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If you read the post, "The Paralegal Profession: [Almost] everything you wanted to know but were afraid to ask," you may already be familiar with the American Bar Association's definition of a paralegal:
A legal assistant or paralegal is a person, qualified by education, training or work experience who is employed or retained by a lawyer, law office, corporation, governmental agency or other entity and who performs specifically delegated substantive legal work for which a lawyer is responsible.
What does this mean to you as an attorney?
It means you're not alone. With the proper education, training, or experience, a paralegal can complete for you pretty much any task you would generally perform as long as he or she does not directly practice law.
[While state laws vary in their definition of unauthorized practice of law (UPL), they generally agree that a paralegal cannot give legal advice, represent a client in court, conduct depositions, share in attorney's fees, or negotiate legal rights. (Consult your state law for more information on what is considered UPL in your jurisdiction.) ]
The benefits of utilizing a paralegal abound. You manage your time and caseload more effectively when you delegate substantive legal tasks to a paralegal and, by doing so, you increase the amount of time you have to address more pressing matters. Utilizing a paralegal can also help you achieve a work-life balance.
However, you aren't the only one who benefits from your use of a paralegal; your clients also benefit. Because the paralegal billing rate is generally less than that of the attorney's, the client's legal fees can be reduced dramatically.
A paralegal can change the way you work, make your practice more efficient, help balance your caseload, and give you more time to focus on pressing matters. It all leads to less stress and a better work-life balance.
As clients increasingly seek high-quality legal work at competitive prices, many are demanding that their attorneys utilize a paralegal to minimize legal fees. Because the lower paralegal billing rate can save clients a substantial amount in legal fees, attorneys who utilize paralegals are increasingly sought after.
For more information about the paralegal profession, check out the ABA Standing Committee on Paralegals. There you will find information on the economic benefits of utilizing paralegals, guidelines for the utilization of paralegals, and information on how paralegals can improve your practice.


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A Pittsburgh radio station talk show host was rebuked by Pennsylvania's health department secretary, who is transgender, for misgendering the secretary during a press call, Penn Live reported.
Marty Griffin, the host of KDKA-AM, called Dr. Rachel Levine "sir" during a conference call with reporters Tuesday, according to Penn Live.
Griffin was asking a question about the different phases the state is implementing to ease stay-at-home orders, and said "sir" twice. Levine responded by telling Griffin "please don't misgender me," and that it was "really insulting."
Griffin apologized multiple times, and self-corrected once to say ma'am.
He also later apologized on Twitter, saying multiple distractions caused him to use the wrong pronouns and that his actions weren't intentional.
I apologize. I apologized twice. I truly did. It was not intentional. It was not. I was not focused. I was doing six things at once. https://t.co/cdBO9r1iF8
— Marty Griffin (@MartyGriffinKD) May 12, 2020
The incident later caused Pittsburgh Mayor Bill Peduto to decide to cancel a scheduled appearance on KDKA Radio, the mayor's spokesperson told Pittsburgh City Paper. Peduto criticized the KDKA station as having changed from "good people who made us proud to be from Pittsburgh" to "shock-jocks, sensationalism & worse."
Cancelled interview w/ Lynne Hayes-Freeland for tomorrow. Not upset w/her, she's always been a fair, strong journalist. But will not support @KDKARadio behavior. Growing up, KDKA had good people who made us proud to be from Pittsburgh. Now, it shock-jocks, sensationalism & worse.
— bill peduto (@billpeduto) May 12, 2020
Griffin was criticized in 2007 for his reporting on a Pittsburgh-area Presbyterian pastor, possibly outing him as gay after KDKA began running teasers including Griffin confronting the pastor at an adult book store.
The station decided not to air the story, explaining that the pastor, Brent Dugan, may be a danger to himself. The pastor had gone missing, and died by suicide, according to Pittsburgh City Paper.
Levine's mother moved out of a personal care home with the health secretary's help after Levine had ordered all nursing homes and long-term facilities in the state to accept coronavirus patients from hospitals, the secretary admitted Tuesday, creating outrage over the conditions residents of these facilities must face without recourse. (RELATED: PA Health Secretary Moved Mother Out Of Personal Care Home After Ordering Nursing Homes To Accept COVID Patients)

subset: commoncrawl


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SM&W Contribution
Shen Milsom & Wilke provided acoustical consulting expertise for Wolters Kluwer's new headquarters. Wolters Kluwer is a global provider of subject matter expertise and a trusted advisor to business and enterprise clients in finance, technology and healthcare. The client moved their headquarters to four floors in a new building after occupying a different office for many years.
This fit-out space included private executive offices, open plan work areas, collaborative workspace, conference rooms, training rooms, pantries, copy/print centers, a data center, call center, and other support areas.
For this project, Wolters Kluwer expressed the need for sensitivity to noise, sound isolation, high quality audio, and office privacy. SM&W provided guidance for partition types including office front system to emphasize acoustic performance. Swing doors were specified for meeting spaces while sliding doors were used in offices. The design also incorporated open ceiling and main ductwork in the workplan. SM&W coordinated with the mechanical engineer to locate noise producing equipment to avoid impacting staff and specified sound attenuators for supplemental units serving the most critical conference spaces and Boardroom.
Once completed in 2019, field testing was conducted to ensure that the contractor adjusted doors and seals to maximize acoustic benefits.


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Plants vs. Zombies Fight on PSN
If you're looking for something new to buy from the PlayStation Network, SOE has announced the release of Plants vs. Zombies, along with some other quite interstingly titled games.
"SOE has delivered more than 6.5 million downloads worldwide on the PlayStation Network, including a mix of classic and original intellectual properties, top-tier casual games, and PlayStation Network exclusives," said Chris Sturr, executive director of business development and corporate strategy at Sony Online Entertainment. "We continually seek creative opportunities to generate new and entertaining ways to enhance a player's gaming experience and our latest line-up proves this with all-new games that are fun and engaging."
Plants vs. Zombies : Scheduled to debut on the PlayStation Network this February, this zombie-zapping downloadable game challenges players to build an arsenal of loyal plants to defend their home against attacking waves of the undead.
Acceleration of Suguri X Edition : SOE and Rockin' Android team up once more to bring the ultimate in anime-style robot-fighting to the PlayStation Network. In Acceleration of Suguri X Edition, players take on the role of a scorned robot to maneuver through arcade storylines and battle other robots.
Slam Bolt Scrappers : Developed by Fire Hose Games, Slam Bolt Scrappers is an intense building and brawling mash-up, exclusive to the PlayStation Network. Players aim to construct the greatest towers in Slam Bolt City while defending against devious baddies and epic bosses.
Akimi Village: Developed by NinjaBee, players obtain blueprints, gather resources and construct a village to help rid Akimi Island of lingering gloom in this PlayStation Network exclusive.
Sideway : Set against the gritty art culture in New York City, Sideway follows the adventures of Nox, a 2D rebellious young artist, as he navigates the 3D urban streets. This audacious new PlayStation Network exclusive by Playbrains and Fuel Industries is scheduled to launch this spring.
Rochard: Players embrace the gravity-bending exploits of space miner John Rochard as he discovers the first proof of extra-terrestrial life. Developed by Recoil Games, Rochard combines space exploration and puzzle-solving in a side-scrolling single player experience.


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While triggers can occur anytime, the holidays are often a particularly difficult time of year for those in recovery from addiction. The holidays are supposed to be a joyful time for loved ones to celebrate together. For some, the holidays cause stress and bring up negative emotions. What are the most common addiction relapse triggers during the holidays?
What are Addiction Relapse Triggers?
A trigger can be anything that brings back thoughts and feelings that have to do with addiction. Triggers cause the addict to think about the drug and can lead to obsessive drug seeking/wanting behaviors. Triggers can manifest as a person, place or thing. The only way to effectively deal with triggers is through repeated exposure without reward. For an addict that means not giving in to their addiction.
Shift in Normal Daily Routine
For those in recovery from addiction, a structured daily routine provides the best success for long-term sobriety. Addiction is a destructive force. People who are active in their addiction rarely maintain healthy routines. In order to break free from unsuccessful past behaviors, positive and healthy routines are crucial. A structured daily routine focusing on self-care is highly suggested in recovery. Normal sleeping patterns, healthy eating habits, engaging in regular exercise, reaching out to others in recovery, staying in regular contact with your sponsor, tending to daily responsibilities and attending regular Alcoholics Anonymous meetings are all ways people in recovery establish a structured and healthy daily routine. The holiday season is a time of year when many people experience a shift in their normal daily routine. People often get time off work, travel to see family and become distracted by the upcoming holidays. A dramatic shift in daily routine can cause a person in recovery to feel triggered. It is imperative for people in recovery to try and maintain their daily routine, even during the busy holiday season.
Financial Difficulties
The holiday season is a time where people often travel to see family and purchase gifts for loved ones. Financial difficulties are common with addiction. Addiction is an all-consuming disease and financial stability is rare. People in early recovery are often struggling to maintain or find employment, may be dealing with legal issues and fines or they may be trying to pay for addiction treatment. For someone in recovery, financial difficulties may cause additional stress and feelings of shame. The negative emotions of stress and shame can cause someone in recovery to feel triggered.
Feelings of Depression, Loneliness and Loss
While most people associate the holidays with family and loved ones, for some it may cause feelings of depression, loneliness and loss. Drug and alcohol addiction doesn't just affect the addict, but everyone in their life. Depending on the actions of the addict during their active using, many relationships may require time to heal. If relationships haven't been mended, the holiday season may cause the person in recovery to feel negative emotions. Many addicts have experienced significant loss in their life; the holidays may highlight that loss and cause them to feel triggered. Dysfunctional family dynamics are one of the most common causes of addiction related triggers.
The Presence of Drugs or Alcohol at Family Gatherings
The holiday season is a time where social gatherings occur more frequently and when drugs and alcohol have a more significant presence. Celebrations and social gatherings where drugs and alcohol are present are one of the most common instances where people in recovery experience triggers. For people in early recovery, attending a social gathering where others are drinking or using drugs may cause an addiction related trigger. In situations where drugs and alcohol will be present it is highly suggested that a person in recovery bring a sober friend for additional support.
Concerned About Yourself or a Loved One?
Triggers are a normal part of addiction but can contribute to the decision to relapse. It is imperative that people in recovery become aware of what triggers them in order to avoid a potential relapse. The only way to effectively deal with triggers is through repeated exposure without reward, for an addict that means not giving in to their addiction.
Last Updated on August 7, 2023


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If on your Management Accounts, the date is pulling incorrectly on your Control tab, it is most likely due to the fact you are new in a "NEW YEAR" and the period dates have therefore changed.
This is not automatically updated on your Management Accounts. Therefore, if the period dates have not been updated, it will be displaying the incorrect date.
To update your period dates on your Management Accounts select the Parameters tab.
There is a section that looks similar to the below:
Update the dates as per new period dates, and then re-run your Management Accounts. The correct date for the period selected should then display.


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Prince Louis' Birth Certificate Has Been Revealed — and We're Cracking up at Will and Kate's Listed Occupations!
Royals — they're just like us! Every baby gets a birth certificate when they're born — and Prince Louis is no different. The document for Prince William and Kate Middleton's third child was released on Tuesday, May 1, and there are some details on the piece of paper that we can't help but laugh about.
The little boy's name was documented as His Royal Highness Prince Louis Arthur Charles of Cambridge, which we expected, but it's his parents' listed occupations that really got us chuckling. His dad's said Prince of the United Kingdom and his mom's said Princess of the United Kingdom. So casual. We also got to see Will's polished signature on the certificate
But believe it or not, there's one major thing we noticed that makes Louis' certificate different from his siblings Prince George and Princess Charlotte's documents. Unlike his big brother and sister, whose certificates were written out in July 2013 and May 2015 respectively, Louis' certificate is typed! We're not thinking too much of it though. The deputy registrar on George and Charlotte's is the same, but there's a new one listed on Louis'. That said, we bet it was just a preference depending on the registrar at the time (or maybe they've just upgraded with technology in 2018).
Kate and William previously welcomed little Louis on Monday, April 23. "Her Royal Highness The Duchess of Cambridge was safely delivered of a son at 1101hrs. The baby weighs 8lbs 7oz. The Duke of Cambridge was present for the birth. Her Royal Highness and her child are both doing well," the statement read at the time. "The Queen, The Duke of Edinburgh, The Prince of Wales, The Duchess of Cornwall, Prince Harry, and members of both families have been informed and are delighted with the news."
And now, the family-of-five is "complete." Royal biographer Ingrid Seward told People, "It completes them. [Kate] is one of three siblings, and it's a good family size. Boy-girl-boy is pretty cool as well." A family friend added, "[Parenthood] suits them really well. They are enjoying it and are very happy." We can't wait to see pics of the entire brood!
Join our Facebook group for the latest updates on Kate Middleton, Prince William, and all things royal!


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Why does vinyl continue to be so popular in the digital age? Here are some explanations
Have you been caught up in the vinyl resurrection? Have you thought to ask why you've become besotted with records again?
Forbes caught up with music writer Marcus Barnes and asked him to explain why vinyl continues to grow in popularity when so much of our other entertainment comes from the digital realm.
Barnes starts by explaining how the appeal of vinyl makes perfect sense even as the world trends towards purely digital means of cultural consumption, "There's an air of romance that surrounds record collecting and the shops that curate, stockpile and sell vinyl. The notion that music in its tangible, 'organic' form has more value than its digital counterpart is one contemporary reason for this romantic idealism."
Barnes continues, reflecting on the historical aspects of vinyl collecting culture, "Way before the digital age was upon us, vinyl still carried that mystique and became a collectible medium. From the days when everyone would gather around the wind-up gramophone to hear those exciting first crackles of a classical recording, to the era when one's Hi-Fi system and record collection was the centerpiece of their living space. Today we still have a multitude of collectors hunting down rare pressings, eager to track down those elusive, mythical one-offs that are said to be out there."
Read the whole article here.


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Welcome to THE LEAF EL PASEO, an elevated marijuana dispensary in the heart of Palm Desert. Catering to both the fully initiated and the newly curious, we offer a carefully curated selection of cannabis products designed to fit your lifestyle - because we understand how you live.
Our friendly, highly educated staff is uniquely qualified to recommend cannabis products that provide comfortable solutions. In this ever-evolving marijuana industry, our team is focused on providing you the customer with unrivaled, individualized service.
At The Leaf, it's never about closing a sale — it's about opening a dialogue.
Located in Palm Desert on El Paseo – the heart of the Coachella Valley's world-class retail, art and dining district – and only minutes from the site of the celebrated Coachella Valley Music & Arts Festival, The Leaf redefines what the modern cannabis dispensary should be.
Our state-of-the-art luxury showroom exudes a relaxed, welcoming vibe, allowing for a uniquely satisfying consumer experience to browse our wide variety of marijuana products.
You must be at least 21 years old to view this site.
You must be +21 to enter. By Entering the site, you acknowledge that you are over 21.


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There's nothing like a hurricane to remind us that we haven't properly prepped the patio and deck to inclement weather. For those of you lucky…Comments closed
Month: July 2019
I have a simple goal with all my job here at to just and explain the design process to as many individuals as you can.…Comments closed
First it is the tiny plastic outlet covers, then security gates and cabinet locks, and all of a sudden your not-so-little one is clambering over…Comments closed
I can still remember gazing through the rear window of my parent Lincoln Town Car as my mom drove to and from work each day.…Comments closed
As a result of the broad selection of lighting choices now available, the sky's the limit when it comes to landscape light. Once you've mastered…Comments closed
Coffers — dropped beams that crisscross a ceiling at a grid — are a hallmark of classic interiors. Their appeal is in the architectural definition…Comments closed
Before upcycling, thrift store sorting and diving through Grandma's linen closet became trendy, London interior stylist Emily Chalmers had her finger on the pulse of…Comments closed


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WHO/WHAT: Mōʻiliʻili Hongwanji Dharma School will hold its Dharma Food Drive, collecting food donations to help struggling families and people during the holiday season. Especially in this economically tough year, the school hopes to gather canned goods (vegetables, fruits, soup), canned meats (Spam, tuna, salmon, chicken, Vienna sausage) and canned meals (stew, spaghetti, chili). Please check expiration dates on cans and packages.
For more information on Honpa Hongwanji Hawaii Betsuin Dharma School in general, see hawaiibetsuin.org/organizations/dharma-school/.
WHEN/WHERE: From Sunday, Nov. 8, through Sunday, Dec. 27, drop off donations (no perishable food, please!) to Mōʻiliʻili Hongwanji at 902 University Ave. See moiliilihongwanji.org/wp-content/uploads/2020/10/WW_11_2020.pdf or call 949-1659 with questions.


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The Crystal™ analytics platform is the all-in-one blockchain analytics tool for law enforcement bodies, capital market companies and financial organizations. This software provides a comprehensive view of the public blockchain ecosystem and uses advanced analytics and data scraping to map cryptocurrency transactions and related entities and to reveal suspicious funds and participants.
One of main applications of blockchain technology is peer-to-peer cryptocurrency payments. The fact that payments are made by 'virtual' participants — owners of crypto-wallets who are not represented by traditional banking credentials — could make blockchain vulnerable to suspicious actors. This vulnerability raises concerns for legal businesses to fully adopt blockchain solutions, despite its many potential benefits to their businesses. We created the Crystal tool to solve this challenge — to give companies a way to track the sources and holders of crypto funds, and for cybercrime investigators to efficiently trace and reveal suspicious blockchain participants. Our goal is to make blockchain and cryptocurrencies safer for everyone.
The Crystal analytics platform is developed and distributed by the Bitfury Group.
Here, we provide an overview of Crystal's key milestones throughout its first year.
The launch of the Crystal software was announced on January 30, 2018 in London. A special ad campaign was prepared for the release, including a video introduction.
Upon its launch, the software attracted attention from both financial institutions and cybercrime investigators, who were able to test out the product's risk scoring, entity and interaction features through the free trial. Financial organizations were drawn to the support it could provide for know-your-customer (KYC) procedures, and law enforcement organizations were interested in the many ways Crystal can boost efficiency in investigations.
The first version of the Crystal tool provided analytics for the Bitcoin Blockchain only.
In April 2018, Bitfury and BASIS ID, the largest provider of KYC and anti-money laundering services in Asia, partnered to integrate Crystal analytics into BASIS ID's customer ID verification service. This integration will enhance BASIS ID's solution by incorporating data from the Bitcoin Blockchain, which BASIS ID lacked before. The Crystal tool serves as another data provider for BASIS ID, providing access to extensive, previously untapped blockchain data.
Read more here.
To deliver the best possible service to our US customers, Bitfury established its US-based subsidiary in May 2018 known as Crystal Blockchain, Inc. The same month, Michael DuBose joined our team as the President of the company. Michael has more than 30 years of experience in senior law enforcement and data security positions. For 11 years, he served as Chief of the U.S. Department of Justice's elite cybercrime unit, the Computer Crime and Intellectual Property Section (CCIPS), where he supervised sophisticated investigations involving computer network intrusions, phishing schemes, botnets, illicit darknet activities, hacktivist groups, software piracy, and theft of trade secrets. His vast experience in prosecuting transnational cybercrime cases helped the Crystal team make the tool even more useful for cybercrime investigators.
Read more here.
In an effort to deliver the best services and tools to its customers, Crystal Blockchain, Inc. became a Gold-level partner of the Association of State Criminal Investigative Agencies. The partnership gives the Crystal team the opportunity to both learn from law enforcement officials and enhance our product, as well as educate cybercrime investigators about blockchain and cryptocurrency analytics.
Read more here.
The Crystal API provides endless possibilities to integrate cryptocurrency analytics into other software tools and services. As an example of the opportunity, Trendalyze Inc. and Bitfury agreed in November 2018 to integrate Crystal blockchain analytics into Trendalyze, a micro-trends analytics, monitoring, prediction and search platform. Thanks to this integration, Crystal's functionality is expanding with transaction analytics and monitoring by adding motif discovery and pattern search capabilities.
Read more here.
Over the course of 2018, the Crystal software was tested by hundreds of organizations and a number of crypto exchanges adopted the tool as a source of blockchain analytics for KYC procedures. Using Bitfury's software, they were able to foresee future cryptocurrency regulations, keep their crypto funds clean of 'dirty' money and trace any suspicious transactions to proactively prevent possible theft.
The Crystal team performed several investigations, including the widely known Bithumb exchange and Zaif exchange hacks. You can find detailed reports prepared by our Crystal analytics here and here.
Throughout 2018, the Crystal tool evolved from version 1.0 to version 1.9, adding a number of new features along the way, including:
· Bitcoin Cash support;
· The "Connections" feature that helps determine with whom an address/entity; interacted at a certain period of time in the specified amounts of funds; and
· A transaction filtering feature that enables you to filter and sort the list of transactions for more efficient analysis.
In addition to these important feature upgrades, we also significantly increased the volume of off-chain data in the Crystal database. By the end of 2018, Crystal's Bitcoin Blockchain database contained more than 100 million wallet addresses owned by more than 30,000 known entities. For the Bitcoin Cash Blockchain, the Crystal software has more than 48.8 million addresses assigned to known entities, and the numbers are constantly growing.
Over 2018, we released several videos:
The first Crystal introductory video.
Crystal analytics presented at Consensus 2018.
Investigating the WannaCry case.
As we enter a new year, we are continuing to develop the Crystal software and bring our customers new functionality on regular basis. We have ambitious plans for the product in 2019, from adding more currencies and analytical techniques to the product, to new business services and partnerships.
Stay updated on our progress.
Or, better yet, get a free trial version and be among the first to try new updates.
You can also send us your questions and comments regarding the product — right from the product interface. Let's make the world of blockchain safer together!
Get in touch if there are any features you'd like to suggest to the team, or if you'd like more information about the platform.


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Installation and Troubleshooting in VPS Servers
The upgrade features 1 hour of custom work on your server, so in the event that you get any one of our VPS servers packages, you'll be able to take advantage of this service and have our administrators perform a variety of tasks that you cannot carry out yourself or you have no time. They can install and set up any piece of third-party software for you in case the installation is complex or they can troubleshoot any app that doesn't function properly for some reason. You could add the upgrade to your package as frequently as you desire depending on the time needed for a specific task and its complexity. Any remaining time shall remain available in your account for the future and you can see how many minutes are left in your billing Control Panel. Our Managed Services upgrade includes thirty minutes of custom work on your machine also, but just in case you require more than that, you may always add the Installation & Troubleshooting upgrade with several mouse clicks through the billing area.
Installation and Troubleshooting in Dedicated Servers
You can take full advantage of our service at any time in the event that you have a dedicated server from our company and you'll be able to add it to your plan with just several clicks. If you require some custom work on the hosting server from the very beginning, for instance, you can obtain the upgrade alongside the plan during the signup procedure, or you could get it from your billing area in case you need assistance at some point afterwards. The Installation & You with any task that you cannot carry out on your own for one reason or another - install a script, set it up or troubleshoot it. In this way, you are able to focus on building your websites without wasting time on hosting server maintenance or software problems since our seasoned staff shall handle these things for you. You are able to add the upgrade as many times as you require it and if some time is left, it'll be listed within your billing CP, so you can use it whenever you need it again.


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In today's topic, we are bringing you some him and her Tweets. Whether it's a married couple, newlywed couple, new couple, or just friends, we found them all. We found Tweets that may make you say that's relationship goals right there. Some Tweets that make you want to try some things out. Even a Tweet to show what men do when you think they're cheating on you. Whatever the case is, this topic is for everyone and we hope you enjoy it!
Him: You can come over.
Her: …but do you want me to come over?
— Bas® (@_the8thapostle) July 27, 2020
her: there's a spider in the bath
me: ok I'll get him a little towel
— john (@mrjohndarby) July 26, 2020
Him: Haha omg you've photoshopped your ex out of your photos and replaced her with a duck 😂😂😂
Me *went on vacation with a duck* haha yeah
— Jon (@ArfMeasures) July 30, 2020
Wife: Today was awful.
Me: Tomorrow is a new day.
Wife: Is that a threat?
— James Breakwell, Exploding Unicorn (@XplodingUnicorn) July 31, 2020
Her: Our relationship is over
Him: Our relationship is what? Over pic.twitter.com/DRFtRwpYEg
— ً (@baby5donquixote) July 27, 2020
him: bend over
her: bend what? over https://t.co/CgZaz8Znse
— valeska ⚖ (@iatemuggles) March 31, 2020
Him: You look like a dork.
Her: I'm about to look like a GENIUS.
Reader: She did. pic.twitter.com/Xl0mzsIzoI
— MC Hammond (@mchammo) April 18, 2020
Her: I actually think Ratatouille is a boring movie
Me *shakes head at waiter bringing the engagement ring*
— Jon (@ArfMeasures) July 30, 2020
I just want a love like this pic.twitter.com/ilfuMyXZLh
— Lakyn like 🥓 (@2Taurean2U) July 29, 2020
Her: "He's probably out there cheating right now"
Him: pic.twitter.com/TQdreswic5
— Dak (Retired) (@RidiculousDak) March 21, 2020


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Kate Middleton's Earrings:
Looking for Kate Middleton's earrings? We've listed 70+ pairs below:
Where does Kate Middleton buy her earrings? UPDATED: 2022
I often get asked where Kate buys her earrings and what her favourite brands are. Kiki McDonough is definitely top of the list. At last count, the Duchess has worn 18 different pairs of earrings by the designer! I'd also say Annoushka. Kate's worn her Annoushka Pearl Drop earrings to 60+ royal engagements. Her Monica Vinader Siren earrings have had 10+ wears (usually with a green outfit). She also owns multiple pieces from Patrick Mavros, Missoma, Asprey, Cassandra Goad and Accessorize.
On this page, I'm creating an archive of the earrings worn by Kate. She owns has more pairs than those listed below, but I am in the process of adding them all.
Kiki McDonough Lauren Leaf Earrings
Sézane Bruna Gold Hoop Earrings
Mappin & Webb Empress Diamond Earrings
Sézane Esmee Earrings in Gold Plated Brass & Black Beads
Heavenly London 'Pearl and Diamond' Earrings
Kiki McDonough Green Amethyst Pear Drop Earrings
Kiki McDonough Citrine Earrings
Maria Black Cha Cha Mother-of-Pearl Drop Single Earring
Annoushka Baroque Pearl Drop Earrings
Accessorize Pearl and Disc Earrings in Gold
Carousel Stella Earrings With Lapis & Moonstone
Zara Golden Cascading Floral Earrings
CHALK Florence Earrings in Regency
Orelia London Chain Huggie Hoop Earrings in Gold
Sezane Dina Earrings in Gold Plated with 'Ocean Blue' Stones
Spells of Love Medium Twist Hoop Earrings
Accessorize Eclectic Gem Statement Long Drop Earrings
Soru Ruby Earrings
Kiki McDonough Classic Hoops in Yellow Gold
Accessorize Twisted Circle Drop Earrings
Missoma Rhodochrosite Gold Mini Pyramid Charm Hoop Earrings
Patrick Mavros Ocean Tides Milky Quartz earrings
Kiki McDonough Eden Citrine and Diamond Flower Drop Earrings
Sézane Gabrielle Earring in Coffee Brown
Kiki McDonough Classic Cushion Drop Earrings
Nadia Irena Maya Gold Statement Hoop Earrings
Van Cleef & Arpells Magic Alhambra earrings in Mother of Pearl
Sézane Taylor Turquoise Hoop Earrings
Sézane Celeste Earrings in Mother of Pearl & Gold
Anthropologie Coral Shell Drop Earrings in Gold & Pearl
Sézane Charlie Earrings in Threaded Blue
Liv Thurlwell Bobble Hoop Earrings
Spells of Love Alia Hoops in Gold
ASOS DESIGN 14k gold plated twist hoop earrings
Accessorize Mini Hammered Doorknocker Hoop Earrings in Gold
Kiki McDonough Yellow Citrine Cushion Drop Earrings
Missoma Gold Zenyu Chandelier Hoops
Monica Vinader Siren Earrings In Green Onyx
Kiki Mcdonough Blue Topaz and Diamond Drop Earrings
Kiki McDonough Morganite Double Drop Earrings
Patrick Mavros Pangolin Haka Earrings in Silver
Blaiz Red Beaded Teardrop Earrings
Kiki McDonough Green Tourmaline, Green Amethyst and Diamond Earrings
Simone Rocha Faux-pearl Curb-Chain Earrings
Freya Rose Mini Hoop Earrings With Detachable Pearls
Kiki McDonough Candy Mini Green Amethyst & Diamond Earrings
Kiki McDonough Lemon Quartz Pear and Oval Drop Earrings
Kiki McDonough Lavender Amethyst Pear and Oval Drop Earrings
Kiki McDonough Classic Peridot and Blue Topaz Double Oval Stud Earrings
Kiki McDonough Lola Blue Topaz and Diamond Hoop Earrings in White Gold
Kiki McDonough Eden Blue Topaz Flower Necklace
Mejuri Organic Pearl Stacked Hoops – possible ID
All The Falling Stars Gold Disc Circle Earrings
Catherine Zoraida Fern Drop Earrings
Accessorize Simple Filigree Short Drop Earrings
Accessorize Polly Petal Earrings
Kiki McDonough Pink Tourmaline & Green Amethyst Earrings
Simone Rocha Crystal earrings
Oscar de la Renta Pearl Sun Star Earrings
Balenciaga pearl clip-on earrings
Cassandra Goad Temple of Heaven earrings
Kate Spade Pretty Pom Tassel Drop Earrings
Shelley Silversmith Ulu Earrings
Pippa Small Large Kite Earrings
Oscar de la Renta earrings
Soru Jewellery Baroque Pearl Drop Earrings
Accessorize Filigree and Bead Drop Earrings
Bhutanese earrings
Azuni London Athena earrings
Links of London Hope Egg earrings
Links of London Effervescence Bubble Earrings
Mirabelle Lolita Earrings
Patrick Mavros Silver Crocodile Stud Earrings
Kiki McDonough Green Amethyst Oval Drop Earrings
Kiki McDonough Grace White Topaz and Diamond Stud Earrings
Beaut Jewellery Eva / Ava Earrings
Tiffany & Co. Sapphire Cabochon Earrings
Patrick Mavros Ndoro Dangle Silver Earrings
Kate must find it difficult to put the lid on her jewellery box. I can only imagine that it's jam-packed full. Filled with heirlooms loaned from the Queen, sentimental items gifted by William, precious pieces that once belonged to the late Princess Diana and, of course, her own personal collection. By my best estimate, I'd say Kate must have worn approximately 100 different pairs during her time in the public eye.
What type of earrings does Kate Middleton wear?
When it comes to earrings, Kate has tried almost every style imaginable. Sparkling chandeliers? Check. Long beaded drops? Check. Colourful gemstones? Check. Diamond studs? Check? Pearls? Hoops? Leaves? Check. Check. Check. Pom-pom tassels? Yes, check!
For everyday wear, Kate will tend to opt for something pretty, fuss-free and elegant. A small colourful gemstone suspended from a hoop, for instance. But she isn't afraid to pull out the big guns if an event warrants it. She's happy to make a statement in rubies or grab headlines in an oversized hammered metal design.
Does Kate wear gold or silver earrings?
I'd say that her style has evolved over the last ten years. She used to wear a lot of white gold and platinum designs. She seems to be adding more gold and gold vermeil into her collection now.
View More from Kate's Wardrobe: All JewelleryNecklacesDressesCoatsShoesBags


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This week is a time of transition… I've left my old job, and haven't yet started my new job. It's really nice to have the time to decompress, breathe, relax, get outside and soak in some of the change. I am loving the sensation of being free of routine and doing what feels right in the moment. I'm thinking happy thoughts about my start date, and by the time Monday rolls around, I'll be ready.
Of course there are errands to run… I need to get the muffler fixed on my car, do some grocery shopping and buy some clothes that are suitable for a non-studio environment (no more jeans and gypsy skirts for me!). And as always, there is cooking and cleaning to do. But spread out across the week, it all seems achievable.
Most of all though, I want to allow myself time this week to simply be.
I've been having long afternoon naps, doing tai chi, and two days in a row now, I've had lovely long walks; each with a kindred spirit. On Sunday my friend David and I walked along the Assiniboine River up to The Forks, and then along the Red River up to Waterfront Drive; then over to the Exchange, through Downtown and back. The air was so crisp, and there was this eerie quiet fog over the water, snow and ice. Today, my Aunt Fenella and I wandered through the Assiniboine Forest with Kato, stopping to appreciate the details (the white layer on the tree trunks, the layers of grass/trees/sky, the small seeds on these gorgeous red shrubs) and then sat a while in one of the teepee forts.
Tomorrow I am going to take advantage of one of my goodbye gifts from The FaQtory and enjoy a few lovely hours at the Riverstone Spa at The Forks. Then home… maybe for another nap.
Yes… breathe, just breathe.


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Patients who expect their pain to worsen after surgery may be at higher risk of lingering postsurgical pain, according to a study published in Anesthesiology. Factors associated with lingering postsurgical pain remain poorly understood.
Researchers retrospectively analyzed a single-center cohort of 3628 postsurgical patients who underwent operations between February 2015 and October 2016 at a US tertiary-care hospital. These patients participated in an observational study called the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS).
During their preoperative assessments, patients completed the Veterans RAND 12-item health questionnaire and a survey about their baseline pain, the reason for surgery, and their expectations about pain 1 month after the operation.
One to 3 months after surgery, patients were asked to fill out a follow-up survey that included questions about whether they were still experiencing pain and, if so, to rank its intensity on a scale of 0 to 10. The investigators defined "lingering postsurgical pain" as an affirmative response to the question, "Currently, do you have any pain in your surgical incision or area related to your surgery?"
Preoperatively, 67% of patients (n = 2414) had positive expectations that they would have no postsurgical pain if they did not have baseline pain or that they would experience an improvement in pain if they did have baseline pain 1 month after surgery. Nineteen percent of patients (n = 686) expected new pain if they reported no pain at baseline or expected their pain to stay the same or worsen if they did have baseline pain.
The remaining 24% said they did not know whether they'd have postoperative pain.
Although 44% of patients with positive expectations had surgeries that are usually done to relieve pain, only 26% of patients with negative expectations had those types of surgeries.
About 36% of patients (n = 1308) reported lingering postoperative pain. The mean severity was ranked 3.8 on a scale of 0 to 10 (standard deviation, 2.1). Patients who expressed negative expectations were more likely to report lingering postsurgical pain (odds ratio [OR] = 1.56; 95% CI, 1.23 – 1.98; P < .001).
Compared to patients with positive expectations, patients with negative expectations were twice as likely to report new or more severe pain (23% vs 11%; P < .001). Other significant risk factors included recollection of severe acute postoperative pain (OR = 3.13; 95% CI, 2.58 – 3.78; P < .001), undergoing a procedure typically meant to alleviate pain (OR = 2.18; 95% CI, 1.73 – 2.75; P < .001), and preoperative pain related to surgery (OR = 1.91; 95% CI, 1.52 – 2.40; P < .001).
"There are risk factors that are better known, like age and perhaps preexisting chronic pain issues," said Simon Haroutounian, PhD, the senior author of the study and the chief of clinical pain research at the Washington University Pain Center, in St. Louis, Missouri, in an interview with Medscape Medical News. "We found that patient expectations, particularly if they have negative expectations, may be independent predictors of patients who are doing worse and still having pain somewhere between 1 and 3 months after surgery," he said.
Lingering postoperative pain can lead to chronic pain, said W. Michael Hooten, MD, a pain specialist at the Mayo Clinic, in Rochester, Minnesota, in an interview with Medscape. "It's important to differentiate between lingering pain and chronic pain. This is a critical time point during which there might be interventions to mitigate the risk of developing chronic pain," said Hooten, who was not involved in the study.
Patient expectations did not always align with their pain outcomes; 26% of patients with positive expectations reported new, unabated, or worsening pain, and 61% of patients with negative expectations experienced no lingering pain or an improvement in their preexisting pain.
It's important to note that the study included "a high degree of heterogeneity in the surgical types and patient populations," said Beth Darnall, PhD, the director of the Pain Relief Innovations Lab at Stanford University, Stanford, California, in an interview with Medscape. For some patients who undergo major surgeries such as total knee replacements, expecting to still be in pain a month after the procedure is perfectly reasonable, she explained. Patient expectations may be influenced by the type of surgery and the preoperative counseling they receive.
More research is needed to understand how patient expectations affect pain outcomes. The effects of negative expectations may range from altering a patient's willingness to participate in rehabilitation to changing pain processing on a physiologic level, Hooten pointed out.
For their next steps, the researchers aim to create a prediction model that could be used to evaluate an individual patient's risk of having chronic pain after surgery, Haroutounian said.
The parent study was funded through institutional and departmental support, including a grant from the Barnes-Jewish Hospital in St. Louis. Haroutounian and Hooten have disclosed no relevant financial relationships. Darnall is the chief science advisor at AppliedVR.
Anesthesiology. 2021;134:915-924. Abstract
Anna Goshua is a reporting intern with Medscape. She is a dual medical and journalism student who has previously written for STAT, Scientific American, Slate, and other outlets. She can be reached at email@example.com or @AnnaGoshua.
For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.
Medscape Medical News © 2021
Send news tips to email@example.com.
Cite this: Pain Expectations Before Surgery Can Be a Self-fulfilling Prophecy - Medscape - Jun 17, 2021.


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COMPLEXION (n.)
ANONYME, The Excellency of the Pen and Pencil, Exemplifying The Uses of them in the most Exquisite and Mysterious Arts of Drawing, Etching, Engraving, Limning, Painting in Oyl, Washing of Maps & Pictures. Also the way to Cleanse any Old Painting, and Preserve the Colours. Collected from the Writings of the ablest Masters both Ancient and Modern, as Albert Durer, P. Lomantius, and divers others. Furnished with divers Cuts in Copper, being Copied from the best Masters, and here inserted for Examples for the Learner to Practice by. A Work very useful for all Gentlemen, and other Ingenious Spirits, either Artificers or others, London, Dorman Newman, 1688.3 quotations
Of Drawing. The First Book, Chap. II, Of Actions, Gestures, Decorum, Motion, Spirit, and Grace in Pictures rightly resembled, p. 10
SECT. II. Of the Passions or Complexions.
Man's Body is composed of the Four Elements.
Melancholly resembles Earth.
Flegm the Water.
Choler the Fire.
Bloud the Air ; and answerable are the Gestures and Humours.
Melancholly bodies are slow, heavy, and restrained ; and the consequents are anxiety, disquietness, sadness, stubborness, &c. in which horror and despair will appear.
Flegmatick bodies are simple, humble, merciful.
Sanguine bodies are temperate, modest, gracious, princely, gentle, and merry ; to whom these affections of the mind best agree, viz. love, delight, pleasure, desire, mirth, and hope.
Cholerick bodies are violent, boisterous, arrogant, bold, and fierce ; to whom these passions appertain, anger, hatred, and boldness ; and accordingly the skillful Artist expresses the motions of these several bodies, which ought Philosophically to be understood.
Conceptual field(s)
Of Limning in Water-Colours, The Third Book, Chap. III, How to prepare a Table for a Picture in small for Limning, to make choice of your Light, the manner of Sitting in respect of Position and Distances, and what necessary Instruments are to lie by you when you are at work, p. 81
5. Have a pretty quantity of Carnation (as some call it) or Flesh-colour, somewhat lighter than the Complexion of the party your are to draw, tempered up in a shell by it self with a weak Gum-water. If it be a Fair complexion, White-lead and Red-lead mixed. If a Swarthie or Brown complexion, to your White and Red-lead add a quantity of Masticote, or English-Oker, or both if occasion be. But whatever the Complexion be, be sure you temper your Flesh-colour lighter than the party ; for by often working upon it you may bring it to its true colour, it being first too light ; but if it be first too sad, there then is no remedy.
Conceptual field(s)
Of Painting in Oyl, Book IV, Chap. III, How to order your Colours upon your Pallat, and how to temper Shadows for all Complexions, p. 96-98
Chap. III, How to order your Colours upon your Pallat, and how to temper Shadows for all Complexions.
Dispose your single Colours upon your Pallat in this order, laying them at a convenient distance one from another, so that they be not apt to intermix. First lay on your Vermilion, then lake, then burnt Oker, India Red, Pink, Umber, Blacks, and Smalt : lay the White next to your thumb, because it is oftenest used, for with it you lighten all your shadows ; next to your White lay a stiff sort of Lake : this done, your Pallat is furnished with the single Colours belonging to a Face ; then for the tempering of your Shadows to all Complexions, observe the following Directions.
1. For a Fair Complexion.
Take a little White, and twice as much Vermilion, and as much Lake temper these well together upon your Pallat with the flat blade of your knife ; lay aside by it self on your Pallat the greatest quantity of this to be used for the deepest Carnation of the Face […].
Your Carnations being thus tempered, and orderly laid upon your Pallat, prepare your faint Shadows. For which,
Take Smalt, and mix it with a little White, which may serve for the Eyes ; lay aside the greatest quantity, and to the rest add a little Pink, this well tempered and laid by it self, will serve for the faint greenish shadows in the Face.
Now prepare your deep Shadows : for which take Lake, Pink, […].
2. For a more Brown or Swarthy Complexion.
Lay your single Colours on your Pallat as before, and in like manner temper them, only amongst your White Lake, and Vermilion, put a little quantity of burnt Oker, to make it look somewhat Tawny […].
3. For a Tawny Complexion.
The general Colours must be the same as before, only the Shadows are different, for you are to prepare them of Umber, and burnt Oker, […].
4. For an Absolute Black Complexion.
Your dark Shadows must be the same as before ; but for your heightnings, you must take White, burnt Oker, Lake, and Black, put but a little White in at first, […].
Here note, that the single Colours at first laid upon your Pallat being tempered together according to the former directions, serve for shadows for all Complexions.


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HPV Vaccination - A Nevada Mom's Perspective
Cancer prevention for children is generally a fairly straightforward task. Parents can feed their children healthy meals, encourage plenty of exercise, ensure they're wearing sunscreen, and teach them about the dangers of tobacco use. One cancer prevention tactic has become a bit more controversial in recent years though, despite its very direct impact on preventing cancer. The HPV vaccination can protect against cervical cancer, anal cancer, and several oral cancers, to name a few. But while some people have raised concerns about vaccine safety, the CDC and several other organizations closely monitor the safety of the HPV vaccine. Some parents have also expressed concern that vaccination for HPV, an STD, which is recommended for youth aged 11 - 12, may encourage earlier sexual behavior. Research has shown this isn't the case.
Ultimately, it's a parent's decision whether to vaccinate their child for HPV to prevent cancer. Recently one northern Nevada mom took to the Reno Mom's Blog to share her thoughts on HPV vaccination.
"There has been a lot of controversy surrounding the Human Papillomavirus (HPV) vaccine. Many parents think that vaccinating their children for a sexually transmitted disease (STD) is encouraging them to have sex. I want to share with you today why I can say with absolute certainty that I will be getting this vaccine for my two sons and my daughter.
I didn't know much about HPV until I got it myself. I waited a LONG time for my first sexual encounter. In fact, when I finally lost my virginity in my mid 20s, it was to a man that I believed was my soul mate. I am an educated and risk averse person. I grew up in the Bible Belt. I was as safe and prepared as could be. We always used protection.
That is why, about a month after that first encounter, I was shocked to find bumps on my nether regions. I promptly went to my OB-Gyn, and after a pap smear, I was diagnosed with HPV."


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The Milky Way is Full of Dead Aliens – Latest Study Suggests
The Milky Way Galaxy may be home to alien civilizations, but according to a new study there is a strong probability that most of them are dead – and their own progression led to their demise.
The statement comes from researchers with NASA's Jet Propulsion Laboratory, the California Institute of Technology and Santiago High School who used an updated version of an equation to calculate the likely existence of intelligent life and determined aliens may have emerged some eight billion years after our galaxy formed.
With these results, the team included the idea that progress of science and technology inevitably leads to the destruction of civilizations and because humans have yet to make contact outside our planet, scientists now think they know why.
'We found the potential self-annihilation to be highly influential in the quantity of galactic intelligent life,' reads the study in arxiv.
'If intelligent life is likely to destroy themselves, it is not surprising that there is little or no intelligent life elsewhere.'
Researchers also note that if there is intelligent life elsewhere in the galaxy, they are 'still too young to be observed by us' and too far from Earth to be identified.
For this study, the team updated the 1961 Drake Equation, which was written by Dr. Frank Drake to estimate the number of active, communicative extraterrestrial civilizations in the Milky Way.
However, according to the new paper, the older version does not take into account the evolving stellar properties on our galaxy like discoveries of supernovas and exoplanets.
The team also looked at the probability of life in the pre-biotic condition, different potential timescales for biological evolution and the probability of self-annihilation of complex life.
'Using our model, if we evaluate how much the quantity of complex life changes in the Milky Way within a specific time range, we could have a better understanding on the hypothesis of life origins, the Rare Earth Hypothesis,' reads the paper.
'The timescale for biological evolution has been largely assumed to be identical to the intellectual species on Earth.'
'Without considering the possibility that life may require varied timescales to evolve, any result of the growth propensity of life is dependent on the ongoing debate whether or not humans on Earth are the paradigm resembling all other evolving complex life.'
The paper also takes into account the possibility of self-annihilation, which has been overlooked by scholars in the past.
These variables produced results that show most intelligent in the galaxy is younger than five million years old 'with values of probability parameter for self-annihilation between 0 – 0.01; with a relatively higher value of the annihilation parameter.'
The findings suggest intelligent life may be common in the Milky Way, but Earth's location is not the region in which it is located and 'SETI practices need to be closer to the inner galaxy.'
Researchers determined that if aliens do exist, they are just 13,000 light-years from the galactic center, whereas Earth and the solar system are approximately 25,000 light-years away.


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Air Transfer Mattress
As you shop for the best air transfer mattress on the market, keep SPH Medical in mind for a superior quality product for your medical facility. Your staff and patients will appreciate the fact that our medical products are made to a higher standard than other air transfer system products- and are priced affordably, to fit your facility's budget. As a reputable medical device manufacturer, we are able to save our clients money by providing well-made air-assisted lateral transfer devices, PPE, and other items without compromising on quality. Feel free to review our entire list of products or reach out to us for a quote today.
Q: What makes your air-assisted lateral patient transfer system better than other single-use products?
A: We double stitch every seam and handle to ensure a longer-lasting product that won't fall apart like other products that are heat sealed or welded. Count on our air transfer mattress to hold up to daily use without showing early signs of wear.
Q: Can single patient use mobile air transfer systems be used safely throughout the day?
A: Depending on the product you choose, you'll notice a dramatic difference in the quality of the product. SPH Medical has designed and manufactured an air transfer mattress specifically for single patient use that can be left under patients all day, without concerns over whether patients will experience soreness or stiffness due to comfort.
Q: Why should our medical facility invest in SPH Medical's air transfer mattresses?
A: Your staff is at risk of back injury due to lifting and repositioning patients throughout their shifts. Manual lifting causes back strain, sprains, and other types of injuries that lead to lifelong pain and an early end of a career. Our product offers your staff a safe alternative that makes lifting duties easier, and with increased efficiency, fewer staff members are required to complete lifting tasks.
Q: Do air transfer mattresses need to be removed during imaging?
A: In most cases, the air transfer mattress system can stay in place throughout x-rays and digital imaging.
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A: Our customers see a high return on their investment due to the following:
- Reduced injuries on the job
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Q: How can I find more information about your products?
A: You'll find a wealth of free resources on our website, including product description pages, articles, FAQs, and quick links located at the bottom of our website. If you have questions that aren't directly addressed on our website, reach our staff by phone at 844-377-4633.
Don't take chances when purchasing medical products, Covid-19 equipment, N95 masks, mobility items, or disinfection services- trust SPH Medical to save you money and deliver exceptional quality products and services that will lead to patient satisfaction and increased efficiency for your staff. Follow us on social media to stay informed about new products and services offered by SPH Medical.


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Outcomes-Based Contracting with Value-Based Insurance Design: Opportunities to Drive More Health per Pharmacy Dollar
Reimbursement that aligns spending with quality and patient-centered outcomes is widely viewed as a key enabler of achieving more value from the $3.7 trillion Americans spend annually on health care. For drugs, outcomes-oriented contracts – financial arrangements that tie payment to achieving pre-specified clinical goals – have received increasing attention. If structured correctly, these contracts have the potential to align the interests of patients, health plans, manufacturers, and society around the shared goal of ensuring prudent use of health care resources while preserving access to care and incentives for innovation.
The number of outcomes-oriented contracts is not known, since private plans and manufacturers do not have to publicly report their agreements. While some estimate that there are only 20 such agreements in effect, momentum for outcomes-oriented contracting is significant and growing.1 According to surveys of key industry leaders, 70 percent of polled payers have interest in outcomes-oriented contracting for pharmaceuticals, as do more than 60 percent of polled manufacturers.1,2 Key public purchasers have recently signaled interest in outcomes-oriented arrangements: the Centers for Medicare & Medicaid Services (CMS) has announced its intent to develop an outcomes-oriented contract with Novartis for the CAR-T cell therapy Kymriah (tisagenlecleucel) for B-cell acute lymphoblastic leukemia, and at least one state Medicaid program has broadcast its intention to develop pay-for-outcomes deals.3,4 Several prominent examples in the commercial sector – including a collaboration between Harvard Pilgrim and Spark Therapeutics to pay for a $850,000 gene therapy for inherited blindness through an outcomes-oriented arrangement – have also made headlines.5
The rise of targeted therapies for narrow patient populations has motivated some share of this growing interest: funds devoted to expensive breakthrough therapies such as gene therapies may be money very well-spent if patients respond to treatment. But given the heterogeneity of possible patient responses and the potential for benefits to accrue over long time periods – up to and including lifetimes – the current state of clinical knowledge may make it difficult or impossible to know before treatment which particular patients will ultimately benefit and which will not. Outcomes-oriented contracts offer an opening for payers to facilitate access in the absence of clinical certainty.
As interest in outcomes-oriented arrangements spreads and new implementations are piloted, one critical player in these arrangements has tended to receive relatively little attention: the patient. After providing an overview on outcomes-oriented contracting, this brief offers a rationale for ensuring consumer perspectives and patient access figure prominently in the design of future agreements. The following sections will lay out suggestions for developing outcomes-oriented contracts that reflect the principles of value-based insurance design (V-BID) to ensure a patient-centered focus.
Developing Outcomes-Oriented Contracts
Executing a mutually advantageous outcomes-oriented contract requires agreement on the outcome of interest. As shown in the Table, there is precedent for targeting a range of specified outcomes. These include patient-centered outcomes (e.g., cardiovascular events), intermediate endpoints (e.g., HbA1c control), and the patient's total cost of care.
Table: Examples of Outcomes-Oriented Payer/Manufacturer Arrangements for Drugs
The method of determining whether an outcome has been met is inherently related to the endpoint selected. For some endpoints, use of claims data is sufficient (e.g., occurrence of a cardiovascular event or a hospitalization). For other endpoints, structured data for intermediate outcomes of interest is already collected for purposes of quality reporting (e.g., HEDIS measures pertaining to diabetes control). For still other endpoints, such as progression-free survival, chart review – perhaps with the benefit of electronic health information exchange – may be necessary given the lack of clinical detail available in claims alone.6 Some see a role for third parties, such as specialty pharmacies, to serve as neutral arbiters of whether targeted outcomes have been achieved.7
How at-risk funds will flow must also be considered. Several approaches are possible. Adjusting the generosity of rebates for future medication fills is the most common approach (see Table). Manufacturers can also directly reimburse payers for potentially avoidable downstream utilization, e.g., re-hospitalizations or ED visits. Novartis, manufacturer of the treatment Kymriah (tisagenlecleucel) has proposed a different approach: simply not charging for the cost of the therapy if the patient does not respond to treatment by the end of the first month.8 Most often, patient-facing incentives are not impacted.
Regulatory requirements can complicate the execution of these arrangements.9 In particular, the Medicaid Best Price Requirement dictates that state Medicaid programs must be offered the lower of (a) the lowest price (net of rebates) for which a given drug is sold on the commercial market, or (b) a discount of at least 23.1 percent off the list price. While it is important to note that the use of differing rebates to administer an outcomes-oriented arrangement could potentially set a new best price, Sachs et al have argued that – in most cases – the best price requirement need not prevent experimentation with outcomes-based contracts.10,11 A thorough treatment of other key regulatory issues, including off-label promotion of drugs and the federal anti-kickback statute, is available in a 2016 white paper.12
Value-Based Insurance Design
According to an April 2017 survey from the Kaiser Family Foundation, 63 percent of Americans believe that "lowering the amount individuals pay for health care" should be a top national priority.13 Furthermore, high cost-sharing for high-value health care medications and services is associated with many deleterious consequences. Hopes that shifting costs to consumers will help bring about smarter consumerism are simply not borne out by experience.14 The literature
is overwhelmingly clear that patients subject to greater cost-sharing tend to reduce use of services and medications – the greater the cost-share, the greater the corresponding reduction in service use.15–17 In response to across-the-board increases in cost-sharing, many studies find that patients reduce use of both high- and low-value care in similar proportions.15,18 Increased acute care utilization and poorer health outcomes may result.16,17,19,20 Research suggests that cost-related underuse of evidence-based services disproportionately impacts poorer Americans and those with chronic conditions.19–23 With the average deductible for self-only employer-sponsored coverage approaching $1,500 – and with high and rising cost-sharing even once any applicable deductible has been satisfied – cost-related non-adherence is a significant risk.24 Research suggests users of more expensive specialty drugs are especially likely to abandon their medications at their pharmacy counter.25
V-BID can reduce the risk of cost-related non-adherence. V-BID entails aligning patients' out-of-pocket cost-sharing with the value of the underlying service – i.e., lowering cost-sharing for high-value services and/or increasing cost-sharing for low-value services. Such an approach encourages the use of high-value care while maintaining or strengthening incentives to avoid low-value spending.26 V-BID incorporates clinical nuance, "recognizing that the clinical benefit of a specific service or therapy depends on who receives it, who provides it, and where and when in the course of disease the service or therapy is provided."27
A 2012 systematic review published in Health Affairs by Lee and colleagues identified thirteen studies of V-BID from the peer-reviewed literature, generally finding modest but meaningful improvements in adherence in association with reductions in cost-sharing. More recent research has produced similar findings.28–31
Incorporating V-BID Principles to Align Patient-Facing Incentives with Outcomes-Oriented Arrangements
As health sciences companies and payers design a new generation of financial arrangements, patient concerns about high out-of-pocket costs – and the cost-related nonadherence they may bring about – ought to remain at the forefront. At the same time, outcomes-oriented arrangements can provide a means for payers to safeguard against excessive expenditures for patients for whom the drug is not appropriate. While historically high cost-sharing has been justified by some as a means of reducing low-value expenditures, such rationale loses its salience in the context of an outcomes-oriented drug agreement.14 The outcomes-oriented reimbursement arrangement itself can serve this purpose. Ultimately, this should translate to patient-facing cost-sharing that is set at low, minimally burdensome levels. For the same reason, payers should ensure that utilization management protocols (e.g., prior authorization requirements) are minimally burdensome when meaningful outcomes-oriented arrangements are in effect.
As of January 2019, cost-sharing for seven million UnitedHealthcare members will reflect the plan-paid price, net of rebates – a potentially trend-setting move praised by Secretary of Health and Human Services Alex Azar.32 In an ideal future state, the same dynamic cost-sharing adjustment might be used to ensure that patients' financial responsibilities align with the principles underlying the outcomes-oriented arrangement. Even without dynamic cost-sharing, payers have moved glucose-lowering agents included in outcomes-based agreements to more preferred prescription drug formulary tiers.33 In many plans, differences between consumer cost-sharing for preferred and non-preferred drugs can vary by $100 or more, suggesting that these formulary tier adjustments may be highly meaningful to patients.34
These are precedents upon which expansion should be based.
Outcomes-oriented arrangements between payers and purchasers can go further than ameliorating the most burdensome elements of managed care. Depending on the nature of the mutually agreed-upon goal – improving blood sugar control, for instance – the patient might be offered a financial incentive for achieving well-defined targets. Adherence itself, the subject of many HEDIS and Medicare Advantage Stars performance measures, might be measured and incentivized by the plan or manufacturer. Such an approach would stand in contrast to one-size-fits-all cost-sharing for drugs that effectively obstructs adherence.
Outcomes-oriented arrangements can also provide a new opening for collaboration around care management and patient activation. For example, many patient assistance programs employ nurse care managers to monitor adherence. With shared incentives – e.g., the avoidance of disease exacerbation in rheumatoid arthritis – existing nurse care managers can broaden their focus beyond ensuring drug use and adherence toward ensuring optimal disease control more broadly. Such collaboration might include support for ensuring other needed care is received (e.g., diabetics' foot care, eye care, etc.), support for addressing disease-relevant social determinants of health (e.g., linkages with key community resources), and support to build greater levels of patient activation more generally.35 With shared interests around patient-centered outcomes, the manufacturer/purchaser relationship might become less transactional and more patient-centered.
The complexity of executing outcomes-oriented reimbursement arrangements is partially responsible for the relatively small number of examples to-date. Recognizing the need for simplicity, the following principles are suggested for new payer-manufacturer agreements:
- Select drugs/conditions where the "juice is worth the squeeze." This likely means focusing on high-cost specialty drugs or moderate-cost branded medications used to treat costly conditions – especially conditions where exacerbation is associated with high-cost outcomes.
- For low-volume, high-cost drugs, consider use of clinical data from medical charts in ascertaining outcomes (e.g., progression-free cancer survival). For high-volume/moderate-cost drugs, use only claims or clinical data that is already being collected for other purposes (e.g., emergency department visits for disease exacerbation, blood glucose control).
- Outcomes-oriented agreements should provide a "win" for targeted patients. Recognizing the centrality of adherence irrespective of the targeted outcome, cost-sharing should be set at minimally burdensome levels. If needed, manufacturers and payers should ensure financial assistance is available and that copay cards may be used without interference.36 Payers should move drugs covered by outcomes-oriented arrangements to more favorable formulary tiers.
From a societal perspective, additional important outcomes can only be ascertained by directly asking patients (e.g., pain control, function) or consulting non-health datasets (e.g., work attendance). At present, outcomes-oriented agreements that incorporate these endpoints are likely not practical, but such arrangements may merit consideration in future years.
Purchasers and health sciences companies should accelerate the movement to value-based reimbursement by giving strong consideration to outcomes-oriented arrangements for medications. Simultaneously, new outcomes-oriented agreements must recognize the central role of the patient.
University of Michigan Center for Value-Based Insurance Design
The University of Michigan Center for Value-Based Insurance Design (V-BID Center) is the leading advocate for development, implementation, and evaluation of clinically nuanced health benefit plans and payment models. Since 2005, the Center has been actively engaged in understanding the impact of innovative provider facing and consumer engagement initiatives, and collaborating with employers, consumer advocates, health plans, policy leaders, and academics to improve clinical outcomes and enhance economic efficiency of the U.S. health care system. For more information, find us at www.vbidcenter.org and follow us @UM_VBID.
Funding for this V-BID Center Brief was provided by Boehringer Ingelheim
Boehringer Ingelheim Pharmaceuticals, Inc., based in Ridgefield, CT, is one of the world's top 20 pharmaceutical companies. Headquartered in Ingelheim, Germany, the company operates globally with approximately 50,000 employees. Since its founding in 1885, the company has remained family-owned and today creates value through innovation for three business areas including human pharmaceuticals, animal health and biopharmaceutical contract manufacturing.
Boehringer Ingelheim is committed to improving lives and providing valuable services and support to patients and their families. Our employees create and engage in programs that strengthen our communities. Please visit our website to learn more about how we make more health for more people through our Corporate Social Responsibility initiatives.
For more information please visit www.boehringer-ingelheim.us, or follow us on Twitter @BoehringerUS.
- Duhig A, Saha S, Smith S, Kaufman S, Hughes J. The Current Status of Outcomes-Based Contracting for Manufacturers and Payers: An AMCP Membership Survey. J Manag Care Spec Pharm. December 2017:1-6. doi:10.18553/jmcp.2017.16326
- Avalere Health. Health Plans Are Interested in Tying Drug Payments to Patient Outcomes.; 2016. http://avalere.com/expertise/life-sciences/insights/health-plans-are-interested-in-tying-drug-payments-to-patient-outcomes. Accessed March 8, 2018.
- Weintraub A. How to cover Novartis' $475K CAR-T drug Kymriah? A 'new payment model' is the only way, Express Scripts says. FiercePharma. /financials/car-t-and-other-gene-therapies-need-new-payment-model-says-express-scripts. Published September 22, 2017. Accessed February 23, 2018.
- National Acdaemy for State Health Policy. NASHP Awards Grants to Colorado, Delaware, and Oklahoma to Tackle Rising Rx Drug Prices. https://nashp.org/nashp-awards-grants-to-colorado-delaware-and-oklahoma-to-tackle-rising-rx-drug-prices/. Published October 10, 2017. Accessed February 23, 2018.
- Beaton T. Outcomes-Based Contracts Offer Payers New Pharmaceutical Options. HealthPayerIntelligence. https://healthpayerintelligence.com/news/outcomes-based-contracts-offer-payers-new-pharmaceutical-options. Published January 10, 2018. Accessed March 8, 2018.
- Fox J, Watrous M. Overcoming Challenges Of Outcomes-Based Contracting For Pharmaceuticals: Early Lessons From The Genentech–Priority Health Pilot. Health Affairs. http://healthaffairs.org/blog/2017/04/03/overcoming-challenges-of-outcomes-based-contracting-for-pharmaceuticals-early-lessons-from-the-genentech-priority-health-pilot/. Published April 3, 2017. Accessed March 8, 2018.
- Thomas J. The Challenge of Measuring Outcomes in Specialty Pharmacy. Specialty Pharmacy Times. https://www.specialtypharmacytimes.com/news/the-challenge-of-measuring-outcomes-in-specialty-pharmacy. Accessed February 24, 2018.
- Daniel G, Leschly N, Marrazzo J, McClellan M. Advancing Gene Therapies And Curative Health Care Through Value-Based Payment Reform. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20171027.83602/full/. Published October 30, 2017. Accessed February 24, 2018.
- Nussbaum S, Ricks D. Discovering New Medicines and New Ways to Pay for Them. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20160129.052814/full/. Published January 29, 2016. Accessed March 20, 2018.
- Sachs R, Bagley N, Lakdawalla DN. Innovative Contracting for Pharmaceuticals and Medicaid's Best-Price Rule. J Health Polit Policy Law. 2018;43(1):5-18. doi:10.1215/03616878-4249796
- Sachs R, Bagley N, Lakdawalla DN. Value-Based Pricing For Pharmaceuticals In The Trump Administration. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20170427.059813/full/. Published April 27, 2017. Accessed February 24, 2018.
- Pearson SD, Dreitlein B, Henshall C. Indication-Specific Pricing of Pharmaceuticals in the United States Health Care System. Institute for Clinical and Economic Review; 2015. http://icer-review.org/wp-content/uploads/2016/03/Final-Report-2015-ICER-Policy-Summit-on-Indication-specific-Pricing-March-2016_revised-icons.pdf. Accessed March 8, 2018.
- Kaiser Family Foundation. Kaiser Health Tracking Poll – Late April 2017: The Future of the ACA and Health Care & the Budget.; 2017. http://files.kff.org/attachment/Topline-Kaiser-Health-TrackingPoll-Late-April-2017-The-Future-of-the-ACA-and-Health-Care-and-the-Budget. Accessed March 8, 2018.
- Capretta J. Compelling Evidence Makes the Case for a Market-Driven Health Care System. Washington, DC: The Heritage Foundation; 2013. https://www.heritage.org/health-care-reform/report/compelling-evidence-makes-the-case-market-driven-health-care-system. Accessed December 15, 2017.
- Newhouse JP, Insurance Experiment Group. Free for All?: Lessons from the RAND Health Insurance Experiment. Cambridge, MA: Harvard University Press; 1996.
- Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298(1):61-69. doi:10.1001/jama.298.1.61
- Eaddy MT, Cook CL, O'Day K, Burch SP, Cantrell CR. How patient cost-sharing trends affect adherence and outcomes: a literature review. P T Peer-Rev J Formul Manag. 2012;37(1):45-55.
- Brot-Goldberg ZC, Chandra A, Handel BR, Kolstad JT. What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics. National Bureau of Economic Research; 2015. doi:10.3386/w21632
- Wharam JF, Zhang F, Eggleston EM, Lu CY, Soumerai S, Ross-Degnan D. Diabetes outpatient care and acute complications before and after high-deductible insurance enrollment: a Natural Experiment for Translation in Diabetes (NEXT-D) Study. JAMA Intern Med. 2017;177(3):358. doi:10.1001/jamainternmed.2016.8411
- Wharam JF, Zhang F, Landon BE, Soumerai SB, Ross-Degnan D. Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Aff (Millwood). 2013;32(8):1398-1406. doi:10.1377/hlthaff.2012.1426
- Wharam JF, Zhang F, Eggleston EM, Lu CY, Soumerai SB, Ross-Degnan D. Effect of High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experiment for Translation in Diabetes (NEXT-D) Study. Diabetes Care. January 2018:dc171183. doi:10.2337/dc17-1183
- Reddy SR, Ross-Degnan D, Zaslavsky AM, Soumerai SB, Wharam JF. Impact of a high-deductible health plan on outpatient visits and associated diagnostic tests. Med Care. 2014;52(1):86-92. doi:10.1097/MLR.0000000000000008
- Rabin DL, Jetty A, Petterson S, Saqr Z, Froehlich A. Among low-income respondents with diabetes, high-deductible versus no-deductible insurance sharply reduces medical service use. Diabetes Care. 2017;40(2):239-245. doi:10.2337/dc16-1579
- Claxton G, Rae M, Long M, et al. Employer Health Benefits 2016. Kaiser Family Foundation, Health Research & Educational Trust, NORC at the University of Chicago; 2016:274. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2016-Annual-Survey.
- Starner CI, Alexander GC, Bowen K, Qiu Y, Wickersham PJ, Gleason PP. Specialty drug coupons lower out-of-pocket costs and may improve adherence at the risk of increasing premiums. Health Aff Millwood. 2014;33(10):1761-1769. doi:10.1377/hlthaff.2014.0497
- Chernew ME, Rosen AB, Fendrick AM. Value-based insurance design. Health Aff (Millwood). 2007;26(2):w195-203. doi:10.1377/hlthaff.26.2.w195
- Fendrick AM, Chernew ME. Precision benefit design—using "smarter" deductibles to better engage consumers and mitigate cost-related nonadherence. JAMA Intern Med. 2017;177(3):368-370. doi:10.1001/jamainternmed.2016.8747
- Yeung K, Basu A, Hansen R, Watkins J, Sullivan S. Impact of a Value-based Formulary on Medication Utilization, Health Services Utilization, and Expenditures. Med Care. 2017;55(2):191-198. doi:10.1097/MLR.0000000000000630
- Hirth RA, Cliff EQ, Gibson TB, McKellar MR, Fendrick AM. Connecticut's Value-Based Insurance Plan Increased The Use Of Targeted Services And Medication Adherence. Health Aff (Millwood). 2016;35(4):637-646. doi:10.1377/hlthaff.2015.1371
- Choudhry NK, Bykov K, Shrank WH, et al. Eliminating Medication Copayments Reduces Disparities In Cardiovascular Care. Health Aff (Millwood). 2014;33(5):863-870. doi:10.1377/hlthaff.2013.0654
- Maciejewski ML, Wansink D, Lindquist JH, Parker JC, Farley JF. Value-Based Insurance Design Program In North Carolina Increased Medication Adherence But Was Not Cost Neutral. Health Aff (Millwood). 2014;33(2):300-308. doi:10.1377/hlthaff.2013.0260
- Morse S. UnitedHealthcare to pass drug rebates directly on to consumers. Health Care Finance. http://www.healthcarefinancenews.com/news/unitedhealthcare-pass-drug-rebates-directly-consumers. Published March 6, 2018. Accessed March 8, 2018.
- Staton T. Lilly's Trulicity joins pay-for-performance trend with Harvard Pilgrim deal. FiercePharma. https://www.fiercepharma.com/pharma/lilly-s-trulicity-joins-pay-for-performance-trend-harvard-pilgrim-deal. Published June 28, 2016. Accessed February 24, 2018.
- Claxton G, Rae M, Long M, Damico A, Foster G, Whitmore H. Employer Health Benefits 2017. Kaiser Family Foundation, Health Research & Educational Trust, NORC at the University of Chicago; 2017. https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/.
- Hibbard JH, Greene J. What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer Data on Costs. Health Aff (Millwood). 2013;32(2):207-214. doi:10.1377/hlthaff.2012.1061
- Center for Value-Based Insurance Design. Precision Patient Assistance Programs to Enhance Access to Clinically Indicated Therapies: Right Drug, Right Time, Right Cost-Share. Center for Value-Based Insurance Design; 2017. http://vbidcenter.org/precision-patient-assistance-programs-to-enhance-access-to-clinically-indicated-therapies-right-drug-right-time-right-cost-share/. Accessed March 8, 2018.


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Grief and Sleep: Coping with Insomnia After Loss
Learn why getting quality sleep is an important step in the grieving process and read tips for sleeping better during difficult times
Jun 9th, 2022 •
Grief is a complicated emotional reaction to loss or change that many of us have and will experience at some point during our lives. Because grief takes many forms, it can be hard to define.
Of itself, grief is not a mental illness, pathological condition, or personality disorder. Rather, grief is a completely natural emotional response that transpires differently in all people.
We experience grief when conflicting feelings caused by the end or change in a familiar pattern or behavior wage war over our emotional stability. This experience most commonly takes place after the loss of a loved one; however, we can also experience grief when a particular life stage comes to an end, such as, losing a job, ending a relationship, or moving to a new place.
Regardless of the cause, grief is a difficult emotion to grapple with. Oftentimes, grief feels "all-consuming" and infiltrates all aspects of daily life, including the hours we spend sleeping. Everyone grieves differently, but if your understand your emotions and the common ways grief transpires in certain people, you'll be one step closer to healing.
What Are the Stages of Grief?
While grieving, your emotions come in phases. Doctors have identified five common stages of the grieving process. These stages do not happen in a linear progression, nor will every person experience all five.
- Denial – a defense mechanism that temporarily assuages the rush of intense emotion. You commonly feel numb or think thoughts like "This isn't happening…" at this stage.
- Anger – facing the pain of your loss as reality sets in. Feelings of frustration and helplessness turn into anger.
- Bargaining – dwelling on what you could have done differently. Asking "If only…" and "What If…"
- Depression – beginning to understand the loss and what the impact it will have on your life. Feelings of intense sadness and loneliness are common in this stage.
- Acceptance – accepting the reality of your loss. Allows you to move forward.
Common Symptoms of Grief
Managing grief is extremely difficult. In some cases, bereaved people struggle to get a hold of their grief and develop prolonged grief disorder, also known as complicated grief. That's why understanding the common symptoms of grief can be extremely helpful for those in mourning.
There are physical, mental, and emotional symptoms of grief that are important to be aware of so you can identify if you develop complicated grief and get appropriate help if needed.
Emotional Reactions to Grief
- Agitation
- Anxiety
- Apathy
- Disbelief
- Guilt
- Helplessness
- Isolation
- Impatience
- Numbness
- Relief
- Sadness
- Shock
- Uselessness
Mental Reactions to Grief
- Obsessive thoughts over the loss
- Difficulty focusing
- Increased nightmares
- Self-destructive thoughts
Physical Reactions of Grief
- Disrupted sleep – too little or too much
- Changes in appetite
- Tiredness
- Muscle tension
- Headaches and stomach aches
- Weakened Immune System
All of these reactions are completely normal when grieving. However, if any become prolonged or go untreated, they can wreak havoc on your overall well being. One of the most important symptoms of grief to keep an eye on is sleep deprivation.
How Grief Affects Sleep
Troubled sleep is very common among individuals in mourning. In fact, many facets of bereavement contribute to sleep disturbance.
Some common reasons grievers might have difficulty sleeping include:
- Anxiety and stress over situations that have occurred as a result of the death
- Increased nightmares
- Anxiety about having bad dreams
- Racing, intrusive thoughts
- Trouble sleeping in the bed they shared with their partner
- The development of disorders like depression, insomnia, and PTSD that are common during grief
All of these conditions impact our ability to either fall asleep, stay asleep, or wake up, maybe all three.
Difficulty Falling Asleep
One of the most common sleep issues bereaved individuals face is difficulty falling asleep. Oftentimes, this insomnia is due to racing thoughts of loss or anxiety caused by stressors that have occurred as a result of the death (i.e. financial or parental stress). When anxious thoughts consume one's mind, it's nearly impossible to relax and fall asleep.
For individuals that have lost a spouse, the emptiness of the other side of the bed can trigger painful memories and difficult emotions that plague their ability to fall asleep. You can try rearranging the room, getting a new bed, or sleeping in another room of the house, but for many, the sense of sleeping beside someone transcends their bedding and the arrangement of the objects in their room. While adjusting to sleeping alone, you might allow your pet to sleep with you to assuage feelings of loneliness.
Difficulty Staying Asleep
Once you do fall asleep, it can be hard to stay asleep.
Many people experience an increase in nightmares and dreams of a lost loved one after their death. This may seem strange, but fairly it's normal. That's because emotional and cognitive processing occurs during the same stage of sleep dreams do, the deepest stage of sleep, called REM sleep.
Nightmares and dreams of a loved one can be difficult to handle or process. When those grieving see loved ones in their dreams or nightmares, it can be unsettling because such dreams do not provide closure. In some cases, especially in the case of nightmares, the negative emotions associated with the dream may wake you up. The regular occurrence of such dreams can eventually cause an anxiousness to sleep itself because you fear to relive those unsettling feelings again.
Sleeping Too Much
Grieving doesn't always mean you will experience insomnia or sleep deprivation. Sometimes excessive sleeping is common as well. Every person faces their grief in different ways; however, the amount and quality of your sleep is commonly affected and is symptomatic of grief. Some people actually sleep more, where people who are facing overwhelming emotions are often reluctant to get out of bed and face the realities of everyday life. Retreating to bed can be an escape when you are working through so many exhausting emotions, but often in these cases, the quality of sleep is still low.
Consequences of Sleep Loss While Grieving
Sleep deprivation is a nasty cycle for the bereaved because lack of sleep intensifies the symptoms of grief, making life even more difficult to manage.
Cognitively, sleep loss impairs the brain's ability to process memories and make sound judgments. Emotionally, losing sleep throws hormones out of whack increasing the likelihood of mood swings. Additionally, a lack of restful sleep weakens the immune system, making it more likely for the individual to fall ill. Finally, fatigue has an impact on emotional outlook. This can prolong one's ability to reach acceptance.
Because sleep loss while grieving poses such a threat to one's overall health and wellbeing, it's important to do everything in your power to protect your sleep when in mourning. Although this may feel impossible, there are a number of small adjustments we can make to our day to help prepare our mind and body for restful sleep despite the challenges against us.
Tips for Getting a Good Night's Sleep While Grieving
Avoid Self-Medicating
When struggling to get proper rest, our first solution tends to be self-medication. Whether they be over-the-counter sleep aids or another drug, many of these substances only make you sleepy enough to fall asleep, they don't actually improve sleep quality. Additionally, substances of this kind can lead to addiction and permanent changes in your sleep architecture when abused. Before using any type of sleep aid, talk to your doctor or opt for a natural remedy to sleep. In any case, sleep medication should only be used as a temporary solution.
Consider Cognitive Behavior Therapy
Cognitive Behavior Therapy (CBT) is a type of psychotherapy that challenges negative patterns of thought about the self and.or world in order to alter unwanted behavioral patterns or treat mood disorders like depression. This type of therapy is commonly used in grief counseling so the bereaved individual can talk through their negative emotions to uncover which ones are leading to unhealthy behavior, such as anxious thoughts and insomnia. Studies have found the use of CBT effective for improving sleep and daytime symptoms of insomnia.
Follow a Regular Sleep Schedule
As hard as it may be to fall asleep, it's important to try and keep a consistent bedtime each and every night. Keeping a steady schedule will help you get a more regular amount of sleep on a nightly basis. Do you best to avoid naps and caffeine during the day that makes it harder to fall asleep at night. We are creatures of habit. The more we stick to our bedtime the faster our body will learn to follow suit.
Craft a 30 Minute Wind Down Routine
As part of creating a sleep schedule, you should also consider crafting a wind-down routine you implement 30 minutes to an hour before bed each night. At the end of the day, our brains don't automatically shut down. Rather, they need to be primed for sleep. This is especially true for individuals struggling with anxious thoughts that keep the mind racing. Some of the best ways to power down before bed are drawing a hot bath, unplugging from all technology, dimming the lights, and picking up a book. This will help quiet and relax your mind for sleep.
Go for a Short Walk Daily
Try exercise as a natural remedy to sleep. Physical activity releases endorphins which help improve mood and physical well-being. Additionally, working out helps to physically tire your body so you can sleep better at night.
What To Do If You Can't Sleep
When you struggle to fall asleep or wake up in the middle of the night, here are a few tips from Dr. Robert Oexman, Sleep Medicine Specialist:
- If you wake, turn your alarm clock around and don't look at the time. This can increase anxious thoughts about the following day and how little time you have left to sleep.
- Lay still for 20 minutes. If after that time you aren't getting sleepy, get out of bed. You don't want your bed to be a place associated with restlessness.
- With the lights off (don't turn them on!) go into another room and pray, meditate, stretch, breathe, anything relaxing that may help relax you. Whatever you do, don't go to another room or the couch to sleep.
- When you begin to get tired, go back to your bedroom and try to fall back asleep. If that doesn't work, lay still for another 20 minutes and then repeat the above exercise. Repeat until you finally go back to sleep.
Keep in mind it can take 2-3 weeks of this type of discipline to be able to fall back asleep upon waking.
Although grief is a natural process that has to run its course, that doesn't mean you have to sit idly by and let it wreck you from the inside out. There are a number of ways to take ownership of your grief so you can stay healthy amidst your time of struggle. Sometimes the best way to do that starts in bed.


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Friends of Build Magazine – NW Home Interiors (Bend, OR)
In this episode, Leslie stops by to talk with Chris Smith of NW Home Interiors in Bend, OR. NW Home Interiors has 3 floors and over 20,000 square feet of furnishings along with complete design services. The designers are on hand every day to help you make the best selections to achieve your home's style. NW Home Interiors specializes in residential space planning, product specialization, and theme integration that creates a balanced home design focusing on comfort and style.
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Note Cards
card is reproduced in high resolution from original color paintings or graphite artworks so that every detail is carefully preserved. They truly are gifts of art suitable for framing, alone or as a set (as stated on the back of each card). I'm always pleased to receive feedback about my cards, but I feel compelled to comment about some of the compliments I hear most often, such as "They're too beautiful to send out... I want to keep them all for myself...I can't part with a single one." While these sentiments are nice, it is my hope that you will allow these cards to bring joy and a smile to your friends and loved ones, and serve as wonderful representations of you and your personal taste. So I ask you to please share them with others! And don't worry, I will continue to print your favorites along with new designs in the future. They are not investment art, so don't hoard your cards; instead, spread the happiness they bring!
Flights of Color
The Dance
The Duel
Wild Paint
White Night
Water Colors
Mountain Blue
Wild Turkey and Rye
Early Spring
Scissor-Tail Fly Catcher
White-Breasted Nuthatch
Black-And-White Warbler
Cedar Waxwing
Winter Companions
Majestic Prince
Quiet Pride
Original Art
Limited Edition Prints
Note Cards
YouTube Channel
Nancy Quinn
Wildlife Artist & Author


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+91 9445922333 email@example.com
Vaccinations should begin early in an infant's life and continue regularly throughout childhood and adolescence, to protect from diseases. Immune defenses keep us protected from harmful disease-causing bacteria, viruses and fungi.
Diseases (caused due to lack of vaccination) can be severe – even deadly – mainly for infants and young children.
Measles and Whooping cough are examples of how vaccine-preventable severe diseases could be. Measles is still a common disease in many parts of the world. It can cause pneumonia, encephalitis (swelling of the brain), and even death. Children are at the highest risk of complications, which, in severe cases, can cause death.
Benefits of Vaccination—
It is the first line of defense for every human. Vaccination is a process by which a person is made disease resistant with the help of vaccines. It stimulates the immune system, improving one's health. Vaccines work with the baby's natural defenses to help them safely build immunity to deadly diseases. Vaccines are a valid medical advancement that continues to save lives every day. They keep other children safe by eliminating or decreasing dangerous conditions that can quickly spread from one child to the other.
During and after pregnancy, the mother and her baby have a feeble immune system making them susceptible to diseases. Therefore, they must receive regular vaccines to keep their immunity up.
Sudden Infant Death Syndrome (SIDS) can occur between 2-4 months. These vaccines protect the mother and child from underlying illnesses like cough, cold, and fever to life-threatening diseases like hepatitis, measles, polio, mumps, tetanus and even diphtheria. Infant mortality in India is still at a shocking high – simple schedule of vaccination, however, can make a world of difference.
Studies show that following an immunization schedule, prevents about four million deaths every year, WHO states that available vaccines can prevent 20% of infant deaths annually.
Keeping track of immunizations
Most of the child's vaccinations are completed between birth to 6 years. Some vaccines are given more than once, at different ages, and in combinations. Keep a careful record of your child's shots.
Studies show that about two-thirds of preschool children are missing at least one routine vaccination. Therefore, it is imperative to make up for the missed immunizations.
We, as a community, can strengthen the foundation of a healthy childhood by supporting easy access to immunization where it matters the most.
Our team at EKAM Foundation can help with education about the right immunization schedule.
Log onto www.ekamoneness.org to connect and learn more.
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