afgoye — but not, critically, the rest of the way to Baidoa.
That remains al-Shabaab’s financial artery.
Ogwal said that any reduction in AU forces would inevitably leave a vacuum that al-Shabaab would fill.
This leaves a growing number of American troops — more than 500, including Special Operation Forces — shouldering the ever-increasing security burden in Somalia.
But this year is the 25th anniversary of the Battle of Mogadishu, the infamous clash in which 18 Americans and more than 1,000 Somalis were killed when US Special Forces attempted to arrest Somalia’s most powerful warlord at the time, Mohammed Farrah Aidid.
Images of a dead pilot being dragged through the dust of the Somali capital swiftly undermined a mission that had been intended to bring humanitarian relief and resulted in a US withdrawal two years later.
But the systems of corruption and manipulation of aid in Somalia remained, and have now been co-opted to finance a terrorist movement that controls about a third of the country and may become a magnet for ISIS jihadists on the run from their former caliphate in Syria and Iraq.
Somalia: More than 1,500 children orphaned after twin blasts
AL JAZEERA — Somalia has suffered countless bomb attacks over the years, but the twin explosions in Mogadishu three months ago were the largest ever, killing more than 500 people.
More than 1,500 children became orphans as a result of the attack in which many of the victims were parents.
Nomadic communities suffer most as drought stalks Somaliland
By Corrie Butler, IFRC — Driving through the rural landscapes of Somaliland, the views are breathtaking – towering blue mountains cutting the glaring sky over dry, thorn-bushed desert. Small dome-like temporary houses, known as ‘aqals’, dot the arid terrain.
These belong to nomads who have survived in these harsh conditions for generations, but for the first time, they are facing an uncertain future.
Years of consecutive drought have spiralled Somaliland’s nomadic communities into a devastating food crisis. Their ability to pack up and move livestock to better grazing pastures would normally give them a major advantage over other farmers. But the unprecedented drought has caused most – if not all – of their camels, sheep and goats to die and, with them, their livelihoods.
The Somali Red Crescent Society, in partnership with the IFRC, is present throughout Somaliland and Puntland, helping communities to respond to the growing challenges that vulnerable groups, including nomadic communities, face.
Dorothy Francis, Operations Manager of IFRC’s Somalia Complex Emergency Appeal, explained: “The nomads are the ones that are suffering the most because their livelihoods have always been based on livestock and that’s based on access to water.
“Because the crisis has deepened, there hasn’t been the rain we expected, so we see coping strategies becoming more negative. They are selling everything. They are leaving home to go further and further away to work so families are being broken up.”
Signs of malnutrition
Hinda Adan, a nomad and mother of four, visited a Red Crescent mobile health clinic in Lamadhadher village, south of Burao, Somaliland, to have her children screened to determine signs of malnutrition. Before the drought, her and her husband were successful livestock herders, owning 120 sheep, goats and camels. They had everything they needed. But the drought has killed almost all their livestock – only ten goats remain.
“Our life depends now on these ten goats,” said Hinda. “We have one to two meals a day. We prioritize our children – to feed them first.”
However, Hinda still feels luckier than others, including her neighbours: “The family had to split up three of their children among relatives. It affected their entire home. It is affecting our entire community,” she says.
Bringing humanitarian assistance to nomadic communities is one of the biggest challenges the Red Crescent faces, as their regular movement means it is often difficult to reach them reliably.
“Often, we arrive in a community to find that [the nomads] have gone to the next area,” explained Hussein Mohamed Osman, Berbera branch secretary for the Red Crescent in the Sahil region. “It also proves to be very costly to travel long distances to reach them.”
One of Somali Red Crescent’s flagship services is its mobile clinics, which are able to travel off-road to remote villages to provide health care services, particularly to nomadic communities who need it most. Built to adapt to the needs on the ground, the mobile clinics can spend half a day or multiple days in one village.
As drought conditions have worsened, the Red Crescent has increased the number of skilled health care workers in each team to prioritize the rising cases of malnutrition among children and expectant mothers.
Understanding local needs
IFRC is supporting the Somali Red Crescent in supplementing their urgent needs over the next three months, including emergency cash for food and other items. All humanitarian assistance is carefully considered to meet the teams’ needs and allow them to remain mobile: jerry cans and aqua tabs to ensure water is clear, and shelter products to keep them warm in the cool desert evenings, including blankets, sleeping mats and tarpaulins.
Although IFRC and the Red Crescent are helping to ensure short-term emergency needs are being met, efforts to implement longer-term interventions have started, which helps communities become more resilient to future emergencies. This includes rehabilitating 95 berkeds – or small dams – in the densely populated areas that have no access to water; rehabilitating wells and other water points; and, where some rain has come, providing villagers with the means to plough their farmland.
“What we are trying to do is cover an entire community with everything so we’ll have a cleaner, safer, healthier community – providing them with food, providing them with water, providing them with shelter,” explained Dorothy.
“It is a huge task but IFRC is working with a very strong Red Crescent society. We are managing to reach the most vulnerable people. We are doing the best we can.”
Fatima Mohamed Yusuf, a nomad in Togdheer region, is one of the community members who received much-needed health care in a Somali Red Crescent mobile clinic close to her temporary settlement. The drought came at a devastating cost to her and her family, who lost 270 sheep and goats.
“If there is no rain, I worry for my remaining livestock and I worry for myself and family. Allah only knows when the rains will come,” said Fatima.
Vital partnerships to tackle drought
IFRC is working closely with the Somali Red Crescent and global partners to continue supporting the needs of the most vulnerable people, but the fight to prevent famine is not over. Somaliland is currently categorized as a stage four emergency (crisis) and could easily descend into famine. It was only six years ago that Somalia experienced a famine that killed a quarter of a million people. IFRC will help to ensure Somalia never has to experience famine again.
Thanks to the generous support of the global community through the International Red Cross and Red Crescent Movement, seven million Swiss francs has been donated to the IFRC Emergency Food Crisis Appeal in Somalia, which will help to bring life-saving support to 353,000 people in some of the most isolated, vulnerable and hard-to-reach communities.


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The National Testing Agency (NTA) is likely to declare NEET 2020 result after the release of the answer keys of NEET 2020.
The National Eligibility cum Entrance Test (NEET) 2020 was conducted on September 13 across India, and around 15 lakh students appeared the exam to find admissions in medical colleges.
At this moment, the students are anxious to select their colleges for their MBBS courses.
Selection of good medical colleges at this stage can make them good doctors in future.
The candidates can check here the list of Top 10 Medical Colleges in India and with the corresponding NEET Ranks required under All India Quota.
The candidates who appeared in the exams are eagerly waiting for the cut-offs to be released by National Testing Agency (NTA) along with the complete results of NEET 2020.
The aspiring candidates can take a look at the table below which reveals the name of the Top 10 Medical Colleges chosen by the students within ranks 1 to 500 in NEET in the past years.
This list has been prepared totally on the basis of the choice of the candidates who cleared NEET.
Top 10 Medical Colleges on India
1. Maulana Azad Medical College New Delhi – General, OBC, SC
2. B.J. Medical College Ahmedabad – General
3. Govt. Medical College Thiruvantampuram – General
4. University College of Medical Sciences, Delhi – General, OBC
5. Govt. Medical College Kozhikode – General
6. Seth G.S. Medical College Mumbai – General, OBC
7. Safdarjung Hospital, New Delhi – General, OBC
8. Medical College Baroda – General
9. M.G.M. Medical College Indore – General
10.B.J. Medical College Ahemdabad – General


NJORD Latvia: Companies, which failed to disclose their beneficiaries, will be excluded from Latvian Register of Enterprises
On 29 June 2019, new amendments to the law “On the Prevention of Money Laundering and Terrorism Financing” (the Law) became effective. In accordance with these amendments, the Register of Enterprises of the Republic of Latvia (the Register) was granted the right to liquidate a commercial company, if it failed to submit to the Register information on its beneficial owners (beneficiaries).
Legal persons registered in the Commercial Register of the Republic of Latvia prior to 1 December 2017, had to determine their beneficiaries and to file information on them for registration to the Register of Enterprises of the Republic of Latvia until 1 March 2018. As it follows from information published on the website of Latvian Register of Enterprises on 17 June 2019, “...approximately 900 SIA have not disclosed their beneficial owners yet…”
In accordance with new procedure, having established that a commercial company (SIA or AS) failed to submit information on their beneficiaries, the Register will send written notice to the legal address of a commercial company, and will give one month to eliminate violation. If upon expiration of one-month period the violation will not be eliminated, the Register will decide on discontinuation of activity of a commercial company, by “launching” procedure of exclusion from the Commercial Register. Such decision of the Register shall enter into force within one month after it was notified to a commercial company, if the decision was not challenged or appealed.
The Register has already selected the first group to be raided – SIA (limited liability companies) where shareholders are foreign legal persons and who failed to submit information about beneficiaries. “Offenders” are expected to receive warnings from the Register in nearest future or even have received it.
Brief information on some other novelties of the Law:
- “The Office for Prevention of Laundering of Proceeds Derived from Criminal Activity”, or shortly - the Control Service is now called “Financial Intelligence Unit”.
- As from 1 January 2020, information from all registers of the Register must be available to any person free of charge.
- As from 1 July 2020, obligation of “foreign subjects”, who have branches and representative offices in Latvia (inter alia, those registered only in the register of tax payers of Latvian State Revenue Service) to disclose their beneficiaries and to inform the Register on them until 1 January 2021. Those, who will fail to comply with provisions of the Law, will be excluded from the respective Register.
- subjects of the Law (i.e., banks, financial institutions, notaries, attorneys-at-law, tax advisers, auditors, etc.), as well as controlling and supervisory authorities, having established that information on a beneficiary specified during survey of the client does not comply with data in the Register, have to inform the Register about it. The Register, upon receipt of such notification, will register the warning that registered information on a beneficiary is, possibly, false.
- when having reasonable doubts concerning information submitted by the legal person, the Register has the right to request from the legal person documentary justification of the monitoring performed, as well as the document confirming compliance with information identifying a beneficiary and a document justifying confirmation concerning impossibility to determine a beneficiary (if such information was already filed).
- When having doubts regarding information filed by a shareholder/owner on absence of a beneficiary, or if foregoing information was not filed at all, and the legal person has a reasonable ground to believe that it has a beneficiary, the legal person by its own initiative will specify and identify its beneficiaries.
- following sanctions are set forth for failure to comply with provisions of the Law: suspension or termination of activity of the commercial company, including suspension or termination of a license (certificate) or annulment of entry in respective register, suspension of economic activity, prohibition of registration of changes in the Commercial Register concerning reorganisation of a commercial company and changes in shareholders, instruction to credit institutions or payment service providers regarding partial or complete suspension of payment operations.


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On the Killing of Jamal Khashoggi
Rep. Chris Smith (R-NJ), Chairman of the House Foreign Affairs Subcommittee on Global Human Rights, issued the following statement on the killing of Jamal Khashoggi:
“The extrajudicial killing of Jamal Khashoggi by Saudi government officials while on the grounds of the Saudi consulate in Istanbul, where he went to obtain a marriage license, shocks the conscience. It is for cases such as this that Congress passed the Global Magnitsky Act—a bill for which I was the House author. Those who perpetrated—or ordered—this heinous act can and should be specifically targeted and sanctioned.
“Saudi Arabia for decades has exported radical Islamist ideology around the world. Indeed, the complicity of certain Saudi royal family members and institutions in the 9/11 attacks led Congress to override President Barack Obama’s ill-considered veto of the Justice Against Sponsors of Terrorism, or JASTA, Act in order to allow families of the 9/11 victims to sue complicit Saudis.
“While many had hoped that with the ascendency of Crown Prince Muhammed bin Salman, Saudi Arabia had turned toward a reformist path, the killing of Jamal Khashoggi casts that narrative into doubt. This in turn jeopardizes the constructive role Saudi Arabia has played in checking Iranian ambitions—and the neo-Ottoman ambitions of Turkish strongman Recep Tayyip Erdogan—in the Persian Gulf and beyond.
“Thus I call on the President to use the selective, surgical sanctioning power Congress provided him in the Magnitsky Act to hold accountable those complicit in the killing of Jamal Khashoggi.”


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San Nicola island: Clear water, amazing food and scuba diving
San Nicola island is the most populated of the islands and historical centre of Tremiti. San Nicola island is perfect for a day between history and sea. The island is considered by many scholars to be a natural open-air museum, where you can get lost among the fortifications as you wander through towers and monuments, including the pretty church of Santa Maria a Mare.
Originally, it was the site of an ancient monastery where legend tells of violent storms breaking out to thwart anyone daring to remove the remains of a monk named Nicolò.
Fortress and island of monks, fortified Benedictine abbey, penal colony and land of confinement: San Nicola is easily reachable by ferry from San Domino.
From the marina, there are two alternatives to get to the fortified village: comfortably with the elevator, or climbing the steps with a view of the sea and the islands – incredibly beautiful.
Once on the top, you should stop at the Fortress and to St. Mary’s Abbey to discover more about the history of Tremiti.
In fact, the history of this island is closely related to the arrival of Benedictine monks in the archipelago, as they founded the Abbey and built much of the town.
The silence here is sacred, interrupted only by seagulls. Heading towards the “donkey plateau” (for donkeys that grazed there), you will discover the remains of a votive altar and some tombs, like that of Julia, nephew of Emperor Augustus, and that of Diomedes, a hero who participated in the war of Troy.
Nowadays San Nicola is a small touristic centre with 4 – 5 restaurants, many bars and some bed and breakfast managed by locals, there are not hotels on the isle. All surrounded by a suggestive medieval setting and 30km of the sea!
Don’t miss: the tour of San Nicola island by boat. Cliffs even sixty meters high that fall on the turquoise seas are an imposing sight.
Here, wherever you dive, you can’t go wrong: between San Nicola and San Domino, at the Secca del Cretaccio shallows, you can swim among torpedoes, moray eels, grins and lobsters.
Best time to visit Tremiti Islands -Puglia
Puglia has a Mediterranean climate with hot, dry summers and mild winters. If you enjoy hot perfect sunny days the best time to visit Puglia is between June and September. The hottest month of the year is July with an average daily maximum of 35 C and an average low of 24 C. The waters of the sea, warm up to a most pleasing temperature, which is perfect for those who love swimming in the sea.
San Nicola Island Hotels – Where to Stay
Best mid-range hotel: La Casa di Gino B&B
Set on the Island of San Nicola, in its historic centre, La Casa di Gino features a sun terrace. A buffet breakfast, with hot drinks and pastries, is offered daily. In warm days, it is served on the sun terrace.The harbour, with ferries to the other Tremiti Islands, is 100 m from La Casa di Gino. A free electric shuttle bus from and to the harbour is available.
Rooms from € 90/night
Best budget hotel: Happy Camp Mobile Homes in Centro Turistico San Nicola
Perfect for families
Boasting a restaurant, a bar as well as a garden, Happy Camp Mobile Homes in Centro Turistico San Nicola is situated in San Nicola, within 1 km of Zaiana Beach and 2.4 km of Calalunga Beach.
All units have a kitchenette with a fridge, living room with a sofa, and a private bathroom with shower. The camping offers a terrace. The property has a kids’ club offering various activities, as well as a playground.
Mobile home from € 30/night
Plan Your Tailor-Made Trip

domain: geography