For those of you wishing to have an online co-op mode for God of War III, sorry folks, the news is all false. Over the weekend, we reported abou…

By Scott M. Fulton, III, Betanews

The reason Windows Vista seemed slow, and somehow, strangely seemed even slower over time, is now abundantly clear to Microsoft’s architects: The evolution of computer hardware, particularly the CPU, exceeded anyone’s expectations at the time of Vista’s premiere in early 2007. But the surge in virtualization, coupled with the rise of the multicore era, produced a new reality where suddenly Vista found itself managing systems with more than 64 total cores.

Architects had simply not anticipated that the operating system would be managing this many cores, this soon — at least, that appears to be the underlying message we’re receiving here at PDC 2009 in Los Angeles. As independent scientists were speculating about possible performance drop-offs after 8 cores, server administrators were already seeing it. There were design tradeoffs for Windows Vista — tradeoffs in efficiencies that could have been obtained through complex methods, for simplicity.

Those tradeoffs were fair enough for the dual-core era, but that only lasted a short while. Quad-core processors are quickly becoming commonplace, even in laptops. So with Vista’s architecture, users could actually feel the lack of scalability. In fact, they were making investments in quad-core systems earlier in Vista’s lifecycle than originally anticipated, and they when they didn’t see four cores as right around double the performance of two cores…and later when they saw Vista’s lag times slow down their computers over time, some critical elements of Vista’s architecture became not an advantage but a burden.

Microsoft performance expert Mark Russinovich is one of the more popular presenters every year at PDC, mainly because he demonstrates from the very beginning of his talks that he absolutely understands what they’re going through. It’s difficult for a performance expert to put a good face on Vista…and Russinovich, to his credit, didn’t even try.

After having quizzed the audience as to how many used Windows 7 on a daily basis (virtually all of the crowd of about 400 people), Russinovich quizzed them, “How many people are sticking with Windows Vista because that’s so awesome?” He pretended to wait for an answer, and just before everyone’s hands had descended, he answered his own question: “Yea, that’s what I thought.

“One of the things we had decided to do with Windows 7 was, we got a message loud and clear, especially with the trend of netbooks, on top of [other] things,” he went on. “People wanted small, efficient, fast, battery-efficient operating systems. So we made a tremendous effort from the start to the finish, from the design to the implementation, measurements, tuning, all the way through the process to make sure that Windows 7 was fast and nimble, even though it provided more features. So this is actually the first release of Windows that has a smaller memory footprint than a previous release of Windows, and that’s despite adding all [these] features.”

To overcome the Vista burden, Windows 7 had to present scalability that everyday users could see and appreciate.

As kernel engineer Arun Kishan explained, “When we initially decided to be able to support 256 logical processors, we set the scalability goal to be about 1.3 – 1.4x, up at the high end. And our preliminary TPCC number was about 1.4x scalability on 128 LPs [logical processors], when compared to a 64 LP system. So that’s not bad; but when we dug into that, we saw that about 15% of the CPU time was spent waiting for a contended kernel spinlock.” What Kishan means by that term is, while one thread is executing a portion of the kernel, other threads have to wait their turn. About the only way they can do that and remain non-idle is by spinning their wheels, quite literally — a kind of “running in place” called spinlock.

“If you think about it, 15% of the time on a 128-processor system is, more than 15 of these CPUs are pretty much full-time just waiting to acquire contended locks. So we’re not getting the most out of this hardware.”

The part of the older Windows kernel that had responsibility for managing scheduling was the dispatcher, and it was protected by a global lock. “The dispatcher database lock originally protected the integrity of all the scheduler-related data structures,” said Kishan. “This includes things like thread priorities, ready queues, any object that you might be able to wait on, like an event, semaphore, mutex, I/O completion port timers, asynchronous procedure calls — all of it was protected by the scheduler, which protected everything by the dispatcher lock.

“Over time, we moved some paths out of the dispatcher lock by introducing additional locks, such as thread locks, timer table locks, processor control block locks, etc.,” Kishan continued. “But still, the key thing that the dispatcher lock was used for was to synchronize thread state transitions. So if a thread’s running, and it waits on a set of objects and goes into a wait state, that transition was synchronized by the dispatcher lock. The reason that needed a global lock was because the OS provides pretty rich semantics on what applications can do, and an application can wait on a single object, it can wait on a single object with a timeout, it can wait on multiple objects and say, ‘I just want to wait on any of these,’ or it can say, ‘I just want to wait on all of these. It can mix and match types of objects that it’s using in any given wait call. So in order to provide this kind of flexibility, the back end had to employ this global dispatcher lock to manage the complexity. But the downside of that, of course, was that it ended up being the most contended lock in most of our workloads, by an order of magnitude or more as you went to these high-end systems.”

In the new kernel for Win7 and Windows Server 2008 R2, the dispatcher lock is completely gone — a critical element of Windows architecture up until Vista, absolutely erased. Its replacement is something called fine-grained locking, with eleven types of locks for the new scheduler — for threads, processors, timers, objects — and rules for how locks may be obtained to avoid what engineers still call, and rightly so, deadlock. Synchronization at a global level is no longer observed, Kishan explained, so many operations are now lock-free. In its place is a kind of parallel wait path made possible by transactional semantics — a complex way for threads, and the LPs that execute them, to be negotiated symbolically.

But the threads themselves won’t really “know” about the change. “Everything works exactly as it did before,” Kishan said, and this is a totally under-the-covers transparent change to applications, except for the fact that things scale better now.”

Next: Speeding processes up by putting processors to sleep…

Speeding processes up by putting processors to sleep

Some of the design changes Windows 7 architects made may seem counter-intuitive on the surface — explained too simply, you might think they went the wrong direction.

For example, Mark Russinovich told the audience this morning, the new system is designed to increase the idle time for processors (both logical and physical), to make them latent for longer stretches. Sending processors fewer clock ticks is one way to bring this about. Why? “Timer coalescing means we minimize the number of timer interrupts that come into the system,” Russinovich explained, “so that the processors stay idle for longer, and then go into sleep states. And then tick skipping means that we don’t send timer interrupts to processors that are sleeping, so we don’t wake them up needlessly.”

In other words, keeping processors busy to reduce latency — one of the methodologies that we were told years ago would help Vista — actually reduces overall efficiency. Multicore processors work better when their logical processors (LPs) can be put to sleep, or “parked,” and their active threads shipped to another LP. Keeping LPs awake put more of a load on the scheduler, and all that scheduling chatter was a burden on Core 0, where all the scheduling activity used to take place — serially, one call at a time.

Here’s another counter-intuitive notion: It’s more efficient for a system to use as much memory as possible — not to fill it with data, necessarily, but to populate memory pages with something. In an illustration for his part of this morning’s workshop, Microsoft Distinguished Engineer Landy Wang showed a Windows 7 Task Manager panel where a machine with 8 GB of DRAM, running just a handful of regular processes, ended up with 97 MB free, or completely “zeroed.” And that was a good thing.

“A lot of people might think, ‘Wow, 97 megabytes doesn’t seem like a lot of free memory on a machine of that size,’ said Wang. “And we like to see this row actually be very small, 97 MB, because we figure that free and zero pages won’t generally have a lot of use in this system. What we would rather do, if we have free and zero pages, is populate them with speculated disk or network reads, such that if you need the data later, you won’t have to wait for a very slow disk or a very slow network to respond. So we will typically take these free and zero pages as we come across them, and pre-populate them with any files you might have read before, or executables we think you might run in the future — we will get that in advance, so you don’t have to wait when you click on something. It’s already in memory, but you shouldn’t take this low counter as implying that we’re using a lot of memory.”

Then Wang paused before adding, “We really are using a lot of memory, but we think we’re using it in a smart way that you really want us to be using it in.”

Microsoft’s Arun Kishan explained the page dispatcher lock, and its abolition in Windows 7, replaced by a more complex symbolic system of semantics that lets threads execute in a more parallel, efficient fashion in the end. Locks that never seemed to be a problem in the Windows XP era ended up being a serious obstacle for Vista in more than one respect, as Landy Wang explained: “As we go into higher and higher numbers of cores, the page frame number [PFN] lock was something that we had historically used for nearly 20 years to manage the page frame database array — a virtually contiguous, although it can be physically sparse, array.”

A page frame number entry describes the physical state of the page of memory, Wang reminded attendees — Is it zeroed out or free, is it on standby, is it active, is it shared, how many processes are communicating with it concurrently? “Basically all the data that we need about the page, such that we can manipulate it into a state transition into any other state that’s needed at any point in time. The size of this array is critical, as well as how to best manage the information.”

On a 32-bit system with 64 MB, at 4K per page, that’s about 16 million pages. Each PFN database is 28 bytes each, fitting into a 32-byte segment, for a total database size of 450 MB of virtual address space. “You would think that’s a fairly cheap price, a cheap tax to pay. It’s definitely below 1% of the physical memory in your machine, so you would think this is pretty good. But for us it wasn’t enough, because we realized that while the physical cost is cheap, the virtual cost is high.”

As was the case with the page dispatcher lock, Windows 7 architects had to do away with certain other methodologies that were implemented for simplicity in Vista, but which failed as workloads increased and cores multiplied.

“The problem with the PFN lock is that the huge majority of all virtual memory operations were synchronized by a single, system-wide PFN lock,” remarked Microsoft’s Landy Wang. “We had one lock that covered this entire array, and this worked…okay 20 years ago, where a four-processor system was a big system, 64 MB was almost unheard of in a single machine, and so your PFN database was fairly small — several thousand entries at most — and you didn’t have very many cores contending for it.”

But more operations and data structures were tacked onto the PFN lock; at the same time, the number of cores and memory in systems ballooned to proportions that engineers had originally planned for something closer to 2016. That increased the pressure on global locks…and it was in Vista where these old architectures began to fail. It was here where Wang presented an astounding statistic that surprised no one in the room who dealt with this subject personally — it confirmed what they already knew:

While spinlocks comprised 15% of CPU time on systems with about 16 cores, that number rose terribly, especially with SQL Server. “As you went to 128 processors, SQL Server itself had an 88% PFN lock contention rate. Meaning, nearly one out of every two times it tried to get a lock, it had to spin to wait for it…which is pretty high, and would only get worse as time went on.”

So this global lock, too, is gone in Windows 7, replaced with a more complex, fine-grained system where each page is given its own lock. As a result, Wang reported, 32-processor configurations running some operations in SQL Server and other applications, ended up running them 15 times faster on Windows Server 2008 R2 than in its WS2K8 predecessor — all by means of a new lock methodology that is binary-compatible with the old system. The applications’ code does not have to change.

We’ve said before that, for the end user’s intents and purposes, Windows 7 “is ‘Vista Service Pack 3.’” But in these critical departments of architectural change, where concepts dating back as much as two decades ended up faltering in Vista were scuttled for seemingly complex but more efficient replacements — ideas that two years ago may have been considered for 2015 — make the new operating system more like Windows 9.

However, we know that processor power and virtualization will only continue to explode, and to magnify each other’s magnitude. So the huge changes under the hood for Win7 may actually end up being stopgap measures, before the onset of a time when more drastic sacrifices will be considered.

Copyright Betanews, Inc. 2009

Guest book review by Peter J. Wolf

There’s little doubt that we Americans love our pets. According to the American Pet Products Association, we’ll spend an estimated $45.4 billion on our non-human dependents this year alone. And what do we get in return? Well, that’s not so easily put into dollars-and-cents terms. The value our pets bring to our lives is, of course—both literally and figuratively—immeasurable. Thankfully, we have authors like Ingrid King to remind us of this fact.

In Buckley’s Story: Lessons from a Feline Master Teacher, King introduces us to Buckley, a tortoiseshell cat rescued from a farm in southwest Virginia who’d become the office cat in the veterinary hospital King managed. Despite her rough and tumble past—or perhaps because of it—Buckley took to her new life with great enthusiasm (though not without some of the expected “tortitude”). “Buckley loved everyone,” writes King. “She checked out anyone who came into the office and, with rare exceptions, she would end up in a visitor’s lap.”

When King left to start her own business (using Reiki on pets), she was astonished by how much she missed her office buddy. “While there had been animals I had come across in my years of working at veterinary hospitals who had tugged at my heart strings,” King writes, “there had not been one that I fell for as hard and as fast as I fell for Buckley.” And so, despite her misgivings about integrating a new cat into the quiet home she shared with her cat Amber, King adopted Buckley.

Amber and Buckley, it seems, knew all along that it was the right move. “I was the only obstacle,” recalls King, a self-proclaimed worrier, “in making the process go smoothly.” While King was getting settled into her new career, the cats were getting settled into their new lives together. But their easy existence was interrupted when, during a routine visit, Buckley’s vet discovered a heart murmur.

Such diagnoses—however unsettling for us humans—seldom mean much to our cats. Indeed, Buckley was thriving with her new family. “The word that probably defined Buckley more than any other,” writes King, “was ‘joy.’”

“She was a joyful being and she brought joy to everyone who came into contact with her… Her entire being was an expression of joy, and her every activity was infused with the essence of joy. She played, ate and loved with abundance… Buckley demonstrated to me how to find joy in every day. By living in the present without worrying about the future or letting thoughts of the past drag her down, this little cat showed me how to find the small joys in each moment.”

Finding those small joys proved increasingly difficult as Buckley’s health took a turn for the worse, and King began devoting more and more time to caring for her. The last few chapters of the book, in which King chronicles Buckley’s decline, are to be savored—though not without a fresh box of tissues at the ready.

•     •     •

There’s something rather magical about certain pets, the ones with which we form an immediate, intense connection. Regardless of how much time we spend with them, they leave an indelible impression. Buckley had been with King for only three years, but, writes King, “I was not prepared for the depth of my grief… it was as deep as if she had been with me my whole life. When these special animals come into our lives and then leave us much too soon, they leave us forever changed.”

Buckley’s Story is sure to resonate with animal lovers, whether they’ve suffered the loss of a beloved pet or not. King’s memoir illustrates the powerful nature of the human-animal bond, and—in sharing Buckley with the rest of us—reminds us of what we love in each of our own cats.

For more from Ingrid King, check out her website and her blog, The Conscious Cat.

BONUS GIVEAWAY: Enter to win a copy of Buckley’s Story!

Ingrid is offering a copy of Buckley’s Story to one lucky Moderncat reader! To enter, please leave a comment on this post. The winner will be chosen in a random drawing on November 24. One entry per person. This giveaway is open to US addresses only.

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This week we will be confronting a fact that, by definition, haunts the average online dater: no matter how much time you spend polishing your profile, honing your IM banter, and perfecting your message introductions, it’s your picture that matters most.

We’re going to look at how your […]

Check this out! It’s my custom cat portrait from CZM! Left to right, we have Flora, Mackenzie, Ando, Sophie, Simba, and Dazzler. I absolutely love it!

And now you can get some of CZM’s fabulous cat art on all sorts of cool products through her online store at Zazzle. There are tons of shirts to choose from (both long- and short-sleeve), plus hoodies, baby apparel, aprons, mugs, neck ties, mouse pads, greeting cards and lots more! So many great holiday gifts for the Moderncat lover!

In a recent study published in Psychological Science, the somewhat logical has been discovered: thinking of a loved one eases physical pain. The study’s co-author Naomi Eisenberger, assistant professor of psychology at UCLA, explains in LiveScience:

This changes our notion of how social support influences people. Typically, we think that in order for social support to make us feel good, it has to be the kind of support that is very responsive to our emotional needs. Here, however, we are seeing that just a photo of one’s significant other can have the same effect.

Using psychological support to ease pain is a natural approach anyone can adopt, reaffirming the importance of love in our lives.  I imagine even the love of a pet can substitute when human relationships go awry.

We were just talking about some indie filmmakers who were happy with the extra attention they’ve been getting from having their movie “leaked” on BitTorrent, and ChurchHatesTucker alerts us to another story of filmmakers embracing file sharing. This one is actually from a few weeks ago, but a Swedish filmmaker made a low budget indie film called Nasty Old People and released it under a Creative Commons license, along with a request for donations. The link is to Metafilter where there’s an interesting discussion about whether or not the experiment is a “success” or a “failure.” It’s a bit of a mixed bag, as at the time of the discussion, the filmmaker had made back 20% of the film’s budget and there were questions if it would get much higher. Thus, it was easy for some to quickly call it a clear failure.

Of course, it’s not really that simple. First, I’ve said for years that I’m no fan of “give it away and pray” business models, which really aren’t business models at all. While it works sometimes, it’s pretty much a crapshoot, and never strikes me as a real business model. So, on the whole, I’m not too surprised that it didn’t bring in much more than 20% of its budget in 2 weeks (though some compare it to blockbuster movies that can often make about the same % of their budgets in the early going.

However, if we compare this situation to what would have happened otherwise (i.e., if the movie were not released this way) the situation becomes a little more interesting. This was a very low budget indie film that likely would not have received any distribution at all. At best, the filmmaker perhaps could have self-printed DVDs, and would have been lucky to have sold a dozen or two. She could have tried to enter it into various film festivals, but that’s quite difficult, and even then there’s a pretty good chance that the movie doesn’t end up actually making any money. Yet, in this case, she not only made money from donations, but the film is getting picked up and shown in theaters around the world. So, compared to that situation, things actually look better than the alternative.

On top of that, while this particular movie may have been a net loss, she could use it for marketing herself. She can go around and show the movie to others, and perhaps use that to get funding for a larger scale project or another film that’s released with a bit more of a complete business model. Nasty Old People becomes marketing and a promotion for Hanna Skold. It has to be better resume filler for a filmmaker to talk about tens of thousands of people downloading and watching your film than just going in cold saying you want to make a film. And, in fact, she’s already hard at work on a new film script, with many people who became fans of Nasty Old People following along and interested in seeing what the new script is like. So, as a marketing tool, it sure seems like giving this movie away has been quite useful.

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Remember that whole Sidekick data loss incident? Well, it seems as if T-Mobile is looking forward to putting it behind them as we’ve just received a statement saying:

“T-Mobile is pleased to announce that Sidekick sales have resumed. New pricing for the Sidekick LX 2009 will be $149.99 with a two-year contract and the Sidekick 2008 will be $49.99 with a two-year contract.”

But after everything that happened, and heck, all the new hotness available, is anyone going to be picking up a Sidekick anytime soon?

The homebrew coders from the Hotelsinus Sound Design is back to release a new version of TonesynthDS, a matrix-based synth sequencer for the Nintendo …

Beginning in 2003, shortly after notorious former governor of Illinois Rod Blagojevich took office, the Illinois prison system effected a change in the diet fed to their inmates.  Hand-in-hand with agricultural giant Archers Daniel Midland – the illinois prison system converted the diet of prisoners to one with grossly high levels of soy – upwards of 100 grams a day (read more about the soy prison case).  Earlier this year, a group of sickened inmates filed a lawsuit seeking to stop the serving of soy as a primary protein source in Illinois prisons.  Since that time, numerous sickened prisoners have come forward – some have even been subject to retaliation by prison staff for their action.

The prisoners began to see the effects of the diet slowly, at first, but the results of the diet have grown ever more dramatic.  First, the inmates suffered from gastrointestinal upset which progressed to extreme distress and eventually to serious health concerns including thyroid disease and other issues.  The prison system’s response to the  prevalent illness showed a complete disregard for the health of the inmates that were clearly suffering due to the toxic levels of soy protein isolate included in their food.  Indeed, excessive consumption of soy isoflavones is linked to wide and varying health problems.  The FDA lists well over 200 studies illustrating soy’s toxic effects on health; yet, despite these clear contraindications to a diet so high in soy, the prison system in Illinois continued to provide a diet in which many foods contained 60-70% soy protein isolate.

The Weston A Price Foundation – a not-for-profit organization devoted to the cause of nutrition and wellness – is championing the case of the Illinois prisoners.  It is, in effect, the first battle ground as the State of Illinois has plans to institute similar soy-based diets into other public institutions – including public schools.  Sally Fallon Morell, founder and current president of the organization, refers to the case as “the Tuskegee of the 21^st century.”  Indeed, the two cases share some striking similarities – namely the systematic exploitation of a marginalized population by government.

You can view videos from the press conference below:

Photo credits and Videos.

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More from Nourished Kitchen

Looking for grass-finished beef or wild-caught fish? What about that exotic sourdough starter you’ve been after? Or water kefir grains? Check out the Nourished Kitchen Where to Buy List that outlines great companies that sell or support real and traditional foods.

Don’t forget: I’m not a doctor, I’m a mom who loves preparing wholesome, natural foods for her family and I enjoy sharing our reasons in choosing these nourishing foods. Read the disclaimer and advertising/link policy and the privacy policy.

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Sandra Colbert sits propped up in a hospital bed at Gundersen Lutheran Hospital in La Crosse, Wis., connected by tubes to oxygen and IV fluids. Doctors have told her she didn’t have a heart attack. But it sure felt that way when she collapsed at the gym a few hours earlier. “It felt like my heart exploded,” she says, then adds. “I thought I was going to die.”

She’s not going to die, the doctor reassured her. But now nurses are asking her to think about dying. Or, more specifically, they’ve asked her to fill out a living will.

It might seem almost rude to ask a woman who just a few hours ago had reason to fear she was about to die — but who now knows she’s OK — to think about how she does want to die some day. Yet it’s a routine question in this Midwestern city on the Mississippi River.

The specially trained nurse, in this case a woman named Laura Wiedman, will spend more than an hour with Colbert — and her husband Jim — and help them both think through the treatment they’d want at the end of life.

Respecting Choices

Wiedman takes out a 12-page document and goes through the questions: Who do you want to make health care decisions for you if you can’t make your own? If you reach a point where it is reasonably certain you will not recover your ability to interact meaningfully with friends and family, do you want tube feedings, IV hydration, a respirator, CPR and antibiotics?

These are complicated questions. It’s something that the Colberts — like most adults in this country — have put off. But after Sandra’s scare today, and Jim’s hospitalization with a head injury this summer after he fell off an electric bicycle, it’s something they both know they need to do.

Sandra cries when she writes down that she wants each of her grandkids to speak at her funeral. But there’s more laughter than tears. Sandra says she wants Pink Floyd’s “Put Another Brick in the Wall” and Ricky Martin’s “Livin’ la Vida Loca” played at her funeral. Jim jokes that he’ll write down in his advance directive which of his daughters really was his favorite — a family joke among the girls.

The Colberts complete the directives and the nurse summons witnesses to watch them sign. Then Wiedman enters them in the health system’s computers.

Now, anytime a doctor in this large health system pulls up their records, their wishes for end-of-life care will be prominently displayed.

The result of all this attention is that nearly all adults who die in La Crosse, 96 percent of them, die with a completed advance directive. That’s by far the highest rate in the country. 

But it’s expensive to spend time with patients filling out living wills. Medicare doesn’t reimburse for the time the hospital’s nurses, chaplains and social workers do this. Bud Hammes, the medical ethicist who started the program, called Respecting Choices, says it costs the hospital system millions of dollars a year. “We just build it into the overhead of the organization. We believe it’s part of good patient care. We believe that our patients deserve to have an opportunity at least to have these conversations.”

And that’s how La Crosse unexpectedly got in the middle of the national debate over health care and the so-called “death panels.”

A New Standard Of Care

There’s a proposal — it’s in the health bill passed by the House of Representatives — that would pay for the kind of periodic and continued end-of-life discussions with patients that are routine in La Crosse. Gundersen Lutheran is pushing for it.

Hammes says claims that government-run panels would pressure sick people to die are bizarre exaggerations — and that the experience of this Wisconsin city proves it. “These are conversations that we have with our patients. They’re not done in a secret room,” Hammes says. “These are open conversations involving family members, pastors, attorneys. It’s part of our community fabric now, it’s part of how we deliver care.”

One result of the way that care is delivered: At Gundersen Lutheran, less is spent on patients in the last two years of life than any other place in the country.

Choosing In Advance

The Dartmouth Atlas of Health Care documents the vast difference in health care costs from one place in the country to another. At Gundersen Lutheran, the cost of care for someone in the last two years of life is about $18,000. The national average is close to $26,000. At one hospital in New York City, it’s more than $75,000.

“When people see the low cost in La Crosse, there are assumptions about rationing care, about denying care, about limiting — that we limit care for our patients,” says Hammes. But it’s not that dying people in La Crosse are denied care, he says. It’s that they’ve thought out their wishes in advance, so they get exactly the care they want. And often that means avoiding excessive and unwanted care.

When Hammes came to Gundersen Lutheran Health System as a clinical ethicist, he often found himself called in to help families who had suddenly found themselves in the middle of a health crisis. “When I asked these family members, ‘what would your Dad want,’ ‘what would your Mom want,’ ‘what did they say to you previously?’ The response was the same again and again and the response was, ‘If I only knew.’”

Hammes realized the shortcoming of the common practice of handing patients a living will. People didn’t fill them out. They gave up trying to figure out confusing issues like whether to withdraw a feeding tube — and when.

So Gundersen Lutheran started training its staff — as well as ministers, lawyers and others in the community — to help people understand — and make — those choices.

Hammes says the point is to help people make informed choices. Decisions made on the spur of the moment, in crisis, can lead to costly and unwanted care. If a patient’s wishes aren’t clear, the default choice of doctors and family is often to provide high levels of care — even when it’s something unhelpful.

But sometimes, getting a patient to think through choices can mean the patient decides he or she does want the most expensive care.

The Option To Change Your Mind

Joe Hauser, who used to run a TV repair shop, recently found out his kidneys are failing. His doctor told him he’s going to need dialysis, soon.

“I don’t want to go on dialysis,” he says, one recent morning as he takes his medicines with a glass of water at his kitchen table in the nearby town of Onalaska. “I don’t want to be tied to a stupid machine for 15 hours a week. My main thing is I don’t want to be a burden on anybody. I figure I’d love to live to be 150 as long as I can do stuff myself without depending on somebody else to do it for me. But once I get to I can’t do nothing, I’d just as soon croak.”

Joe’s wife, Janice, sits next to him and shakes her head. She wants her husband to go on dialysis.

“Maybe I shouldn’t say that,” says Janice, “but I’m being optimistic about it anyway.”

“See, good old Ma,” says Joe. “She would like to keep me around here as long as possible.”

“Well he’s right,” his wife says with an affectionate laugh. “Who else would put my eye drops in?”

So with some prodding from Janice, Joe recently talked to a nurse at Gundersen Lutheran about what it means to go on dialysis. Joe worried that once he started on dialysis, he wouldn’t be able to stop. That’s not how it works, said co-director Linda Briggs, a nurse in the Respecting Choices program.

Then Briggs invited Joe and Janice to visit the dialysis center and to drop in on a support group meeting, so they can talk to other patients.

Joe hasn’t taken up the nurse on that. He says he still doesn’t want dialysis.

But then there’s a surprise. He extends his left arm across the kitchen table. He wants to show what he calls his “buzzer.” It’s a spot at his wrist where you can feel the vibration from an artery and a vein that a surgeon has joined together.

It turns out that Joe Hauser’s decided to be ready, if he changes his mind. And if he decides he wants dialysis, then the needle of the dialysis machine can slip right in to that spot — the fistula — that the surgeon has prepared at his wrist.

And that gets to the point of why doctors and patients keep talking about end-of-life care in La Crosse: because choices are complicated. Because people’s feelings change about the treatment they want. And the best way to handle that is to know all your options, well in advance of a health care crisis.

Every morning at 10 a.m. sharp, Juanita Wood, 87, taps “okay” on a screen to start up a device that takes her blood pressure and transmits the information to her medical clinic. At 10:30 a.m., her husband, Arthur, 91, touch-starts his own device, neatly lined up next to hers. The machine calculates his blood pressure and weight and sends them off, along with a blood sugar count that he enters by hand.

The Woods, of Catonsville, Md., are participants in one of several pilot projects that home health-care providers, retirement communities and others are conducting to see if high-tech but simple devices can help doctors closely monitor aging patients at home. The goal is to help control problems before they escalate and cut back on the need for costly long-term care and hospital admissions – especially repeat hospital visits for chronic conditions.

Although proponents of health-care reform tout its potential for improving efficiency, often missing from the national debate are specific examples of how changes in the system might improve patient outcomes and reduce costs. These pilot projects are exploring some easy-to-use technology that might make a difference to patients and doctors.

“This helps us detect harbingers of a bad event for patients,” said William Russell, vice president and regional medical director for Baltimore County-based Erickson Retirement Communities, which is running the pilot program in which the Woods are participating. “Early detection systems are important because more often than not, elderly patients do not come out of hospital stays with a better outcome.”

Seniors and others with chronic health problems such as diabetes, congestive heart failure and high blood pressure often wind up in hospital emergency rooms after forgetting to take their medication or when their condition deteriorates at home without anyone noticing. When that deterioration is severe enough, patients can be forced to move out of their homes into assisted living or nursing facilities, a costly and emotionally wrenching transition. The hope is that by closely monitoring patients at home, some of these events can be avoided or managed better.

Medicare spends more than $12 billion a year on “potentially preventable” repeat hospital admissions, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress. And that number, according to the commission, is likely to grow, given that the Census Bureau projects that by 2025 there will be nearly 64 million Americans older than age 65, an increase of more than a third over today’s total.

The pilot projects are not designed to have doctors diagnose illnesses remotely or to substitute for hands-on care. Instead, they are intended to allow elderly or infirm patients to get ahead of changes in their chronic conditions that could tip them into a medical emergency.

Juanita Wood, a retired secretary, had some fainting incidents possibly related to blood pressure problems. She hopes that keeping track of her blood pressure and transmitting the readings to her clinic in real time will help her avoid future episodes.

So every morning she straps on a blood pressure cuff attached to her monitoring machine, presses a button to start it up and waits for the cuff to inflate. Her pressure is recorded and then transmitted to the clinic at Erickson’s Charlestown community, where the Woods live.

Arthur Wood, a retired architect, takes his blood pressure and weighs himself. Because he is a diabetic, he also is learning how to register his blood sugar levels, using a separate finger-prick device and then manually entering those numbers into his touch-screen unit. The Woods send in their information every morning, and employees at their clinic monitor the readings and alert them if something seems amiss, hopefully before anything major goes wrong.

The monitors that the Woods use are among a variety of devices being tested in the pilot programs. Others are simple scales, to monitor sudden weight gain, which is a warning sign for those with congestive heart failure. There are also motion sensors placed under a bed, to make sure a person has gotten up in the morning, and wall sensors that can tell whether a person is moving around the house normally.

The Woods’ devices feature a smallish computer screen that comes awake when a patient taps it, displaying his or her personal information. The device is set to blink with a blue light at the same time every morning to prompt patients to do their monitoring. There’s no log-in or complex system for the device, and each machine is programmed individually to deal with one patient’s specific medical issues.

The devices are built by Intel, which has been working to develop technology to bolster home health-care services. Last spring Intel and General Electric Healthcare announced they would jointly commit $250 million to develop wireless products to connect the patient to the physician. The companies are focusing on such products because of research showing that “more than 80 percent of health-care spending focuses on patients with one or more chronic diseases,” according to Louis Burns, vice president and general manager of the Intel Digital Health Group.

Right now, the biggest impediment to high-tech monitoring is that Medicare and private insurers generally do not reimburse for it. And the devices can be expensive. As part of a pilot project, Juanita and Arthur Wood get their devices for free; normally patients would have to pay about $100 a month to rent them.

Also, insurance plans typically do not reimburse doctors for treating patients based on data sent remotely, only for face-to-face care. Some patient advocates also worry that electronically conveyed data might be substituted for direct medical care, which the organizers of the pilot projects say is not the goal.
Instead, they say, the devices will allow doctors to accumulate data on a patient over time; this information can then be used in a face-to-face visit with the patient.

This approach allows the doctor to “spend more time with patients so they are able to plumb the depth of the patient’s problem,” Russell said.

And if the digitally sent data show that something may be going wrong, medical professionals can step in immediately rather than wait for the patient’s next routine appointment. “We set up thresholds, and anything above or below that, then the doctors get notified,” explained Kelley Gurley, project manager for the Erickson study. “If the blood sugar is low, the patient would receive a call [from the clinic] that says, ‘Please call your doctor,’ ” she said.

The device itself also is programmed to remind patients, in a friendly computer voice, about their medications and food consumption if a reading falls outside the parameters set by their doctors. In addition, a “Learn More” prompt on the touch-screen is linked to informational videos related to the data he or she has transmitted. If, for example, a blood pressure reading is high, the machine offers the patient the option of watching a short video in which a doctor explains how to bring the pressure down, such as by sitting down and relaxing for 30 minutes.

The device that the Woods use is known as the Intel Health Guide. Other companies, including General Electric, have their own home health monitoring systems. GE QuietCare is a sensor system most often used in assisted living and similar facilities to track patient activity.

Eric Dishman, general manager of Intel’s Research and Innovation Group, said these devices perform an increasingly important function: “You just can’t crank out enough medical students to solve our personnel shortage in this country. You need to rely on other means, especially technology, to bridge that gap.”

At their home one recent morning, Arthur and Juanita Wood were reminded by the flashing lights on their machines to start their monitoring process. The prompts were delivered by a female voice, which Arthur Wood noted was “sweet,” adding, jokingly, “But I love it when she says goodbye.” Because then it means he’s done for the day.

The latest episode of a great of web radio show, Family Life Behind Bars, focuses on the job search after incarceration, and includes two guests who offer important perspectives on the topic.

David Koch — a pilot, business owner and author — served two years in prison before beginning his career in 1980 at the bottom rung, mowing lawns and cleaning floors at a flight school. He offers some clear and actionable advice to newly released prisoners, but he doesn’t mince words — he’s such a believer in self-determination that he almost denies the challenges are there. He says that the stigma of a felony conviction exists in the felon’s mind more than it does in society. He recommends that newly released prisoners take “jobs that nobody wants” or volunteer their time to help others and get their foot in the door. I’m not sure if he’s offering sound advice or living in a fantasy land.

From the other end of the spectrum, guest Aric Coleman was freed last month in Michigan after serving seven years in prison. He’s struggling to find a job, and he says he sees the stigma against hiring felons as real in society, but then agrees with Koch that it must first be conquered within oneself.

Listen to the podcast here.

(more…)

Hey guys and girls, I am sure you may have caught the news from last week about supposed integration of PS3 and your Facebook account (leaked picture) and this evening Sony Computer Entertainment has confirmed its entrance into social media. Though you won’t be able to get full functionality of your Facebook management (like updating your status), Sony says the first baby steps of integration will be available this Thursday Wednesday under new 3.10 firmware update. Check out video below for a walk through.

From PS3 Blog:
Hi everyone, here’s an early peek at PlayStation 3 (PS3) firmware update (v3.10). The latest update incorporates Facebook into the PS3 experience. By linking your PlayStation Network account to your Facebook account, you will have the option for the PS3 to automatically update your Facebook News Feed with Trophy and PlayStation Store activity. This update also enables developers to set specific criteria in their titles to publish additional game information to your News Feed. You can then check out your updates, and those of your friends, on Facebook, Twitter, and other social media favorites through the PS3’s built-in web browser.

This is just the beginning of our integration with Facebook and we are looking forward to adding new features enhancing the experience in future updates.

Additional highlights from update 3.10 include:

* The Photo category on the XMB has been revamped to make it easier to see more of your photos stored on the PS3.
* The PSN Friends List has been modified based on feedback we received after update 3.00. Additionally, you can now choose a color for your PSN ID on the XMB.

So this is kind of cool. It’s a NAS that uses 2.5″ hard drives, making for a much smaller form factor. In fact, it’s about the size of a standard USB hard drive enclosure.

The Thecus N0204 will use either HDD or SSD drives, with a maximum capacity of 1TB. Due to the fact that the NAS only has two bays, you are of course restricted to RAID 0, 1, or JBOD. The best part? The price. The Thecus N0204 retails for just $150; you’ll have to provide your own drives, though.

The Thecus also functions as a print server, which could be handy. It’s compatible with both Mac and PC networks and will work with Wi-Fi orGigabit LAN via the ethernet connection on the back of the unit.

[via Legit Reviews]

The “de-make” is a class of indie game where a popular new game is crushed into a low-fidelity environment; we’ve seen D-Pad Hero, Gang Garrison II (my favorite), and a whole competition based on the idea over at The Independent Gaming Source.

The latest victim of this ridiculous trend is Left 4 Dead, which has apparently been recreated in loving 8-bit fashion by one Eric Ruth. It’s worth mentioning that it had an even more deconstructive de-make in Left 4k Dead, but this one is more extensive. Would it be too much to ask to make a zombie version of River City Ransom?

The game, about 30% done at this point, will be released to PC gamers in early January and will comprise all four missions from start to finish, with special infected and everything. So awesome.

[via 1up]

Heads up to all PlayStation 3 owners! Sony has just revealed some more details about the upcoming PS3 firmware update version 3.10 which is scheduled …

We’ve been receiving multiple reports that BlackBerry Internet Service, or BIS, is down for many people — possibly worldwide. Initially, we thought the outages were only affecting certain carriers, but users from multiple carriers have reported a service interruption for what seems to be a few hours now. Naturally, we’ll keep you updated as we receive more news, but for now we’re not quite sure what’s causing this outage as it seems to be possibly affecting BlackBerry users on a global scale and we have numbers of around 75-80% in terms of users affected. Is there anyone out there currently experiencing data issues? Let us know in the comments!

We’ve discussed how the UK is used for “libel tourism” quite frequently, since its libel laws are more draconian than elsewhere. Thus, if someone is upset about what someone else has said about them, they’ll often file a lawsuit in the UK, arguing that because the content is available online, it’s been “published” in the UK. Thankfully, the UK courts have been a bit better about cracking down on these sorts of cases when they’re obviously frivolous. In one recent case, the court rejected the claim by noting that there was little evidence many people in the UK saw the article, which was published in a South African publication. Specific evidence over how many UK readers viewed that article were not provided, but log files showed that only a grand total of 65 readers viewed the article at all over the 2 months following publication (so you could even say that if all 65 were in the UK, the “damage” was pretty limited). But, the publication did show that its site normally gets about 6.79% of its visitors from the UK, which would translate to about 4 UK visitors — not nearly enough to prove “publication” in the UK. It’s good to see the UK courts being a bit more careful about these things, though it would still be much better if the UK updated its outdated libel laws to avoid this kind of lawsuit altogether.

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