text:
1Department of Surgery, University of Pittsburgh, USA
2Department of Psychology, University of Pittsburgh, USA
3Department of Surgery, Psychiatry and Psychology, University of Pittsburgh, USA
Submitted date: October 25, 2018; Accepted date: December 24, 2018; Published date: December 31, 2018
Background: The aims of the study were to examine if living donors followed the recommended UNOS medical visits postsurgery examinations and to assess if medical outcomes after donating a kidney were different by insurance status.
Methods: Data was collected from the medical records of 680 consecutive living kidney donors between January 2010 and June 2015.
Results: Significant predictors of having health insurance included higher levels of education (p=0.007) and being married (p=0.031). Post-surgical visits were lower for those without insurance at six months (43% versus 77%; p=0.029) and one year (35% versus 77%, p<0.001) than those with insurance. A robust trend was observed whereas lack of health insurance was predictive of higher systolic blood pressure (p=0.05). Significant predictors of higher systolic blood pressure included being older (p<0.001), male (p<0.001); and non-Caucasian (p=0.012). Significant predictors of higher diastolic blood pressure were being male (p<0.001) and non- Caucasian (p=0.020); and prior drug use (p=0.003).
Conclusion: Development of interventions to improve postsurgical follow up for kidney donors without insurance is warranted to potentially reduce poor health outcomes such as hypertension post kidney donation.
Insurance; Kidney donors; Outcomes; Postsurgical; Retrospective
ESRD: Endstage Renal Disease; CHD: Coronary Heart Disease; GFR: Glomerular Filtration Rate; UNOS: United Network for Organ Sharing; UPMC, University of Pittsburgh Medical Center
Fifteen percent of Americans are without health insurance and over 40,000 deaths per year have been attributed to lack of health insurance [1,2]. The uninsured are less likely to receive preventative care and access to quality care, resulting in poorer health outcomes and increased risk of mortality [2-4]. One explanation of increased risk of mortality is that those without health insurance are more likely to have treatable diseases diagnosed significantly later and have greater complications as a result of the delayed diagnosis [4].
Specific to the proposed study, the uninsured are at an increased risk of a delay in diagnosis of hypertension, which initially presents as asymptomatic [1]. To illustrate the asymptomatic nature of early hypertension, 25% of the general population who have been diagnosed with hypertension did not visit a physician within the last year [5]. Predictors of those who did not visit a physician in the last year included not having health insurance, low income, inadequate education, minority status and lack of access to care [5]. Keng and Sheu [6] found that Taiwanese elders with lower socioeconomic status who did not have health insurance benefitted significantly more from gaining health insurance than those who had higher socioeconomic status. Moreover, the Institute of Medicine [4] found that in areas where much of the population does not have health insurance, the access to medical care is poor for the entire community.
Living kidney donation has been found to result in better outcomes for the recipient when compared to cadaveric donation [7]. Common reasons for declination for living kidney donation have included renal function, hypertension, kidney anatomy and psychosocial reasons, but not for lack of health insurance [8,9]. For the majority of transplant centers in the U.S., living kidney donors are not required to have health insurance [10]. The Organization for Transplant Professionals [10] found that only 4% of transplant centers required donors to have health insurance prior to surgery. Dew et al. [11] found that approximately 18-25% of donors do not have health insurance. Gibney et al. [12] theorized that lack of health insurance may impact the frequency of medical follow-up after surgery and therefore complications associated with donation may be less likely identified early, particularly conditions that are asymptomatic such as hypertension. The United Network for Organ Sharing (UNOS) requires transplant centers to follow living donors for two years [13,14]. However, donors without insurance may not be able to pay for these follow-up visits and as a result some transplant centers offer no-cost follow up exams and laboratory testing for the first two years after donation [1,12- 14]. Nonetheless, donors may still have difficulties with the cost of the visit (e.g., gas, parking) even if the follow up testing and exams are of no charge to the donor. With increasing age and possible weight gain, donors are more likely to experience problems with high blood pressure after the two year follow up period [1]. Furthermore, some investigators have reported that living kidney donors may have difficulties obtaining health insurance post-donation despite limited complications associated with living donation [11,12,15]. As a result, those who chose to donate without insurance may be at risk for high blood pressure and End-Stage Renal Disease (ESRD) later in life without health insurance or the financial ability to treat these, or other medical conditions that are associated with hypertension [11,16,17].
Boudville et al. [16] found in a meta-analysis that kidney living kidney donors had a five-mm Hg average increase in blood pressure five years after surgery when compared to healthy controls. This average increase was defined as a six-mm Hg increase in systolic blood pressure versus a four-mm Hg increase in diastolic blood pressure for living kidney donors over five years [16]. Increases in blood pressure have been linked to an increased risk of mortality from coronary heart disease (CHD;18). Van den Hoogen et al. [18] found that for every tenmm Hg increment of increased systolic blood pressure or fivemm Hg increment of diastolic blood pressure, a 1.28 relative risk in mortality from CHD was observed. The SPRINT study team [19] found that maintaining a systolic blood pressure of 120 mmHg greatly reduced risk of cardiovascular disease when compared to maintaining a systolic pressure of 140 mmHg. Yet kidney donors without health insurance may be less likely to engage in annual preventive exams or be aggressively treated for high blood pressure [20]. Mehrotra and Kessler [21] found that for every 10% increase in health insurance coverage is linked with a 1.8% lower incidence of ESRD. With regard to donors, antihypertensive medicines were found to be the most prescribed medications to living kidney donors post-donation and more likely to occur if the donor had insurance [22].
The aims of the study were to examine sociodemographic differences between patients with and without health insurance. Then, we investigated the reasons for donor candidates to be excluded from surgery. Finally, we examined differences by insurance status on blood pressure, urine creatinine, urine protein, urine albumin, urine-albumin ratios, serum creatinine, and glomerular filtration rate (GFR) pre- and post-surgery. Finally, we examined the rate of return to the transplant center of primary care physician for follow up after donor surgery by insurance status.
The study is a retrospective medical chart review of longitudinal data concerning living kidney donors pre- and post-surgery.
A total of 680 consecutive living kidney donors from January 2010 to June 2015 who were evaluated at the University of Pittsburgh Medical Center (UPMC)'s Transplant Center were included in this study. Patients who were evaluated at a different transplant center and did not pursue surgery at UPMC were excluded.
Sociodemographic status and insurance data: We collected data on participants' age at time of the evaluation, gender, race, education, marital status, job status and number of children from the patients' medical chart. Insurance data was verified by a combination of scanned insurance cards on file, reported by social work or the medical team. Only insurance status (yes/no) was included for the purposes of this study.
Mental health and medical conditions: Both psychiatric diagnoses and medical conditions before and after surgery were collected from medical charts including the surgical, nephrology, social work, and psychiatric evaluations to account for potential reasons for declination from surgery.
Donor candidacy: The final documentation from the multidisciplinary selection committee decision was used to determine if the individual was approved for living kidney donor nephrectomy. Patients were approved for surgery or declined for surgery. Specific reasons for declining the candidate from surgery were recorded. Three patients who did not have a decision, for reasons such as nonadherence to evaluation procedures and were excluded.
Blood pressure
Both systolic and diastolic blood pressures in millimeters of mercury (mmHg) were obtained from the patients' medical chart prior to surgery, operationally defined as the highest pressure during the evaluation process. Post-surgical values were obtained from follow-up reports at 6 months, 1 year and 2 years after surgery.
Laboratory tests
Urine creatinine, urine protein, urine albumin, urine-albumin ration, serum creatinine, and GFR were obtained from the patients' medical chart prior to surgery. Post-surgical values were obtained from follow-up laboratory reports at 6 months, 1 year and 2 years after surgery.
This study was approved by the University of Pittsburgh's Institutional review board. This study involved a retrospective review of patient charts and all identifying information was removed prior to analyses.
Data analysis
All data was entered and verified on SPSS Version 22 (IBM Corp, Armonk, NY). Chi-square and Mann-Whitney U tests were performed to test between group differences by insurance status. Fisher's Exact Test was performed in cases when the number of patients in one subgroup was less than ten. Significant factors in the univariate analyses were then entered into a linear regression model to determine predictors of insurance status. Next, Mann-Whitney U tests were performed to examine the reasons for declination from surgery such as physical or psychosocial reasons as well as the laboratory values by insurance status. Lastly, systolic and diastolic blood pressure, urine and serum creatinine, urine protein, urine albumin, urinealbumin ratios, and GFR values were compared between donors with and without insurance before surgery and 6 months, 1 year and 2 years after surgery. Mann-Whitney U tests were used to examine factors were predictive of blood pressure and all laboratory tests. Bonferroni corrections were used on all analyses to address the multiple comparisons. Using the results from univariate analyses, significant factors were entered into a mixed model linear regression to determine if the changes in blood pressure were significantly different between those with and without insurance after adjusting for significant predictors of systolic and diastolic pressure.
Demographic characteristics of potential living kidney donors and health insurance
Of the 680 participants evaluated for living kidney donation, a total of 263 of the potential living kidney donors were male (39%) and 419 (61%) were female. The majority of participants were Caucasian (89%) and African American (7%). Of all the living donors evaluated, 306 were approved for donation (45%), and 143 (21%) were approved but did not have surgery at the time of the analyses for reasons including but not limited to the recipient received a deceased organ or passed away, the surgery had not yet been scheduled, or donors was unable to identify a suitable caregiver. A total of 231 (34%) were declined for surgery. Three patients did not have a decision regarding if they should proceed with surgery and were not included in the analyses. Sample characteristics are presented in Table 1.
|Evaluated Patients (n=680)
|Patients who underwent surgery (n=306)
|Insurance (n, %)
|592 (87%)
|270 (88%)
|88 (13%)
|36 (12%)
|263 (39%)
|119 (39%)
|417 (61%)
|187 (61%)
|602 (89%)
|278 (91%)
|69 (10%)
|28 (9%)
|Age at Time of Evaluation
|Mean (S.D)
|42.9 (12.2)
|42.3 (11.1)
|Mean (S.D.)
|27.5 (4.6)
|26.8 (4.5)
|Initial SBP
|Median (IQR)
|126.0 (17.0)
|123.0 (16.0)
|Initial DBP
|Median (IQR)
|74.5 (14.0)
|74.0 (14.0)
|Alcohol Usage (n, %)
|473 (70%)
|226 (74%)
|207 (30%)
|80 (26%)
|Tobacco Usage (n, %)
|139 (20%)
|49 (16%)
|541 (80%)
|257 (84%)
|Drug Usage (n, %)
|31 (4.6%)
|13 (4.2%)
|649 (95%)
|293 (96%)
|Education (n, %)
|High school or below
|192 (28%)
|89 (29%)
|Some college and above
|488 (72%)
|212 (69%)
|Children (n, %)
|Have children
|268 (39%)
|120 (39%)
|No children
|401 (59%)
|183 (60%)
|Job status (n, %)
|549 (81%)
|261 (85%)
|Not employed
|120 (18%)
|44 (14%)
|Marital status (n, %)
|404 (59%)
|119 (39%)
|274 (40%)
|187 (61%)
Table 1: Sociodemographic characteristics of the sample.
There were 592 (87%) potential donors evaluated who had health insurance at the time of the evaluation and 88 (13%) who did not have health insurance. The participants' mean age was 42.9 (SD=12.2) with an average BMI of 27.5 (SD=4.6). Rates of substance usage for the potential donors included 473 currently consumed alcohol (70%), 139 currently used tobacco (20%) and 31 currently reported drug use (5%). The majority of the potential donors reported some college (72%), were employed (81%), were married (59%) and did not have children (59%). The majority of candidates were donating to family members (77%), friends (20%), and 3% of donors were non-directed donations. Potential donors had a median systolic blood pressure of 126 mmHg (IQR=17) and diastolic blood pressure of 74.5 mmHg (IQR=14) prior to surgery.
Characteristics of donors based on health insurance status
The Bonferroni correct p-value for this set of analyses was 0.005. Potential living kidney donors who did not have health insurance were significantly younger (Mann-Whitney U=34,405.5, p<0.001); more likely to be from a minority background (χ2=6.849, p=0.009); less likely to complete college (χ2=30.417, p<0.001); and less likely to be married (χ2=31.124, p<0.001). With the p-value adjusted, no significant differences with regard to insurance status based on alcohol use (χ2=1.674, p=0.196); drug use (χ2=0.293, p=0.588); tobacco use (χ2=6.518, p=0.011); BMI (Mann-Whitney U=26,766, p=0.676); employment status (χ2=5.434, p=0.020); or gender (χ2=4.423, p=0.035). The descriptive data are presented in Table 2.
|Has Insurance
|No Insurance
|n=592 (87%)
|n=88 (13%)
|n = 680
|Approved for Surgery (n, %)
|421 (71%)
|58 (66%)
|479 (70%)
|171 (29%)
|30 (34%)
|201 (30%)
|Gender (n, %)
|220 (37%)
|43 (49%)
|263 (39%)
|372 (63%)
|45 (51%)
|417 (61%)
|Race (n, %)*
|53 (9%)
|16 (18%)
|69 (10%)
|530 (90%)
|72 (82%)
|602 (89%)
|Age at Time of Donation*
|Mean (S.D.)
|43.8 (12.1)
|37.2 (11.8)
|43.0 (12.2)
|Mean (S.D.)
|27.5 (4.6)
|27.3 (4.7)
|27.5 (4.6)
|Initial SBP
|Median (IQR)
|126.0 (17.0)
|127.0 (19.0)
|126.0 (17.0)
|Initial DBP
|Median (IQR)
|75.0 (14.0)
|74.0 (13.3)
|74.5 (14.0)
|Alcohol Usage (n, %)
|417 (70%)
|56 (64%)
|473 (70%)
|175 (30%)
|32 (36%)
|207 (30%)
|Tobacco Usage (n, %)
|113 (19%)
|27 (31%)
|140 (21%)
|479 (81%)
|61 (69%)
|540 (79%)
|Drug Usage (n, %)
|26 (4.3%)
|5 (5.7%)
|31 (4.6%)
|566 (96%)
|83 (94%)
|649 (95%)
|Education (n, %)*
|High school degree and below
|145 (25%)
|49 (56%)
|192 (28%)
|Some college and above
|422 (71%)
|39 (44%)
|461 (68%)
|Children (n, %)
|Have children
|240 (41%)
|28 (32%)
|268 (39%)
|Some college and above
|343 (58%)
|58 (66%)
|401 (59%)
|Job Status (n, %)
|486 (82%)
|63 (72%)
|531 (78%)
|Not Employed
|99 (17%)
|22 (25%)
|Marital Status (n, %)*
|Not married
|215 (36%)
|59 (67%)
|274 (40%)
|376 (64%)
|28 (32%)
|404 (59%)
Indicates FET was performed.
*Adjust p-value with Bonferroni correction =0.005.
Table 2: Univariate analysis of potential predictors of insurance status.
Predictors of health insurance status
The Bonferroni correct p-value for these analyses was 0.006. Univariate analyses of significant group differences were performed and those without health insurance were younger in age (Mann-Whitney U=34,405.5, p<0.001), non-Caucasian (χ2=6.849, p=0.009), had a lower educational attainment (χ2=30.417, p<0.001), and were not married (χ2=31.124, p<0.001). After adjusting for all the significant predictors in a mixed model linear regression only higher levels of education (β=1.100; 95% CI, 1.358 to 6.640; p=0.007) and being married (β= 0.913; 95% CI, 1.087 to 5.712; p=0.031) were significant predictor of health insurance. These data are presented in Table 3.
|Standard error
|Odds Ratio
|Marital Status
|Job Status
|Current Tobacco
Table 3: Logistic regression analyses examining the predictors of health insurance.
Reasons for being declined for surgery
Those without insurance were more likely to be declined for psychosocial reasons (33%) than those with insurance (11%), χ2=11.773, p<0.001. Table 4 shows the physical and psychosocial reasons for being declined for living kidney donation. The majority of donors who were declined for physical reasons (85%) including hypertension (16%), obesity and weight issues (16%), risk of kidney stones (10%), cardiac issues (7.4%), structural kidney issues (6.9%), low GFR (6.1%), and risk/ current diabetes (6.1%). The most common psychosocial reasons for being declined were substance abuse disorders (6.9%), unmanaged psychiatric disorders (2.6%) and concerns about nonadherence (2.2%).
|Variable Has Insurance No Insurance Total
n=195 (84%) n=36(16%) n=231
|PhysicalReasons (n, %)* 173 (89%) 24 (67%) 197 (85%)
|Current/ undiagnosed HTN 34 (17%) 4 (11%) 38 (16%)
|Obesity/ weight issues 34 (17%) 2 (5.6%) 36 (16%)
|Risk of/ current kidney stones 16 (8.2%) 7 (19%) 23 (10%)
|Cardiac Issues 15 (7.7%) 2 (5.6%) 17 (7.4%)
|Kidney Structural Related Issues 15 (7.7%) 1 (2.8%) 16 (6.9%)
|Low GFR 13 (6.7%) 1 (2.8%) 14 (6.1%)
|Risk of/ current Diabetes 11 (5.6%) 3 (8.3%) 14 (6.1%)
|Non-Kidney GI/GU issues 8 (4.1%) 1 (2.8%) 9 (3.9%)
|Risk of/ Current Kidney Disease 7 (3.6%) 1 (2.8%) 8 (3.5%)
| COPD/ Respiratory 6 (3.1%) 1 (2.8%) 6 (2.6%)
New onset/ current Cancer 5 (2.6%) 1 (2.8%) 6 (2.6%)
Other medical reasons 9 (4.6%) 1 (2.8%) 10 (4.3%)
|Psychosocial Reasons (n, %)* 22 (11%) 12 (33%) 34 (15%)
| Substance abuse 10 (5.1%) 6 (17%) 16 (6.9%)
Unstable Psychiatric disorder 3 (1.5%) 3 (8.3%) 6 (2.6%)
|Nonadherence 4 (2.0%) 1 (2.8%) 5 (2.2%)
|Other non-medical reasons 5 (2.6%) 2 (5.6%) 7 (3.0%)
*p < 0.05; **p < 0.001 level
Table 4: Reasons for donors being declined from surgery.
Factors influencing pre-surgical blood pressure
The Bonferroni correct p-value for these analyses was 0.0125. Univariate analyses were performed and significant predictors of systolic blood pressure included male gender (Mann-Whitney U=7,545.50, p<0.001) and being older (r=0.166, p<0.001); and race (Mann-Whitney=5,008.0, p=0.011). Past drug use was not significant with the adjusted p-value (Mann-Whitney U=1,201.5, p=0.025) Significant predictors of diastolic blood pressures included male gender (Mann-Whitney U=7,035.0, p<0.001). Race (Mann- Whitney=4,751.5, p=0.049) and past drug use (Mann- Whitney U=1,243.5, p=0.035) were not significant with the Bonferroni correction.
Post-surgery blood pressure
Blood pressures were obtained at six-months for 219 living kidney donors (follow up rate=74%), one-year for 176 donors (follow up rate=66%) and two-years for 116 donors (follow up rate=66%). Follow-up rates were significantly lower for those without insurance at six months (43%) (χ2=5.203, p=0.029) and one year (35%) (χ2= 12.563, p<0.001) than those with insurance (77%, 69%). At two years, the follow-up rate of donors without insurance (53%) was lower than those with insurance (64%), but not statistically significant (χ2=1.778, p=0.204). These response rates are graphed below in Figure 1 based on levels of insurance. Pre-surgical and post-surgical follow-up systolic blood pressures and diastolic blood pressures were graphed by insurance status as seen in Figures 2 and 3 respectively.
A mixed-model linear regression was performed using factors that were significant in between-group analyses for the initial blood pressure including age, gender, race and drug use to compare the changes in blood pressure over the next two years (age was not included in the diastolic analysis as it was not significant in univariate analyses) by health insurance status. The results of this linear regression can be viewed for systolic and diastolic blood pressure in Tables 5 and 6 respectfully.
|Fixed Effect
|-9.839 to -5.603
|0.125 to 0.316
|0.984 to 7.811
|Drug use
|-9.951 to -0.001
|-6.902 to 0.083
Table 5: Mixed models linear regression of predictors of systolic blood pressure at 2 years post-surgery.
|Fixed Effect
|-6.155 to -3.522
|0.406 to 4.658
|Drug use
|-7.699 to -1.588
|-2.318 to 1.937
Table 6: Mixed models linear regression of predictors of diastolic blood pressure at 2 years post-surgery.
Significant predictors of systolic blood pressure included male gender, (β=7.721; 95% CI, -9.839 to -5.603; p<0.001); non- Caucasian race (β=4.398; 95% CI, 0.984 to 7.811; p=0.012); and older age (β=0.221; 95% CI, 0.125 to 0.316; p<0.001). Health insurance was found to be not a significant predictor of blood pressure although there was a robust trend toward significance after adjusting for these demographic variables (β=-3.409; 95% CI, -6.902 to 0.083; p=0.056). Current drug use did not significantly predict lower follow-up systolic blood pressure (β=-0.190; 95% CI, -2.318 to 1.937; p=0.861).
Significant predictors of diastolic blood pressure included male gender (β=-4.838; 95% CI, -6.155 to -3.522; p<0.001); non- Caucasian race (β=2.532; 95% CI, 0.406 to 4.658; p=0.020); and past drug use (β=-4.644; 95% CI, -7.699 to -1.588; p=0.003). Insurance status did not predict follow-up diastolic blood pressure after adjusting for these factors however a robust trend was observed (β=-4.976; 95% CI, -9.951 to -0.001; p=0.050). No significance was found for the potential interaction effect (p=0.850).
Post-surgery laboratory results
Univariate analysis for urine creatinine, urine protein, urine albumin, urine-albumin ratios, serum creatinine, and GFR only revealed significant differences between patients with and without insurance in one-week follow-up urine creatinine (p=0.032). A robust trend was also observed for one- week urine protein (p=0.09) and serum creatinine (p=0.057). However, with a Bonferroni corrected and an adjusted p-value of 0.008, no differences in laboratory values was observed between those with and without insurance. The kidney donors without insurance had higher levels of each of these lab values when compared to kidney donors with insurance. However, at 6-months, 1 year and 2-year follow-up no significant differences were observed between kidney donor with or without health insurance Table 7.
|Health Insurance
(Median, IQR)
|No Health Insurance
(Median, IQR)
|0.80 (0.20)
|0.9 (0.225)
|Urine Creatinine
|120.5 (128.7)
|163.25 (159.83)
|Urine Protein
|0 (9.23)
|8 (12.5)
|Urine Albumin
|0.40 (0.60)
|0 (0.6)
|Urine Albumin Creatinine Ratio
|3.5 (2.3)
|2.8 (1.4)
|Glomerular Filtration Rate
|All >40*
|All >60
|1 Week Post-Surgery
|1.2 (0.3)
|1.2 (0.5)
|Urine Creatinine
|102.45 (150.28)
|186 (95.55)
|Urine Protein
|9.5 (24.0)
|14 (16.5)
|Urine Albumin
|0.5 (1.1)
|0.5 (0.85)
|Urine Albumin Creatinine Ratio
|6.6 (8.9)
|4.3 (13.5)
|Glomerular Filtration Rate
|56.45 (15.74)
|57.9 (23.56)
|6 months Post-Surgery
|1.2 (0.3)
|1.3 (0.3)
|Urine Creatinine
|94.5 (126.4)
|72.25 (128.08)
|Urine Protein
|8 (13.68)
|6 (12.0)
|Urine Albumin
|0 (0.6)
|0.35 (0.8)
|Urine Albumin Creatinine Ratio
|5 (4.93)
|7.1 (12.76)
|Glomerular Filtration Rate
|60.16 (16.52)
|57.86 (18.61)
|One year Post Surgery
|1.2 (0.4)
|1.2 (0.3)
|Urine Creatinine
|93.45 (122.25)
|72.25 (128.08)
|Urine Protein
|6 (12.0)
|6 (12.0)
|Urine Albumin
|0 (0.5)
|0.35 (0.80)
|Urine Albumin Creatinine Ration
|4 (7.3)
|7.1 (12.78)
|Glomerular Filtration Rate
|60.61 (16.99)
|57.99 (19.32)
|Two year Post Surgery
|1.17 (0.23)
|1.19 (0.37)
|Urine Creatinine
|71.4 (125.5)
|79 (102.2)
|Urine Protein
|5 (12.0)
|7 (18)
|Urine Albumin
|0 (0.725)
|0.3 (1.1)
|Urine Albumin-Creatinine Ratio
|5.7 ()
|3.9 (2.88)
|Glomerular Filtration Rate
|59.71 (16.78)
|66.45 (21.95)
|All donors with insurance had a pre-surgical GFR >60 except for six donors who had a GRF 40, 45, 48, 56, 58 and 60
*Significant after adjusting p-value with a Bonferroni correction (p=0.008)
Table 7: Laboratory values pre- and post- surgery by insurance status.
In the U.S., access to and affordability of health insurance remains an important topic of debate [1,2]. A few potential links between lack of health insurance status and health include lower access to quality care and lower likelihood of going to a physician, which then may result in later diagnoses and poorer health [1-4,16]. Living kidney donors are no exception, as the incidence of living donor nephrectomy has increased with evidence of better recipient outcomes [7]. Despite the increase in living kidney donor surgeries, the majority of donor candidates are still not required to have health insurance in the U.S. [10,14]. Furthermore, living kidney donors may experience financial hardships as roughly 2-9% may have trouble acquiring health insurance post donation as the surgery may be considered a pre-existing condition [11]. While there has been research to suggest that living kidney donors may be at certain risks for increases in blood pressure as a result of surgery, limited research has been performed to examine the potential risk factors of longterm complications from kidney donation by health insurance status [11,16].
In the present single center study, we observed fewer patients without insurance prior to surgery (13%) than reported by Dew et al. [11] in a multiple center trial (18-25%). In our study, patients without health insurance were found to be significantly younger in age, which has also been reported by Fang et al as one of the predictors of insurance status [5]. Fang et al. [5] found that being from a minority background also was associated with lack of insurance. Although we did not observe this, donors from our transplant center were predominantly Caucasian Furthermore, Fang et al. [5] found that insurance status was indicative of whether or not a patient has visited a physician within the past year. These findings are particularly concerning for patients who have donated a kidney as the lack of insurance may risk a delay in diagnosis of treatable diseases such as hypertensions [5,16].
We then examined reasons for donors to be declined from donating a kidney. These reasons included hypertension, high BMI, risk of kidney stones, cardiovascular problems, structural kidney issues and substance abuse disorders, and the rates of which were similar to other studies [8,9]. In this study, we expanded these analyses to examine patient insurance status. No difference was observed with regard to insurance status and being declined, however those without insurance were three times more likely to be declined from surgery for psychosocial reasons, such as substance abuse and unstable psychiatric disorders. These results were similar to the general population, which indicated that those without insurance were more likely to need mental health treatment. In a survey conducted by the American Psychological Association in 2004, 87% of participants felt that lack of health insurance prohibits one from obtaining mental health care [23-25]. Specific to this study, the donors who were uninsured may not have sought psychiatric care and thus could have more untreated psychiatric problems when evaluated for donor surgery [24-26].
In order to examine potential short-term consequences to donors without health insurance, blood pressures and laboratory tests were analyzed and compared for living donors at baseline (pre-surgery), and at six months, one year and two years post-surgery. Furthermore, laboratory results were similarly compared for laboratory tests by donors with and without health insurance prior to surgery, 1 week, and 6, 12- and 24-months post-surgery. Insurance status was not found to be a significant predictor of follow-up systolic or diastolic blood pressure. However, there appeared to be a robust trend with systolic blood pressure being higher at two years post-donation for those kidney donors without health insurance. These findings may be an underestimate as there was a much lower response rate for those without insurance. We found that participants without health insurance had much lower follow up rates with the transplant center or their primary care physician post-surgery than those with insurance. Lack of follow-up could lead to later diagnoses of hypertension and potentially more complications from the disease, and thus careful monitoring of the blood pressure of those without insurance is warranted [5,12,16]. Furthermore, these results cannot be accurately compared to the five-year study conducted by Boudville et al. [16], as our analysis only encompassed only two years of follow-up.
Insurance status did not ultimately impact one of the most common complications from kidney donor surgery, high blood pressure, after adjusting for other significant predictors of hypertension [16,17,22]. However, the trend was robust and warrants further research specifically following donors over a longer period of time and with a larger number of transplant centers. High blood pressure may go unrecognized within a limited two-year period and necessitates longer monitoring [1,16,18]. For example, Van den Hoogen et al. [18] found a significant relative risk in mortality as a result of CHD comparing six worldwide populations related to blood pressure, but analyzed over a twenty-five-year period, suggesting a need for longer follow-up of living kidney donors. While it may be ideal to follow donors after surgery for longer periods of time to get a more definitive conclusion regarding the risks of donation based on insurance status limitations such as cost of follow up care, donor willingness to be followed, and limitations regarding the requirements for follow up by UNOS decrease the ability for donors and the transplant community to know the true risk of cardiovascular disease in living kidney donors [11,12]. Other limitations of this study include not examining other potential medical conditions such as end-stage renal disease, gestational hypertension and preeclampsia (in women), and gout and albuminuria that may develop in kidney donors [27,28]. While living kidney donation has significant benefits to the transplant recipient and even the donor [7], continued investigation of the short- and long-term consequences to health are warranted.


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Welcome to the Adult Numeracy Network!
This is an area for both non-members and members of ANN to get acquainted and to stay connected to each other. What is the Adult Numeracy Network (ANN)? We are a community dedicated to quality mathematics instruction at the adult level. We support each other, we encourage collaboration and leadership, and we influence policy and practice in adult math instruction.
The Adult Numeracy Network was formed by adult education practitioners at the first national Conference on Adult Mathematical Literacy in March 1994. Researchers, program administrators, government officials and others joined together to discuss the status of adult numeracy education and to determine future directions. The conference was co-sponsored by the National Council of Teachers of Mathematics (NCTM), the National Center on Adult Literacy (NCAL), and the Office of Vocational and Adult Education (OVAE) of the U.S. Department of Education (now OCTAE).
As practioners at the grassroots level, we formed the Adult Numeracy Network to continue the work initiated at the conference. We adopted a constitution and by-laws in 1995, at our first annual meeting.
Since its founding, the ANN:
- Conducted annual meetings with professional development in conjunction with the annual NCTM national meetings and in conjunction with the Commission on Adult Basic Education (COABE)
- Sponsored numeracy strands at COABE
- Co-sponsored the Adults Learning Maths (ALM) international researchers conference
- Became an affiliate of NCTM, COABE, and ALM
- Began publishing a newsletter, The Math Practitioner, for ANN members
- Obtained funding to enable adult ed math teachers, learners, and other stakeholders to participate in a national planning project for system reform
- Published A Framework for Adult Numeracy Standards: The Mathematical Skills and Abilities Adults Need to be Equipped for the Future
- Submitted a policy statement on numeracy to the National Literacy Summit Initiative
- Consulted with U.S. Department of Education, Division of Adult Education and Literacy, about a strategic plan for numeracy
- Published The Teaching and Learning Principles
- Testified before The National Mathematics Advisory Panel
- Provide grant money to support practitioner research projects for teachers
For more information about ANN, please visit our webpage at AdultNumeracyNetwork.org.
Hi All,
I want to repeat Brooke's invitation to get to know more about ANN - the Adult Numeracy Network. I'm the current president of ANN, was a math teacher in adult ed for about 15 years, and currently volunteer as a math teacher in a college transition program. I'm also a vice president at World Education and a trainer for Adult Numeracy Instruction (ANI), the math professional development offered through LINCS. Being part of ANN has connected me to math teachers and changes in math teaching over the past several years. The next ANN event is a pre-conference at COABE: Bringing Students to a Higher Level in Math. Please come if you can! We'll be focused on helping students build deep conceptual understanding through hands-on problem solving. We'll look at building mathematical thinking by asking effective questions, and we'll have a lot of fun working together. We'll hear from two math teachers who received practitioner research grants from ANN this past year - what questions they explored and what they learned. Also, stay tuned here as other ANN members introduce themselves and talk about their involvement with ANN.
Sally Waldron
Thanks for the reminder Brooke. I will get my $$$ (using decimal training) and membership application form to you.
For those unfamiliar with ANN, let me say that Brooke and her group are doing amazing things bringing adult math education out of the worksheet era and into active, lively and meaningful discussions and classroom activities. I'm a novice in the field, but the more I use ANN in the GED classroom, the more engaged and more successful my students are.
If you have the opportunity to work with Brooke and the ANN people in workshops or conferences, take it! You won't be sorry.
Greetings everyone! As Sally has suggested, please do come to Denver and our COABE preconference. Participants that have attended in the past always give our preconference high ratings.
This year we mark 20 years since we held our first preconference meeting on April 5, 1995 in Cambridge, Massachusetts lead by our first president and founder of ANN, Mary Jane Schmitt. It is with sadness that we will mark our 20th year without Mary Jane who passed away on January 25. We will be honoring her memory during our lunch time meeting. If any of you have memories or pictures to share please send them my way. Mary Jane would have loved this forum that Brooke has created for practitioners to share their triumphs and struggles in the field. It is important that we honor Mary Jane' legacy by moving the numeracy field forward and continuing the work she started 20 years ago.

subset: commoncrawl


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Why the lunatics are completely wrong Nov 29, 2019 7:39:54 GMT -5 beth likes this
Post by fretslider on Nov 29, 2019 7:39:54 GMT -5
From Not A Lot Of People Know That:
Environmental journalists and advocates have in recent weeks made a number of apocalyptic predictions about the impact of climate change. Bill McKibben suggested climate-driven fires in Australia had made koalas "functionally extinct." Extinction Rebellion said "Billions will die" and "Life on Earth is dying." Vice claimed the "collapse of civilization may have already begun."
Few have underscored the threat more than student climate activist Greta Thunberg and Green New Deal sponsor Rep. Alexandria Ocasio-Cortez. The latter said, "The world is going to end in 12 years if we don't address climate change." Says Thunberg in her new book, "Around 2030 we will be in a position to set off an irreversible chain reaction beyond human control that will lead to the end of our civilization as we know it."
Sometimes, scientists themselves make apocalyptic claims. "It's difficult to see how we could accommodate a billion people or even half of that," if Earth warms four degrees, said one earlier this year. "The potential for multi-breadbasket failure is increasing," said another. If sea levels rise as much as the Intergovernmental Panel on Climate Change predicts, another scientist said, "It will be an unmanageable problem."
I asked the Australian climate scientist Tom Wigley what he thought of the claim that climate change threatens civilization. "It really does bother me because it's wrong," he said. "All these young people have been misinformed. And partly it's Greta Thunberg's fault. Not deliberately. But she's wrong."
Apocalyptic statements like these have real-world impacts. In September, a group of British psychologists said children are increasingly suffering from anxiety from the frightening discourse around climate change. In October, an activist with Extinction Rebellion ("XR") — an environmental group founded in 2018 to commit civil disobedience to draw awareness to the threat its founders and supporters say climate change poses to human existence — and a videographer, were kicked and beaten in a London Tube station by angry commuters. And last week, an XR co-founder said a genocide like the Holocaust was "happening again, on a far greater scale, and in plain sight" from climate change.
Climate change is an issue I care passionately about and have dedicated a significant portion of my life to addressing. I have been politically active on the issue for over 20 years and have researched and written about it for 17 years. Over the last four years, my organization, Environmental Progress, has worked with some of the world's leading climate scientists to prevent carbon emissions from rising. So far, we've helped prevent emissions increasing the equivalent of adding 24 million cars to the road.
I also care about getting the facts and science right and have in recent months corrected inaccurate and apocalyptic news media coverage of fires in the Amazon and fires in California, both of which have been improperly presented as resulting primarily from climate change.
Journalists and activists alike have an obligation to describe environmental problems honestly and accurately, even if they fear doing so will reduce their news value or salience with the public. There is good evidence that the catastrophist framing of climate change is self-defeating because it alienates and polarizes many people. And exaggerating climate change risks distracting us from other important issues including ones we might have more near-term control over.
I feel the need to say this up-front because I want the issues I'm about to raise to be taken seriously and not dismissed by those who label as "climate deniers" or "climate delayers" anyone who pushes back against exaggeration.
With that out of the way, let's look whether the science supports what's being said.
First, no credible scientific body has ever said climate change threatens the collapse of civilization much less the extinction of the human species. "'Our children are going to die in the next 10 to 20 years.' What's the scientific basis for these claims?" BBC's Andrew Neil asked a visibly uncomfortable XR spokesperson last month.
"These claims have been disputed, admittedly," she said. "There are some scientists who are agreeing and some who are saying it's not true. But the overall issue is that these deaths are going to happen."
"But most scientists don't agree with this," said Neil. "I looked through IPCC reports and see no reference to billions of people going to die, or children in 20 years. How would they die?"
"Mass migration around the world already taking place due to prolonged drought in countries, particularly in South Asia. There are wildfires in Indonesia, the Amazon rainforest, Siberia, the Arctic," she said.
But in saying so, the XR spokesperson had grossly misrepresented the science. "There is robust evidence of disasters displacing people worldwide," notes IPCC, "but limited evidence that climate change or sea-level rise is the direct cause"
Science has served its purpose and is no longer in itself alarming enough:
The UN's Devastating Climate Change Report Was Too Optimistic


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The first edition of Gadi Mirrabooka was popular and sold out before I knew it. Sadly I had sold the last copy.
Fortunately, a further printing has been produced which is the same beautiful quality as the first edition.
We now keep a good stock of quality prints and can deliver on demand.
Helen McKay


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At the Tampa Top Acupuncture & Herbs LLC, we are here to serve you both body and soul. We will care for you with the entire spectrum of treatment, not only providing time-tested therapy from the ancient times but also modernized oriental medical remedies to maximize your well-being.
We are not only preventative, but we also want to see you restored with refreshed energy, a new outlook, and continous improvement. Our unique emphasis on integrative medicine can customize a specific treatment plan with acupuncture, herbs, holistic education, and regular follow-ups.
We also specialize in the most challenging issues for which Western medicine is limited, such as:
– Stress
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We do more than treat symptoms: we are about providing quality, patient-centered care.
Career and Experiences:
– Licensed as Acupuncture Physician in Florida. License Number: AP 3615
– Previous Director of Jacksonville Acupuncture & Herbs Clinic LLC.
– Studied Acupuncture at Florida College of Integrative Medicine, graduated Suma Cum Laude with Bachelor of Professional Health Studies and Master in Science in Oriental medicine.
– Worked as a Research Scientist for 17 years at Baylor College of Medicine, Howard Hughes Medical Institute in Houston, and Mayo Clinic in Jacksonville.
– Studied Molecular & Cell Biology at University of Texas in Dallas, graduated with Master and finished PhD program.
– Worked as a patent applicant in pharmaceutical company related to interferon and hepatitis B vaccine (C.J.), Samsung Group in South Korea.
– Graduated with B.S. in Biological Science in SungKyunKwan University in South Korea, Valedictorian among 5000 Graduates.


text:
esd has been executing successful campaigns for decades. We've developed a clear understanding of buyers and what motivates them throughout the buying cycle.
We aim to understand every detail of your business and customer. Working with a wide range of marketing tactics, we ensure your brand remains present in the consciousness of buyers.
We develop targeted messaging throughout each stage of the buying cycle, while simultaneously conducting analytical research that allows us to continually adapt for optimized results.
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A successful digital marketing strategy requires more than marketing optimization. Our integrated approach includes a social media strategist, web designer, researcher, copywriter and an analytics professional.
We forge elements of communication that are based on person-to-person contacts, with no technology other than a simple handshake.
Great video is the result of good planning and attention to detail. Our videographers—armed with the latest technology in lighting and broadcasting equipment—produce your video from start to finish.
The keys to executing a successful event are meticulous planning, hard work and an extraordinary team.


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title: cinderellacountry: united statesdirector: kenneth branaghrelease date: march 12th, 2015 (imdb link)
been anticipating the movie since its trailer released. although cinderella is not my fave story from disney, there's always something romantic and enchanting about a girl finding his man (or in this case, the opposite), isn't it? and also, richard madden. do i need to say a word?
warning, review may contain spoiler.
the movie; usually oversaturated movie made me dizzy. and this one is no exception. in some scenes it looks too bright for my eyes. but it really enhances the details and the dreamy-fairytale world it brings. so i guess it's a nice touch. it does look like a real-life fairytale though.
the casts; tbh, i come to see helena bonham carter! she's just, captivating. i really like her being casted as hairy dogfather, um, fairy godmother. it just so fresh. lily james looks like she's a real-life cinderella, and richard madden is as prince-y as he could bring the prince alive with such gorgeous set of blue eyes. and cate blanchett... a canon thought. if the prince saw the stepmother first, perhaps he'll pick her instead. because cate blanchett, 10/10 would bang.
the story; you know how it goes so it's kind of predictable. there's been some twists here and there but nothing too stand out. i wish there'd be some kind of maleficent moment, y'know. but nah. and some scenes are just a wee bit too exaggerated. to me, i feel like it was pretty lack of character depth so it gets kind of boring.
the fashion; here is where i just want to give the crews a standing applause. everyone seems to dress on point! there was no dull in their clothing even on the ordinary people's. i believe it has something to do with the saturation though. but, damn i want ella's wedding dress.
overall; i enjoyed the adaptation. i wouldn't say i'm an aesthetic lover but this pleases my ears and eyes so much. for the sake of curiosity, go watch. but don't except too much.
rating; 6.8 out of 10
have you seen it? what do you think about this movie?
can i interest you in some mist? it's homemade
little update in the past week:
// suddenly having this urge to learn spanish
// contemplating about the next red lipstick. bourjois personne ne rouge or mac russian red? or the classic ruby woo? thoughts?
// finally put on some header. kinda tacky looking. i think i'm going to move it to the sidebar but idk.
// spent weekend at home because bro fell sick. damn you, change of weather.
// finally put on some header. kinda tacky looking. i think i'm going to move it to the sidebar but idk.
// spent weekend at home because bro fell sick. damn you, change of weather.
hope you'll have a great weekend! x
Life Lately
life lately. in few words.
// lately i've been so fed up with social interaction. it's been too overwhelming to have conversation with people so i took a break from quite a number of social platforms and it eased me up a bit. still trying to figure out what is actually going on in my head.
// found an interesting note from a friend which translates "woman on PMS, if she run through a wall, it's the wall that apologizes." while it's hilarious, i can't help but totally feel connected in spiritual way. sometimes i couldn't help but feel like all those mood swings during PMS are ridiculous *cue facepalm*, but then it's the spur-of-the-moment's-moment which made it so adrenaline-y? (is that makes sense?) i'm trying to tame the beast. it caused many hassles lately fml
// movies i managed to watch lately: whiplash (too awesome for words. i was shaking after i watched it!), theory of everything (i found eddie redmayne's performance is moving and splendid), metallica through the never (dane dehaan tho), fury, penguins of madagascar, big hero 6, red riding hood, the raid, the raid 2, source code (it's a forever fave).
// excited for cinderella! my friend made a pretty cruel joke "can we imagine watching cinderella in 2015 and they show the wedding of ella and the price and it turns into the red wedding // the evil stepsister will stab the prince and be like yo the lannisters send their regards. bye." why, bruh. why.
other things:
go support onehundredandforty because they're all sorts of awesome!
that young and freelance life (still trying to step up my game)
of all runway to crash, zoolander 2 hits valentino. hard.
behold, my all time favorite flickr account.
corina nika's photos of the sea is always on point. (it's my current phone wallpaper at the moment!)
joining the bandwagon of promoting cat island. would you live there?
hope you'll have a great week!
Ode to My Father
title: ode to my fathercountry: koreadirector: youn jkrelease date: december 17th, 2014 (imdb link)
been so ecstatic about this movie eversince i saw its trailer in imdb. not only it features the cameo of one of my fave singer in korea, it's also a movie about father, in which i'm such a sucker of (taken, hello). so when the news came about its arrival in blitz indonesia, moreover it premieres on my birthday, i immediately set date to watch. but then i fell sick and due to circumstances i couldn't go to watch until the very end of february.
warning, review may contain spoiler.
the movie; it was so so good. damn. i haven't watch such beautiful and humble movie for so long. basically the story is about a boy which made a promise to his father to be a good head of the family in which he almost sacrifices everything and putting his family first. the whole movie has an interesting back and forth, future-past pace. so much lessons about life can be found here. i cried once or twice, i guess. but the movie also has so many happy and laugh-until-your-tummy-hurt moments. very interesting balance between the two.
the casts; i have seen some familiar faces among the casts and all i know they are great actors from south korea, so i have no doubt that this would be a great movie. and damn they pulled my heartstrings each time. i can relate in a weird way but i can also learn so much from them. also, all the kids' casts are cute cute cute!
the story; a humble, family story can easily be found in so many movies. also the hardships of a family member is such a common theme. but what made me think that the movie is special is how the male lead carry his character throughout the movie with all his determination and innocence. laso interesting to see how the characters around him shaped his life and making impact on his decisions, which later make impact on their life. it's amazing how he could achieve so much for his family but also never neglect his life despite the sacrifices he made. also the story is something that could related greatly by the korean people which have suffered so many loss and tried to re-build their life since war. it's an interesting insight to see their struggles, their take on life, the stark contrast on the younger vs older generation. i think the movie is great to take as a small window to the ordinary life of south korean people.
the fashion + setting; i think their consistencies to try to stay true to the era was worth of two thumbs up. the fashion is also humble, nothing too extravagant, but also deeply corelated to the era in which taken place on. also the hair and make up. i like that they can manage to look so natural including in weight loss part. woah.
overall; i deeply recommend this movie for those of you who wanted some simple and humble movie about life but also not too serious about it. it's a light, happy movie but also could make you go teary-eyed during watching.
the fashion + setting; i think their consistencies to try to stay true to the era was worth of two thumbs up. the fashion is also humble, nothing too extravagant, but also deeply corelated to the era in which taken place on. also the hair and make up. i like that they can manage to look so natural including in weight loss part. woah.
overall; i deeply recommend this movie for those of you who wanted some simple and humble movie about life but also not too serious about it. it's a light, happy movie but also could make you go teary-eyed during watching.
rating; 7.8 out of 10
*maybe some of you noticed that i haven't review any western movies. oops. i'm working on it.
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Israeli Prime Minister Benjamin Netanyahu said Wednesday he was "not impressed" by Muslim leaders' statements on Jerusalem after they urged the world to recognise the city's eastern sector as the capital of Palestine.
"We are not impressed by all these statements," Netanyahu said in a speech, saying he believed many countries would follow US President Donald Trump's lead and recognise Jerusalem as Israel's capital.
His comments came after an emergency summit of the world's main pan-Islamic body, the Organisation of Islamic Cooperation (OIC), on Trump's move last week.
Facebook Comments


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On Sept. 30, the State issued its Utah School Accountability System (UCAS) report for all schools in Utah (view the reports by school here). This follows a single letter grade report for schools issued earlier in the month, as required by new legislation.
The UEA, on behalf of teachers, has taken the position that both the current UCAS model, which was developed in response to a previous school grading law, and the single-grade reporting system are seriously flawed in the way they measure and report what's happening in our schools. This position is shared by statewide associations representing school board members, superintendents, principals and parents.
"An appropriate school accountability model should be collaboratively developed by education experts and stakeholders," said UEA President Sharon Gallagher-Fishbaugh. "School accountability should be comprehensive, account for student growth and address other issues that impact student learning, such as poverty. There must also be a way to direct resources and assistance to schools where identified help is needed. The State's current accountability models are extraordinarily lacking in many of these areas."
In a meeting held Aug. 20, the Utah Public Education Coalition – which includes representatives from the UEA, PTA, Utah School Boards Association, Utah School Superintendents Association, Utah Elementary School Principals Association and Utah Secondary School Principals Association – unanimously passed a resolution to support and advocate for a school accountability system that:
The UEA is urging those concerned with the current school accountability legislation and the impact it is having on communities, schools and classrooms to contact their state legislators and ask them to repeal current school grading law and replace it with collaboratively developed, comprehensive school accountability.
In representing Utah teachers, the UEA has been working and will continue to work with legislators, the State Board of Education, the Utah State Office of Education and other stakeholders to establish a valid and appropriate statewide school accountability system. This work will continue through the 2014 Legislative Session, so expect updates.
If you have information you'd like to share with the UEA about this issue, please feel free to respond to this email.
More information about grading schools in Utah


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"As Long as You Follow" is a song by the British-American rock band Fleetwood Mac. Written and sung by band member Christine McVie, and her then-husband Eddy Quintela, the song was one of two new tracks on the band's 1988 greatest hits album.
Released as a single on 28 November 1988, the song reached number 66 on the UK Singles Chart late in the year.[1] It narrowly missed the Top 40 in the United States, peaking at number 43 on the Billboard Hot 100 chart in the early part of 1989; however, the song did spend one week at number 1 on the Billboard adult contemporary chart in January 1989.[2]
The B-side to "As Long as You Follow"'s individually sold cassette tape single is a live version of the band's 1969 song, "Oh Well", which peaked at number 2 in the UK when originally released. This live version was recorded at a 1987 Fleetwood Mac concert at the Cow Palace in San Francisco, California (filmed as the Tango In The Night concert video), and featured lead vocals by new band member Billy Burnette. The 12-inch and CD single formats further included the original 1977 studio version of the Stevie Nicks track "Gold Dust Woman", as featured on the 1977 album Rumours. The cover sleeve is identical to its parent album, Greatest Hits.
Christine McVie – lead vocals, keyboards, synthesizer
Mick Fleetwood – drums, percussion
John McVie – bass guitar
Stevie Nicks – backing vocals
Rick Vito – lead guitar, backing vocals
Billy Burnette – rhythm guitar, backing vocals


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Ecuador posted a 2.31 per cent increase in banana exports in the first seven months of 2019 in spite of lower production and falling demand in some of its biggest markets.
Figures from exporter association Acorbanec show exports between January and July reached 213.07m boxes, up from 208.24m boxes in the year-earlier period.
This showed a slowdown in growth compared with the corresponding period of 2018 and 2017, when exports grew by 5.54 per cent and 3.60 per cent respectively.
The association's executive director, Richard Salazar said a fall in shipments to the European Union, Southern Cone and Russia had been offset by a sharp rise in sendings to China, Algeria, Saudi Arabia, the UAE and Eastern Europe.
Exports to the European Union contracted by 12.84 per cent, mainly due to the increased presence of Guatemala, which has virtually doubled its shipment volume to this market compared to 2018.
Shipments to South America registered a fall of 8.54 per cent, largely as a result of the worsening economic situation in Argentina. Nevertheless, Chile and Uruguay both increased their purchases in the first seven months of the year.
In Russia, meanwhile, a 1.68 per cent fall in exports was principally due to lower demand caused by the devaluation of the rouble.
By contrast, exports to the US increased by 4.34 per cent with respect to the same period of 2018. Organic bananas, in particular, performed well and now account for around 10 per cent of shipments to the US.
The Middle Eastern market is also growing strongly and is now the third destination for Ecuadorean bananas, accounting for 14.17 per cent of total shipments or 30.2m boxes between January and July, a 9.9 per cent increase on the previous year.
In Asia, strong demand in China and Asia helped push shipment volumes up by 55.25 per cent. Problems with domestic production led to a surge in demand on the Chinese market, with exports climbing 123.5 per cent to 12.3m boxes. However, exports to South Korea and Singapore were down on the previous year.
Africa is another growing market, with shipments surging by 100.27 per cent, on the back of strong demand in Algeria and Tunisia.
Commenting on the figures, Salazar expressed "concern about the loss of important markets such as the EU and US, which together accounted for 40.38 per cent of exports from January to July of 2019, compared to 45.29 per cent in 2018 and 90 per cent 21 years ago".
He added that the hotter European summers seen in the past three years had also impacted demand and affected prices in Ecuador.


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Indira Jaising: What Stops Indian Courts from Delivering #Justice to #Women?
(Additional Solicitor General of India)
I write to lodge my strong protest against the comments made by the Judge [Kirubakaran] to the effect that women are responsible for crimes against them. The clear inference is that women would be well advised to stay at home to avoid being raped.
It is the primary duty of all courts to eliminate all forms of discrimination, bias and prejudice against women. No amount of Fast Track Courts and Special Courts will deliver justice to women, if those who hold the high office of a Judge of the High Court hold and express such male chauvinistic views.
Of all the promises made in the [Indian] Constitution, the most important are the promises of the 'right to life', the 'right to dignity', the 'right to personal liberty' and the 'right to bodily integrity and health.' However these promises are yet to be redeemed for [Indian] women. Rape and other forms of sexual assault,domestic violence, dowry death and honour killings the most brazen violation of these rights are a real and daily danger for most women.
It is the sacred duty of judges to prevent violence against women in the home; at the work place and on the streets and hold the perpetrators accountable.
What is it that stops courts from securing justice for women? Why has the law not been able to convict the accused when it comes to crime against women?
[It is because we in India] women and men, legitimise the presence of sexism in our lives and carry it to the corridors of the court and into the courtrooms and into judgments.
[Judges] decide what is the legitimate use of the law for women, based on a deeply sexist view of how a woman should behave; what she should desire and how much violence she should tolerate. A casual glance at the kinds of questions a woman is asked in any prosecution of gender- based violence or a reading of judgments of the court will reaffirm this view. On one occasion when a woman lawyer asked for an adjournment, a district judge said,"I know how you women lawyers make it." He was rewarded [with a promotion] by being appointed to the High Court.
A few years ago, a woman who I represented in a classic case of sexual harassment, once asked me why her appeal was not being listed before a woman judge in the Supreme Court. My answer was simple, "because there is no woman judge in the Supreme Court." At this she expressed her amazement and asked, if the Supreme Court could mandate that the chairperson of a sexual harassment committee which was to be set up by employers must be a woman, how come that law does not apply to the court itself? I had no answer.
A demand for accountability of institutions of justice delivery, the police and the courts must accompany the demand for appropriate laws.
It is time for standards to be put in place as to how judges must behave with women lawyers and litigants. No judge, let alone a Supreme Court judge must ever be allowed to use sexist language in judgments or during the course of arguments in court.
Accountability starts at the top with the Supreme Court, what a judge of the Supreme Court thinks and says today, will be said and done by the 17,000 subordinate court judges who deliver justice under the supervision of the high courts.
This is the time when the Chief Justice of India must rise to the occasion and speak to the nation and inform us what will be done to restore the confidence of the people in the justice system. Besides his role as a judge, he has a role as the head of the judiciary responsible for the administration of the justice
Indira Jaising is the Additional Solicitor General of India. The above are excerpts from a letter of protest she sent in August 2013 to the Chief Justice of India, P Sathasivam, to bring attention to Judges who pass gender biased comments and judgments in Indian courts, as well as an excerpt from an earlier article by her 'Blind to what, Your Honour?' in The Times of India, on the same issue.


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Remi Dyon, Business Intelligence Product Manager, has more than 10 years' experience in the extended retail industry and is recognized as the Symphony RetailAI technology business intelligence leader. Remi currently manages the development of the Symphony RetailAI analytical platform (for mobile and desktop) from specs to development, QA and implementation (technologies: Stormbase, Node.js, jQuery Mobile, Fusion Charts, Cordova, HTML5, JavaScript, Java, H2, Oracle, PL/SQL).
Remi Dyon, Business Intelligence Product Manager, has more than 10 years' experience in the extended retail industry and is recognized as the Symphony RetailAI technology business intelligence leader. Remi currently manages the development of the Symphony RetailAI analytical platform (for mobile and desktop) from specs to development, QA and implementation (technologies: Stormbase, Node.js, jQuery Mobile, Fusion Charts, Cordova, HTML5, JavaScript, Java, H2, Oracle, PL/SQL).
This blog covers a few key points:
• Hurdles that prevent retailers from making informed business decisions
• The need for predictive KPIs based on timely and accurate data
• How supply chain KPIs must aggregate data across the entire retail organization including all supplier partners
• The importance for retailers to be able to develop their own KPIs into their data management system
There are a lot of companies struggling with performance and having a true understanding of their consumers and where to focus. What are some of the issues you see based on your experience working with customers on business intelligence analytics?
I see time as a major impediment. Everyone is concerned about strategy and making the best decisions for the business, but retailers are challenged to make fast decisions and that can only be done well when you have time and accurate information – which so many retailers lack. They're missing the facts and decisions are being made by a gut feel.
There is no question that there is a real need for predictive KPIs as well as the ability to customize and fit for individual needs. If you tell a retail customer you have real-time data and visibility they don't perk up much as this is not new in the market. But, if you talk about tools that enable self-leadership, tools that promote business discussions to a new level using data, facts and insights, then you get attention. Relevant data needs to find you, not vice versa.
What is the most important element of a good business intelligence tool?
The need for quick technology that is scalable. Business intelligence technology (like in-memory processing where calculation time is measured in seconds) must provide a fast implementation for rapid results accessing an enormous amount of data in real-time without any question.
Can you share with us some examples of customers you've worked with that have seen real results?
I've been working with a Tier One retailer with more than 3,000 outlets in Europe for both food and non-food industries. With 50+ distribution centers and over 2,000 suppliers, it is critical to have analytics in place to support effective performance and collaboration, especially in terms of supplier performance for on-time delivery and quantities. It's essential to process huge amounts of data in a matter of seconds and to smoothly integrate with many other systems as well.
Tell us more about the valuable insights in this recent use case.
We implemented a tool with the ability to integrate orders, receipts and inventory, and analyze data to provide supply chain KPIs. All of this data came from SR Retail Data Management platform integrated with the Replenishment Insights.
Orders and receipts for each supplier and each distribution center can be evaluated for individual suppliers' service performance in terms of quantity, quality, and punctuality. It is crucial to have a reliable and solid tool that cannot be questioned by the suppliers, centralizing contract inputs, raw data recovery, and penalties, and connecting them all to one reporting tool.
How does this tool support visibility and collaboration for supplier partners?
We replaced a tool that was not powerful enough to process the massive amount of supplier data. Now all orders can be analyzed in their entirety. As a result, the performance indicators are available for all suppliers, which allows both for better management of the performance and for the invoicing of a larger number of penalties.
Now users can be strategists and, enabled with instant insights to the business, make proactive decisions by analyzing the activity forecast to anticipate shortages or overload of warehouses. This provides better visibility at all levels of the company. Additionally, users can create custom queries and access different indicators in real time via a unique and user-friendly interface.
As I mentioned earlier, scalability and the need for quick technology is key. So good to note, the performance key indicator data for the service cost levels, including the logistics, the supplier performance and the stock performance levels, are processed in only a few seconds, which allows for a complete on-demand analysis.
Another benefit is that the project has been developed in collaboration with the customer's IT department. We have trained a few of their resources on using our proprietary software development kit. So now they are autonomous and can add more KPIs and are more efficient in being able to answer the needs of the business.
Overall key benefits in this specific use case are:
- A unified dashboard measuring and displaying the performance of 2,000+ suppliers and 57 distribution centers
- A more accurate overview of the inventory management, in real time
- Collaboration with the suppliers: sharing of KPIs for performance enhancement
- Better assessment of penalties for all suppliers and improved invoice management, which allows for a significant rise of the penalties invoiced each month
Learn more about Supply Chain Insights.


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Diversity in mainstream beauty standards is catching up to reality, and bloggers like Patrice Grell Yursik deserve much of the credit.
A former newspaper editor, Yursik saw a void and in 2006 created Afrobella.com, a blog celebrating natural beauty of women of color. Since then, Yursik, a native of Trinidad, moved from Miami to Chicago and focused full time on the blog, becoming known as the "godmother of brown beauty blogging."
Yursik will host an event Saturday for TextureMedia at New York Fashion Week.
Q. How has Afrobella evolved?
A. Afrobella began as a passion project. I wanted to see a dedicated spotlight to women of color, women with natural hair and plus-sized women who want to be fashionable — all of those things I really thought were being overlooked. There has been such an overwhelming wave of natural hair, plus-size and black beauty bloggers, now I'm part of a community.
The content has become more sophisticated, visual and polished over time. It began with me doing reviews of drugstore beauty products and has evolved into photo shoots, fashion look books and Afrobella merchandise.
Q. How has the beauty world changed over that period?
A. Brands that used to have six shades of foundation now maybe have eight or 10. It used to be natural hair products were relegated to two or three shelves in a drug store.
Luvvie Ajayi, the humorist and and socially conscious blogger, has transformed herself into an innovative digital strategist whom corporations entrust with their social media.
Now there are entire sections of natural hair products in bigger, flashier retail stores. Target, Sephora and Ulta have natural hair brands, and these are places where you could not have found that kind of product in 2006.
Q. How does that progress compare to your ideal?
A. You can see it in the representatives for some of these mainstream makeup brands. Cover Girl does a beautiful job. They've got a celebrity spokesperson of every nationality and every skin tone. Lancôme brought in Lupita Nyong'o to be the face of their brand, making a huge statement.
That gives you hope. But I still hear from readers who say, "I can't find a shade of foundation that matches me." They're still not necessarily providing the right kinds of pigmentation or tonality to match a variety of skin tones.
Q. Tennis great Serena Williams, who has endorsed beauty products, has been body-shamed and under-appreciated. What's your take on that?
A. It makes me angry, of course because I identify with that. It's the kind of thing we deal with as black women. But that's exactly why my blog exists: to remind us that we are beautiful on our own terms no matter what, and we have to continually do that for ourselves.
Women of Color in Tech offers a set of free stock photos that show women of color in professional and technical settings.
But at the same time, that limited opportunity that Serena Williams has dealt with has made her stronger. It's made her become an entrepreneur in some ways and innovate herself and try things that maybe some of her peers who were just handed opportunities don't have the courage or the need to try.
Q. How has the rise of black culture online and in pop culture played into the growth of Afrobella?
A. Now the things that we thought to ourselves and said to each other in private spaces are able to drive a conversation online and shift the cultural barometer through Twitter, Instagram, Facebook or Tumblr where we can each raise our voice.
I was thinking about this today because I received my Ava DuVernay Barbie doll. What a remarkable testimony that is of the evolution of beauty standards because of the Internet.
Who thought that there would be a Barbie that I could identify with and that isn't wearing little plastic high heels and that has natural hair? That comes from the outcry on the Internet that we want and need this. We've seen a lot of change, but more change is coming.
Q. What has been your biggest lesson as an entrepreneur?
Latest Blue Sky
A. I had a brand take advantage of me and use my face in a nationwide advertising campaign. I didn't know I could negotiate. I didn't know what my value was and the fact that they ran full-page ads in magazines for as long as they did.
I didn't even know enough to protect myself, so I wound up signing a contract that I couldn't release myself from. I learned that brands have a greater idea of your monetary value than you might when you are blogger, especially coming up as a digital influencer.
Q-and-As are edited for length and clarity.
Kate MacArthur is a freelance writer.


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For some reason there are Christians who find it difficult, even impossible, to accept the idea that God really does love terrorists and rapists and murderers. Even though they all quote scriptures like "For God so loved the world..." and "While we were yet sinners Christ died for us" and many other verses, the idea of actually believing that God loves those evil people is too much to bear.
When we say that God's love is unconditional, that's exactly what it means. He loves us because He is love, not because of anything we have done to deserve that love. God's love for us is not based on our goodness, in fact it's in spite of our lack of goodness. His love is unmerited. His grace is lavished upon the filthy. That's what makes it "Amazing Grace". Because if we were basically good people then His grace would only be "Nice" it wouldn't be "Amazing."
The truth is that if God can't love Osama Bin Laden, or Hitler, or the Umpire who blew that call in the World Series, then He can't love you and me. We're all sinners. We all deserve punishment. We all sent Jesus to that cross. And what did Jesus say to those who nailed him there? He forgave them. He forgave us all.
Granted, not everyone has received that love and mercy. But if those of us who have received His mercy and amazing grace do not extend it to those who have yet to taste of it, then how else will they ever see it? If those of us who have been forgiven don't love those who don't deserve it, then how will they ever know His unconditional love?
See, it's not just that God loves those filthy sinners, it's that you and I are also commanded to love them too.
"If you love those who love you," Jesus said, "What credit is that to you? Don't the pagans do that?"
We are called to love our enemies, and to pray for those who do evil, and to show mercy and grace and compassion to those who don't deserve it, because we don't deserve it either.
Jesus shared a parable about this once. He told a story about a man who was forgiven a massive debt and then went out and demanded payment from another person for a very small amount. When the Master who had forgiven the large debt heard this, he called the man back into court and said, "I showed you great mercy, and yet you were unwilling to forgive someone even a small debt? Because of this I will throw you into prison and you will not get out again until you have payed me back every penny you owe." (See Matt. 18:21-25)
See, if we really believe that we are sinners saved by grace, then we need to love and forgive others in the same way. Not just those who insult and injure us, but also those who harm others.
Just listen to what the worst sinner of all has said about this:
"Here is a trustworthy saying that deserves full acceptance: Christ Jesus came into the world to save sinners—of whom I am the worst. But for that very reason I was shown mercy so that in me, the worst of sinners, Christ Jesus might display his immense patience as an example for those who would believe in him and receive eternal life." – Paul the Apostle, (1 Tim. 1:14-16)
So, God really does love the filthiest of all sinners. We need to learn to accept this unbelievable truth, because if we can't accept that, then we're lying to ourselves about our own condition. We believe that we are better than everyone else if we can't accept that the worst of all sinners is the one who looks back at us in the mirror each morning. Either God's love is unconditional or it's not. What do you really believe?


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Veterinary Care Support Saved Lives Thanks to YOU! Niko & Pirata's Story
Niko, a cat with nine lives who always seemed to beat the odds, suddenly stops eating.
Pirata, a dog who never leaves his little girl's side can hardly lift his head.
Their loving families offer treats, bring the water bowl closer, fluff their bedding and softly stroke their fur, but none of this seems to bring the pets comfort.
Niko's dad is on disability and is the sole supporter of his four grandchildren. Pirata's dad works 7 days a week just to put food on the table. Desperation grows for these families as their pets get sicker because there is no extra money to cover a large vet bill.
Can you imagine seeing your beloved dog or cat in this state and feeling so helpless? You have children to feed, you have rent to pay, and you don't want your furry family member to suffer.
Where do you turn?
Both families hoped the shelter could ease their pet's suffering. Through streaming tears, they shared their struggles with our shelter intervention counselor.
Niko and Pirata were desperately sick when they each arrived in the lobby, barely clinging to life and limp in their owners' loving arms.
Because of your generous contributions, there was still hope.
Veterinary Care Support Prevents Surrendered Pets
Your donations covered life-saving veterinary care for these pets in need and both pets were treated with fluids and IV antibiotics to combat what turned out to be serious infections.
Thanks to you, Niko and Pirata will have many more years with the people who love them most.
Niko has since returned to his chosen post-ruling the garage and bossing the dog of the house, a huge Mastiff, around. A sure sign he is feeling better, according to his owners!
Pirata is back to watching over his little girl and dutifully sleeps by her side every night.
Unfortunately, there are thousands of families who face sudden and tough decisions no one should have to make. And since many Arizonans are one or two paychecks from being in this position, it's a problem more than a few of us are likely to encounter.
I Want to Help More Pets in Need like Niko & Pirata
When you make a gift to The Arizona Pet Project, you are supporting families and saving pets just like these in our community. Can we count on you to donate today?


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Perhaps these configurations appear to be common to many configurations, but this is a cost-effective mobile phone. The price is not high, it is suitable for the taste of the masses.
I am a fan of HUAWEI. I was very excited when I saw HUAWEI release new machines. In the survey of the mobile phone configuration, etc., I did not hesitate to buy it. And my question is, I would like to transfer the old HUAWEI contacts to the new mobile phone, there is a simple way?
Mobile Trans, as the name suggests, it is a mobile phone file transfer tool. It can transfer data in different mobile phones and systems. It can transfer data including contacts, SMS, calendar, music, photos, videos and so on. In addition, in addition to the function of transferring files, it can also backup your phone files to the computer; you can restore the backup data to the computer. What's more, you can also use it to completely remove your mobile phone files and protect your privacy. This software is a set of multiple functions in a tool, you deserve to have.
Next I will introduce how to transfer Contacts from the old HUAWEI mobile phone to Nexus 6P.
Step 1. Download Mobile Trans, install and run it. Then you can find that the program has four functions for you to choose, please click "Phone To Phone Transfer".
Step 2. Two USB lines were used to connect your phone to your computer. After the success of the connection, you can find the main interface of the two mobile phones is displayed on the left and right sides of the window. And at the moment, you just need to confirm whether the old phone is displayed on the left, if not, please click "Flip".
Step 3. Select contacts and transfer. You can see that the file type that can be transferred is displayed in the middle. According to your requirements, you only need to check the "contact" and cancel check other documents. Next, click "Start Transfer". Finally, wait for a while, a window pops up, click "OK", then, the transfer file is completed.
It is worth noting that, in the whole process of two mobile phones are successfully connected to the computer.
More Related Articles:
How to Transfer Contacts from Nexus 4/5 to LG G5
Transfer Everything from Galaxy S3/S4 to S7/S7 Edge


text: Usually on a day as beautiful as today I try to spend as much time outdoors as possible. But I'm so behind on work that the influx of enthusiastic family makes for some much-needed childcare instead. The radio says tonight and tomorrow just before sunrise are supposed to be the best time to see the Perseid meteor shower– looks like we'll be out on the lake before dawn looking to see some shooting stars!


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About Us
I am Mark Riley and thanks for visiting by blog. Hopefully you will find something interesting here that you can use in your home or garden. When not working at my full time job or running after my 2 year old I like to work on my small allotment and fix things around the home. I like to write about what I have learned through the years in both gardening and DIY so hopefully you can pick up some tips that you have not come across before. If you have any questions or suggestions for new blog topics send me an email to email@example.com.


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We understand that the cleanliness of washrooms and hygiene areas is a priority for all establishments. Brayborne supply a comprehensive range of services to guarantee a safe and hygienic environment for your staff, visitors and customers.
Our daily cleaning schedule can include more specialist deep cleaning tasks, whether it be the removal of scale or water markings, we are fully equipped to provide a fast, efficient service as part of a scheduled periodic contract or one-off solution.
In partnership with our preferred supplier, we also offer competitive rates for aircare, vending, sanitary disposal and water management services.
For more information on our Janitorial support services, click here.


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Mai-Tai 2.0
Our craft cocktails are now available in bottles for take away & delivery.
We always strive to provide you with premium spirits, homemade ingredients such as cordial and syrup, as well as collaborating with local artisans and markets.
How to enjoy your drink?
Our cocktail are ready to be served and include garnishes.
- Chill the bottle in your fridge.
- Pour 10cl in a glass fill of ice cubes.
- Garnish your glass
- Enjoy your drink!
Keep in a cool and dry place with no direct sunlight.
After opening, keep the bottle in your fridge and drink within 2 weeks.
Drink responsibly, don't drink and drive, don't drink if you are pregnant.
We are donating 1€ to charity for every bottled cocktail sold. Read more!
Do you want more product like our Mai-Tai 2.0? Be sure to check our bottled cocktail menu or our rum list.


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Turkey Pumpkin Pasta is lean ground turkey is paired with a creamy pumpkin sauce and penne pasta, then baked up until golden brown. It's a comfort food dish for two!
Making dinner for a big family can be a challenge, but so can cooking for just two people. It might sound easy, when you think about the small amount of ingredients you'll need, but that's not where the problem lies. The toughest part about cooking for two is scaling the ingredients down to just two servings.
Think about it for a minute.
Packages of ground meat at the store are usually 1 pound (16 ounces) or larger. A typical serving size of meat is usually 4-5 ounces per person.
What are you supposed to do with the other 8 ounces of ground turkey? This is where meal planning for the week can fit into the picture perfectly. Have a recipe close by that uses similar ingredients and freezes well and you'll be on your way to tackling two meals in no time.
For example, when I made this low fat turkey pumpkin pasta casserole recipe, I took the remaining 8 ounces of turkey and created a batch of my baked turkey meatballs. It was super easy and convenient.
The recipes have more in common than the fact that they use turkey.
They're also both quick to make, and healthy, too. They're both low in fat, and thanks to the pasta we use that has 5 grams of fiber and 7 grams of protein per serving, this pumpkin pasta casserole is healthier than similar pasta recipes would be.
I love making healthier choices for our family. This is a meal that I can feel good about making, and it's so filling that I didn't even feel the desire to overindulge in it.
Preparing it as a 2-serving dish made it an even better choice, because there were no leftovers to worry about!
Low Fat Turkey Pumpkin Pasta for Two
- 4 ounces (1/4 pound) dry penne pasta (or similar pasta)
- 1 teaspoon unsalted butter
- 2 Tablespoons white or whole wheat panko breadcrumbs
- 8 ounces (1/2 pound) lean ground turkey
- 1 tablespoon grapeseed (or other heart healthy) oil
- 1 shallot finely minced
- 1/2 teaspoon ground cinnamon
- 1 teaspoon dried or 2 Tablespoons fresh thyme leaves
- 2 cups loosely packed kale thick stems removed and leaves chopped into 1-inch pieces (measure AFTER cleaning)
- 1 pound fresh (or 18 oz canned) pumpkin puree (not pumpkin pie filling)
- 2 Tablespoons shredded Parmesan cheese
- 1/8 cup shredded low fat cheddar cheese
- 2 ounces (1/4 liquid cup) lowfat milk (any variety)
- 1/4 teaspoon salt (more or less to taste)
- 1/4 teaspoon freshly ground black pepper (more or less to taste)
- Bring a large pot of water to boil, and cook the pasta to al dente, according to package directions.
- Melt butter in a small saute pan over medium heat. Add breadcrumbs and saute for 2 minutes or until toasted, stirring occasionally to prevent breadcrumbs from burning. Remove from heat and set aside.
- As the pasta cooks, heat oil in a heavy bottomed 12-inch skillet over medium high heat.
- When the oil is shimmering, add the ground turkey. Cook for 5 minutes, then reduce heat to medium and add shallot; cook for 1 minute before adding the cinnamon, thyme, and kale. Continue cooking over medium heat for 3 minutes, or until turkey is browned and Kale is somewhat wilted.
- Add pumpkin puree, both cheeses, and milk to the skillet. Stir to combine and cook until warmed through (cheese should melt).
- Season generously with salt and pepper before tossing the (drained) pasta with the pumpkin mixture.
- Pour into a serving dish and garnish with toasted breadcrumbs.


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Check out Tesolcourse.com about TEFL Manning Iowa and apply today to be certified to teach English abroad.
You could also be interested in:
This is how our TEFL graduates feel they have gained from their course, and how they plan to put into action what they learned:
The means of learning/acquiring language is a complex process that is still debated. It has been suggested that due to biological factors, one's first language is acquired, while a second language, as it might utilize different cognitive faculties in the brain, is learned. L1, or one's native language, has biological connections. In her book Language Matters, Donna Jo Napoli states that a language gene was discovered called FOXP2 (5). This supports ideas that L1 occurs naturally: it begins in the womb with FOXP2, and is developed with the formation of the auditory system around the seventh month. Before the child is born, it hears its mother and can be calmed by her voice after birth. It can be concluded then that the acquisition of L1 begins before an individual is born. Not only do studies show that children who are exposed to ordinary speech learn at the same rate as those primarily exposed to "motherese," but even those children who do not receive any conscious language teaching still acquire language at the same rate of other children around the world. In some cultures, such as Samoa, children learn from overhearing adults speak rather than having adults speak to them or purposefully teach them language (Napoli 4). Theories suggest that there is a psychological language mechanism that changes in the brain at an early age, which explains why L1 acquisition is easier for younger learners, but is more difficult, if not impossible after age five. This theory supports the case of the Wild Boy of Averyon who grew up in almost complete language deprivation and then could not even mimic language once he was rescued at an 'older' age (Napoli 4). The idea of a psychological language mechanism is also supported by the fact that people who have linguistic damage as a result of strokes and other brain injuries still maintain their intelligence. Generally speaking, at a year old, kids start to produce single words. Around two years, they start putting together two-word phrases, usually an object and a word that operates on that object. By age three, kids usually form longer sentences with varying degrees of complexity. These kids are using principles of natural language, or Universal Grammar, that are somehow 'programmed' into the language mechanism in their brain, even if they do not have access to any community languages. Napoli sums this idea up, "We acquire our specific native language in a natural way, by sifting through what we are exposed to or what we create with the Universal Grammar principles that we are born with" (15). While it is clear that the language mechanism in the brain has certain linguistic parameters, like word order, from the first language, there is debate as to whether or not the parts of the brain used for second language (L2) learning are separate from those used for L1. This examination has presented itself because while L1 acquisition occurs naturally, the learning of L2 has to be consciously taught, and is further affected by self-confidence, anxiety, and motivation issues (Napoli 18). Similarly, while L1 occurs by age five, L2 can happen anytime. Though language learning can be faster for those who have a higher proficiency in L1, the younger the individual, the more proficient they can become in L2. This is partially because L1 serves as the model for which mistakes, particularly in grammar, are made with L2. Therefore, if L2 is learned at a younger age, the child is still discovering both languages and is less likely to make the same mistakes that an older learner would make. From this information, one can conclude that while there are a few similarities between the process of L1 and L2 acquisition, there are vast differences that can present challenges for L2 that are not present for L1. While there is not enough room to explore the Sapir-Whorf Hypothesis and what that means for language acquisition, it would be certainly be pertinent for further study. Clearly more research needs to be done to better understand the relationship of first and second language acquisition.


text: marts 27 Posted September 8, 2019 Can we get a proper day/overcast? (Wales especially) I think Codies have really gone overboard with the brightness in current weather conditions. There isn't enough threatening conditions that aren't raining, can we get the heavy rain conditions without the rain? Skies look good, but we don't need the sun bleering through ALL the time, even when supposedly overcast. Most locations have Sunny. Cloudy (but still sunny) and rainy. Overcast is missing. Poland has proper overcast, the game looks good when it's not so bright and saturated but so few stages have a decent overcast setting. Share this post Link to post Share on other sites


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Tim Farron's Leader speech for me, screamed out a hilarious, school boy case of a person trying too hard to show he was a strong leader. But what he doesn't understand is that being strong isn't about shouting out the normal rhetoric about widely taken beliefs. It's not about trying to be in the middle for everything and looking to please everyone. Being strong is about standing up for your values that are clear cut, not looking to please all parties. Being strong is about taking a clear stance on issues that you seriously believe in. These beliefs will put you in the firing line with some people, but also put you into the ascendancy with others. And if there is a feeling, as there is at the moment, that people are disillusioned with politics and politicians due to exactly this reason, now is the perfect time to take a clear stand and crush disillusionment by leading.
What Tim Farron did was play on the very things that are easy to talk about. He kept talking about liberal values – individual independence from state, equality of opportunity – while not actually addressing how he was going to make these come about. He didn't, for example, state that he was going to attack universal benefits (universal benefits contradict the reason the benefit system was set up in the first place: to aid the people who were struggling). But what he did do was use sit-on-the-fence, easy applause material to pretend to be an inspirational leader.
He shamelessly and distastefully used the refugee crisis boy's image to try and whip up the hatred for Cameron's so called inhumane response to the refugee crisis to gain support. His reaction was the same emotional reaction that the media had to the situation. The same immoral reaction and quite frankly, in my eyes, inhumane. He accused Cameron of maximising the PR from the situation to gain support, where in reality, all Farron did was use this for his own benefit and a few seconds of applause. This is the easy and "in" thing at the moment and for him to jump on the bandwagon with that gesture showed, for me, what this speech was all about. It was all about following, rather than leading. Exactly as he put it. But while what he meant was he was the leader and others were just following, I mean the opposite. He is no leader. He is no revolutionary. And he needs to stop reacting and start acting. Acting as a true liberal.Movie All Is Lost (2013)Roblox HackBigo Live Beans HackYUGIOH DUEL LINKS HACKPokemon Duel HackRoblox HackPixel Gun 3d HackGrowtopia HackClash Royale Hackmy cafe recipes stories hackMobile Legends HackMobile Strike Hack
Read the complete Liberal Awakening Manifesto at: