text:
Cardiovascular risk factors among Chamorros
Binh Chiem1,3,
Victoria Nguyen1,3,
Phillis L Wu1,3,
Celine M Ko1,
Lee Ann Cruz4 &
Georgia Robins Sadler1,2,4
Little is known regarding the cardiovascular disease risk factors among Chamorros residing in the United States.
The Chamorro Directory International and the CDC's Behavioral Risk Factor Surveillance System Questionnaire (BRFSS) were used to assess the health related practices and needs of a random sample of 228 Chamorros.
Inactivity, hypertension, elevated cholesterol and diabetes mellitus were more prevalent in this Chamorro sample compared to the US average. Participants who were 50-and-older or unemployed were more likely to report hypertension, diabetes and inactivity, but they were also more likely to consume more fruits and vegetables than their younger and employed counterparts. Women were more likely to report hypertension and diabetes, whereas men were more likely to have elevated BMI and to have never had their blood cholesterol checked.
The study provides data that will help healthcare providers, public health workers and community leaders identify where to focus their health improvement efforts for Chamorros and create culturally competent programs to promote health in this community.
Cardiovascular disease, which encompasses heart disease, stroke and hypertension, was responsible for 16.7 million deaths in 2003. This number represented one-third of total deaths worldwide [1]. In the United States, cardiovascular disease alone is responsible for approximately 1 in every 5 American deaths [2]. It is currently the number one cause of death in developed countries, and the World Health Organization (WHO) projects that by 2010, cardiovascular disease will also be the major cause of morbidity and mortality in developing countries [1].
Cardiovascular disease is the leading cause of death across all ethnic groups, including Caucasians, African-Americans, Hispanics, American Indians/Alaskan Natives. Among Asian Americans and Pacific Islanders (AAPI) [2, 3] it is virtually tied with cancer as the leading causes of death. Compared to other ethnic groups, the frequency of cardiovascular disease is relatively low in the AAPI community [4]. This has resulted in a relative lack of research of the AAPI populations as a focus group among public health efforts to prevent or delay cardiovascular disease [5]. The groups within the AAPI community, such as the Chamorro community which is discussed in this paper, have received even less attention.
Cardiovascular disease is a major cause of morbidity and mortality within the AAPI community, accounting for over 25% of all AAPI deaths in 2001 [3]. Complicating the assessment of cardiovascular disease and health promotion interventions in the AAPI community is the way that Census data were collected for the Asian and Pacific Islander community. Prior to the 1990 Census, Asians and Pacific Islanders were aggregated into a single group. While the 1990 Census allowed Asians and Pacific Islanders to select a subgroup for membership, it did not allow respondents to select multiple sub-groups, a particular problem for a community where a high proportion of people are multiracial. For the 2000 Census, it was possible for respondents to select multiple racial categories and thereby more accurately depict their racial heritage [6]. Certain subgroups within the AAPI conglomerate suffer more from cardiovascular disease than others. For example, data collected by the Missouri State Health Department showed that overall, AAPI mortality from heart disease is half the rate of Caucasians, and one-third the rate of African-American. However, closer scrutiny of the AAPI data, reveals that the Hawaiian subgroup, for example, has mortality rates 2.4 times that of Caucasians and 1.6 times that of African-American [7]. The AAPI population is highly heterogeneous. Understanding the specific variations that exist in the backgrounds, cultural practices, and morbidity and mortality rates of AAPI subgroups will facilitate the creation of optimal health interventions that can be "narrow casted" to those AAPI sub-groups known to have the greatest risk of developing premature cardiovascular disease [8]. Narrowcasting of health promotion messages involves the development of a social marketing campaign that is to be focused on a narrowly defined audience [9–11].
Thus to develop a niche social marketing campaign, it is first necessary to understand the audience, the outcomes to be accomplished, and the messages to be delivered toward this end. In this study, Chamorros and cardiovascular disease were the focus of the research team. While Pacific Islanders comprise only 0.3% of the total U.S. population [12], they are the second fastest growing ethnic group after Asians at-large. The Census Bureau projections indicate that by 2050, the number of Pacific Islanders living in the United States will have tripled [13]. Thus it is imperative that adequate public health information be gathered about this group so that optimal health promotion intervention can be provided to this growing community.
The Pacific Islands are divided into three large geographical regions: Micronesia, Polynesia, and Melanesia. Chamorros are indigenous people of the Mariana Islands, a sub-division of Micronesia. The vast majority of this ethnic group is found in Guam, an island of the Marianas archipelago, and the continental United States. According to the 2000 Census, of those Chamorros living in the continental United States, more than one-third resided in California, with San Diego County home to the largest Chamorro community outside of Guam [14, 15]. Thus, San Diego is an ideal site for a study of the continental U.S. Chamorro population. The health needs of the Chamorros have often been overshadowed by the larger, more visible AAPI ethnicities. An exhaustive search of the scientific literature yielded little information regarding the health status of the Chamorro people residing on the continental United States, especially in relation to cardiovascular disease [16–22]. Even in the 2001 Center for Disease Control and Prevention, National Center for Health Statistics (CDC/NCHS) publication, no reliable data were reported for the incidence of cardiovascular disease, even in the larger category of Pacific Islanders [4].
In this paper, the authors report on the risk factors for cardiovascular disease that were identified in San Diego's Chamorro community. By documenting such baseline data in this rapidly growing minority group, health care providers and community leaders can identify and create culturally competent, specific interventions for Chamorros.
Subject recruitment
The Center for Disease Control and Prevention's 2001 core Behavioral Risk Factor Surveillance System (BRFSS) [23] and five of 14 optional modules were used to survey participants. The national data gathered using the 2001 BRFSS were used as the reference point to which the data collected from the Chamorro community was compared.
The Chamorro Directory International (a telephone directory composed exclusively of people who self-identified as members of the Chamorro community) was used to reach members of the local Chamorro community. Leaders of the Chamorro Community have maintained the Directory since 1995, updating and reprinting it every 5 years. Data is gathered by word-of-mouth requests for entry information and more recently, by Internet solicitations. As identifiable information is received, every potential entry is contacted to confirm the accuracy of the information and to secure written approval to publish the information. Using a University of California San Diego IRB-approved protocol, all 658 names in the Chamorro Directory International [24] for the local region were entered into a computerized database. Then a computer-generated call list was created to determine who would be called and in what order they would be called. Calls were made until at least 100 men and 100 women from the Chamorro community had been recruited to the study. The sample size was limited by the modest size of the planning grant ($10,000) that was received to help the community conduct a health assessment. The first adult to answer the phone was invited to complete the survey. The invitation to participate included the IRB-approved verbal informed consent script which included a strong statement of confidentiality. If he/she refused to participate, other household members were invited and likewise consented. Of those households contacted, the individual response rate was 62.8%. To obtain a sample diverse in age and socioeconomic status, calls were made seven days a week, from early morning until late evening. The survey workers were bilingual members of the Chamorro community. The community newspaper and a word-of-mouth campaign by the Pacific Islander Cancer Control Network (PICCN) leaders helped encourage participation in the study.
A midpoint review of the sample's socio-demographic data indicated an under-representation of men and male and female Chamorros less than 50 years of age. To address this problem, the recruitment strategy was modified such that surveyors randomly asked to speak with the oldest adult, youngest adult, or any adult male in the family throughout the remainder of the data collection process. Completed surveys were individually reviewed for specific health problems and risk factors. Based on their perceived needs, participants were mailed a packet of personalized health promotion information such as preventive care and self-help resources. At the end of the project, a second packet was mailed containing a letter describing the project's findings and information regarding the community's most pressing overall health risks and needs. All transactions were mailed first-class, so that undelivered mail could be tracked. Only one packet of the 250 mailed was returned as undeliverable. Three of the 228 participants requested that no packet be mailed. All were given this opportunity.
The collected data were entered into an ACCESS 2000 database and analyzed with SPSS for Windows 10.0 [25]. Chi-squared tests were used to establish relationships between socioeconomic characteristics and cardiovascular disease risk factors. A p-value of < 0.05 was considered statistically significant. Risk factors were analyzed by gender, age (< 50 versus ≥ 50), and employment status to determine whether differences existed within those sample subsets.
Frequencies of the eight known risk factors for cardiovascular disease (BMI, physical activity, diet, hypertension, blood cholesterol, diabetes, smoking, and alcohol consumption) were also contrasted with the American Heart Association data [26, 27].
Sample description
This study sample consisted of 100 male and 128 female Chamorros from San Diego County. The male participants ranged in age from 18 to 87 years. Average age for the men was 48.7 years (SD = 17.7); the median, 47.0. The female participants ranged in age from 19 to 88 years. Average age for the women was 54.7 years (SD = 15.2); the median, 57.5. The median education category for this sample group was "1 to 3 years of college," with a range from grade school to at least four years of college. More than half of the study participants withheld information regarding household income, so all results related to income should be interpreted with caution. Of the 49.6% who reported an income, the median household income was "$35,000 – $50,000." Women were much more willing than men to volunteer their income data: 63% of female versus only 33% of male participants reported their income. The vast majority (93%) of participants had healthcare coverage, while a large portion (47%) reported excellent/very good health. Most of the participants were middle-aged (47%), married (61%), and had no children living in the household (62%). Participants' sociodemographic data are presented in Table 1.
Table 1 Participants' Sociodemographic Data
Eight risk factors of cardiovascular disease
1. Body Mass Index (BMI)
According to the National Heart, Lung and Blood Institute (NHLBI), an ideal BMI ranges from 18.5 to 24.9. Any person with a BMI of 25 to 29.9 is considered overweight, while a BMI of 30 and greater is considered obese [28]. In this study sample, the BMI was not available for 21% of the participants as 28 males and 20 females declined to provide either their height or weight. Of those who reported their height and weight, the average BMI was 27.4 (male 28.0, female 27.0) with a range of 17.2 to 47.7 (male 18.3 – 44.1, female 17.2 – 47.7) and an overall standard deviation of 5.6 (male 4.4, female 6.3). The majority of study participants were either overweight or obese: 31.1% were overweight while an additional 21.1% were obese (Table 2). Men were significantly more likely than women to be overweight or obese (p < .05). Participants who were employed were much more likely than the unemployed to be overweight or obese: (p < .05). Higher income also correlated with an elevated BMI (0r = .250, p < .05).
Table 2 Cardiovascular Disease Risk Factors
2. Physical activity
Physical activity was calculated as number of days/week multiplied by amount of time/day a person spent doing either moderate or strenuous physical exercise. The CDC recommends a minimum of 150 minutes of moderate exercise or 60 minutes of vigorous exercise per week [29] and the American Heart Association's (AHA) recommended 90 minutes of moderate physical activity per week. Among the participants, 66.7% did less than 150 minutes of moderate exercise per week, 67.4% did less than 60 minutes of vigorous exercise per week, and 34% did not exercise at all (Table 2). Participants who were 50 and older or those not employed were at significantly higher risk of failing the AHA guideline (p < .05).
3. Diet
Daily consumption of fruits and vegetables was calculated for each participant. Total fruit included fruit and fruit juices, whereas total vegetables included green salad, non-fried potatoes, carrots, and others. The AHA's Food Pyramid recommends eating at least 3 servings of vegetable and 2 servings of fruit per day [30]. Sixty percent of the study participants failed to consume the minimum of 5 servings of vegetable and fruit per day (Table 2). Participants who were younger than 50 or employed outside of the home tended to eat less fruit or vegetable than their older and unemployed counterparts (p < .05).
4. Hypertension
Of the 228 study participants, 42.5% reported they had been diagnosed with hypertension, but only 34.2% reported taking medication for their hypertension (Table 2). Females, those aged 50 and over, and those unemployed were diagnosed with hypertension at significantly greater frequencies than their male, younger, and employed counterparts (p < .05). Among the female participants hypertension was associated with less education, but this trend was not seen in the male participants. Less educated women reported hypertension at a much greater frequency than their more educated counterparts (p < .05).
5. Blood cholesterol
The AHA recommends that all adults starting at age 20 should obtain a full lipid profile once every five years [31]. Seventy percent of study participants reported compliance, but 27% never had blood drawn for a lipid panel (Table 2). This is especially true among the male participants. Significantly more men than women had never had their blood cholesterol checked (p < .05). Those participants who were male, aged less than 50, and employed were significantly more likely than their counterparts to have never checked their blood cholesterol (p < .05).
6. Diabetes
Of those Chamorros surveyed, 16.2% were diabetic, and an additional 2.6% reported gestational diabetes (Table 2). The mean age of diagnosis for men was 58.0 years (median age 60, SD = 11.3) and 46.1 years for women (median 50, SD = 9.1). Participants who were female, aged 50 and above, and not employed were significantly more likely to have diabetes than those who were male, younger than 50, and employed (p < .05).
7. Tobacco use
Fifteen percent of study participants were smokers. Half (51%) of those who smoked had tried to quit within the last year (Table 2). The average age for first time smoking cigarettes was 14.9 years (± 4.2 SD) for men and 19.1 years (± 7.8 SD) for women. The average age when they first started smoking regularly was 16.8 years (± 4.2 SD) for men and 20.9 years (± 5.9 SD) for women. Forty-one participants (21 men and 20 women) reported smoking at least 100 cigarettes in their lifetime but were current nonsmokers. The survey also queried about smoking restrictions encountered at home and in the workplace. Within the home, 83% of the 35 smokers indicated they could not smoke inside the house at all, 3% could smoke in certain designated areas or at certain times, 6% could smoke anywhere, and 8% had no rules about smoking inside the home. Of those same 35 smokers, 57% worked indoors, and 80% of these indoor workers were prohibited from smoking in public and work areas.
8. Alcohol consumption
The daily consumption of alcoholic beverages was calculated for each participant as the number of days per month in which one had at least one drink, multiplied by the average number of drinks consumed on each of those days, then divided by 30 to obtain a daily average. The AHA recommends drinking should be limited to an average of one to two drinks per day for men, and one drink per day for women [32]. Out of the 228 participants, only four averaged more than one drink per day, and most (63.6%) had not drunk at all in the month preceding the survey (Table 2).
Cumulative risk factors
The mean number of cumulative cardiovascular disease risk factors (CRF) for this study population was 2.01 per person. As seen in Table 3, 35% had at least three CRF. Participants who were 50 years and older, unemployed, and less educated reported substantially higher CRF than their younger, employed, and more educated counterparts (p < .05).
Table 3 Chamorro Cumulative Risk Factors
Table 4 shows that more than half of the study participants were actively managing their weight: 25% were trying to lose weight, 25% were trying to maintain current weight, and 5% responded "yes" to both options. Women were more likely than men to report that they were trying to lose or maintain their weight (p < .05). Of those 128 individuals trying to manage their weight, 16 (13%) used exercise only, 25% (32) used diet only, and 57% (73) used both diet and exercise to achieve their goals. In total, 105 dieted and 89 exercised (overlap exists where participants reported both dieting and exercising). Of those 105 who dieted to control their weight, 18% (19) cut back on calories only, 37% (39) cut back on fat only, and 45% (47) chose to reduce both calories and fat intake. Participants aged 50-and-above preferred to lose weight by dieting, whereas younger participants under-50 preferred exercising (p < .05). Those who had a BMI of 25 and above reported they were trying to lose weight with much greater frequency than those with a lower BMI (p < .05). When queried about an ideal weight, 122 of the 228 participants responded. Of those respondents, 6 wanted to gain weight, 26 wanted to maintain their current weight, and 86 wanted to lose weight. Among those who wanted to lose weight, the mean amount of weight loss desired was 28.60 lbs (24.44 lbs for men, 30.31 lbs for women) with a range of 2 lbs to 150 lbs. The "desired weight" reported by each participant was converted to a "desired BMI" based on the individual's height. As shown in Table 4, the ideal weight reported by most respondents fell within the healthy BMI range of 20 to 25. However, when examined by gender, most (57) female respondents desired a BMI of 20 to 25, whereas most (24) male respondents desired a higher BMI of 25 to 30.
Table 4 Weight Control
Cardiovascular disease is the number one cause of death in the U.S., making it a major national health threat with far-reaching consequences. Since individual health behaviors are highly predictive of disease development and mortality, an effective disease prevention campaign begins with an assessment of modifiable disease behaviors. This study provides an assessment of the cardiovascular disease-related health behaviors of San Diego's Chamorro population. The data can be used by health care providers, public health advocates, and indigenous community leaders to develop cardiovascular disease prevention and intervention strategies that are culturally specific, sensitive, and appropriate to this AAPI ethnic subgroup.
While the data in this study has not been age-adjusted, compared to state and national data [33] the Chamorros in this study appeared more susceptible to four of the eight risk factors: low physical activity, hypertension, high blood cholesterol, and diabetes. Chamorros (66.7%) appear to be less likely to adhere to the CDC's weekly recommendation for moderate exercise compared to state (53.3%) and national (52.8%) averages. Hypertension and diabetes were present among the Chamorros at an alarming rate. Chamorros in this study reported hypertension (42.5%) at a much greater frequency than other Californians (23.4%) and nation-wide numbers (24.8%). The prevalence of diabetes among Chamorros (16.2%) was more than twice the state (7.2%) and national (7.1%) figures. Gestational diabetes among Chamorros (2.6%) reflected similarly disproportionate figures compared to the state (1.1%) and national (0.7%) rates. In addition, Chamorro women reported high blood cholesterol (40.6%) more frequently than the average Californian woman (30.5%) and national average (32.1%). In contrast, the prevalence of high blood cholesterol was slightly lower in Chamorro men (31.0%) than their state (35.1%) and national (33.8%) counterparts.
As expected, the sociodemographic characteristics of age, gender, and employment status were often aligned with the behavioral risk factors. Participants who were 50 years and older and unemployed tended to report hypertension, diabetes, and low physical activity, but they also consumed more fruits and vegetables than their younger and employed counterparts. Women were more likely than men to be hypertensive and diabetic; but men were more likely than women to have an elevated BMI and to have never had their blood cholesterol checked. Men were more likely than women to have set a optimal weight goal that would result in an unhealthy BMI. These are clearly opportunities for interventions by primary care health providers, public health policy makers, the media, and community leaders. Women started smoking later than men, at an age (19.1 years ± 7.8 SD) which coincides with the beginning of gynecology care. This may indicate a role for gynecologists in the primary prevention of smoking in Chamorro women. Conversely, the fact that male participants started smoking at a much younger age (14.9 years ± 4.2 SD) indicates the need for earlier intervention in the male Chamorro population.
Among the eight behavioral risk factors examined, BMI is considered to be of great importance due to its relationship to the other risk factors. There has been discussion within the scientific community as to whether the BMI used in the U.S. is applicable to other ethnic minority groups. Some research suggests that there are bone size differences among various ethnic groups that make the simple calculation using height and weight recordings less accurate than a calculation that includes bone size considerations. Further, while these studies suggest that ethnic specific cut-off points for BMI would be more appropriate, there are no widely accepted standards for Pacific Islanders. Therefore, for this community health assessment, the standard BMI cut-off point was necessarily used.
Reducing BMI has also been shown to reduce one's risk of developing diabetes, hypertension, and elevated blood cholesterol. Given the immense health benefits of BMI reduction to patients, it is important to ensure patients' related health knowledge and access to supportive services. If health professionals can broach and discuss the topic in a culturally sensitive manner, patients will be more receptive to recommendations and also more likely to cooperate. When helping patients plan a weight loss program, it is important to set attainable goals. The concept of an ideal weight is inherently related to ideal body image, which in turn is determined partly by culture. It is a well-known fact that body image varies widely among cultures. Fat and obesity carry a powerful stigma in modern-day Western society, but are held in high regard among many of the Pacific Islander traditional cultures [34]. Among Hawaiians and Samoans, for example, corpulence was dignifying and indicative of wealth [35, 36]. A cross-cultural comparison between Australian and Samoan women indicated overweight Samoan women felt healthier and more attractive than their Australian equivalents [37]. One study comparing body size perceptions between different ethnic groups living in New Zealand revealed that Pacific Islanders most frequently underestimated their body weight [38]. These findings may indicate that among Pacific Islanders, being overweight or obese is more socially acceptable. Since continental US Chamorros are descendants of the Pacific Island heritage, they may also possess this cultural propensity for obesity. To be effective counselors, health professionals should first determine how the patient perceives his or her own body weight currently, and then ascertain that an "ideal weight" in the clinical sense matches the patient's expectations.
Once a patient's weight and fitness goals have been established, the next step is to devise a weight loss and exercise program that will fit into the community's cultural structure. An earlier paper that assessed this community's risk for diabetes began to address the cultural challenges health care providers will need to be sensitive to, as they strive to help the community improve its over all health status [18]. Diet has an important cultural context among Chamorros. Researchers have cited Western influence on the native Chamorro's diet as a cause of adverse health effects. A study of children's diet in Guam documented a drastic change from the traditional vegetarian and fish diet to a Westernized, meat-based diet consisting of fatty and processed food [21]. Chamorro populations with increasing Western influence were found to eat a higher-fat diet and suffer higher coronary heart disease mortality [19]. Chamorros living in the continental US also experience this "Westernization." Health educators can take advantage of cultural pride by encouraging Chamorro patients to modify their diet toward the more traditional ethnic diet of plants and fish [18]. It has been postulated that Westernization has made a greater impact on Pacific Islanders' diet and lifestyle than it has on their cultural perspectives on body image [34]. The basis for this statement arises from a study of Samoans' body size perception where, although the Samoan defined thinner bodies as ideal, which reflected a definite Western influence, they were not overtly concerned with striving for this ideal [39]. Overweight individuals were quite satisfied with their large body size, and obese Samoan women were no more likely to try and lose weight than their thinner counterparts. The same may also hold true for continental US Chamorros, and the resulting health effects can be detrimental.
The Chamorro leaders who helped to initiate this community health assessment have demonstrated their ability to undertake a campaign to improve the health of their community. Through focus groups and community town hall meetings, as well as the exchange of information with other Chamorro communities, these same leaders can next begin to evaluate the universality of these findings. Where appropriate, they can also begin to develop strategies to address identified problems or develop plans for further investigation. The interventions they develop are likely to be closely aligned with the values and social fabric of their community. To be optimally resourceful in their program development, Chamorro leaders will need to call upon available public health educators and clinicians to help them interpret the latest medical literature to assure that the health promotion goals they set are grounded on evidence-based research.
This study is only the first step in the process of understanding how to optimize the health and well being of the Chamorro community. This study has definite limitations as regards the generalizability of the findings, including the potential for self-selection bias (62.8% response rate), the use of self-reported information that could not be verified in person, the small sample size, the unwillingness of those contacted to report about household income and body mass index and the narrow geographic eligibility for the sample. However, as an exploratory study, the information gathered and analyzed can lay the groundwork for the development of future studies and testable interventions to address those behaviors which increase this community's risk of cardiovascular disease.
Lessons for the international scientific community
This baseline health risk assessment for the Chamorro community was initiated by the leaders of the local Chamorro community to identify and address the factors that contribute to improving and diminishing the health of their community. It is a demonstration of a community-campus partnership in action. Through this collaboration with members of the local scientific community, the Chamorro leaders now have preliminary knowledge to help their members gain more personalized insight into their cardiovascular risk status and how to improve it. In turn, the University and the Chamorro community leaders now have a solid partnership that they can use as a foundation for future mutually beneficial undertakings.
Healthcare providers play a crucial role in the crusade against cardiovascular disease. Their frequent interactions with patients give them the opportunity to alter the course of this deadly illness by stressing behavioral risk reductions and other prevention strategies. Increasing awareness of the health needs of the Chamorro community and providing culturally competent intervention will enhance health providers' effectiveness as counselors with this ethnic group. Chamorro leaders have an equally important role to play in guiding their community toward the adoption of optimally healthful life styles. This paper presents baseline cardiovascular disease-related health data specific to the continental U.S. Chamorro population. It also relates various Pacific Islander cultural values and practices that may affect Chamorro patients' responsiveness to health professionals.
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Metcalf PA, Scragg RK, Willoughby P, Finau S, Tipene-Leach D: Ethnic differences in perceptions of body size in middle-aged European, Maori and Pacific people living in New Zealand. Int J Obes Relat Metab Disord. 2000, 24 (5): 593-599. 10.1038/sj.ijo.0801202.
Brewis AA, McGarvey ST, Jones J, Swinburn BA: Perceptions of body size in Pacific Islanders. Int J Obes Relat Metab Disord. 1998, 22 (2): 185-189. 10.1038/sj.ijo.0800562.
The contents of this article are the sole responsibility of the authors and do not necessarily represent the official beliefs of the funding agencies. The authors thank the following Chamorro community leaders for their help with this project: Rachel Mae C. Acfalle, Beverly Ann C. Acfalle, Frances Benito, Fred G. Blas, Lillian A. Blas, Tara Lyn Blas, Felipe G. Borja, Mario Borja, Jess A. Cruz, Juan S. Cruz, Eloise M. Gogue, Ron Charfauros, Tony Treltas, Thomas Guzman, Thomas Cruz, Joaquin Naputi, Jeanette Perez, Jess L.G. Perez, Julita Santos, Jess Quitugua, John Fejeran, Angelina Mummert, and Dennis Rodriguez.
Dr. Man Li Shi contributed to the conceptualization and data collection and organization for this project. Elizabeth Gilpin, M.A., director of the Biostatistics Unit of the Moores UCSD Cancer Center offered statistical guidance. In addition, the authors thank Drs. Allan Hubbell and Maria Reyes of UCI for their help with this project. Most importantly, the authors acknowledge the 228 men and women from the Chamorro community who generously gave of their time to help assess the health and well being of San Diego's Chamorro community.
This project was funded by a National Cancer Institute (NCI) grant R25CA65745, a San Diego County DHHS Chronic Diseases & Injury Prevention/Health Promotion Mini-grant, a National Heart, Lung, and Blood Institute grant 5 T35 HL07491, a NCI P30 grant and CURE Supplement, and a NCI Pacific Islander Cancer Control Network grant U01CA86073, the National Institute of Health, Division of National Center on Minority Health and Health Disparities EXPORT Grant P60MD00220; the National Cancer Institute Minority Institution/Cancer Center Partnership Program Grants #U56 CA92079 and #U56 CA92081.
Moores UCSD Cancer Center, La Jolla, California, USA
Binh Chiem, Victoria Nguyen, Phillis L Wu, Celine M Ko & Georgia Robins Sadler
Department of Surgery, University of California, San Diego School of Medicine, La Jolla, California, USA
Georgia Robins Sadler
University of California, San Diego School of Medicine, La Jolla, California, USA
Binh Chiem, Victoria Nguyen & Phillis L Wu
Pacific Islander Cancer Control Network, Office of Chamorro Affairs, Inc, San Diego, California, USA
Lee Ann Cruz & Georgia Robins Sadler
Binh Chiem
Victoria Nguyen
Phillis L Wu
Celine M Ko
Lee Ann Cruz
Correspondence to Georgia Robins Sadler.
All of the authors read and approved the final manuscript.
Chiem, B., Nguyen, V., Wu, P.L. et al. Cardiovascular risk factors among Chamorros. BMC Public Health 6, 298 (2006). https://doi.org/10.1186/1471-2458-6-298
Behavioral Risk Factor Surveillance System
Cardiovascular Disease Risk Factor
Elevated Body Mass Index


Below are the results of your search for postcards associated with 'Wilson Line'.
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While we are still waiting for an official game from the Grand Theft Auto series to be launched in the Windows Store by Rockstar Game, you might download the companion app Grand Theft Auto: iFruit on your Windows 8 tablets.
A while ago, I was thinking about the fact that an official Grand Theft Auto game would look awesome on my Windows 8 tablet and that I am eagerly expecting the moment when that will happen. Until that happens, we can resort to the single touch app released by Rockstar in the Windows Store for Windows 8 users – Grand Theft Auto: iFruit. For those who don't know, this is the official companion app for Windows 8 tablets.


text:
U19 Women's World Cup 2023
Match 7: England U19 v Zimbabwe U19 | Squads | Players to Watch | Fantasy Playing XI | Live streaming
Juili Ballal
The seventh match of the inaugural edition of the ICC Women's U19 T20 World Cup will be played between England and Zimbabwe on January 15 at Senwes Park in Potchefstroom, South Africa. The game will begin at 5.15 PM IST (1.45 PM LOCAL).
Both teams have played a couple of warm-up fixtures ahead of the World Cup against West Indies and Indonesia. While England won both their games, Zimbabwe lost their two encounters.
England: Ellie Anderson, Hannah Baker, Josie Groves, Liberty Heap, Niamh Holland, Ryana MacDonald-Gay, Emma Marlow, Charis Pavely, Davina Perrin, Lizzie Scott, Grace Scrivens (c), Sophia Smale, Seren Smale, Alexa Stonehouse, Maddie Ward
Zimbabwe: Kelis Ndlovu (c), Kelly Ndiraya, Kay Ndiraya, Adel Zimunu, Natasha Mtomba, Vimbai Mutungwindu, Danielle Meikle, Tawana Marumani, Michelle Mavunga, Olinder Chare, Kudzai Chigora, Betty Mangachena, Chipo Moyo, Faith Ndhlalambi, Rukudzo Mwakayeni
Grace Scrivens:
Player Profile of Grace Scrivens – U19 England Cricketer on Female Cricket. PC: Getty Images
The captain of England Women's U19 is a left-handed batter and a right-arm off-spinner. In the second warm-up fixture against Indonesia Women's U19, she muscled an unbeaten 26 off 15, including four boundaries. She is an attacking batter. She can also be handy with the ball.
Sophia Smale:
Player Profile of Sophia Smale – U19 England Cricketer on Female Cricket. PC: Getty Images
The wily left-arm spinner of England Women's U19 has claimed two wickets in as many warm-up games. She is known for her consistency with her lines and lengths and has good control over the ball. Besides being a wicket-taker, she is an economical bowler.
Natasha Mtomba:
Player Profile of Natasha Mutomba – U19 Zimbabwe Cricketer on Female Cricket. PC: Getty Images
The opening batter of Zimbabwe Women's U19 top-scored with 15 off 24 in the first warm-up match against Indonesia Women's U19. As an opener, she will have to shoulder the responsibility of providing a steady start to her side and laying the foundation for the batters to follow.
Also Read: Match Officials for Knockouts matches in U19 World Cup Announced
Olinder Chare:
Player Profile of Olinda Chare – U19 Zimbabwe Cricketer on Female Cricket. PC: Getty Images
She has been the most successful bowler for Zimbabwe Women's U19 in the two warm-up matches that were played before the start of the World Cup. She bagged four wickets and bowled at a decent economy rate. She will be expected to provide crucial breakthroughs to her side.
It will be the tournament's second game at this venue, with the first one being played early in the day. Before the World Cup, 10 women's T20Is have been played here, with the teams batting first, winning two, the teams batting second, winning seven, and one match not producing a result. Expect a good batting surface that will produce plenty of runs.
The weather is expected to be hot with abundant sunshine. The maximum temperature attained during the day will be 34 degrees Celsius. There will be a seven percent cloud cover and a zero percent chance of rain. The wind will blow from the northeast.
Fantasy Playing XI
Maddie Ward, Vimbai Mutungwindu, Grace Scrivens, Kelly Ndiraya, Natasha Mtomba, Alexa Stonehouse, Kelis Ndlovu, Liberty Heap, Olinder Chare, Ryana Macdonald-Gay, Sophia Smale
Time: 5.15 PM IST (1.45 PM LOCAL)
Venue: Senwes Park, Potchefstroom, South Africa
Live streaming: Fan Code
Follow Female Cricket on Instagram and Twitter for all the latest news and updates
I am a former cricketer having represented Mumbai University at All India University level. I was a part of MCA probables for the U-19 and U-23 age group. I have been an avid cricket writer for the last five years. Currently I am pursuing my Ph.D from IIT Bombay.
Also Read: Match 3: Manchester Originals v Trent Rockets Women | Squads | Fantasy Playing XI | Live streaming
Tags: Alexa Stonehouse, Grace Scrivens, Kelis Ndlovu, Kelly Ndiraya, Liberty Heap, Maddie Ward, Match 7: England U19 v Zimbabwe U19, Natasha Mtomba, Olinder Chare, Ryana MacDonald-Gay, Sophia Smale, Vimbai Mutungwindu
Match 8: Indonesia U19 v New Zealand U19 | Squads | Players to Watch | Fantasy Playing XI | Live streaming
UAE U19 defeats Scotland in the second match of the ICC U19 Women's World Cup

redpajama_set_name: RedPajamaCommonCrawl


text:
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Naruto characters profiles-Transgender hormone therapy (male-to-female) - Wikipedia
Transgender hip growth after estrogen-How to Transition From Male to Female - VICE
by Antonia L.
Collage by Michelle Thompson. Recommendations on finding them are forthcoming. Not all transgender people transition, and transitions look different for all kinds of people. They can be fast, or slow, and include lots of different kinds of treatments. Whatever your identity is, some things are true of transitioning across the board.
Groath can look into this process using some of the resources mentioned in the section above about where to go for help as you transition. But the most terrifying thing about Halloween is Mercury retrograde. Retrieved 17 January Views Read Edit View history. The Road to Becoming Unapologetically Transgender. Additionally, HRT often makes the nipples more sensitive to stimulation. This is the most common process of breast development for cisgender women, too.
Fishy smells and burning during sex. More from Wellness
Clinical Endocrinology. An assessment of the risks and benefits". Hate it but love myself afterwards. Transgender Medicine. I agree with you that supportive locations can help. Total Members. See also. They've both offered me advice and cheered me on when I needed it. Health care and medicine. The "AC" might refer to which type it is.? Williams 24 January
We offer a safe, inclusive community for transgender and gender non-conforming folks, as well as their loved ones, to find support and information.
Transgender hormone therapy of the male-to-female MTF type, also known as feminizing hormone therapy , is hormone therapy and sex reassignment therapy to change the secondary sexual characteristics of transgender people from masculine or androgynous to feminine.
Collage by Michelle Thompson. Recommendations on finding them are forthcoming. Not all transgender people transition, and transitions look different for all kinds of people. They can be fast, or slow, and include lots of different kinds of treatments. Whatever your identity is, some things are true of transitioning across the board. Chief among these: Transition is not one-size-fits-all. You may be comfortable altering your gendered existence without hormones or surgery; other people will feel those kinds of physical transitions are necessary for their survival.
There are lots of tools at your disposal, like changing your pronouns, your name, or what you wear. This is a popular question among early transitioners.
I realized that something about my gender felt mismatched when I was a teenager, but I convinced myself I was wrong because I was ashamed of admitting that I wanted to be a girl. No one had ever told me that those sort of feelings were valid. Rather, I was constantly called a girl as an insult to my masculinity, and my bullies used my femininity to degrade me on the basis of my assumed male gender. I was gay, according to every source at my disposal. It never crossed my mind that I had a choice about my body, my name, or that I could self-identify gender.
When I first came out as trans when I was 23, I struggled to accept whether my experience was authentic. In those early days before I made the dive into transition, I called a trans woman I knew and talked to her for two hours, trying to explain why I wanted to transition—as if I needed to justify the decision.
Really, I was trying to convince myself that I was making the right choice. LGBTQ centers specialize in issues related to the queer community. It was this sort of facility that helped me when I began transitioning six years ago. Working with a doctor and a therapist with experience treating trans clients made the process feel less scary, and it was a relief to know that my physician had done all this before when, for me, it was totally new.
In large cities like New York, Los Angeles, and Boston, there are major gender identity clinics that provide rapid, affirmative transition care. Many places, like Callen-Lorde in Manhattan, will treat patients regardless of their insurance status or ability to pay. Planned Parenthood also offers transgender medical care. Working with a doctor and a therapist with experience treating trans clients made the process feel less scary.
It can be tricky to find someone, but there are resources that could help you. Psychology Today offers a search engine for mental health providers who list care for transgender people as a speciality, and sites like Trans Health and MyTransHealth offer lists of gender-affirming and trans-focused medical care. The National Center for Transgender Equality has compiled many similar resources for people seeking help. If you have gender dysphoria, transitioning may be the right choice for you, and you deserve to talk with someone who is both knowledgeable and compassionate as you make that serious decision.
Transition is notoriously expensive, and for most trans people, many of our basic medical costs are prohibitively expensive. Surgery, hormones, clothing, name changes—they all cost money, and while there are ways to get these things paid for through insurance or with the aid of nonprofit programs, you may find yourself in a situation where you can't afford everything you need. That's one reason that knowledge is so powerful during transition—we need to know what our options are in order to take care of ourselves.
Otherwise, the whole thing can be overwhelming. The only reason we do is because heterosexual cisgender society pushes us into invisible subcultures, then feigns shock when we wander out of the underground. Just one day after I realized I was trans, I decided to call and tell them anyway.
Fortunately, they totally accepted me, but not everyone is so lucky. This is really personal, so work with people you trust to figure out how to best navigate coming out. Be safe, take care of yourself, and know that part of taking care of yourself is being informed. In getting ready to tell my family I am trans, I found it useful to do a lot of research, ingesting articles, forum posts, pamphlets, and books about transition.
Many trans people I know have benefited by sharing these resources with their parents. PFLAG is one organization that is known for helping families of trans and other LGBTQ people be supportive of their loved ones— they have reading lists, movie lists, and more. The Human Rights Campaign has also compiled resources for people who have a transgender person in their lives. Lots of trans people change their name and their legal gender marker. Sometimes, that name change happens a few times—I went through, like, three names before I chose Diana.
Changing your name and legal gender ID marker is easier in some states than others. The National Center for Transgender Equality has a superb search engine to figure out what your local laws are around document alteration. It can be a bit expensive to change your name, but that also varies by state.
That sounds pretty intense, but it can be easier than it might seem. The court will then give you a legal order of name change, which you can present to places like the DMV to make them update your ID.
You usually need medical letters to get your gender marker altered. You can look into this process using some of the resources mentioned in the section above about where to go for help as you transition. Then you have the joy of visiting the bank, or whatever else has your old name on it. Good luck trying to get PayPal to do it. Good luck. When I had my documents changed, it was really rewarding. Seeing my chosen name and true gender on government issued identification made the whole thing feel real on another level.
And it was a big fuck you to boring cis society, which is always a plus in my book. For a lot of us, the whole thing can be really triggering and difficult, but the results are often surreal and validating. As with all of this, you may encounter ignorance out there. Hormone replacement therapy HRT is closely associated with the healthcare of transgender people. For trans women, HRT typically comes in two parts: A medication to block testosterone in your endocrine system, and estrogen to replace it.
The degree of change, however, is different for every person. Goodman also says that penises tend to reduce in size once a person is on estrogen. This scar is typically darker in color to the surrounding skin, and runs like a seam all the way toward the anus. It is called the perineal raphe , and is where the urogenital swellings fuse together in utero after the production of testosterone.
All bodies, regardless of sex assigned at birth, have the potential to react to hormones. HRT began to redistribute my body fat around four months into taking hormones, starting with my face. I noticed subtle, but profound changes that altered the way the public was reading me. Over the following months and years, more fat kept moving around, making my legs, hips, chest, and arms, all look different. It effectively restructured my body from one that looked masculine to one that looked feminine.
YMMV is intended to help newly transitioning people have a realistic perspective on what hormones can accomplish. Sometimes big changes happen, other times, the changes are less pronounced. Goodman says. Nonetheless, HRT can have significant results on people well beyond puberty, including effects like breast development and fat redistribution. Cross-sex hormones saved my life, and are one of my forms of body modification. That said, it was fucking terrifying going on HRT.
As with any medication, only pursue it if you honestly believe that HRT can improve your quality of life. In my case, a few months after I started HRT, I felt better about myself even before any physical changes occurred.
It felt empowering to take control over my body after many years of feeling like I was its victim. Breasts are so fabulous they deserve their own section. One of my favorite odd-corner-of-the-internet resources for trans breast discourse is Second Type —a relic on the transgender web, with data mostly written in the year The website has a great breakdown of the development of breasts in AMAB trans women, explaining the different stages that both breasts and nipples go through at different points in HRT.
This is the most common process of breast development for cisgender women, too. Since those of us who undergo HRT literally have a second puberty, things are a bit different.
Breast development can be one of the quickest changes to occur during HRT. Two to three weeks after taking my first estrogen pill, I woke up and noticed my nipples looked and felt different—they were softer and more sensitive. The Trump administration is threatening Obama-era protections that mandate transgender medical care be covered by insurance, but it is still possible to get transgender-related procedures covered for the time being.
It seems only fair to me that they should—after generations of the criminalization , pathologization , and repression of transgender people, this country owes us free breast implants, at the very least. A lot of trans women, myself included, go full-throttle femme in the beginning of transitioning.
After years of suppressing your femininity, the desire to celebrate it can be powerful. I looked exceptional when I was in my early stages of transition, often wearing enormous platform heels and lingerie around in public just because I could—I had a lot of pent-up femininity that wanted to express itself.
Lots of people looked at me weirdly, but the public had always seen me as a freak anyway—I was grateful to finally be accepting myself. It would have been fine to live in that lacy, foot-achey stage forever, but that was just one stop on my journey. The physical changes I experienced because of HRT made it easier for me to make decisions about clothing that were more related to my personal style than my need to express my gender identity, because now my body expresses my gender identity.
These days, I wear a contrast of oversized menswear and tiny thot clothes. The more feminine my body has become, the more comfortable I have been in wearing whatever the hell I feel like wearing. In some places, there are even transgender clothing swaps , which is a really good idea. It was empowering to purge any relic of my former self. But I definitely miss some of those chic clothes that I used to think were just for guys.
When it comes to another element of the way you present: Facial hair can be so triggering and frustrating, and not easy to get rid of.
Pharmacology for Women's Health. Br J Urol. Curr Opin Endocrinol Diabetes Obes. Nat Clin Pract Endocrinol Metab. Exam and tests happen every 4 months.
Transgender hip growth after estrogen. Welcome to the TransPulse Forums!
Testosterone and estrogen are the hormones associated with gender. The average male, female and everyone in between have bodies that run on and need both. Today we are going to explore estrogen and the effects of it on the transgender female. Please note before we proceed that if you are currently undergoing or thinking of undergoing hormone replacement therapy with estrogen that we strongly recommend you do so under the care of a physician. There can be many dangers and health risks if estrogen is not administered and monitored properly.
Any of a group of steroid hormones that promote the development and maintenance of female characteristics of the body. Such hormones are also produced artificially for use in oral contraceptives or to treat menopausal and menstrual disorders. Though estrogen cannot reverse the effects of puberty, HRT with estrogen can help develop female characteristics and make a patient look more like the female gender they identify with.
It causes significant social and psychological changes while affecting your mood, energy, appearance and overall health. Though not a full cure it is very effective at treating patients with gender dysphoria.
Estrogen can be administered by injections, pills, patches and sub-dermal pellet implants. There are many changes that occur when taking estrogen. Some are permanent and some are reversible. Permanent changes. Reversible changes. What estrogen cannot change. Changes to the face over time. Other known changes. The affects on bone structure. Both testosterone and estrogen are needed for healthy bone and to prevent osteoporosis.
Estrogen is the predominant sex hormone that slows bone loss. The hips will rotate slightly forward due to changes in the tendons so hip discomfort is not uncommon. If estrogen therapy is conducted prior to the pelvis ossification that occurs around the age of 25, the pelvic outlet and inlet open slightly. This widening will also widen the femora as they are connected to the pelvis.
The pelvis will still have some masculine characteristics by default but the end result will be wider hips than a normal male and closer to a cis female. Fat redistribution. The body will now tend to accumulate new adipose tissue fat in a typically female pattern. This includes the hips, thighs, rear, pubis, upper arms, and breasts.
Metabolic risks associated with estrogen. Possible mental risks associated with estrogen. Typical hormone levels in females and males. Hormone Replacement Therapy can have many great benefits for male to female patients when administered correctly. In addition to estrogen many male to female transgender patients also take an anti-androgen to reduce the production of testosterone.
Again we highly recommend you see a medical professional such as an Endocrinologist who has experience treating transgender patients if you are taking or considering taking estrogen. Community Independent Journal. Sort: Newest. Featured Community Editor Clara Barnhurst. Oct 8, New Comment. The Road to Becoming Unapologetically Transgender. Editor Mila Madison. Apr 23, I Love Being Transgender! Don't You Love Being Trans? Editor Olivia Jaramillo. Dec 20, Jan 9, When Your Transition Goes off the Tracks.
Sep 17, I Never Wanted to Be Transgender. Apr 3, Aug 6, The Transgender Cinderella Effect. Apr 16, What Might Be. Nov 7, Jan 2,
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text:
require File.expand_path(File.dirname(__FILE__) + '/spec_helper')

WORD_FORMAT = '%012o'
DEFAULT_FORMAT = '%p'
TEST_WIDTH = 36
TEST_WORD_SLICES = %w{half_word byte character packed_character bit integer}
STRING_SLICES = %w{character packed_character}
NON_STRING_SLICES = TEST_WORD_SLICES - STRING_SLICES
SIGNED_SLICES = %w{integer}
TEST_WORD_SLICE_CLASSES = TEST_WORD_SLICES.inject({}) do |hsh, slice_name|
  hsh[slice_name.to_sym] = slice_name.gsub(/(^|_)(.)/) {|match| $2.upcase}
  hsh
end
FORMATS = %w{default inspect octal decimal binary hex}
STRING_FORMATS = FORMATS + %w{string string_inspect}

SLICE_COUNTS = {:byte=>4, :character=>4, :packed_character=>5, :half_word=>2, :bit=>TEST_WIDTH, :integer=>1}
SLICE_TEST_WIDTHS = {:byte=>9, :character=>9, :packed_character=>7, :half_word=>18, :bit=>1, :integer=>TEST_WIDTH}
SLICE_BITS   = {:byte=>9, :character=>7, :packed_character=>7, :half_word=>18, :bit=>1, :integer=>TEST_WIDTH}
SLICE_STRING = TEST_WORD_SLICES.inject({}) do |hsh, slice_name|
  hsh[slice_name.to_sym] = !!STRING_SLICES.include?(slice_name)
  hsh
end
SLICE_SIGN  = TEST_WORD_SLICES.inject({}) do |hsh, slice_name|
  hsh[slice_name.to_sym] = !!SIGNED_SLICES.include?(slice_name)
  hsh
end

$bytes = TestWord.new(0111222333444)
BYTE_ASC_VALUES = {
  :character=>[0111, 022, 0133, 044],
  :packed_character=>[0b0100100,0b1010010,0b0100110,0b1101110,0b0100100],
}
BYTE_VALUES = {
  :byte=>[0111, 0222, 0333, 0444],
  :character=>BYTE_ASC_VALUES[:character].map{|v| v.chr},
  :packed_character=>BYTE_ASC_VALUES[:packed_character].map{|v| v.chr},
  :half_word=>[0111222, 0333444],
  :bit=>[0,0,1,0,0,1,0,0,1,0,1,0,0,1,0,0,1,0,0,1,1,0,1,1,0,1,1,1,0,0,1,0,0,1,0,0],
  :integer=>[0111222333444],
}
$strings = TestWord.new([?A,?B,?C,?D].inject(0) {|value, ch| value<<9 | ch.getbyte(0) })
$positive = TestWord.new(1)
$negative = TestWord.new(eval('0b' + '1'*TEST_WIDTH))
$negative_twos = $negative
$negative_ones = TestWordOnes.new(eval('0b' + ('1'*(TEST_WIDTH-1)) + '0'))
$words = TestWords[1,2,3]

def is_numeric?(v)
  v.is_a?(Numeric) || v.is_a?(GenericNumeric)
end

shared_examples "with width" do |object, width|
  width ||= TEST_WIDTH
  it "should define correct width" do
    object.width.should == width
  end
end

shared_examples "with slices" do |object|
  it "should define slices" do
    expect { object.slices }.not_to raise_error
  end

  context "slices" do
    it "should be a Hash" do
      object.slices.should be_a_kind_of Hash
    end

    it "should contain Slice::Definitions" do
      all_defns = true
      object.slices.each do |key, defn|
        all_defns &&= defn.should be_a_kind_of Slicr::Slice::Definition
      end
      all_defns.should be_true
    end
  end
end

shared_examples "a segment" do ||
  include_examples "with width", $parent, $width
  include_examples "with slices", $parent
end

shared_examples "slice method" do |slice_name|
  it "should define <parent>.#{slice_name}" do
    $parent.should respond_to slice_name
  end
end

shared_examples "slice definition" do |slice_name|
  slice_name = slice_name.to_sym
  slice_object = $parent.send(slice_name) rescue nil
  it "sets .count" do
    slice_object.count.should == SLICE_COUNTS[slice_name]
  end

  it "sets .width" do
    slice_object.width.should == SLICE_TEST_WIDTHS[slice_name]
  end

  it "sets .significant_bits" do
    slice_object.bits.should == SLICE_BITS[slice_name]
  end

  it "sets .string?" do
    slice_object.string?.should == SLICE_STRING[slice_name]
  end

  it "sets .sign?" do
    slice_object.sign?.should == SLICE_SIGN[slice_name]
  end
end

shared_examples "slice class" do |slice_name|
  slice_class_name = TEST_WORD_SLICE_CLASSES[slice_name.to_sym]
  slice_class = TestWord.const_get(slice_class_name) rescue nil

  context "#{slice_class_name} class" do
    it "exists" do
      slice_class.should be_a_kind_of Class
    end

    it "defines .formats" do
      slice_class.should respond_to :formats
    end

    it "defines .string?" do
      slice_class.should respond_to :string?
    end
  end
end

# Spot check only -- the thorough checking is in indexable_basic_spec.rb
shared_examples "slicr is indexed" do |object, expected_values|
  size = expected_values.size

  it "should allow indexing" do
    object.should respond_to :[]
  end

  it "should return nil for self[-(size+1)]" do
    object[-(size+1)].should be_nil
  end

  it "should return nil for self[size]" do
    object[size].should be_nil
  end

  size.times do |i|
    it "should retrieve self[#{i}]" do
      object[i].should == expected_values[i]
    end
  end

  size.times do |i|
    it "should retrieve self[#{i-size}]" do
      object[i-size].should == expected_values[i]
    end
  end

  [false, true].each do |negative_i|
    [false, true].each do |negative_j|
      [-(size+1), -(size.div(2)), 2, size.div(2), size-1, size+1].each do |i|
        next if (negative_i && i >= 0) || (!negative_i && i<0)
        [-(size+1), -(size.div(2)), 2, size.div(2), size-1, size+1].each do |j|
          next if (negative_j && j >= 0) || (!negative_j && j<0)
          it "should retrieve self[#{i}..#{j}]" do
            object[i..j].should == expected_values[i..j]
          end
        end
      end

      [-(size+1), -(size.div(2)), 2, size.div(2), size-1, size+1].each do |i|
        next if (negative_i && i >= 0) || (!negative_i && i<0)
        [-(size+1), -(size.div(2)), 2, size.div(2), size-1, size+1].each do |j|
          next if (negative_j && j >= 0) || (!negative_j && j<0)
          it "should retrieve self[#{i}...#{j}]" do
            object[i...j].should == expected_values[i...j]
          end
        end
      end
    end
  end

  [false, true].each do |negative_i|
    [-(size+1), -(size.div(2)), 2, size.div(2), size-1, size+1].each do |i|
      next if (negative_i && i >= 0) || (!negative_i && i<0)
      [-1, size.div(2), (size+1)].each do |l|
        it "should retrieve self[#{i},#{l}]" do
          object[i,l].should == expected_values[i,l]
        end
      end
    end
  end
end

shared_examples "it is sliced" do
  TEST_WORD_SLICES.each do |slice_name|
    context slice_name do
      include_examples "slice method", slice_name
      include_examples "slice definition", slice_name
      include_examples "slice class", slice_name
    end
  end
end

describe Slicr::Word do
  it "should define String#pluralize" do
    "abcdef".should respond_to :pluralize
  end
end

describe "word" do
  $parent = TestWord
  $width = TEST_WIDTH
  it_behaves_like "a segment"
  it_behaves_like "it is sliced"
end

describe "instance" do
  $parent = $bytes
  $width = nil

  context "automatically installs formats" do
    it "understands formats" do
      expect { $bytes.integer(0).unsigned.octal }.not_to raise_error
    end
  end

  it_behaves_like "a segment"
  it_behaves_like "it is sliced"

  TEST_WORD_SLICES.each do |slice_name|
    defn = $parent.class.slices[slice_name]
    slices_name = slice_name.pluralize
    slice_class_name = TEST_WORD_SLICE_CLASSES[slice_name.to_sym]
    slice_object = $bytes.send(slice_name) rescue nil
    slice_count = slice_object.count

    context slice_name do
      it_behaves_like "slicr is indexed", slice_object, BYTE_VALUES[slice_name.to_sym]

      $bytes.send(slice_name).count.times do |i|
        context "#{slice_name}[#{i}]" do
          slice = $bytes.send(slice_name)[i]

          it "should define the .format method" do
            slice.should respond_to :format
          end

          it "the .format method should use the default format" do
            slice.format.should == slice.format(:default)
          end

          it "should define the .value method" do
            slice.should respond_to :value
          end
        end
      end

      it "should allow access to all the slices by .#{slices_name}" do
        $bytes.should respond_to slices_name
      end

      context ".#{slices_name}" do
        before do
          @slices = $bytes.send(slices_name)
        end

        it "should be an Array" do
          @slices.should be_a_kind_of Array
        end

        it "should contain the expected number of elements" do
          @slices.size.should == SLICE_COUNTS[slice_name.to_sym]
        end

        it "should contain instances of the proper slice class (#{slice_class_name})" do
          @slices.inject(true) {|value, slice| value && slice.is_a?(TestWord.const_get(slice_class_name)) }.should == true
        end
      end
    end
  end

  context "slices" do
    context "with significant_bits < width" do
      it "should mask out non-significant bits" do
        $bytes.character[2].asc.should == 0133
      end
    end

    context "slices with width > underlying data width" do
      it "should have 0 count" do
        StrangeWord.too_long.count.should == 0
      end
    end

    STRING_SLICES.each do |slice_name|
      slice = $bytes.send(slice_name) rescue nil
      slices_name = slice_name.pluralize

      context "string slice #{slice_name}" do
        it "should define all string formats" do
          slice.formats.keys.map{|f| f.to_s}.sort.should == STRING_FORMATS.sort
        end

        it "should return true for .string?" do
          slice.string?.should == true
        end

        slice.count.times do |i|
          context "[#{i}]" do
            slice_object = slice[i]

            # it "should create a .string" do
            #   slice_object.should respond_to :string
            # end

            # it " .to_s should == .string" do
            #   slice_object.to_s.should == slice_object.string
            # end

            slice.formats.keys.each do |fmt|
              context "format #{fmt}" do
                it "should display .format(#{fmt})" do
                  expect { slice_object.format(fmt) }.not_to raise_error
                end

                if fmt == :default
                  it " .format(#{fmt.inspect}) should == .string_inspect" do
                    slice_object.format(:default).should == slice_object.string_inspect
                  end

                  it " .format should == .format(#{fmt.inspect})" do
                    slice_object.format(:default).should == slice_object.string_inspect
                  end
                else
                  it " .#{fmt} should == .format(#{fmt})" do
                    slice_object.send(fmt).should == slice_object.format(fmt)
                  end
                end
              end
            end

            it "should define the .asc method" do
              is_numeric?(slice_object.asc).should be true
            end

            it "should define the .plus method" do
              slice_object.plus(2).should == (slice_object.asc + 2)
            end

            it "should have .asc >= 0" do
              slice_object.asc.should be >= 0
            end

            it "should allow .asc.format" do
              expect { slice_object.asc.format }.not_to raise_error
            end

            it "should return a string as .value" do
              slice_object.value.should be_a_kind_of String
            end

            it "should have .value == .asc.chr" do
              slice_object.value.should == slice_object.asc.chr
            end

            it "should define the + operator as concatenation" do
              (slice_object + "a").should == (slice_object.value + "a")
            end

            it "should allow prefix +" do
              expect { "a" + slice_object }.not_to raise_error
            end

            it "should allow postfix +" do
              expect { slice_object + "a" }.not_to raise_error
            end

            it "should not define .sign?" do
              expect { slice_object.sign? }.to raise_error
            end
          end
        end
      end

      it ".<slices_name> should create a merged string using .join" do
        $strings.characters.join.should == "ABCD"
      end
    end

    NON_STRING_SLICES.each do |slice_name|
      slice = $bytes.send(slice_name) rescue nil
      slices_name = slice_name.pluralize

      context "non-string slice #{slice_name}" do
        it "should return false for .string?" do
          (!!slice.string?).should == false
        end

        it "should define all relevant formats" do
          slice.formats.keys.map{|f| f.to_s}.sort.should == FORMATS.sort
        end

        it "should define .sign?" do
          expect { slice.sign? }.not_to raise_error
        end

        slice.count.times do |i|
          context "[#{i}]" do
            slice_object = slice[i]

            it "should not define the .asc method" do
              expect {slice_object.asc }.to raise_error
            end

            # it "should not define the string format" do
            #   expect {slice_object.string }.to raise_error
            # end

            it "should not define the string_inspect format" do
              expect {slice_object.string_inspect }.to raise_error
            end

            it " .to_s should == default format" do
              slice_object.to_s.should == slice_object.format
            end

            slice.formats.keys.each do |fmt|
              context "format #{fmt}" do
                it "should display .format(#{fmt})" do
                  expect { slice_object.format(fmt) }.not_to raise_error
                end

                if fmt == :default
                  it " .format should == .format(#{fmt.inspect})" do
                    slice_object.format.should == slice_object.format(:default)
                  end
                else
                  it " .#{fmt} should == .format(#{fmt})" do
                    slice_object.send(fmt).should == slice_object.format(fmt)
                  end
                end
              end
            end

            it "should not define the .plus method" do
              expect {slice_object.plus(2) }.to raise_error
            end

            it "should return a number as .value" do
              slice_object.value.should be_a_kind_of Numeric
            end

            it "should return the proper value" do
              slice_object.value.should == BYTE_VALUES[slice_name.to_sym][i]
            end

            it "should define the + operator as addition" do
              (slice_object + 2).value.should == (slice_object.value + 2)
            end

            it "should allow prefix arithmetic" do
              expect { 2 + slice_object }.not_to raise_error
            end

            it "should allow postfix arithmetic" do
              expect { slice_object + 2 }.not_to raise_error
            end

            # TODO slice_object.sign? should be possible
            if slice.sign?
              context "with signs" do
                it "the default format should be decimal" do
                  slice_object.format.should == slice_object.format(:decimal)
                end

                it "should define the .signed method" do
                  slice_object.should respond_to :signed
                end

                it "should have value == signed" do
                  slice_object.value.should == slice_object.signed
                end

                it "should define the .unsigned method" do
                  slice_object.should respond_to :unsigned
                end

                it "should allow .signed.format" do
                  slice_object.signed.should respond_to :format
                end

                it "should allow .unsigned.format" do
                  slice_object.unsigned.should respond_to :format
                end

                it "should allow .unsigned.octal" do
                  slice_object.unsigned.should respond_to :octal
                end

                it "should have .unsigned >= 0" do
                  slice_object.unsigned.should be >= 0
                end

              end
            else
              context "without signs" do
                it "the default format should be octal" do
                  slice_object.format.should == slice_object.format(:octal)
                end

                it "should not define .signed" do
                  expect { slice_object.signed }.to raise_error
                end

                it "should not define .unsigned" do
                  expect { slice_object.unsigned }.to raise_error
                end
              end
            end
          end
        end
      end
    end
  end

  context "with positive values" do
    it "should have .signed == .unsigned" do
      $positive.integer.signed.should == $positive.integer.unsigned
    end
  end

  context "with negative values" do
    it "should have .signed < 0" do
      $negative.integer.signed.should be < 0
    end

    it "should handle negative math okay" do
      ($negative_twos.integer.value * $negative_ones.integer.value).should == 1
    end

    context "in two's complement format" do
      it "should have .signed set properly" do
        $negative_twos.integer.signed.should == -1
      end

      it "should have .unsigned set properly" do
        $negative_twos.integer.unsigned.should == eval('0b' + '1'*TEST_WIDTH)
      end

      it "should handle -(-1) properly" do
        (-($negative_twos.integer.value)).should == 1
      end

    end

    context "in one's complement format" do
      it "should have .signed set properly" do
        $negative_ones.integer.signed.should == -1
      end

      it "should have .unsigned set properly" do
        $negative_ones.integer.unsigned.should == eval('0b' + '1'*(TEST_WIDTH-1) + '0')
      end
    end
  end

  context "any slice" do
    it "should default to .value" do
      ($bytes.byte[1] + 2).should == (0222 + 2)
    end
  end

  context "any field" do
    it "should collapse" do
      ($positive.integer.signed).should == $positive.integer[0]
    end

    it "should default to .value" do
      ($positive.integer + 2).should == 3
    end
  end
end

describe Slicr::WordsBase do
  it "should set size" do
    $words.size.should == 3
  end

  it_behaves_like "slicr is indexed", $words, [1,2,3]

  it "should allow accessors" do
    $words.bytes.to_a.should == [0,0,0,1,0,0,0,2,0,0,0,3]
  end

  it "should allow indexed accessors" do
    $words[1,2].half_words.to_a.should == [0,2,0,3]
  end
end
# TODO Write tests for Blocks
# $double_word = Bun::Block[1,2]
# show_value "$double_word"
# show_value "$double_word[0]"
# show_value "$double_word[0].class"
# show_value "$double_word[1].to_s"
# show_value "$double_word.word_and_a_halfs"

redpajama_set_name: RedPajamaGithub


Vegan Cuts Family Starter Kit!
I'm already a big fan of Vegan Cuts snack and beauty box subscription service. I was so excited to hear they were coming out with a Family Starter Kit box. I don't know why but new products for my baby just get me giddy! Not to mention all products are cruelty free and vegan! Vegan Cuts are experts at curating their boxes; finding new limited-time, limited-quantity exciting vegan food, fashion and body care products. They did an awesome job putting The Vegan Family Starter Kit together; it is one of my favorite boxes I have received! My little guy really enjoyed this box too!
This lovely box, co-curated with Sayward Rebhal of Bonzai Aphrodite, is filled with cruelty-free products designed for babies, toddlers, and you, too! From food pouches to creams to wipes, everything you need for happy little ones is contained inside.
4 edible, 1 for storing food, 6 personal care, 1 toy plush, 1 coupon. 4 out of the 13 products were labeled Organic.
Like I said before I LOVE this box; especially all the organic products. Several of the products were new to me and I am grateful I got to try them. This box is awesome for any family with kids. I think it would make a great gift too.
If you love being exposed to new, awesome, vegan and cruelty free products then you will love Vegan Box too!
Buy The Family Starter Kit: $27.95 with free shipping to the US Here. ($25 shipping to Canada, $40 shipping Worldwide).
Vegan Cuts also offers snack and beauty box subscription services.
Visit Vegan Cuts to shop and discover the best vegan products!
Disclosure: rays of bliss received the products mentioned above for free. Regardless, I only recommend products or services I use personally and believe will be good for my readers. This post contains affiliate links.


This gown has been cleverly designed to give a bust to those who don't have one…It's all in the magical cowl neckline!
It has a lace up back, is lined and has no zipper so it gives the super stretch, and slinky look you want in a gown like this.
Available in store now in sizes AU4 to AU12.
Available colours: red, white, black, navy and wine, petrol, rose gold and yellow.


text:
Media Moves at CNBC & WSJ, The Atlantic Promotes Three
March 26, 2019 / in Media Moves US , Media Blog / by Anna Marevska
The Wall Street Journal has hired John Murawski as a reporter for WSJ Pro: Artificial Intelligence digital newsletter, and covers artificial intelligence, its developments, and its applications. He previously spent a year at The Herald-Sun as a business reporter, and before that was on staff for more that 15 years at The News & Observer.
CNBC has shuffled several staff at its Asian properties, including "Street Signs Asia" and "Squawk Box Asia:"
· Tanvir Gill has joined CNBC's on-air team in Asia as an anchor of the morning shows "Street Signs." She previously spent a decade as a senior anchor at "Markets" on ET NOW.
· Matthew Taylor has moved from CNBC International to CNBC's Singapore bureau as senior correspondent. He was most recently an Australia reporter since 2007, and before that worked for Network Ten as a news producer.
· Nancy Hungerford is now an anchor for "Squawk Box Asia." She was previously the co-anchor of "Capital Connection," and relocated to Singapore from CNBC's EMEA headquarters in London in July 2017.
· Sri Jegarajah is now also an anchor for "Squawk Box Asia." He was previously a Singapore-based anchor and regional correspondent of CNBC's "Capital Connection" and has been with the network since 2005. Before that he was a business correspondent for Bloomberg LP.
Binyamin Appelbaum has been named lead writer on business and economics for The New York Times editorial board. He previously spent nine years as an economics reporter for The Times in Washington. Before that he was a reporter for the Washington Post and the Boston Globe before that.
The Atlantic has promoted three staff to top editorial positions for the print and online properties of the brand:
· Adrienne LaFrance has been upped to executive editor of the Atlantic Online, Atlantic Studios, and Atlantic Podcasts. She joined the staff in 2014 as a senior associate technology editor, and most recently served as the editor of the website.
· Swati Sharma has moved from deputy to managing editor and guides the daily reporting at TheAtlantic.com and oversees all of the site's sections—Politics, Culture, Technology, Ideas, Science, Family, Global, Health, and Education—and their teams. She joined The Atlantic in January 2018.
· Sarah Yager is now the managing editor and operations chief for The Atlantic and is the primary editorial lead on budgeting and personnel. She started at The Atlantic as a fellow, and has been a researcher, fact-checker, and story editor.
Rick McLaughlin has joined WAPT-TV, the ABC affiliate in Jackson, Mississippi, as news director. He comes from NBC's WESH-TV in Orlando, where he spent the last five years as assistant news director. Before that he worked as an EP at WHDH-TV in Boston and KMOV-TV in St. Louis, Missouri.
Longtime Chicago Reader political writer Ben Joravsky has a new web radio show which will air online via the Reader and the Chicago Sun-Times websites. "The Ben Joravsky Show" is a two-hour program and runs four times a week (Tue – Fri) streaming live from 1 to 3 p.m. Joravsky was most recently on air as afternoon host on Newsweb Radio progressive talk WCPT-AM in Chicago.
The Cision research team makes over 20,000 media updates to our influencer database each day! If you have a media move, send it to mediamoves@cision.com. Also, follow us on Twitter at twitter.com/media_moves.
Tags : Media Moves US
About Anna Marevska
Anna Marevska is an editor and writer for Cision Blog, and writes media updates, media influencer and industry features. She is also the senior manager of content and client data at Cision's research department, and the editor of FashionFilesmag.com. Find her on Instagram @AnnaMar3.


text:
Unity Retail, Pakistan's Retail Startup Raises Six-figure Seed Funding
Faysal Bank has been awarded "Best Emerging Islamic Bank – 2019"
Press ReleaseLast Updated: Feb 21, 2020
Faysal Bank is one of the fastest growing banks in Pakistan and is on its journey to convert from a conventional bank to a full fledged Islamic Bank, which is regarded as the largest conversion in the financial sector.
The Bank has already successfully converted a large portion of its conventional banking network and portfolio into Islamic. At the end of 2019, Faysal Bank has a total of 555 branches, out of which 414 are dedicated Islamic branches.
The Bank, in the last two years, has grown significantly in terms of its footprint, Islamic products and its customer base both through its expanding network and digital banking.
Check out? 15 Best Open World Games for Android Offline in 2020
On this occasion, the CEO reiterated the vision of the Bank to be the leading Islamic Bank in Pakistan with customer centricity and technology as the pillars of growth.
Faysal Bank has been awarded "Best Emerging Islamic Bank – 2019". Mr. Yousaf Hussain, CEO of Faysal Bank received this award from the Governor SBP, Mr. Raza Baqir at the CEO Summit Asia, held at Karachi.


text:
Ophthalmology Grand Rounds 2016
Program Description:
Advanced in clinical and bench research in ophthalmology has produced multiple new treatment options for a variety of ocular diseases. New technology, including the fast growing field of ocular imaging, is been used to further understand eye anatomy and pathology. Progress in the field of ocular surgery has introduced new techniques and better outcomes. The clinical and research environment is complex; issues related to ethics, quality improvement and new technology affect all eye care providers. The Eye Institute has, as one of its mission, the goal of being at the forefront of research, clinical care and education. Our goal is to educate the academic and community eye care providers, residents, researchers and medical students on the best and newest clinical and surgical treatments, cutting edge research and important non-clinical topics available in the field.
ACCME Accreditation Statement:
The Medical College of Wisconsin is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
AMA Credit Designation Statement:
The Medical College of Wisconsin designates this Live Activity for a maximum of 1.00 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Hours of Participation for Allied Health Care Professionals
The Medical College of Wisconsin designates this activity for up to 1.00 hours of participation for continuing education for allied health professionals.
CME Coordinator Contact Information
Mary Schafer
mschafer@mcw.edu
Series date:
Friday, January 1, 2016 - 7:00am to Friday, March 17, 2017 - 8:00am
Series location:
Eye Institute
16069 Ophthalmology Grand Round - "Transverse Sinus Stenting for Severe IIH" January 6, 2016 01/06/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "The Importance of Clinicians in Medical Innovation" February 3, 2016 02/03/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Pearls on the Surgical Management of Some Common Eyelid Malpositions" March 2, 2016 03/02/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Genetic Studies of Congenital Ocular Disorders" April 6, 2016 04/06/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Advances in Glaucoma Therapy" June 1, 2016 06/01/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Uveitis in JIA and Pediatric Rheumatic Diseases" July 6, 2016 07/06/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "The Idiopathic Intracranial Hypertension Treatment Trial Results & Implications" August 3,2016 08/03/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Improving The Quality of Teaching at the Medical College of Wisconsin" September 7, 2016 09/07/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "New Ideas in Glaucoma" October 5, 2016 10/05/2016 - 7:00am to 8:00am
16069 Ophthalmology Grand Round - "Childhood Ptosis: Epidemiology, Clinical Characteristics and Management" November 2, 2016 11/02/2016 - 7:00am to 8:00am


Lightly raced, but highly talented is Historian (5g Choisir x Cyclonic, by Marauding), who has become the latest Group I winner for leading sire Choisir after winning the Thorndon Mile at Trentham in New Zealand on Saturday. Runner-up in the 2011 New Zealand Derby, five year-old gelding Historian has always shown Group I ability, but his path to glory has been anything but smooth. A $40,000 purchase from the Lyndhurst Farm draft at the NZB Select Yearling Sale, Historian started his career with Tony Pike winning two of his first four starts before closing out his three year-old campaign with that fine derby second to Jimmy Choux. Then sent to Hong Kong, it all went pear shaped from that point for Historian as injury took over and he did not race for the best part of two years. Nurtured back to top condition by Cambridge trainer Gary Alton, Historian reappeared at the races on December 15 and followed with another run at Ellerslie on New Year's Day, both efforts sound albeit behind the placegetters. Raising the bar to Group I company for his third run back and drawn gate 16 in a field of 16, Historian rose to the challenge, surging home late for Rosie Myers to win the 1600 metre feature by short head. In the process, Historian provided trainer Gary Alton with his first Group I winner from only the second starter he has lined up at this level. "We got him back from Hong Kong after his injury and although he's been in work for seven months he hardly ever sees a track with most of his work done on the treadmill," said Alton. "He's a day-to-day proposition and you know you're only going to get so many runs with him before he may have another problem so it's great to see him get his win today as he deserves it." Wining rider Rosie Myers was full of praise for the winner's effort. "He got a terrible run after being caught three wide the entire race and really didn't travel until Jetset Lad came around him at the 600 metre mark," said Myers. "He picked up the bit and got his momentum up and found the line in a very brave effort." Historian has the overall record of three wins and four placings from 10 starts with prizemoney in excess of $535,000. He is the first stakes-winner for Marauding mare Cyclonic, who traces back to an influential Australian producer in Valour, whose descendants include Champion 2YO and Golden Slipper winner Burst as well as Group I winners Victory Prince and Bush Padre. Historian is the 47th stakes-winner for Choisir and is his fifth Group I winner, the son of Danehill Dancer currently back in Ireland to serve the Northern Hemisphere season.


It started with the no-one has to die intro followed by path in which Troy was killed in no-one has to die – Troy dies then a quick look at a no-one has to die – Troy Steve dies bad end where no one survives. So if Troy Lionel dies while Steve and Christina remains, what will the two talk about?
After Lionel died it is time for either Christina or Steve to die as well.
Both Christina and Steve arguing about who should die. Well just kill off one first and then the other in order to see both of their endings.


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We need our country to commit to deeper carbon cuts and a 100% renewable energy future, to build momentum toward a robust global agreement at the Paris summit.
Election results matter. Pick an issue, any issue. Pick the topic that first brought you to the Sierra Club. Whatever you're most concerned about, the federal government probably has an impact, for good or for ill.