text:
Manufacturing Contempt for Venezuela
A profile of the Venezuelan opposition's systematic misinformation campaign and social media's contribution to it.
"Initial, inaccurate information will be retweeted more than any subsequent correction," wrote Craig Silverman, journalist and founder of the blog Regret the Error, for the Poynter Institute in a post in 2010. Silverman's insight reveals the dangers, often ignored, about the use of Twitter and social media as a news source, as well as a tool for liberation and uprisings.
However, the way social media is being used, or some might say abused, in Venezuela is not the result of a few "bad apples" or some mischievous students taking part in opposition protests. In fact, this propaganda technique is being used by high profile opposition figures, while training anti-chavista Venezuelans to use social media has been a project of Washington for some time now.
According to Caracas-based journalist and attorney Eva Golinger, the US spent "nearly $15 million annually by 2007…directed towards youth and student groups [in Venezuela], including training in the use of social networks to mobilize political activism. Student leaders were sent to the US for workshops and conferences on Internet activism and media networking. They were formed in tactics to promote regime change via street riots and strategic use of media to portray the government as repressive."
The adoption of social media as a tool to advance US foreign policy objectives, including regime change, did not end with President George W. Bush's administration. Actually, former Secretary of State Hillary Clinton further developed it as a coherent policy tool labelled "21st Century Statecraft." I wrote about this and how Venezuela and other ALBA countries were targets for this new technological imperialism back in 2012.
In the article I noted how Judith McHale, former under secretary for Public Diplomacy and Public Affairs at the State Department, provided clarity about how exactly Washington planned to use these new technologies in a forum hosted by John Hopkins University in March 2011.
"New media and connective technologies enhance our ability to listen…Social media provides new ways for us to keep our ear to the ground," said McHale. "Of course, we are not interested in developing social media platforms for the sake of having them. We are interested in applying social media to promote our strategic objectives in the Americas." A few months later at a June 2011 Senate Hearing Assistant Secretary of State for Western Hemisphere Affairs Roberta Jacobson said that the State Department "has programs that support media training in Bolivia, Nicaragua, Venezuela, and Ecuador; these programs address the use and impact of social media…."
McHale's remarks and Jacobson's admission seem salient now in light of the use of how social media in Venezuela has been used to spread misinformation in attempts to destabilize the country and delegitimize that country's democratically-elected government.
CNN published an article exposing numerous examples of misinformation disseminated by opposition folks via Twitter. One example of propaganda was tweeted by Venezuelan "political consultant" Esteban Gerbasi, using a photo from Brazil as a means to suggest Venezuela is a dictatorship. Gerbasi was quoted by the Associated Press in an article last November about planned anti-government protests where he expressed his displeasure with the opposition's leadership for not taking a more confrontational, and some might say more undemocratic position, towards the government.
"The Marcha Autoconvocada's purpose is precisely to demonstrate to Maduro and the opposition leadership that their time is up and that now the way out is taking to the streets," said Gerbasi, offering a warning and foreshadowing of the recent turmoil.
Another egregious example highlighted by CNN's report was a photo tweeted by Venezuelan actressAmanda Gutierrez which was allegedly lifted from a US-based porn site. The photo was used by her to "prove" sexual abuse by police against anti-government protesters.
Then there is Francisco Toro, a Venezuelan blogger whose "musings" at Caracas Chronicles (a website he founded) are "a must-read for foreign journalists," according to the Associated Press. In an article that went viral on both Twitter and Facebook entitled "The Game Changed in Venezuela Last Night – and the International Media are Asleep at the Switch", Toro wrote about a "tropical pogrom" that allegedly took place one night in Venezuela – except it didn't. There was no massacre by "paramilitaries." One person did die from injuries sustained that night, however that was four days later. This death is a tragedy, but it is a far cry from a "pogrom" or massacre. After this misinformation and gross exaggeration was exposed and criticized Toro took to Twitter and admitted to "overstatement in the heat of the moment." He also addressed it in a blog post which garnered a whopping 14 likes on Facebook and 12 Tweets – in contrast with the hundreds of thousands of Facebook likes and over 10,000 Tweets his original, factually challenged blog post amassed. This supports Silverman's aforementioned thesis about how error corrections are not retweeted and viewed as much as the initial errors.
Furthermore, Toro took to Twitter again to defend himself, this time by suggesting that Caracas Chronicles shouldn't be considered journalism – something I wholeheartedly agree with – though their should be a disclaimer at the top of each page so as not to confuse international journalists like the one at the Associated Press, who considers Toro a "must-read." Toro is also an oped contributor for The New York Times.
Julia Buxton, writing for the Latin America Bureau, put the dangers of social media effects on traditional media in perspective:
"Despite claims that social media 'democratises' the media, it is clear that in Venezuela it has had the opposite effect, exacerbating the trend towards disinformation and misrepresentation, with overseas media groups and bloggers reproducing – without verification – opposition claims and images of student injuries allegedly caused by police brutality and attacks by government supporters."
Cyril Mychalejko is an editor at www.UpsideDownWorld.org.


text:
The Christmas cards are ready! We finished printing and cropping, then tipping vellum enclosures inside with Elmer's All-Purpose Glue Stick. Our message this year:
The people that walked in darkness have seen a great light.
— Isaiah 9:2
Here's the image, Tiny in The Little House, all eyes and ears in the aftermath of a snowstorm last winter. A touch of Photoshop's "Paint Daubs" filter lends the image a bit of a painterly blur.
For the curious, here's a glimpse of our Christmas Card Workshop from years past.

subset: commoncrawl


text:
McKENZIE, CHARLES, fur trader; b. c. 1778 in Ferintosh, Scotland; m. some time before 1805, according to the custom of the country, and formally 6 March 1824 in Montreal, Mary McKay, a Métis, and they had one son and three daughters; d. 6 March 1855 in the Red River settlement (Man.).
Charles McKenzie was engaged as an apprentice clerk by McTavish, Frobisher and Company, one of the firms in the North West Company, for service in the fur trade by the terms of a contract signed in Montreal on 30 Dec. 1802. He proceeded in 1803 to the area around the Red and Assiniboine rivers where, in October 1804, NWC clerk Daniel Williams Harmon* met him at Fort Montagne à la Bosse (near Routledge, Man.). McKenzie was serving as clerk under Charles Chaboillez*, NWC partner in charge of the Fort Dauphin department, when on 11 November he was sent, with NWC clerk François-Antoine Larocque* and others, to trade with the Mandan Indians on the upper Missouri River. The party reached the Gros Ventre (Hidatsa) Indians, close neighbours of the Mandans on the Missouri, by the end of November and, discovering four Hudson's Bay Company men among these Indians, Larocque left McKenzie and another man with them to compete with the English company's traders. McKenzie passed the winter with the Gros Ventres, and both he and Larocque, who stayed in a nearby village, were in close contact with the American exploration party under Meriwether Lewis and William Clark which was wintering among the Mandans. McKenzie returned to the Assiniboine River in the spring of 1805, arriving at Fort Assiniboine (Man.) with Larocque on 22 May.
He made three other trading expeditions to the Missouri in 1805–6 and he was with the Gros Ventres when Chaboillez and Alexander Henry* visited the Mandans in the summer of 1806. McKenzie, who was at ease with the Indian way of life, was reproached by the two NWC proprietors for having adopted Indian dress. In his journal he wrote: "Let any man living with the Indians take the idea of 'Savage' from his mind and he will find their dress much more convenient. He can pass through the crowd, day and night, without exciting curiosity or draw a throng of children and barking dogs"; furthermore, he noted, their dress was "very light and cool in the warm season."
The Missouri trade had been found unprofitable, and was discontinued by the NWC in 1807. McKenzie was posted to the Monontagué department, near Lake Nipigon, Upper Canada, under John Haldane, where he took charge of the relatively unproductive post on Lac Seul. He remained at this post after the union of the NWC and the HBC in 1821, and, except for a brief period from 1823 to 1827, was there until his retirement in 1854. In 1823 he resigned from the HBC, discontented with his salary and other arrangements. He accepted a position with the king's posts but when it proved to be unsatisfactory he returned to the HBC.
The journals of his ventures to the Missouri River were forwarded to Roderick McKenzie* of Terrebonne, Lower Canada, in 1842, and were eventually published in 1889–90. Those he kept at Lac Seul are more voluminous and more informative about his character. He was a strong advocate of Indian concerns, which often involved fur-trade policies he considered detrimental to their welfare; for example, he called the ready-barter system of trade "a most cold cold calculating system," because it prevented the Indians from obtaining in advance, on credit, the supplies upon which they had become dependent for hunting, trapping, and survival. He demonstrated a certain relativism towards Indian culture and he described, sometimes in detail, their hunting practices and other patterns of behaviour. He was very proud of his wife who had been raised as an Indian, and in his journal for 1831 he noted that "she hunts for her own pleasure, & tho' I pay her, as I would an Indian out of the Company's shop – wastes more in wear & tear than she gets & the only profit I see by it is she keeps herself in employment & her body in health." He also wrote extensively about events at the post, the habits of animals, and other natural phenomena. In the mid 1840s a series of epidemics killed many Lac Seul Indians and in August 1845, when the post was turned into a hospital, McKenzie himself became quite ill; his wife acted as nurse and comforter to the sick.
McKenzie remained a clerk until his retirement from the HBC, a fact that caused him much resentment. As early as 1827 Governor George Simpson had decided not to promote him, observing that "his best days are gone." McKenzie was convinced that promotions were based on favour and in November 1853 wrote to his son, Hector Æneas, who had himself been in the service of the HBC from 1839 to 1851, that "if there was any merit I would be ahead of most of their present Chief Factors." In his later years he suffered poor health, complaining of sore eyes and "decayed Bowels." Upon retirement he and his wife joined their son on his farm in the Red River settlement. McKenzie died there in 1855.
The record of McKenzie's long tenure at Lac Seul would indicate that he had managed the post well and had been generally liked by the Indians. The detailed and perceptive journals he kept during these years are his greatest contribution to history and science.
The PAC has in MG 19, A44, a collection of letters exchanged between Charles McKenzie and his son as well as other members of the family for the years 1828–87. McKenzie's reports on the four expeditions to the Missouri River are published in "The Mississouri Indians: a narrative of four trading expeditions to the Mississouri, 1804–1805–1806" in Les bourgeois de la Compagnie du Nord-Ouest (Masson), 1: 315–93.
ANQ-M, CN1-29, 17 janv. 1800. PAM, HBCA, A.34/1: f.73; A.34/2: ff.38–38d; A.36/9: ff.186–87; A.44/3: 107; B.107/a/2, 6–31; B.107/b/1; B.107/d/1; B.107/e/3–5; B.107/z/1; Red River burial reg. Harmon, Sixteen years in the Indian country (Lamb). New light on early hist. of greater northwest (Coues). F.-A. Larocque, "The Missouri journal, 1804–1805," Les bourgeois de la Compagnie du Nord-Ouest, 1: 297–313. C. A. Bishop, The Northern Ojibwa and the fur trade: an historical and ecological study (Toronto and Montreal, 1974). [M.] E. Arthur, "Charles McKenzie, l'homme seul," OH, 70 (1978): 39–62.
© 1985–2023 University of Toronto/Université Laval
Cite This Article
Charles A. Bishop, "McKENZIE, CHARLES," in Dictionary of Canadian Biography, vol. 8, University of Toronto/Université Laval, 2003–, accessed September 25, 2023, http://www.biographi.ca/en/bio/mckenzie_charles_8E.html.
The citation above shows the format for footnotes and endnotes according to the Chicago manual of style (16th edition). Information to be used in other citation formats:
|Author of Article:
|Charles A. Bishop
|Title of Article:
|McKENZIE, CHARLES
|Publication Name:
|Dictionary of Canadian Biography, vol. 8
|University of Toronto/Université Laval
|Year of publication:
|Year of revision:
|Access Date:
|September 25, 2023


text:
List of RSS Readers Available in Ubuntu Linux
Sponsored Link
The benefit of RSS is the aggregation of content from multiple Web sources in one place. RSS content can be read using software called an "RSS reader", "feed reader" or an "aggregator", which can be web-based or desktop-based. A standardized XML file format allows the information to be published once and viewed by many different programs. The user subscribes to a feed by entering the feed's link into the reader or by clicking an RSS icon in a browser that initiates the subscription process. The RSS reader checks the user's subscribed feeds regularly for new content, downloads any updates that it finds, and provides a user interface to monitor and read the feeds.
Liferea is a simple FeedReader clone for GNOME. It is a reader for RSS/RDF feeds which also supports CDF channels, Atom/Echo/PIE feeds and OCS directories.Liferea is an abbreviation for Linux Feed Reader.
Install liferea in Ubuntu
sudo aptitude install liferea
Evolution RSS Reader Plugin
This plugin adds RSS Feeds support for evolution mail.With this package you are able to have RSS in same place as mails, eliminating the need of having a separate RSS reader since a RSS Article is like an email message.Evolution RSS can display an article using summary view or HTML view.
Install Evolution RSS Reader Plugin in Ubuntu
sudo aptitude install evolution-rss
NRSS is a console based RSS reader allowing uses to read and manage RSS feeds with a simple to use interface. Like most graphical RSS readers it provides a three pane interface for ease of use in managing multiple feeds.
Install nrss in Ubuntu
sudo aptitude install nrss
console RSS reader that monitors a feed and outputs new entriesThis small, simple application reads an RSS feed an outputs it like the tail 'tail' command.
Install rsstail in Ubuntu
sudo aptitude install rsstail
RSS reader for the notification areaYet Another RSS Reader is an RSS aggregator and reader that displays its results in the GNOME or KDE system tray (notification area). To view the contents of the feed just click the menu-item and it will launch in your favorite browser.
Install yarssr in Ubuntu
sudo aptitude install yarssr
Feeds (RSS/Atom) reader plugin for Claws MailThe RSSyl plugin provides feeds reading capability for Claws Mail mailer.Supported formats are RSS (1.0, 2.0 and probably 0.9x versions) and Atom feeds.It integrates also with dillo viewer plugin to allow online browsing of entries, and has per-feed customization features, transforming your Claws Mail into a powerful lightweight feeds reader.
Install claws-mail-feeds-reader in Ubuntu
sudo aptitude install claws-mail-feeds-reader
an RSS aggregator for GNOMEImendio Blam is an RSS aggregator written in C# using Mono, GTK#, Atom.NET and RSS.NET.
Install blam in Ubuntu
sudo aptitude install blam
mail/news client with RSS and integrated spam filter supportThunderbird is a mail/news/RSS client.
Install thunderbird in Ubuntu
sudo aptitude install thunderbird
Firefox delivers safe, easy web browsing. A familiar user interface, enhanced security features including protection from online identity theft, and integrated search let you get the most out of the web.
This browser was previously known as Firefox 2, Firebird and Phoenix.Install this firefox package too, if you want to be automatically upgraded to new major firefox versions in the future.
Install Firefox 3 in Ubuntu
sudo aptitude install firefox-3.0
desktop news aggregator for GNOMEStraw is a desktop news aggregator for the GNOME environment. News aggregators collect news, weblog posts, and other information from the web so that they can be read in a single place.
Install straw in Ubuntu
sudo aptitude install straw
news ticker applet for KDEThis is a news ticker applet for the KDE panel. It can scroll news from your favorite news sites, such as lwn.net, /. and freshmeat.net. To achieve this, KNewsTicker requires the news sites to provide a RSS feed to newsitems. KNewsTicker already comes with a selection of good news sources which provide such files.This package is part of KDE, as a component of the KDE network module. See the 'kde' and 'kdenetwork' packages for more information.
Install knewsticker in Ubuntu
sudo aptitude install knewsticker
RSS feed aggregator for KDEaKregator is a fast, lightweight, and intuitive feed reader program for KDE. It allows you to quickly browse through hundreds of thousands of internet feeds in a quick, efficient, and familiar way.This package is part of KDE, and a component of the KDE PIM module. See the 'kde' and 'kdepim' packages for more information.
Install akregator in Ubuntu
sudo aptitude install akregator
lightweight RSS and Atom feed reader for FirefoxSage is a Firefox extension that reads RSS (2.0, 1.0, 0.9x) and Atom feeds. It integrates with the "Live bookmark" feature of firefox.Sage has highly customizable rendering via the use of style sheets. It also features feed discovery, and RSS search engine integration.
Install firefox-sage in Ubuntu
sudo aptitude install firefox-sage
text mode rss feed reader with podcast supportnewsbeuter is an innovative RSS feed reader for the text console. It supports OPML import/exports, HTML rendering, podcast (podbeuter), offline reading, searching and storing articles to your filesystem, and many more features.Its user interface is coherent, easy to use, and might look common to users of mutt and slrn.
Install newsbeuter in Ubuntu
sudo aptitude install newsbeuter
Text mode RSS newsreaderSnownews is a text mode RSS/RDF newsreader (similar to what lynx is for web-browsing). It supports RSS 1.0 feeds that comply with the W3C RDF specification and also supports Radio Userland's RSS 0.91 and 2.0 versions. It also includes the following additional features:
HTTP proxy support
Correctly handles HTTP 301, 304, and gzip/deflate Content-Encodings.
Imports OPML (Outline Processor Markup Language) subscription lists
Fully customizable key bindings
Customizable color support
Install snownews in Ubuntu
sudo aptitude install snownews
console RSS aggregatorRaggle is a console RSS (RDF Site Summary) aggregator, written in Ruby . Features include: customizable keybindings, basic HTML rendering, HTTP proxy support, OPML import/export, themes, support for various versions of RSS, browser auto-detection, bookmarks and more.
Install raggle in Ubuntu
sudo aptitude install raggle
Subscribing to newsfeeds with Opera is extremely simple, as most newsfeeds will automatically be subscribed when you click their links on a Web page. The feed will show up under "Newsfeeds" at the bottom of your "Mail" panel.
Download opera from here and install .debpackage using the following command
sudo dpkg -i packagename
Applications that collect data from RSS-compliant sites are called RSS readers or "aggregators." RSSOwl is such an application. RSSOwl lets you gather, organize, update, and store information from any compliant source in a convenient, easy to use interface, save selected information in various formats for offline viewing and sharing, and much more. It's easy to configure, available in many many languages and the best of all: It's platform-independent.
Other than this list there are online rss readers like google reader,bloglines and many more


text:
Dr. Weeks' Comment: Many things conspire to interfere with immune-maintaining, health restoring deep (stage 3,4) sleep. This is especially so in children whose levels of sleep enhancing neurotransmitter melatonin are extinguished by their lifestyle habit of staring into lit screens (TVs, computers, ipads, phones etc.) right up until the moment they shut their eyes and try to go to sleep. The light from these devices is quite intense! (If you don't believe me, turn one on at night and see how painful it is to look into it when the room is dark!) Now we are reminded that sleep disruption disrupts other important functions like…. reproduction! This is worth discussing with your kids.
"….Researchers found that the majority of LH pulses that occur after sleep are preceded by deep sleep suggesting that deep sleep is intimately involved in pubertal onset…."
Puberty Turned On by Brain During Deep Sleep
ScienceDaily (Sep. 11, 2012) "" Slow-wave sleep, or 'deep sleep', is intimately involved in the complex control of the onset of puberty, according to a recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology and Metabolism (JCEM).
The many changes that occur in boys and girls during puberty are triggered by changes in the brain. Previous studies have shown that the parts of the brain that control puberty first become active during sleep, but the present study shows that it is deep sleep, rather than sleep in general, that is associated with this activity.
"If the parts of the brain that activate the reproductive system depend on deep sleep, then we need to be concerned that inadequate or disturbed sleep in children and young adolescents may interfere with normal pubertal maturation," said Harvard researcher, Natalie Shaw, MD, of Massachusetts General Hospital and Boston Children's Hospital who led the study. "This is particularly true for children who have been diagnosed with sleep disorders, but may also have more widespread implications as recent studies have found that most adolescents get less sleep than they require."
In the study, researchers examined pulses of luteinizing hormone (LH) secretion in relation to specific sleep stages in children ages 9-15. LH is essential for reproduction and triggers ovulation in females and stimulates the production of testosterone in males. Researchers found that the majority of LH pulses that occur after sleep are preceded by deep sleep suggesting that deep sleep is intimately involved in pubertal onset.
Other Harvard researchers participating in the study included James Butler of Brigham & Women's Hospital; and Scott McKinney, Susan Nelson, Jeffery Ellenbogen and senior author Janet Hall, all of Massachusetts General Hospital.
Journal Reference:
- N. D. Shaw, J. P. Butler, S. M. McKinney, S. A. Nelson, J. M. Ellenbogen, J. E. Hall. Insights into Puberty: The Relationship between Sleep Stages and Pulsatile LH Secretion. Journal of Clinical Endocrinology & Metabolism, 2012; DOI: 10.1210/jc.2012-2692


text:
UPDATE: See our latest skywatching tips to see Mars at opposition here: Mars Visible in Night Sky, But Its 2 Moons Are Hard to Spot
Mars will make a close approach to Earth Saturday (March 3), and interested skywatchers can follow the action live online.
Every 26 months, the orbits of Earth and Mars align such that the two planets form a relatively straight line with the sun. This cosmic event is called an opposition, because the Red Planet sits on the exact opposite side of Earth from the sun.
Mars will be in opposition to Earth Saturday, and it will be visible even to stargazers under the cloudiest of skies. That's because the online Slooh Space Camera will broadcast a free, real-time feed of the Mars opposition, beginning at 11:00 p.m. EST (0400 GMT on March 4).
Slooh will provide footage from multiple observatories around the world, including Arizona and the Canary Islands off the coast of Africa. The broadcast can be accessed at Slooh's homepage, found here: http://events.slooh.com/
Though the opposition occurs Saturday, the Red Planet's actual closest approach to Earth won't come until Monday (March 5), when the two bodies are separated by about 62.6 million miles (100.7 million kilometers). This discrepancy in dates is caused by Mars' elliptical path around the sun. [Amazing Mars Photos]
The Red Planet's oval orbit also dictates that some oppositions bring it much closer to Earth than others. Saturday's opposition isn't one of the closer ones, because it occurs when Mars is near aphelion, or the farthest it gets from the sun during an orbit.
The Mars opposition of 2003, on the other hand, occurred when the Red Planet was near perihelion, or its closest distance to the sun. During that approach, Mars came within about 34.8 million miles (56 million kilometers) of our planet — the closest the two planets have been in nearly 60,000 years.
Skywatchers who want to observe the Mars opposition the old-fashioned way can find the Red Planet in the constellation Leo on Saturday. Mars will rise in the east at about the same time the sun sets in the west.
This sky map of the Mars opposition shows how the Red Planet will appear in the night sky.
Mars will outshine all the stars in Leo; it should be readily visible to the naked eye as an unblinking pale red dot. With a decent telescope, skywatchers should be able to see the Red Planet's ice caps and perhaps some other surface features.
This isn't the first time that the Slooh Space Camera has broadcast live views of cosmic events. Last month, for example, the online skywatching service webcast a live look at a rare triple conjunction that brought Venus, Jupiter and the moon close together in the night sky.
If you snap an amazing photo of Mars or any other skywatching target and would like to share it for a possible story or image gallery, please contact SPACE.com managing editor Tariq Malik at firstname.lastname@example.com.
- Our Solar System: A Photo Tour of the Planets
- Telescopes for Beginners — 2012 Reviews
- Skywatching Books: Sky Maps and Charts for Night Sky Viewing
Copyright 2012 SPACE.com, a TechMediaNetwork company. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
Bill Watterson, the famously reclusive creator of beloved comic strip Calvin and Hobbes, returned to your newspaper's comics page this week, and you probably didn't even notice. The sub rosa comic strips – three of them, to be exact – are the first Watterson has illustrated and published in almost 20 years.
So why didn't you notice Watterson's return – and how come you didn't hear about it sooner? Two reasons.
- The comics were a collaboration between Watterson and cartoonist Stephan Pastis, creator of Pearls Before Swine, but ran under Pastis' name.
- Pastis promised that he would keep the collaboration a secret until all three of Watterson's strips had run.
Pastis kept his word. Watterson's strips ran on June 4th, 5th and 6th. This morning, Pastis went public on his blog. There, he tells the story of how the collaboration came to be. The story begins with the following comic strip, which Pastis sent to Watterson in thanks "for all his great work and the influence he'd had on me." He never expected a reply.
Not only did Watterson reply, he told Pastis he had an idea for a strip:
He said he knew that in my strip, I frequently make fun of my own art skills. And that he thought it would be funny to have me get hit on the head or something and suddenly be able to draw. Then he'd step in and draw my comic strip for a few days.
That's right.
The cartoonist who last drew Calvin and Hobbes riding their sled into history would return to the comics page.
To draw Pearls Before Swine.
...The idea I proposed was that instead of having me get hit on the head, I would pretend that Pearls was being drawn by a precocious second grader who thought my art was crap.
The collaboration was born.
Pictured above, in the middle panel, is the first of illustration of Watterson's to appear in a newspaper's funny pages since the final strip of Calvin and Hobbes was published on December 31, 1995. (A near exception: Watterson recently provided the poster art for the cartoon documentary Stripped.) Watterson's second strip in almost 20 years appears at the top of this post.
Watterson's final strip, and the two strips in which Pastis introduces Libby, Watterson's 7-year-old alter ego, can be accessed via Pastis' blog, where he relates the story from start to finish with characteristic humor and humility.


text:
Your privacy is important, and we will do our best to protect it.
We will not share names, addresses, emails, or any other info with any third party. The only exception to this would be a government/law-enforcement agency with a subpoena.
We do not 'rent' a list, and we do not send third party advertisements to our membership.
Also, we will store your IP address and browser-type, in case the cookie is removed.
Bottom line: We collect no personal info for just visiting our site
This is our current and complete privacy policy, as of January, 2006.
Any changes to this will be noted at http://vs-trex.com/privacy.php.


text:
Pouring On Better Health: Drink Me Slim Launches A First-Ever Caffeine-Free Appetite Suppressant & Fat-Burning Beverage.
Delicious New Shot-Size Drink Powered By Proven, Natural Weight Loss, Metabolism-Boosting Ingredients Garcinia Cambogia, L-Carnitine and Green Tea.
LOS ANGELES, CA, APRIL 2, 2013 – Representing the first product of its kind in the category and a distinct alternative to dysfunctional functional beverages, Drink Me™ Slim is being introduced as the only caffeine-free appetite suppressant and fat-burning drink available today.
Packaged in convenient 3-ounce, 10-calorie bottles that can easily be carried in purses, jackets, gym bags, briefcases and backpacks, Drink Me Slim beverages are ideal for consumers yearning to manage their portions – the ultimate key to long-term weight control – and burn additional fat during exercise workouts. MSRP is $3.29 per bottle.
The new brand is being introduced this Spring, first in the Ft. Worth area and then soon thereafter in Los Angeles. The company is in discussions with a wide array of national distributors and retailers and is expected to announce additional major market locations shortly.
Berry-flavored Drink Me Slim is also available for purchase on the www.drinkmeslim.com website, with several prominent etail partners expected to soon carry the novel product as well.
Created to offer consumers a delectably efficacious alternative to the countless unreliable and even unhealthy weight-loss and fat burning beverages that have flooded the market during recent years, Drink Me Slim is not only completely free of caffeine, but is powered by a proprietary blend of five proven appetite-suppressant and metabolism-boosting natural ingredients:
- Green Tea – A timelessly popular drink first used to treat ailments in ancient China, green tea today has been widely shown to help suppress appetites and even help lower one's risk of developing heart disease or certain types of cancer.
- Garcinia Cambogia – Deemed the holy grail of weight loss by Dr. Oz, Garcinia Cambogia extract (hydroxycitric acid or HCA) has been clinically proven to promote fullness, reduce appetite and inhibit fat production. Added benefits include a decrease in belly fat, a mood-balancing increase in serotonin and the management of the stress hormone cortizol. Garcinia Cambogia is derived from a small, pumpkin-shaped fruit native to Indonesia but also grown in other parts of Asia and in Western and Central Africa.
- L-Carnitine – A nutritional supplement known to boost metabolism and serve as a mild appetite suppressant, L-Carnitine is widely regarded as perhaps the most effective fat burner available today. Carnitine is a nitrogen-containing compound that assists in fat metabolism and is responsible for transporting fatty acids into the mitochondria so they can be used for energy production.
- Fibersol 2 – Clinical studies have repeatedly shown the health benefits of increased fiber intake, especially in helping those facing weight management, digestive and diabetes-related issues. Researchers from the U.S. National Cancer Institute reported recently that increased dietary intakes of fiber are also associated with helping combat cardiovascular, infectious, and respiratory diseases.
- Chromium Picolinate – Often used in alternative medicine to promote lower cholesterol or improve the body's use of glucose, Chromium Picolinate works in tandem with insulin produced by the pancreas to metabolize carbohydrates.
Drink Me Slim is also free of high-fructose corn syrup and provides 100% of the recommended daily amount of vitamins B-12 and B-6, along with 50% RDA of vitamin C. Consumers should consume three bottles per day before meals for optimal results, including one bottle 20 to 30 minutes before exercising. The product is recommended for consumers aged 12 and up.
According to an article on the Mayoclinic.com site, energy drinks containing sugar may contribute to weight gain, while excess caffeine can result in tension, irritability, insomnia, rapid heartbeat and increased blood pressure. Drink Me Slim is free of both sugar and caffeine, while providing effective ingredients such as L-Carnitine and Garcinia Cambogia in a much more appealing form than bulky supplement pills. All of which explains why Drink Me Slim is already taking off as the ultimate natural, caffeine-free chaser.
"Our goal in developing Drink Me Slim was to create the first caffeine-free appetite suppressant and fat-burning shot-sized beverage on the market and to ensure that it remained every bit as tasty and healthy as it is effective," said Drink Me Slim co-founder and CEO Christopher Dyson. "We're extremely heartened by the initial reaction to the product among both women and men, most of whom – like me – had spent years investing in weight loss and energy enhancement products loaded with calories, sugar and caffeine, driven by hype, and decidedly unappetizing to consume. We look forward to a very successful launch in Texas, a state trying to cope with a very high obesity rate, and Los Angeles, which has helped set health trends in the country for decades."
About Drink Me Slim
Created to offer consumers a delicious, natural and caffeine-free appetite suppressant and fat burner in one conveniently portable bottle, Drink Me™ Slim is the only beverage of its kind on the market today. Powered by a proprietary blend that includes the proven weight management and fat-burning properties associated with green tea, Garcinia Cambogia and L-Carnitine, Drink Me Slim is launching in Dallas/Ft. Worth and select retailers in Los Angeles in March, 2013, and is also available direct to consumers at www.drinkmeslim.com.


text:
About Alstroemeria
ALSTROEMERIA PERUVIAN LILY. All are outstanding cut flowers and like a well drained, fertile soil. Mulching, especially the first winter, can make them hardy in colder zones than stated.
PLEASE read the following important information about growing and shipping Alstroemerias, which is very important to USDA hardiness zones 7 and colder, less so for zone 8 and less still for zone 9. As you may have noticed, Alstroemerias, especially tall ones, are hard to come by. The following will explain some of that.
BEST TIME TO ORDER is early January; we make all varieties available in the first days of the year.
GUARANTEE/COLD HARDINESS: The USDA hardiness zones indicated are to be used as a guide only to determine which are hardier than others, which is a guess at best. As with any plant, cold hardiness depends on many more factors than just average minimum winter temperatures: Soil type, fertility, microclimate, time of planting, abnormal weather patterns etc. This is truer to Alstroemerias than with most other perennials and thus we cannot guarantee their winter survival in your area, regardless of your zone. A good layer of mulch over winter is essential in zones 7 and lower. If you are not sure if they'll grow in your area, try just a few for starters or ask/join a local garden club. Alternatively, you can grow them in pots and winter over in a cold but frost free room – the cooler the better.
STRONG GROWERS: Following a list of our strongest growers, recommended if you've never grown them before, had trouble growing them or for colder zones: 'Adonis', 'Apollo', Apricot [Butterscotch], 'Casablanca', 'Cerise', 'Dusty Rose', 'Etna', 'Glory of the Andes', cream-white tall, 'Inca Ice', 'Majestic Henri', Majestic Lire', Majestic Louis', 'Mauve Majesty', 'Moulin Rouge', Peachy Orange, 'Purple Rain', 'Sussex Gold', 'Tessa', 'Third Harmonic' and 'Watermelon'
SHIPPING/TIMING: The best time to plant and ship Alstroemerias is as early in spring as possible. This way the plants have all season to get established and also ship much better instead later in the season when they are up to 3 feet tall. Into the second week of April we can ship them without top growth, in which state they'll travel better than with top growth and shipping cost may be reduced (explained later). Later in the season Alstroemerias don't like to be trimmed down and have to be shipped with tops. This is fairly easy for the remainder of April. Later, May thru mid June they get long, tender stems, up to 2 feet and more, and since they are in 4" pots, sometimes may have only 2-3 stems. Mid June through mid July we don't recommend shipping them at all (except the dwarfs; 18" and shorter) but can do so at your own risk. The second best time to plant and ship is mid July thru August, as they again can be shipped without tops. But keep in mind that this could affect the cold hardiness in colder zones.
SHIPPING COSTS: Mid July into the second week of April (April 11, 2023; need order by April 6) we ship them without top growth and can fit 6 plants into a medium flat rate box. On orders of at least 4 Alstroemeria, if the shopping cart charges $22.50 and over, we'll reimburse for amounts over $20.00. 9 plants can fit into a large flat rate box, then we'll reimburse shipping if you get charged $27.50 and over for the amount going over $25.00. This, however, only works if you can receive US Mail and choose them as carrier. The third week of April thru June we don't recommend it as this is the main growth and blooming season for them.
Filter by:Clear All


text:
Gujarat Rojgar Samachar (30/12/2020):- The government of Gujarat publishes various government and private jobs from time to time through Gujarat Samachar Employment News. Applicants, As per Analysis, We Get the Information that around 3.57 million People unemployed in Gujarat so aspirants who're finding Jobs in Gujarat may get Gujarat Rozgaar Samachar in Gujarati/English language and apply for particular posts as soon as possible. You can acquire whole information about Gujarat Samachar Job Vacancy News from this page which is created by the team of www.sandeshedu.com
Gujarat Rojgar Samachar (30/12/2020):-
Rojgar is the salary that we will find from getting a line of work. So the Gujarat Rojgar Samachar is a news release that will assist right now jobless individuals with getting a vocation. The news magazine is also open in a pdf structure in the Gujarat information site. It is of monstrous assistance as everything is clarified in a decent and basic manner
Teachers are great sources of knowledge, prosperity, and enlightenment from which anyone can be benefited for a whole life. They serve as the real light in everyone's life as they help students to make their way in life. They are the God gifted people in everyone's life who lead us towards success without any selfishness. Really, we can call them builders of the dazzling future of our nation through education.
The teacher plays a very essential role in the field of education who teaches students very nicely to be a person of good morals and behavior. They make students academically superb and always encourage them to do better in life. They equip students with lots of knowledge, skills, and positive attitudes so that students can never feel lost and go ahead. They help students to get sure about their goals of education through clear vision and ideas. Without teachers in life, one cannot grow mentally, socially, and intellectually
Main Topic In Gujarat Rojgar Samachar (30/12/2020)
- The Posts of Gramin Dak Sevaks: Gujarat Sirsale
- Gujarat State Electricity Corporation Limited
- State Bank of India
- Question Bank
- Confusion and Guidance
Important Link
Gujarat Rojgar Samachar (30/12/2020)
More Gujarat Rojgar Samachar
www.sandeshedu.com provides information about all types of new jobs, academic news, and competitive exam materials in Gujarat and India. From here you can get different jobs. Such as graduate jobs, engineer jobs, diploma candidate jobs, MBA jobs, low jobs, and various other jobs. Our site is famous for the preparation of competitive exams. We provide complete examination material for examinations conducted from TET, HIT, TET, Police Examination, Clerk Examination, GPSC Examination, Panchayat Clerical Examination, and other Gujarat Levels. Visit every day for the latest offers of various brands and other technology updates.


text:
It will be replaced with a food outlet, concept to be determined, operated by the university's Residential and Dining Services (R&DE), Jamie Beckett, director of communications for the Stanford School of Engineering, said Friday.
"Although the exact format hasn't been determined, R&DE will offer a variety of menu options inspired by fresh and locally grown products," Beckett said. "Student focus groups will work with the new vendor to tighten the concept and select a name for this new café."
Ike's service contract is set to expire in June, meaning the space went up for bid earlier this year. Owner Ike Shehadeh said in January he planned to put in a bid to reclaim the space, and rumor had it other popular on- and off-campus eateries like Coupa Café threw their hat in the ring as well.
An online petition to keep Ike's on campus circulated for the past few months and successfully passed its goal of 1,000 signatures. But a committee of students and staff from all four buildings in the Science and Engineering Quad unanimously chose R&DE, Beckett said.
"Selection was based on several criteria, including the ability to meet the needs of Science and Engineering Quad (SEQ) users," she said. "Other deciding factors included sustainability and commitment to green practices, as well as reputation and staff pay, benefits and turnover."
The Stanford Daily reported that a group of students protested the decision on Saturday afternoon. It also published a student op-ed this wee that criticizes the committee's decision and urges R&DE to forfeit its new lease.
Beckett said SEQ surveyed more than 900 students to help make the decision, with 83 percent rating quality of food as their top priority, followed by price/value for money (77 percent with 62 percent preferring prices between $5 and $7.50), ease/convenience (77 percent), healthy options (36 percent) and variety/rotating choices/seasonal food (21 percent).
Beckett said survey respondents also indicated they prefer wait times of less than 10 minutes.
R&DE operates a number of other campus eateries, including Russo Café at the law school, Med Café at Li Ka Shing and the café at the Arrillaga Alumni Center.
The new eatery will open on Sept 2.
Ike's owner Shehadeh said he has no new location to transfer to, on or off campus, but has looked preliminarily in the area.


text:
SAVANNAH, GA – Zombie experts from across the world are predicting an uprising of Zombies in May of next year.
Zombie researchers at the University of Georgia, Princeton University and the University of Notre Dame wrote a paper entitled, "The Zombie Revolution" early this year and presented to the U.N. Panel on Zombies just a few weeks ago.
In the paper the top Zombie researchers in the country say that the climate, the economic downturn, rise of digital technology and the "dumbing down" of society are all contributing to an unrest among Zombies.
The unrest has been building for ten years. Many experts from many different organizations, including the CDC, have already predicted a Zombie Apocalypse, but researchers say that it will be more of an "uprising" or "revolution".
"Zombies want to overturn the current way of life in America," said Professor Joseph Bunstrov of Princeton University. "Zombies see a decline in ethics, morals, and a general decline in "common sense." In the past, when Zombies have risen up – most notably in the 1936 and 1974 – they have tried to stir the general population into some sort of action to reverse a particular cultural course in America."
Bunstrov went on to say that the Zombie Revolution predicted for 2012 has the potential to be ten times as large as any in the past. "No community in America will be spared," Bunstrov warned. "Zombies have become more sophisticated over the years. They are now capable of taking advantage of technology – thought they strongly oppose it. Zombies have better communication between the different Zombie Tribes. It will be a massive revolution."
So what cities do researchers predict will affected the most?
"It's hard to say right now," said Bunstrov. "In a few months we will have a clearer picture. Washington DC seems to be a city we mentioned frequently in the communications we have intercepted recently. But for some odd reason, Buffalo, New York is also mentioned – as is Austin, Texas."
There are multiple militia groups forming to prepare to fight the Zombies next May. "We gotta be prepared for these monsters," said Dale Carson of Grand Rapids, MI. "Zombies will not get me and my family. You can bet on that."
We sure do hope so, Dale.
WWN will be following this story closely. In the meantime, here's a helpful video:


text:
Life After Failing TVM Treatments is a Rollercoaster of Side Effects for Women
04/03/2013 // Concord, CA, USA // Vaginal Mesh Website // Life Care Solutions Group // (press release)
Imagine what it would feel like to have a cheese grater wearing at your tissue every time you moved. For women with transvaginal mesh (TVM) implants this stomach wrenching analogy can hit home all too closely. Complications from the surgical mesh began being reported shortly after it was introduced in the 1990's. With years of data supporting the dangers of transvaginal mesh the question arises – Why did the FDA not issue a warning until 2008?
Conditions Treated by Transvaginal Mesh
The practice of inserting surgical mesh into women arose as a solution to multiple medical conditions involving the bladder and reproductive organs. TVM was used to treat:
* Pelvic organ prolapse, a condition marked by weakened pelvic muscles and organs (such as the bladder, rectum and uterus) dropping into the vagina. Prolapse most often affects women after childbirth, a hysterectomy or menopause.
* Stress urinary incontinence, a problem marked by leaking urine as a result of pelvic muscles that are unable to support the bladder and urethra.
These types of conditions were treated with surgical slings made of the mesh. In research reviewed by the FDA ten percent of women treated with TVM to correct pelvic organ prolapse faced severe and life changing complications within one year of the surgery.
Complications Caused by Transvaginal Mesh
The most serious complication of TVM is mesh erosion or mesh extrusion. Transvaginal erosion occurs when the coarse edges of the synthetic material cut through the vaginal lining and other neighboring organs. This can cause a number of problems including infection, bleeding, organ perforation, painful intercourse or even urinary incontinence. Other less severe complication caused by transvaginal mesh are constipation, vaginal scaring and bladder infections.
Resources for Sufferers of Transvaginal Mesh Side Effects
Four major manufacturers produced the majority of surgical mesh used in the United States. These companies have been served with over 700 lawsuits from women affected by the transvaginal mesh product. Receiving financial compensation alone is not enough for the women who suffer from TVM complications. The side effects of the mesh often leave life-long physical and emotional damage that leave women unable to live the lives they were meant for.
There is a resource for women in need of assistance to rebuild their lives and planning for the future after transvaginal mesh or surgical sling implants failed them. To assist sufferers of mesh implant complications Dr. Greg Vigna, a Certified Life Care Planner and founder of the Life Care Solutions Group, recently launched TVM123.com. Commenting on the TVM resource Greg notes, "I am pleased to mention Dr. Michael Hibner, an internationally recognized authority in the field of urogynecology, along with attorney Howard Nations who together with the Life Care Solutions Group are offering the best in medical information and comprehensive legal solutions for your transvaginal mesh case." Women are encouraged to visit TVM123.com to learn how to take their life back after experiencing mesh surgery side effects.
Media Information:
Address: 1401 Willow Pass Road, Concord, CA 94520
Phone: 888.855.1674
Url: http://tvm.lifecare123.com/life-after-failing-tvm-treatments-is-a-rollercoaster-of-side-effects-for-women_9022.html


text:
Monday, March 12, 2012
Review: Bourne
Lisa T. Bergren
Historical Young Adult
Available Now
Received from author for review
THE STORY (from author website)
In this e-novella, River of Time #3.1, the dramatic tale about the Betarrinis and Forellis continues, picking up directly after where Torrent left off… The battle is done at the front, but the battle is only beginning back at Castello Forelli. Marcello fights for his life; Lord Greco fights to find his place; and Lia fights for love.
A read that's easily devoured in a single sitting, Bourne is a treat for fans of The River of Time series, returning us to the Betarrinis for a brief but emotionally and physically intense visit before leaving us wanting more of everything from the characters and world we've come to care about so much. This novella gives a little something new in the form of Lia's point of view, allowing us into the head of the younger Betarrini sister as she and Luca continue their romantically-tense dance, but with the new we also have the familiar comfort of Gabriella's perspective as she and Marcello deal with the aftermath of the events of Torrent. As always, Ms. Bergen sublimely depicts both the beauty and the ugliness of life in medieval Italy, sweet flirtations accompanying the brutality of war to leave us utterly exhausted by the end given all the energy we've expelled reveling in the happy moments and despairing in the tragic ones.
Gabi and Lia are as enjoyable as ever, both strong-willed women who've proven themselves to be skilled fighters, and it's nothing short of an absolute pleasure to watch as these modern young woman are courted in a time of chivalry and extreme gallantry. Both girls delight in Marcello and Luca's ingrained sense of honor at the same time they rebel against it, wanting to take up arms and defend those they love with every ounce of strength they possess instead of playing demure ladies who simply wait for their loved ones to return from battle. Spending extra time with Lia and Luca is thrilling, the tension between them crackling so strongly we can almost feel the tingles in our fingertips as we touch the pages (or screen as it were), our desire to see their romance unfold all-encompassing now that Marcello and Gabi are married.
Fans of Lord Greco may be slightly disappointed in this novella as Rodolfo is present throughout but definitely relegated to the background when Lia and Luca take center stage, and though we certainly won't complain about the new couple at the forefront, we can't help but want more time with the man who is an undeniably intriguing mystery–sometimes a friend and sometimes a foe, but always someone who draws our gaze whether or not he is meant to be the object of our unwavering focus. Overall, Ms. Bergren packs a great deal of action as well as a touch of romance in a short number of pages, reminding us of what we love about this world and the characters who inhabit it while also making it glaringly apparent that we'll not be satisfied until we have happy endings for every single person to whom we've been introduced.
Rating 4/5
33 comments:
I'm really in love with the last line of your review because that's exactly what I think a novella is for! <3 It's meant to be entertaining and to remind us what we love about the characters, so I'm glad that this novella does that! :) And the chemistry between Lia and Luca (who have very awesome names) sounds combustible!ReplyDelete
Beautiful review, Jenny! This series is slowly but surely making its way to the top of my TBR pile, and this review just gave it a little boost! ;) <3
Hmmmm never heard of this before, but you have a way of making me want to read books I would never otherwise consider (naturally) ;)ReplyDelete
Great review!
Mimi - I really enjoyed this series, it was fun to see modern day young women sent back to the medieval time period:) And Marcello, Luca, and Greco are super swoon worthy!ReplyDelete
Melissa - I think you would like these books! They're really fun with some grit and darkness mixed in to suit the time period:)
I have heard nothing but good things about this series. I really need to read it already! I think I have the first book on my Nook... I need to check on that! Glad you enjoyed this!ReplyDelete
Thanks so much for reading River #3.1, Jenny! You are truly a She-Wolf among book reviewers...What a comprehensive review! Rodolfo is coming along...Felt like he really needed some time to digest what has happened before he takes center stage in TRIBUTARY (#3.2, coming in June!). A hero's heart, after all, has to be whole, before it can be shared with another. Right? xoxoReplyDelete
- AnonymousMarch 12, 2012 at 11:51 AM
Jenny- Love love your review! I agree with you....more Greco!! I think book 4 will blow us all away I..cant wait!!!ReplyDelete
Oh my gosh this series has my hackles all up too when people give it a hard time...I left a snarky comment on an Amazon review because they said something mean about Lisa...I NEVER DO THAT!!!!!!! Im starting my own GR scandal.....Dont mess with Greco or its creator.......lol
You just reminded me that I need to catch up and get started on book two!ReplyDelete
Nice review :)
Christy - I just love this series, the characters are brilliantly executed in my opinion!ReplyDelete
Lisa - Of course! You know my love for this series (and GRECO!!!!!) runs deep:) Also, I might die waiting for TRIBUTARY. Just saying.
Tina - MORE GRECO!!!! That will always be my wish for this series no matter how much Greco we actually get:) And I wrote you an email.
Lea - YAY! I think the books get better as they go:)
I agree with Mimi. Sometimes we want to know what's going on with everyone! Again, a beautiful review. I love the Medieval Era, but have never read anything that took place in Italy.ReplyDelete
I think this may be the book to get me back to reading. I feel like I'm in a massive slump right now and it seems that characters I've already grown to love do a lot for my reading slumps. :) I've got to go pick this book up from Amazon.ReplyDelete
This series is new to me. I'm glad that you really enjoyed it.ReplyDelete
I LOVE the River of Time series. It's definitely one of my all time favourites and I am determined to get round to this short as soon as possible. It'll be nice to return to that world, even if for a few short hours. :) Wonderful review!ReplyDelete
I have only read the first book in this series. It has quite a fan following. I thought I recenlty read something about a continuation of the series. I love,nice short little novelllas. Oh I see reading the comments that Lisa is working on another book. I need to read the other two books now.ReplyDelete
I really liked Luca and Lia and I want to see them together.
"romantically-tense dance"ReplyDelete
Oh, what a delicious way to word their love story, Jenny. Those two!
But, you're right, I'm a little disappointed we don't get more Greco face time. I was really hoping the story would be told from his POV.
Well I've yet to read the first 3 books in this series... But everyone raves about those too! LolReplyDelete
I think I am thinking of the right series but I better google to be sureReplyDelete
Pam - Yep. I want more of everyone in this series! Especially Grego. Have I made that clear? ;-)ReplyDelete
Jen - It's a super quick read, you'll blow through it in no time. Loved:)
Jennifer - I'm a huge fan of this series - really amazing characters:)
Sam - YAY! ME TOO! Can't wait to see what you think:)
Heidi - I'm hoping she'll get to do more full length novels, but I'm content for now with fun novellas:)
Missie - Love Lia and Luca, but Greco is my guy. I want LOTS more of him:)
Ashley - DO IT! I think you'll like them:)
Linda - I highly recommend these books:)
Yep, I want more Lord Greco too! We have to talk EVERYONE we know into buying this whole series so she can sell more of her books so we can get more Lord Greco!ReplyDelete
I've always wanted to take the time to read this series but I've never taken the time to DO IT. I even have the first book. What's my problem, Jenny?ReplyDelete
I think it'd be fun to go back and be "courted" and have men treat me gallantly. I'm sure I'd tire of all the other bits--no deodorant, poor hygiene, death at a young age--but it'd be fun to be pampered for a while.ReplyDelete
And novellas sometimes fill that big gap between books, like a snack between meals.
I hear such great things about this series from everyone, including you, I can't believe I still haven't started it yet! Love the review. These novellas are always so great when you want a taste of the writer's style or you're missing the characters. :)ReplyDelete
YOU TOTALLY DESCRIBED THE WAY I FELT. It's like you plucked the words and feelings jumping around in my head and poured them out so eloquently. Gosh, THIS IS A TREAT for us fans. I adored this story so much, I was grinning almost the whole way through :DReplyDelete
— Asher
*sobs to hear that Rodolfo was relegated to the background* On the other hand, I'm curious to see things through the eyes of Lia and thrilled that we get more of Luca. I can't wait for book 4!ReplyDelete
Oh, and Rodolfo's happy ending shall be with me.
I love this cover. Though I haven't read the Rive of Time series yet I do remember hearing how great is is from you and from other bloggers.ReplyDelete
Okay, I didn't read the review, because I haven't read past Waterfall yet. I know for shame, for shame. But I will! Could we have another read-a-long?ReplyDelete
Sounds great. I would miss Lord Greco's presence, but I can't get enough of Luca. And I like that Lia's POV is in there now. Is this one free?ReplyDelete
Thanks for the fabuous review Jenny !! I ordered the first book in the River of Times series yesterday because I've heard amazing things about it and I can't wait to get it and start reading this wonderful series !!ReplyDelete
- AnonymousMarch 13, 2012 at 4:09 PM
ACK! Can you believe I still have the first one on my tbr staring at me... willing me to read it. Oh I think I need to get this one to add to that reading list. It looks like a great addition!ReplyDelete
BTW... anon was me... don't know why it did that. :PReplyDelete
So excited for this book! Loved the review Jenny!ReplyDelete
I was just saying on Tweet that I wish she'd come up with more books, I feel like the story is far from being over! There's so much more...ReplyDelete
I wish it weren't a novella but it does give me hope that she's not completely done with the series!
Thank you so much for sharing this!!! Big hugs for this info and off I go to get it!
Oh gosh, here is another series that I have had for a while but have yet to read! I love the fact that you can read this entire novella in one sitting and I especially love the fact that Lisa works so hard in making sure that each of her characters get the ending that they deserve! Must move this up in my TBR pile!ReplyDelete
This was an awesome book! I was immediately transported back in time right where Torrent left off. Ms. Bergren includes all the aspects of a great book, and I loved getting back into Gabi and Lia's life. It was neat getting to read from Lia's point of view, but I am so glad she included Gabi's too.ReplyDelete


text:
CABG indicates coronary artery bypass grafting; CAD, coronary artery disease; CI, confidence interval; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; OR, odds ratio; PCI, percutaneous coronary interventions; PHQ, Patient Health Questionnaire; SAQ, Seattle Angina Questionnaire. Error bars indicate 95% CIs. The ORs in the model represent cumulative probabilities between a predictor variable and each combination of higher risk vs lower risk outcome categories (eg, >6 hours vs ≤6 hours and >2 hours vs ≤2 hours).
Customize your JAMA Network experience by selecting one or more topics from the list below.
Smolderen KG, Spertus JA, Nallamothu BK, et al. Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction. JAMA. 2010;303(14):1392–1400. doi:10.1001/jama.2010.409
© 2023
Author Affiliations: Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology and Neuropsychology, Tilburg University, Tilburg, the Netherlands (Dr Smolderen); Saint Luke's Mid America Heart Institute, Kansas City, Missouri (Drs Spertus and Chan and Ms Tang); Department of Internal Medicine, School of Medicine, University of Missouri, Kansas City (Dr Spertus and Chan); VA Health Services Research and Development Center for Excellence and Department of Medicine, University of Michigan Medical School, Ann Arbor (Dr Nallamothu); Robert Wood Johnson Clinical Scholars Program (Dr Krumholz), MD/PhD Program, Yale University School of Medicine, New Haven, Connecticut (Dr Krumholz and Mr Rathore); Section of Health Policy and Administration, Department of Epidemiology and Public Health, and the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut (Dr Krumholz); Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York (Dr Ross); HSR&D Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York (Dr Ross); Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota (Dr Ting); and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina (Dr Alexander).
Context Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI).
Objective To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI.
Design, Setting, and Patients Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews.
Main Outcome Measure Prehospital delay times (≤2 hours, >2-6 hours, or >6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.
Results Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P < .001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21 [95% confidence interval, 1.05-1.41]; P = .01) and with uninsured patients (adjusted odds ratio, 1.38 [95% confidence interval, 1.17-1.63]; P < .001).
Conclusion Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.
More than 45 million individuals in the United States are without health care insurance1 and another 25 million avoid care because of financial concerns.2 Although insurance status has been shown to affect use of preventive screening and chronic care,3,4 little is known about how health care insurance status affects decisions to seek care during an emergency medical condition, such as an acute myocardial infarction (AMI). While current public policy measures, such as the US Emergency Medical Treatment and Active Labor Act, ensure the provision of care during emergency medical conditions irrespective of insurance coverage, there is no guarantee that patients with health care insurance can afford such treatment.5 As a result, patients may still delay seeking care for acute, life-threatening conditions because of the potential financial costs of care.
Acute myocardial infarction is a clinical condition for which delays in seeking care can have significant, adverse consequences on patients' outcomes.6-9 Acute myocardial infarction is common, affecting almost 1 million individuals in the United States each year,10 and the benefits of early treatment are clear and substantial.11,12 Prior studies of prehospital delays for AMI to date have focused primarily on nonmodifiable patient factors such as age, race, and sex, and education-based community interventions, which have not been shown to reduce prehospital delays.13,14 However, studies have not examined whether financial concerns from the patient's perspective about accessing medical care in those with health care insurance is associated with prehospital delays. Prior studies have defined patients with difficulty affording health care services or treatment despite having some form of health insurance as being underinsured.15-17 Because prehospital delays are associated with higher AMI morbidity and mortality,6-9 demonstrating that patients with no insurance or those with insurance but reporting financial concerns about accessing care are at higher risk for prehospital delays is important because it would suggest that reducing financial barriers to care—perhaps through expansion of benefits or health insurance coverage—could reduce delays and improve outcomes.
To address this current gap in knowledge, we examined the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study. Given the growing number of uninsured and insured individuals in the United States with financial concerns about accessing care, an understanding of the effect of health care insurance, from a patient's perspective, on decisions to seek prompt medical attention for AMI may have important implications in the current debate on US health care reform.
Participants were consecutively enrolled between April 11, 2005, and December 31, 2008, from 24 US urban hospitals as part of the TRIUMPH study, which maintained a multisite, prospective AMI registry focused on specific gaps in knowledge about racial differences in AMI care. Participating hospitals within TRIUMPH were geographically diverse and included both academic and nonacademic institutions (see eAppendix 1 for a list of the participating study sites). Patients were eligible for inclusion if they were aged 18 years or older, had elevated cardiac enzymes (troponin I or creatinine kinase MB) within 24 hours of hospital admission and supporting evidence suggestive of AMI, including either prolonged ischemic symptoms or electrocardiographic ST elevation changes. Exclusion criteria were patients who were incarcerated, refused participation, were unable to provide consent, did not speak English or Spanish, were transferred to the participating hospital from another facility more than 24 hours after initial admission, died, or were discharged prior to being contacted by the investigators.
Of the 6163 patients who met eligibility criteria, 1823 patients refused to participate in the study. Compared with patients who consented, patients who refused participation were more likely to be white (74% vs 67%; P < .001), older (mean [SD], 62 [14] vs 59 [12] years; P < .001), and have health insurance (85% vs 80%; P < .001). No difference in participation by sex was noted (refused participation: 34% female; agreed to participate: 33% female). Among the 4340 patients who provided consent and were enrolled in TRIUMPH, patients were excluded if they had missing information on insurance status (n = 63 [2%]), if prehospital delay time was not documented (n = 534 [12%]), or if delay time could not be determined because they did not experience ischemic symptoms prior to hospital arrival (n = 22 [0.5%]). The final study cohort consisted of 3721 patients.
Demographic, social, clinical, health status, and psychological data for patients were collected from chart abstraction and baseline interviews by trained staff within 24 to 72 hours of the index AMI admission. All participants provided written informed consent and the study protocol was approved by the institutional review board at each participating center.
For this study, 3 categories of health insurance coverage were compared: no insurance, insurance with financial concerns about accessing care, and insurance without financial concerns. Health insurance information was determined from the medical records. In instances in which patients had more than 1 form of health insurance, the following hierarchy was used: (1) fee-for-service (preferred provider organization), (2) health maintenance organization, (3) Medicare, (4) Medicaid, (5) Veterans Administration, (6) other, or (7) none. Using structured interviews, patients with health care insurance were further classified as having or not having financial concerns in accessing medical care. Using patient-centered questions that have been used to describe economic barriers to seeking care in patients with coronary artery disease,18,19 patients with health insurance were defined to have financial concerns in accessing care if, because of concerns about costs, they either (1) avoided care in the past year, (2) were nonadherent to medications in the past year, or (3) were currently having difficulty obtaining health care services.
The primary outcome was time to hospital presentation (prehospital delays), which was determined as the time from symptom onset to hospital presentation, and was obtained from the available medical records (including all emergency department and physician records). Time to hospital presentation was collected in discrete categories (≤1 hour, >1-2 hours, >2-4 hours, >4-6 hours, >6-12 hours, >12-24 hours, and >24 hours). To enhance interpretability, the number of categories was reduced by merging them into commonly used and clinically relevant classification categories (≤2 hours, >2-6 hours, or >6 hours).8,9,20 As a sensitivity analysis, time to hospital presentation also was examined using the original 7 time categories.
Demographic variables included age, sex, race, and residential area. Information on race was self-identified and collected during patient interviews. Residential area was determined from the 2000 US Census21 by examining the proportion of rural residents for each zip code and then patients were categorized as living in an urban (<10% rural), mixed (10%-33% rural), or rural (>33% rural) environment.
Additionally, during the index AMI hospitalization, detailed information on patients' social background, health status, and psychological factors—variables that have not been systematically examined in prior studies of prehospital delays—also was obtained because these may confound the association between insurance status and prehospital delays. Social variables included marital status (single, widowed, or married), educational level (did not complete high school, high school graduate, college graduate, or graduate school degree), and perceived social support as measured by the 7-item Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Inventory. Based on prior work,22 low social support was defined as a score of 3 or greater on 2 or more items (excluding items on instrumental social support and marital status) and having a sum score of 18 or greater on the remaining 5 items.
Patients' baseline disease-specific health status (including angina frequency and angina stability over the 4 weeks preceding the index AMI) was assessed using the Seattle Angina Questionnaire (SAQ), a validated disease-specific quality-of-life instrument for coronary artery disease.23 Scores for each SAQ domain range from 0 to 100, with higher scores indicating better functional status (ie, less frequent angina and more stable angina). Angina frequency was categorized into 3 clinically meaningful categories: daily to weekly angina (scores of 0-60), monthly angina (scores of 61-99), or no angina (score of 100).24
The TRIUMPH registry also collected information on psychological variables, including depression and perceived stress. Depression was assessed with the 9-item Patient Health Questionnaire (PHQ).25 Patients were classified as having no depression (PHQ scores of 0-4), mild depression (PHQ scores of 5-9), and moderate to severe depression (PHQ scores of 10-27).26 Levels of perceived stress were measured with the 4-item Perceived Stress Scale,27 with scores of 4 or greater categorized as representing high perceived stress.28
Unadjusted analyses evaluated baseline differences between the 3 insurance coverage groups (no insurance, insured with financial concerns, and insured without financial concerns) using analyses of variance for continuous variables and χ2 tests for categorical variables. Normality was confirmed for continuous variables.
Because the primary outcome was ordinal, multivariable hierarchical cumulative-logit models were constructed to evaluate the independent relationship between health insurance and prehospital delay. This method adjusts for clustering at the site level and between-hospital effects and provides a single odds ratio (OR) of cumulative probabilities for the relationship between a predictor variable and each combination of higher risk vs lower risk outcome categories (eg, >6 hours vs ≤6 hours and >2 hours vs ≤2 hours).
Besides insurance status, all models included established predictors of prehospital delay (age, race, sex, diabetes mellitus, residential area [rural, mixed, or urban]),6 social factors (marital status, education level, and perceived social support), patients' health status (SAQ angina frequency and angina stability), psychological factors (depression and perceived stress), and other clinical variables (see eAppendix 2 for definitions of clinical variables). Clinical variables included medical comorbidities (hypercholesterolemia, hypertension, peripheral arterial disease, prior AMI, prior percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery, prior stroke, chronic kidney disease, chronic obstructive pulmonary disease, chronic heart failure), recent smoking, obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥30), family history of coronary artery disease, AMI characteristics and severity (ST elevation vs non–ST elevation AMI, left ventricular ejection fraction <40%, and Killip class [class I-II vs III-IV]), absence of chest pain in the prehospital setting, and time of day during hospital presentation (weekday, weeknight, or weekend admission).
At least 1 study covariate was missing in 12.3% of patients and the average number of missing data fields per patient was 0.23. Missing covariate data were assumed to be missing at random and imputed using IVEware software version 2.0 (University of Michigan Survey Research Center, Institute for Social Research, Ann Arbor).29 Rates of missing delay time were not significantly different across insurance status categories (P = .65) and potential bias attributable to those without prehospital delay times was addressed by creating a nonparsimonious model for the propensity of missing data on delay time.30 The reciprocal of this probability was used to weight the associations among responders in the hierarchical cumulative-logit model. Results with and without weighting were comparable so only the weighted results are presented.
As a sensitivity analysis, while time to hospital presentation was evaluated as 3 clinically meaningful categories, the relationship between insurance status and the original 7 time categories described above also was examined. Additionally, each of the 3 questions used to define insured patients with financial concerns were systematically eliminated and the robustness of the relationship between insurance status and prehospital delays was examined. In all models, the validity of the ordinal relationship between insurance status and the dependent variable (ie, the assumption of common slopes for all cumulative logits) was verified.
As secondary analyses, whether prehospital delays among patients presenting with ST-elevation AMI were associated with lower rates of treatment with thrombolytic therapy or PCI also were examined using multivariable modified Poisson regression models. All statistical analyses were conducted using SAS software version 9.1.3 (SAS Institute Inc, Cary, North Carolina), IVEware, and R software version 2.6.0 (Free Software Foundation, Boston, Massachusetts). All tests for statistical significance were 2-tailed and were evaluated at a significance level of .05.
Of 3721 patients in the cohort, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Among those with insurance reporting financial concerns, 82.8% avoided medical care, 55.6% avoided taking medications, and 12.8% had difficulty obtaining health care services due to costs; 44.1% met at least 2 of these criteria. Compared with insured patients without financial concerns, a greater proportion of insured patients with financial concerns received their insurance coverage from Medicaid (11.3% vs 5.5%) and a smaller proportion had fee-for-service plans (43.0% vs 52.7%) (P<.001 for difference across plans; Table 1).
There were substantial differences in baseline characteristics between the 3 insurance groups (Table 1). Compared with insured patients without financial concerns, uninsured patients and insured patients with financial concerns were more frequently younger, nonwhite, single, and current smokers, and less likely to have completed high school. These patients also had higher levels of perceived stress, more severe depressive symptoms, and more frequent angina in the weeks preceding their index AMI. Furthermore, compared with patients with any insurance, uninsured patients were less likely to have had a prior AMI, PCI, or coronary artery bypass graft surgery; less likely to have coexisting hypercholesterolemia, hypertension, peripheral arterial disease, stroke, chronic kidney disease, and chronic obstructive pulmonary disease; and more likely to live in urban areas and present with a left ventricular ejection fraction of less than 40% during the index AMI.
While 1273 patients presented promptly within 2 hours of symptom onset (34.2%), 1567 patients had delay times exceeding 6 hours (42.1%). There were important differences in time from symptom onset to hospital presentation during AMI by insurance status (P < .001; Table 2). A greater proportion (36.6%) of insured patients without financial concerns arrived within 2 hours of symptom onset compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients. Conversely, a smaller proportion (39.3%) of insured patients without financial concerns arrived more than 6 hours from symptom onset compared with 44.6% of insured patients with financial concerns and 48.6% of uninsured patients.
In analyses adjusted for study site only, compared with insured patients without financial concerns, insured patients with financial concerns (OR, 1.22; 95% confidence interval [CI], 1.06-1.40) and uninsured patients (OR, 1.30; 95% CI, 1.12-1.51) were more likely to delay seeking care during AMI. After adjustment for demographics, clinical comorbidities, AMI characteristics, baseline health status, social factors, and psychosocial variables, insured patients with financial concerns (adjusted OR, 1.21 [95% CI, 1.05-1.41]; P = .01) and uninsured patients (adjusted OR, 1.38 [95% CI, 1.17-1.63]; P < .001) continued to have longer delays to hospital presentation (Table 3). In sensitivity analyses, these estimates were similar when prehospital delay was examined as 7 distinct time categories (results not shown). Moreover, because patients with managed care or public insurance plans also were more likely to have prehospital delays (see eAppendix 3), payor type was additionally adjusted for in the subgroup of patients with any insurance. The relationship with longer delay times remained similar for insured patients with financial concerns (adjusted OR, 1.23 [95% CI, 1.06-1.43]; P = .008) (see eAppendix 4). The relationship between insurance status and prehospital delays remained robust when each of the criterion questions used to define financial concerns was systematically eliminated among those with health insurance (see eAppendix 5 and eAppendix 6).
The final model results for prehospital delays are presented in the Figure. Consistent with prior studies,6,7,9 coexisting diabetes mellitus and weekday working hours were associated with an increased risk of prehospital delays, while a low Killip class, a prior history of AMI, or prior coronary revascularization were each associated with shorter delay times. However, previously described associations between age, female sex, and black race with prehospital delays6,7,9 were attenuated after adjustment for insurance status, social and psychological factors, and clinical characteristics. Notably, lower educational level, higher angina frequency in the weeks preceding the AMI, and depressive symptoms were associated with prehospital delays, whereas patients with higher perceived stress scores were more likely to present to the hospital within 2 hours of symptom onset (Figure).
Among patients presenting with ST-elevation AMI, those with prehospital delays exceeding 6 hours were less likely to receive primary reperfusion therapy with either thrombolytics or PCI (≤2 hours [reference group], 93.5%; >2-6 hours, 92.5% [adjusted relative risk, 1.00; 95% CI, 0.97-1.04; P = .88]; >6 hours, 83.9% [adjusted relative risk, 0.91; 95% CI, 0.85-0.96; P = .002]; Table 4).
In this prospective, multisite AMI registry study, we found that nearly 2 in every 5 patients were uninsured or were insured but reported financial concerns in accessing care. These patients, in turn, were more likely to delay seeking emergency care for an AMI, even after extensive adjustment for clinical, social, and psychological factors. These findings underscore important consequences from inadequate health care insurance coverage for the substantial number of individuals in the United States experiencing AMIs. The data also suggest that efforts to reduce prehospital delay times may have limited impact without first ensuring that access to health insurance is improved and financial concerns are addressed in patients who seek emergency care.
To our knowledge, this study is the first to demonstrate an association between the lack of health care insurance and prehospital delays during AMI. While this observation may seem intuitive, uninsured patients have not been found to have higher rates of prehospital delays in other studies.31,32 Our findings on insurance status may have differed from earlier studies because of a higher proportion of uninsured patients in this contemporary registry. Moreover, our study's use of patient interviews (rather than administrative data) allowed us to adjust for patients' health status and important social and psychological confounders to better clarify the independent association of insurance status with prehospital delays in AMI.
Perhaps most importantly, our study was also able to evaluate the impact of financial concerns in accessing medical care among those with insurance who had delays in seeking care. Through detailed, structured interviews, we identified individuals who reported financial burdens related to the use of health care services despite the presence of insurance. This process used a patient's perspective as a data source and is a significant advance from the use of coarse administrative data sources. Remarkably, more than half of all insured patients with financial concerns in our study had fee-for-service (preferred provider organization) or health maintenance organization insurance plans. Thus, having private health care insurance did not guarantee use of health care services that were essential for these patients, perhaps because they perceived them as unaffordable in the face of competing financial demands.
Several studies have described patients who forego routine medical treatment because of high cost burden as the underinsured.15-17,19,33 Such avoidance of care due to costs was associated with more angina, poorer health status, and higher rates of rehospitalization.19,33 While underinsurance has not been well studied to date, this group represents a growing US patient population susceptible to disparities in care for emergent conditions like AMI. In this study, we were able to show an association between financial concerns in accessing care among insured patients and delays to hospital presentation. However, we did not have sufficiently detailed information on patients' health insurance plans or preferences in decision making to determine whether perceived financial concerns were due to underinsurance or personal choices to forego broader insurance plans for lower premiums. To further inform health-policy decision making, additional studies are required to determine whether and which aspects of underinsurance—high out-of-pocket health care costs (copayments, coinsurance, deductibles), low lifetime health benefit ceilings, or lack of catastrophic or stop-loss provisions—may be responsible for perceived cost burden.
The finding that uninsured and insured patients with financial concerns about accessing medical treatment delay seeking care for potentially fatal but treatable medical conditions raises particular concerns because the majority of these families in the United States are classified as the working poor (often with 2 full-time workers in the household).1,4,34 The inability to address patients' concerns about costs of emergency care may, in part, explain the failure of prior intervention studies to reduce prehospital delay times during AMI.14,35 Moreover, because black and female patients are more likely to have financial concerns about accessing medical care despite having insurance coverage or be uninsured,19 addressing insurance coverage has the potential to reduce disparities in care for these vulnerable populations. In fact, we found that previously described associations between race, age, and sex—which are largely nonmodifiable demographic characteristics—with prehospital delays7,9 were substantially attenuated after adjustment for insurance status and other social, psychological, and clinical variables in this study.
It is likely that uninsured patients and insured patients with financial concerns about accessing care not only delayed seeking care for AMI, but also delayed care for other common medical conditions, such as stroke, pneumonia, and appendicitis.36 As a result, interventions that broaden and ensure the affordability of health insurance coverage in the United States may reduce times to presentation for all emergent medical conditions. Such policy interventions are particularly important in light of a recent analysis that found that as many as 45 000 deaths annually in the United States are attributable to lack of health insurance alone.37 These interventions would also address critics of US Emergency Medical Treatment and Active Labor Act, who argue that the legislation's unfunded mandate over the past 2 decades has imposed undue economic burdens on hospitals and paradoxically decreased the availability of emergency care services that the law was intended to promote.38,39
Finally, our study also provides insights into other novel, and potentially modifiable, patient characteristics associated with prehospital delays during AMI that are distinct from previously described but often nonmodifiable predictors, such as age, sex, race, diabetes mellitus, and absence of chest pain. Specifically, we found an association between prehospital delays and lower educational level, more frequent recent angina, and depressive symptoms. In contrast, high levels of perceived stress were associated with shorter times to hospital presentation. Because large community-based education programs for AMI in the United States have not been previously successful in reducing times from symptom onset to hospital presentation,14,35,40 future educational public health efforts may need to address these specific predictors (in addition to insurance status) in developing new interventions.
Our study should be interpreted in the context of the following limitations. Delay times were not documented in the medical records in 12% of patients and we did not have a mechanism to validate delay times reported in the medical records. However, documenting delay times by patients' recall has been widely used in other studies; rates of missing delay times in this study did not differ from prior studies.7,9 Importantly, rates of missing delay times were similar across insurance groups and were accounted for in our propensity-weighted analyses.
Second, while our models adjusted for an extensive number of demographic, social, clinical, and psychological factors, we did not have information on other factors that may have influenced prehospital delay times, including the use of emergency medical services for hospital transport, geographical distance from site of ischemic symptom occurrence to presenting hospital, and traffic patterns in urban and rural areas. Moreover, we did not have information on each patient's annual hospital expenditures, deductibles, medical copayments, and covered medical benefits to directly assess underinsurance. We also did not have information on annual household income and expenses to determine the extent to which perceived financial concerns about accessing care were due to limited disposable income rather than patients' choices to forego broad insurance coverage in exchange for lower premiums. Nevertheless, because the goal of insurance is to ensure access to care and treatment without having to bear the undue financial burden of obtaining care, our definition is consistent with the concept of underinsurance.
Third, while we found that uninsured patients and insured patients with financial concerns were associated with delays, nearly 2 in 5 insured patients without financial concerns also had delays to hospital presentation exceeding 6 hours. This suggests that other patient factors accounted for prehospital delays; improving health insurance coverage, while important, is but one component in a comprehensive strategy to reduce times to hospital presentation during AMI. Fourth, our cohort was drawn from a sample of 24 urban hospitals throughout the United States and may not be generalizable to other sites or regions. Lastly, our study cohort does not include patients who never sought care or who died before hospitalization. Because we found that uninsured and insured patients with financial concerns had greater delays in seeking treatment, our estimates may represent conservative estimates of the association between insurance status and prehospital delay for AMI.
In conclusion, in this large multicenter registry, we found that uninsured patients and insured patients with financial concerns about accessing medical treatment were each more likely to delay seeking emergency care for AMI, a commonly occurring condition. Efforts to reduce prehospital delays for AMI and other emergency conditions may have limited benefit unless US health care insurance coverage is extended and improved.
Corresponding Author: Paul S. Chan, MD, MSc, Mid America Heart Institute, Fifth Floor, 4401 Wornall Rd, Kansas City, MO 64111 (email@example.com).
Author Contributions: Dr Chan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Smolderen, Nallamothu, Ting, Chan.
Acquisition of data: Spertus, Krumholz.
Analysis and interpretation of data: Smolderen, Spertus, Krumholz, Tang, Ross, Ting, Alexander, Rathore, Chan.
Drafting of the manuscript: Smolderen, Chan.
Critical revision of the manuscript for important intellectual content: Smolderen, Spertus, Nallamothu, Krumholz, Tang, Ross, Ting, Alexander, Rathore, Chan.
Statistical analysis: Tang.
Obtained funding: Spertus.
Administrative, technical, or material support: Spertus.
Study supervision: Smolderen, Ting, Chan.
Patient enrollment: Alexander.
Financial Disclosures: Dr Spertus reported that he developed and owns the copyrights for the Seattle Angina Questionnaire. None of the other authors reported financial disclosures.
Funding/Support: The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study was supported by grant P50 HL077113 from the National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease. Dr Ross is supported by grant K08 AG032886 from the National Institute on Aging and by the American Federation of Aging Research through the Paul B. Beeson Career Development Award Program. Mr Rathore is supported, in part, by CTSA grant UL1 RR024139 from the National Institutes of Health's Center for Research Resources, grant 5T32GM07205 from the National Institute of General Medical Sciences Medical Scientist Training Program, and dissertation grant 1R36HS018283-01 from the Agency for Healthcare Research and Quality.
Role of the Sponsors: The funding organizations and sponsors of the study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.