text:
Disparities and ethical considerations for children with tracheostomies during the COVID-19 pandemic
Issue title: COVID-19's Impact on the Practice of Pediatric Rehabilitation Medicine: Insights and Recommendations
Guest editors: Matthew McLaughlin and Christian Vercler
Authors: Kana, Lulia A.a | Shuman, Andrew G.a; b; c | Helman, Jenniferb | Krawcke, Kellyb | Brown, David J.a; b; d; *
Affiliations: [a] University of Michigan Medical School, Ann Arbor, MI, USA | [b] Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA | [c] Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA | [d] Office for Health Equity and Inclusion, Michigan Medicine, Ann Arbor, MI, USA
Correspondence: [*] Corresponding author: David J. Brown, Department of Otolaryngology-Head and Neck Surgery University of Michigan Medical School 1540 E Hospital Dr. SPC 4227 Ann Arbor, MI 48109, USA. Tel.: +1 734 936 5730; E-mail: [email protected].
Keywords: COVID-19, ethics, pediatric tracheostomy, chronic disability
DOI: 10.3233/PRM-200749
Journal: Journal of Pediatric Rehabilitation Medicine, vol. 13, no. 3, pp. 371-376, 2020
The COVID-19 pandemic is exacerbating longstanding challenges facing children with tracheostomies and their families. Myriad ethical concerns arising in the long-term care of children with tracheostomies during the COVID-19 pandemic revolve around inadequate access to care, healthcare resources, and rehabilitation services. Marginalized communities such as those from Black and Hispanic origins face disproportionate chronic illness because of racial and other underlying disparities. In this paper, we describe how these disparities also present challenges to children who are technology-dependent, such as those with tracheostomies and discuss the emerging ethical discourse regarding healthcare and resource access for this population during the pandemic.
The COVID-19 pandemic is exacerbating longstanding challenges facing children with tracheostomies and their families. Children with tracheostomies have comorbid conditions and require complex healthcare delivery services [1, 2, 3, 4]. Personnel and adequate tracheostomy supplies to prevent complications and maintain wellness are critical for these children [5, 6]. Many ethical concerns arising in the long-term care of children with tracheostomies during COVID-19 revolve around inadequate access to care, healthcare resources, and rehabilitation services.
Marginalized communities such as those from Black and Hispanic origins have been reported to face disproportionate chronic illness because of racial and other underlying disparities during the pandemic in the adult world [7, 8]. We postulate that such disparities also impact children who are technology-dependent, such as those with tracheostomies. This paper will explore how racial disparities and societal inequities have framed the emerging ethical discourse regarding healthcare and resource access for this population and how as a result, the pandemic has limited and will likely continue to limit access to medical services for children with tracheostomies.
2.Disparities and ethical considerations
There is a collective ethical duty to care for those infected with COVID-19 as well as those with other medical problems. As medically fragile children depend on technology and well-trained caregivers, there is a special duty to ensure their safety and take special steps to minimize harms. Due to their frequent comorbidities [2, 3], children with tracheostomies will be at greater risk for worse outcomes compared to their peers if they become infected with the virus [9, 10]. They will also likely require additional healthcare resources including personnel, durable medical equipment, and personal protective equipment in the hospital. As SARS-CoV-2, the virus causing COVID-19, is spread through respiratory droplets and caring for tracheostomies requires manipulation of the aerodigestive tract, there is an increased infection risk for caregivers and providers [11]. From not only an ethical but a public health standpoint, ensuring children with tracheostomies stay out of the hospital during the pandemic stands to benefit all of society.
The caregivers of children with tracheostomies will invariably experience hardship navigating the healthcare system and in their day-to-day lives during the pandemic. This hardship may likewise extend to children and young adults as they are inherently vulnerable due to their disability [12] and require additional resources to combat physical, emotional and developmental challenges [13]. Barriers to communication and their need for constant caregiver support are examples of these vulnerabilities. With hospital policies limiting access to patient visitors, barriers to communication are exaggerated, making it challenging for these children to advocate for themselves [14]. Any restrictions on patient visitors will limit the potential for additional support that multiple caregivers at the bedside might well provide [15]. Further, because children with tracheostomies require extensive human support, caregivers who cannot work from home or work in high-risk infection jobs may experience challenges in providing optimal and safe homecare.
Certain children with tracheostomies may further experience compounded disparities during the pandemic. While 29% and 22% of the population in New York is comprised of Hispanic and Black people, respectively, they account for 34% and 28% of COVID-19 deaths [8]. In Michigan, while only 14% of the population is Black, 41% of COVID-related deaths are in Black patients [8]. The infection and death rate from COVID-19 in Black communities in the United States is estimated to be about 3 and 6 times higher, respectively [7]. It is hypothesized that differences in infection and death during pandemics are due to disparities in exposure risk, comorbid conditions and access to treatment for those of certain ethnic backgrounds [16, 17]. Black communities, which have been historically marginalized, have disproportionately been affected by the pandemic, likely as a result of discrimination and long-standing societal inequities from institutional, interpersonal, and structural racism [8, 17]. Examples of these inequities include limited choices in housing leaving families to live in crowded apartments where social distancing is not possible, limited access to healthy foods due to food deserts and reliance on buses and subways for transportation [8, 17].
While the demographic characteristics of children with tracheostomies are heterogenous, there are data to suggest that underlying racial disparities are compounded amongst this population and their likelihood of adverse outcomes are also worse, which is particularly concerning during this pandemic. One study using a national database that is presumed to be an approximation of the U.S pediatric inpatient population reported that 21% of children who undergo tracheostomies are Black and 20% Hispanic, clearly disproportionate to the US population [18]. Hispanic infants with tracheostomies also had an increased likelihood of mortality [19]. While the cause for this increased likelihood is not elucidated in the study and is likely multifactorial, their adverse event rates were also higher in comparison to non-Hispanic patients [19]. These pre-COVID-19 data collectively confirm that disparities already impact children with tracheostomies.
For children with tracheostomies and their families from marginalized backgrounds, these issues can translate to other problems and risk factors pertinent during the pandemic, including food insecurity and ability to work from home. Uneven access to the Internet can negatively impact accessing telehealth visits, which can ultimately affect progress with ventilator weaning and titration of settings. Even practicing safe social distancing for children with tracheostomies can be a matter of privilege. Further, because children with tracheostomies require constant care, this can make it challenging for financially strained caregivers to tend to basic household needs, such as having access to healthy foods. As a result, the effect that the virus has on marginalized communities for adults will most certainly carry over to the care of their children [20].
Addressing societal disparities is a core tenet of public health ethics [21]. There is an ethical duty for providers and policy makers to understand how healthcare disparities impact vulnerable communities, such as children with tracheostomies. Victims of the virus and the nation's response to it have showcased the inherent institutional, interpersonal, and structural racism present today [17]. The disproportionate suffering of marginalized communities due to long-standing inequities serves as a sobering reminder of how much work is still left to be done as a nation to achieve fairness and equity when it comes to caring for society's most vulnerable [17, 20, 22]. While legal and policy measures can be implemented to mitigate disparate outcomes, such as with regards to access of treatments and vaccines, in the short-term, this response is insufficient; only when interventions are aimed at addressing the true sources of inequity can health justice be achieved for all [17].
3.Manpower
Because children with tracheostomies require extensive caregiver support, ensuring adequate human capital to care for these children during the pandemic should be a priority and especially for those from underrepresented populations. First, homecare nursing is vital for managing tracheostomies [5, 23, 24, 25]. For children, pediatric-specific home health services are already stressed and often non-existent outside of major cities and their immediate surrounding counties [26]. However, the pandemic has, more broadly speaking, raised issues over access to safe homecare nursing due to infection transmission and inadequate personal protective equipment for home and visiting health staff [27, 28]. While limited data exist regarding homecare nursing infection rates, healthcare workers have been demonstrated to be vectors of transmission globally, comprising 9% of infections in Italy [29], and 14% in Spain [30]. Without access to safe homecare nursing and personal protective equipment for nursing staff, children with tracheostomies can be at risk for infection, positioning not only themselves at risk, but their entire family unit. This can be especially problematic for families who chose to forgo homecare nursing over concerns of infection transmission, placing additional burden and stress on caregivers who are also the breadwinners [31].
Second, access to hospitals and specialist clinics has also impacted follow-up care for children with tracheostomies during the pandemic. For example, elective surgical procedures such as reconstructive surgeries for decannulation and tracheotomy revisions or removals are being postponed or cancelled [32]. While telehealth services are being used in these settings [33] the importance of in-person multidisciplinary care remains irreplaceable. For example, as a tracheostomy impairs speech, the rehabilitative services offered by speech language pathologists are crucial towards restoring essential communication [14, 34]. Since supervision and training are needed when trialing speaking valves [34], the services offered by these providers are difficult to substitute via a virtual visit alone. Further, school cancellations mean that children with tracheostomies have likely lost access to the benefits of in-person individualized education programs, services that offer one-to-one nursing staff in addition to many other resources to ensure effective learning experiences for children with disabilities [35].
Finally, the impact the pandemic has had on families is massive. Caregivers are vital to providing care to children with tracheostomies, which includes conducting regular respiratory assessments, tracheostomy tube suctioning, other procedures and providing care during a medical emergency [5, 6]. However, for families who do not have the luxury to work from home or are at risk of infection because of their occupation, caring for children with tracheostomies will undoubtedly be compromised. The role that racial disparities have in this context is particularly relevant, as Black workers are more likely to be employed in professions requiring contact, with 20% of Black workers being able to work from home compared to 30% of white workers [36].
4.Ethical decision-making when advocating for justice
The fluctuating global supply chain due to COVID-19 has threatened access to durable health equipment [28, 37]. While concerns have centered on ventilator and personal protective equipment shortages [28, 37], the destabilization of the supply chain can cause bottlenecks and shortages in other healthcare sectors as well [38, 39]. As a result, this can translate to shortages of essential equipment to care for tracheostomies in the long-term.
Children with tracheostomies require numerous supplies, such as suction machines, portable nebulizers, suction catheters, spare tracheostomy tubes, and a process to order supplies from a supply manager [5, 23]. During the pandemic, tracheostomy supplies may not be available to patients due to shortages and delivery delays [31]. Equipment shortages of inner cannulas, humidifiers and suction catheters, have forced supply companies and all involved in the supply chain to think of creative solutions to extend the use of supplies through home reprocessing techniques and equipment-changing regimens, ultimately causing concern for infection and equipment failure [31]. Due to concerns over access to care and resources for children with tracheostomies during the pandemic, discussing the role of ethical decision-making in resource allocation for this population is crucial.
Proactive and transparent discussions incorporating ethical principles such as beneficence, nonmaleficence, autonomy and justice are emphasized by ethicists and providers in the creation of guidelines for resource allocation during a pandemic response [40, 41]. However, schemas that incorporate quality of life presumptions are problematic for many with disabilities, and by extension, children with tracheostomies [42]. The "disability paradox" was coined to highlight the discordance between people with disabilities and people without disabilities when reporting a disabled person's quality of life [43]. In healthcare, those with disabilities may report their quality of life to be superior to what is anticipated by providers [44, 45]. Thus, when practitioners and policy makers are empowered with formulating decision-making protocols for who can have access to supplies and medical services, children with tracheostomies may be negatively impacted by such triage policies [42]. From a disparity perspective, attempts towards crafting objective ethical allocation schemas are likely not sufficient if social determinants of health are overlooked. Racial and ethnic disparities in access to care and health outcomes are constant reminders of how inequities in service and social injustices across communities still perpetuate and compromise the health of those most vulnerable [46]. Discrimination has the potential to creep into poorly designed triage protocols that more or less designate a child with a tracheostomy as having a potential contraindication to accessing a scarce resource. Society will undoubtedly grapple with how strategies that prioritize utility and equality will compromise those most vulnerable [41].
While many rationing schemas are formulated within hospital systems, a great deal of rationing also occurs upstream. Children with tracheostomies are likely grappling more with issues of resource access from the supply side as outpatients rather than from within hospital systems. Vendors and government agencies may be competing with one another for access to these scarce resources [28, 37, 47]. Uneven access to care translates on a systems level for children with tracheostomies: companies with more power, privilege and money are better positioned to acquire access compared to others who are less connected [41]. These issues will be further augmented for children who are victims of racial and socioeconomic disparities.
To mitigate these concerns, routine communication amongst government, hospitals, and supplier companies might ensure equitable and consistent approaches to rationing schemas across cities and states. Increasing representation of children with tracheostomies and their caregivers to elevate their voices during policy discussions can be integral towards promoting a patient-centered approach to solve these issues [42]. Finally, efforts directed towards collecting data on parameters that are known to be influenced by disparities, such as race, would be beneficial so that scarce resources can be optimally deployed to communities most in need [17, 36].
COVID-19 is straining the contemporary healthcare system in ways previously unimaginable. Children with special needs, including those with tracheostomies, are disproportionately experiencing issues related to inadequate access to care. The impact the pandemic has on children with tracheostomies merits reflection on how long-standing racial disparities and societal inequities frame the ethical discourse regarding resource allocation and healthcare access. An ethical duty lies herein to recognize that in addition to responding to the acute care needs of COVID-19 positive patients, children with tracheostomies and other children with special needs also face ongoing challenges during the pandemic in the form of difficulties acquiring the healthcare services and supplies necessary for optimal health, growth, and development. Providers and policy makers are well-positioned to advocate for the rights and health of children with tracheostomies to ensure fair and equitable access to healthcare not only during the COVID-19 pandemic but in its aftermath as well.
The authors have no conflicts of interest to report.
Graf JM, Montagnino BA, Hueckel R, McPherson ML. Pediatric tracheostomies: a recent experience from one academic center. Pediatr Crit Care Med. 2008; 9(1): 96-100. doi: 10.1097/01.PCC.0000298641.84257.53.
Liu C, Heffernan C, Saluja S, Yuan J, Paine M, Oyemwense N, et al. Indications, Hospital Course, and Complexity of Patients Undergoing Tracheostomy at a Tertiary Care Pediatric Hospital. Otolaryngol Head Neck Surg. 2014; 151(2): 232-9. doi: 10.1177/0194599814531731.
Maunsell R, Avelino M, Caixeta Alves J, Semenzati G, Lubianca Neto JF, Krumenauer R, et al. Revealing the needs of children with tracheostomies. Eur Ann Otorhinolaryngol Head Neck Dis. 2018; 135(5s): S93-s7. doi: 10.1016/j.anorl.2018.07.007.
Muller RG, Mamidala MP, Smith SH, Smith A, Sheyn A. Incidence, Epidemiology, and Outcomes of Pediatric Tracheostomy in the United States from 2000 to 2012. Otolaryngol Head Neck Surg. 2019; 160(2): 332-8. doi: 10.1177/0194599818803598.
Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013; 148(1): 6-20. doi: 10.1177/0194599812460376.
Callans KM, Bleiler C, Flanagan J, Carroll DL. The Transitional Experience of Family Caring for Their Child With a Tracheostomy. J Pediatr Nurs. 2016; 31(4): 397-403. doi: 10.1016/j.pedn.2016.02.002.
Thebault R, Tran AB, Williams V. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post [newspaper on the Internet]. 2020; Apr 7 [cited 2020 May 12]; National: [about 5 p]. Available from: https//www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true.
Owen WF, Carmona R, Pomeroy C. Failing Another National Stress Test on Health Disparities. JAMA. 2020; 323(19): 1905-6. doi: 10.1001/jama.2020.6547.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020; 8(5): 475-81. doi: 10.1016/S2213-2600(20)30079-5.
Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan CA, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. 2020 May 11; 174(9): 1-6. doi: 10.1001/jamapediatrics.2020.1948.
Givi B, Schiff BA, Chinn SB, Clayburgh D, Iyer NG, Jalisi S, et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic. JAMA Otolaryngol Head Neck Surg. 2020 Jun 1; 146(6): 579-584. doi: 10.1001/jamaoto.2020.0780.
World Health Organization [Internet]. [Geneve]: World Health Organization; 2020. Disability considerations during the COVID-19; outbreak. 2020 Mar 26 [cited 2020 May 20]; [about 14 pages]. Available from: https//www.who.int/publications-detail/disability-considerations-during-the-covid-19-outbreak.
McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck PW, et al. A new definition of children with special health care needs. Pediatrics. 1998; 102(1): 137-9. doi: 10.1542/peds.102.1.137.
Hess DR. Facilitating speech in the patient with a tracheostomy. Respir Care. 2005; 50(4): 519-25.
Frampton S, Agrawal S, Guastello S. Guidelines for Family Presence Policies During the COVID-19 Pandemic. JAMA Health Forum [journal on the internet]. 2020 Jul 6 [cited 2020 Jul 15]. Available from: https//jamanetwork.com/channels/ health-forum/fullarticle/2768108: [Epub ahead of print].
Blumenshine P, Reingold A, Egerter S, Mockenhaupt R, Braveman P, Marks J. Pandemic influenza planning in the United States from a health disparities perspective. Emerg Infect Dis. 2008 May; 14(5): 709-15. doi: 10.3201/eid1405.071301.
Yearby R, Mohapatra S. Law, Structural Racism, and the COVID-19 Pandemic. J Law Biosci. 2020 Jun 29; 7(1): lsaa036. doi: 10.1093/jlb/lsaa036.
Sakai M, Kou YF, Shah GB, Johnson RF. Tracheostomy demographics and outcomes among pediatric patients ages 18 years or younger-United States 2012. Laryngoscope. 2019; 129(7): 1706-11. doi: 10.1002/lary.27463.
Watters K, O'Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with Medicaid following tracheostomy. Laryngoscope. 2016; 126(11): 2611-7. doi: 10.1002/lary.25972.
Yancy CW. COVID-19 and African Americans. JAMA. 2020; 323(19): 1891-2. doi: 10.1001/jama.2020.6548.
Gostin LO, Powers M. What does social justice require for the public's health? Public health ethics and policy imperatives. Health Affairs. 2006; 25(4): 1053-60. doi: 10.1377/hlthaff.25.4.1053.
Global Tracheostomy Collaborative [Internet]. [place unknown]: Global Tracheostomy Collaborative; 2020 [updated 2020 May 19; cited 2020 May 24].
Everitt E. Tracheostomy 3: care of patients with permanent tracheostomy. Nursing Times. 2016; 112: 21-3.
Amar-Dolan LG, Horn MH, O'Connell B, Parsons SK, Roussin CJ, Weinstock PH, et al. "This Is How Hard It Is". Family Experience of Hospital-to-Home Transition with a Tracheostomy. Ann Am Thorac Soc. 2020 Jul; 17(7): 860-868. doi: 10.1513/AnnalsATS.201910-780OC.
Estrem B, Wall J, Paitich L, Maynard R. The Ventilator-Dependent Child: What Every Home Care Nurse Needs to Know. Home Healthc Now. 2020; 38(2): 66-74. doi: 10.1097/NHH.0000000000000853.
Foster CC, Agrawal RK, Davis MM. Home Health Care For Children With Medical Complexity: Workforce Gaps, Policy, And Future Directions. Health Aff (Millwood). 2019; 38(6): 987-93. doi: 10.1377/hlthaff.2018.05531.
Ollstein AM, Kenen J. Disabled, elderly going without home care amid shortage of protective gear and tests. Politico [newspaper on the Internet]. 2020 May 3 [cited 2020 May 12];Health Care:[about 9 p.]. Available from: https//www.politico.com/news/2020/05/03/home-care-coronavirus-229723.
Schlanger Z. Begging for Thermometers, Body Bags, and Gowns: US. Health Care Workers Are Dangerously Ill-Equipped to Fight COVID-19. Time [newspaper on the Internet]. 2020 Apr 20 [cited 2020 May 12]; Health: [about 9 p.]. Available from: https//time.com/5823983/coronavirus-ppe-shortage/.
International Council of Nurses [Internet]. Geneve: International Council of Nurses; 2020. High proportion of healthcare workers with COVID-19 in Italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority: 2020 Mar 20 [cited 2020 May 12]; [about 3 p.]. Available from: https//www.icn.ch/news/high-proportion-healthcare-workers-covid-19-italy-stark-warning-world-protecting-nurses-and.
Minder R, Peltier E. Virus Knocks Thousands of Health Workers Out of Action in Europe. New York Times [newspaper on the Internet]. 2020 Mar 24 [cited 2020 May 12]; World: [about 7 p.]. Available from: https//www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19.html.
Global Tracheostomy Collaborative. Navigating Public Health Crises for Individuals and Families Living with Tracheostomy: COVID-19 and Beyond [webinar]. [place unknown]: Global Tracheostomy Collaborative; 2020 May 5 [cited 2020 May 6]. Available from: https//www.gotostage.com/channel/c4d2288975ce453daf8d9e09860c8da4/recording/52e8b71e3da84677a20bd1acc19ffb34/watch?source=CHANNEL.
American College of Surgeons [Internet]. Chicago: American College of Surgeons; 2020. COVID-19: Recommendations for Management of Elective Surgical Procedures; 2020 Mar 13 [cited 2020 May 12]; [about 1 p.]. Available from: https//www.facs.org/covid-19/clinical-guidance/elective-surgery.
Pollock K, Setzen M, Svider PF. Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: An invited commentary. Am J Otolaryngol. May-Jun 2020; 41(3): 102490. doi: 10.1016/j.amjoto.2020.102490.
Hull EM, Dumas HM, Crowley RA, Kharasch VS. Tracheostomy speaking valves for children: tolerance and clinical benefits. Pediatr Rehabil. 2005; 8(3): 214-9. doi: 10.1080/13638490400021503.
Dalton MA. Education rights and the special needs child. Child Adolesc Psychiatr Clin N Am. 2002; 11(4): 859-68. doi: 10.1016/s1056-4993(02)00021-4.
Green J, Gu J. Majority Black Counties See Triple the Covid Death Rate. Bloomberg [newspaper on the Internet]. 2020 May 11 [cited 2020 May 18]; Graphics: [about 3 p.]. Available from: https//www.bloomberg.com/graphics/2020-coronavirus-outbreak-us-african-american-death-rate/.
Ranney ML, Griffeth V, Jha AK. Critical Supply Shortages – The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic. N Engl J Med. 2020; 382(18): e41. doi: 10.1056/NEJMp2006141.
Bohmer RMJ, Pisano GP, Sadun R, Tsai TC. How Hospitals Can Manage Supply Shortages as Demand Surges. Harvard Business Review [magazine on the internet]. 2020; April 3 [cited 2020 May 12]: [about 12 p.]. Available from: https//hbr.org/2020/04/how-hospitals-can-manage-supply-shortages-as-demand-surges.
Shuman AG, Fox E, Unguru Y. Preparing for COVID-19 Related Drug Shortages. Ann Am Thorac Soc. 2020 Aug; 17(8): 928-931. doi: 10.1513/AnnalsATS.202004-362VP.
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020; 382: 2049-2055. doi: 10.1056/NEJMsb2005114.
Tobin-Tyler E. In Allocating Scarce Health Care Resources During COVID-19, Don't Forget Health Justice. Health Affairs [journal on the internet]. 2020 Apr 25 [cited 2020 May 12]; [about 5 p.]. Available from: https//www.healthaffairs.org/do/10.1377/hblog20200422.50144/full/.
Savin K, Guidry-Grimes L. Confronting disability discrimination during the pandemic. The Hastings Center [journal on the internet]. 2020; Apr 2 [cited 2020 May 26]; [about 7 p.]. Available from: https//www.thehastingscenter.org/confronting-disability-discrimination-during-the-pandemic/.
Albrecht GL, Devlieger PJ. The disability paradox: high quality of life against all odds. Soc Sci Med. 1999; 48(8): 977-88. doi: 10.1016/s0277-9536(98)00411-0.
Gerhart KA, Koziol-McLain J, Lowenstein SR, Whiteneck GG. Quality of life following spinal cord injury: knowledge and attitudes of emergency care providers. Ann Emerg Med. 1994; 23(4): 807-12. doi: 10.1016/s0196-0644(94)70318-3.
Shakespeare T, Iezzoni LI, Groce NE. Disability and the training of health professionals. The Lancet. 2009; 374(9704): 1815-6. doi: 10.1016/s0140-6736(09)62050-x.
Tartak JC, Khidir H. Opinion: US. Must Avoid Building Racial Bias Into COVID-19 Emergency Guidance. National Public Radio [newspaper on the Internet]. 2020 Apr 21 [cited 2020 May 26]; The Coronavirus Crisis: [about 5 p.]. Available from: https//www.npr.org/sections/health-shots/2020/04/21/838763690/opinion-u-s-must-avoid-building-racial-bias-into-covid-19-emergency-guidance.
Estes C. States Are Being Forced Into Bidding Wars To Get Medical Equipment To Combat Coronavirus. Forbes [magazine on the Internet]. 2020 Mar 28 [cited 2020 May 8]; Healthcare: [about 5 p.]. Available from: https//www.forbes.com/sites/claryestes/2020/03/28/states-have-are-being-forced-into-bidding-wars-to-get-medical-equipment-to-combat-coronavirus/#555676641cde.


text:
Fishing Outfit
→Top 10 Best Trout Fishing Lures Used By Expert
Top 10 Best Trout Fishing Lures Used By Expert
Trout is one of the most popular kinds of fish that one could catch in either freshwater or seawater. Apart from the fact that it could be cooked and enjoyed as a meal when captured, this sheer abundance of trout makes it a popular target species to catch among those who love fishing. For them to do so, a lot of people take the time to actually study the trout's behavior such as how deep they swim, and the food that they eat. Also, one of the things these enthusiasts study is the type of bait they would attract them the most. In connection to this, the following are the 10 best trout fishing lures you could make use of.
Quick Navigation1. Northland Reed Runner 1/4oz Red Hook2. Flies Direct BH Woolly Bugger Black Assortment Trout Fishing Flies3. Rebel Lures Wee-Crawfish Fishing Lure4. Berkley Gulp Fat Floating Trout Worm Bait5. 4-Pk. Mister Twister 3″ 1/4-oz. Meeny Jig Combos6. Rapala 1 1/2 inch Ultra Light Minnow7. South Bend Kastaway Trophy Spoons8. Yakima Bait Wordens Original Rooster Tail Spinner Lure9. Leland Lures 87660 Trout Slayer, 6-Pack, Crawdad10. Shelure Soft Lures Shrimp Bait SetConclusion
1. Northland Reed Runner 1/4oz Red Hook
via Amazon.com
The Northland Reed Runner Red Hook is touted as the ultimate fish catcher, not just for Trout, but for other kinds such as the Big Bass, Muskie, and Nothern Pike as well, making it a great all-around fishing hook. It's also virtually weedless, to make it look just like smaller fish, given that certain trout species, especially the bigger ones, eat the smaller varieties of fish as well.
To ensure a good catch, it's also got a Lip-Stick Hook that's blood red, and a single-spin blade that's tracking in nature to make sure that fish don't escape the moment they get a hold of the bait. The RRS4C-6-1015 models are available in Lime and Chartreuse colors and thus looks just like real fish. Lastly, to help provoke fish and somehow excite them, there it's equipped with a Crazy-Legs-Silicone Swim and Skirt.
2. Flies Direct BH Woolly Bugger Black Assortment Trout Fishing Flies
Fishes are often left amazed marabou tails, which would definitely want them to grab a bite of this kind of bait whenever they get their eyes on it. This is most especially true among trout. With the Flies Direct BH Woolly Bugger Trout Fishing Flies, you could be guaranteed a good time at fishing, and of course, be assured that you would most definitely catch fish.
Moreover, it comes in an earthy black color that is sure to attract fish, which blends well with the environment they are in. One of the greatest advantages you have with this fishing lure for trout is that its price is affordable compared to other materials. This does not make it too painful on the pocket if you end up losing them while you go fishing.
3. Rebel Lures Wee-Crawfish Fishing Lure
Given that certain species of trout thrive in freshwater, the Rebel Lures Wee-Crawfish Fishing Lure is a great one to catch trout. The reason for this is that Trout tend to eat Crawfish as well. In order for it to work, users are advised to cast it in an erratic manner to make it look like a real crawling crawfish and get the trout's attention.
The Pulsating Action that this lure does works well for constantly running bodies of water like streams and rivers. This pulsating action mimics that of real crawfish. To further guarantee, users are advised to utilize a double loop knot for a test line that's 8-10 lb as this type of bait is actually kind of heavy for the fishing line to handle compared to other baits.
4. Berkley Gulp Fat Floating Trout Worm Bait
While real worms could be used to lure fishes in, the reality is that finding buckets upon buckets of earthworms is one a cumbersome task to do apart from being cruel, the reality is, Trout, as well as other species of fish, are into worms as well. The reason for this is that their wriggling nature provokes them into eating it the moment they see it. Having said that, one thing that you could make use of in lieu of live worms are artificial worms like the Berkley Gulp Fat Floating Worm Bait.
It's made to fit rigs that are wacky, thanks to its unique shape. It could also give help to anglers by being able to catch more fish. It's made from materials of the highest quality, has a scent dispersion feature, to attract fishes even more.
5. 4-Pk. Mister Twister 3″ 1/4-oz. Meeny Jig Combos
If you're looking for a variety of lures that you could use, then look no further! This 4-pack Mister Twister Jig Combo guarantees you a great performance whenever you make use of it for catching fish. This is one of the lure types that have been used and trusted among fishers for a long time already.
It combines the best of both worlds as it looks like a worm, but with a tail that looks like that of a fly. Also, its white hue makes it easily seen by Trout you wish to catch from underwater. This is great for newbies as not only is this extra affordable for you, but each purchase comes with more than one piece so that it wouldn't really hurt if one of these gets lost.
6. Rapala 1 1/2 inch Ultra Light Minnow
Who would've though such a small bait would guarantee you huge action? The Rapala 1.5 inch Ultra Light Minnow lives up to its name, as its extra light weight, while allowing it to sink, would also enable it to roll and wobble in a bid to lure the fish in and ultimately grab a bite of the hook. The lip design and wobble are unparalleled and are something that other fishing lures just don't have.
Also, one of the reasons why this is extra effective for catching trout is the fact that among the kinds of food that trout eat, minnows are one of their most preferred, and one which they could easily find in whatever body of water it is. It's also tank tested and hand tuned to ensure its effectiveness, and to make it look more realistic, is equipped with external scales as well.
7. South Bend Kastaway Trophy Spoons
Great things come in threes, as they say. If you're looking for the simplest, most basic kind of fishing tools, then the South Bend Kastaway Trophy Spoons is one which is best for you. Spoons are known for resembling fish while being light and coming in attractive colors that are sure to attract fish.
The light weight of these baits allows them to wriggle freely underwater, which would eventually lure the Trout into thinking that these fish actually are alive. If you're into non-complex materials for use in fishing, then this is definitely one of the best ones you could make use of.
8. Yakima Bait Wordens Original Rooster Tail Spinner Lure
The Yakima Bait Company is one of the longest-serving bait-making companies in the whole world. Having said that, they have made a name for themselves by creating so many kinds of baits to be used in order to lure fishes and make the experience a much easier one for those who are into fishing. They have been at it for so long, that its humble beginnings could be traced back to 1934, with the Worden's Floating Spinner Company.
To this day, their company still makes the best, top-quality baits for other re-sellers and companies as well. This background of the said company assures you that the Original Tail Spinner Lure is made of high-quality materials while being able to deliver your needs for a spinning tail bait, one of the most attractive kinds of bait for trout.
9. Leland Lures 87660 Trout Slayer, 6-Pack, Crawdad
This lure for trout is made to look like real crawfish. Having said that, it falls silently into the water and is made to fall flat on the surface. It also has natural wriggling movements that would allow it to look just like it's alive while stimulating and exciting the trout that would want to go near it.
It manages to catch the biggest varieties of trout, making it one of the most popular ones among the experienced fishers, and those who wish to catch the bigger and heavier fish. In order for you to properly use it, make it a point to put the rod close to the water as possible, with occasional movements of the fishing line to ensure that the crayfish actually moves around underwater.
10. Shelure Soft Lures Shrimp Bait Set
If you're looking for a bait set that's guaranteed effective for catching so many kinds of fish, then the Shelure Soft Lures Shrimp Bait Set is most definitely the best for you. Apart from being soft, it's also made to look exactly like a real shrimp, complete with body details in high resolution, with mechanisms that make the bait look like it's actually swimming in water.
Just like crawfish, these shrimps are also well-loved by these crawfish as well. Apart from appearing attractive to the target fish of choice, it's also easy to use for those even for beginners, as the silicone that this material is made of is pretty much compatible with the hook.
Did you like any or all of the options for best trout lures we gave you? Always remember that as much as you want to search for the best trout lures, you have to make sure that other apparatuses you would be using for fishing are also made of the best quality.
Lucas Bryant
Updated a couple of years ago
Hi, I'm Lucas Bryant and fishing is one of the most important parts of my life. I usually go fishing with my friends and have many fishing competition. That why I like to research and create many tips to get more fishes to win a race. I hope my experience will be useful for you.
How To Buy the Best Castable Fish Finder 2017
Why Are Yeti Coolers So Expensive? A Comprehensive Explanation 2017
What Does Trout Taste Like? – All Answers Will Make You Surprising
How To Cook Walleye When Going Camping? Easy And Simple Ways
Best Portable Wood Fire Pizza Oven For the Money
What Does Walleye Taste Like? One More Answers Make You Sense
Best Tips On How To Buy An Equip Travel Hammock
The Simplest Ways For How To Fillet A Walleye
Grilled Walleye Recipes- All You Need To Know To Have Great Meals
A Guide On How To Buy The Best Camping Pillow In 2017
Copyright text 2017 by BearCaster.

redpajama_set_name: RedPajamaCommonCrawl


text:
Miracle Worker —en español: Trabajador milagroso— es el primer sencillo de rock supergrupo SuperHeavy de su auto-titulado álbum debut. Se trata de una canción de reggae/rock interpretada por Damian Marley, Joss Stone y Mick Jagger. Fue lanzado el 7 de julio de 2011 como una descarga digital en el Reino Unido. La canción llegó al número 136 en el UK Singles Chart, pero fue un gran éxito en Japón, alcanzando el número 9. En Italia fue certificado oro por descargas superiores a 15.000 unidades.

Video musical
Un vídeo musical para acompañar el lanzamiento de "Miracle Worker" fue subido a YouTube el 12 de agosto de 2011 a una longitud total de cinco minutos y ocho segundos. Fue dirigido por Paul Boyd y filmada en los Paramount Studios en Los Ángeles, el video muestra a los cinco miembros de la banda.

Listas de canciones

Sencillos debut de 2011
Canciones compuestas por Mick Jagger
Canciones de 2011

redpajama_set_name: RedPajamaWikipedia


text:
Project Isizwe served 21 000GB free data to bus riders in six months
Lungelo Shezi
It's been just under six months since the Project Isizwe free WiFi service was first made available on the Tshwane Bus Rapid Transit system and so far, 163 126 unique users have logged onto the network while waiting for or on a bus.
More stats reveal that a total of 6 461 327 sessions have been logged since the transport project started and 21 242.3GB has been uploaded and downloaded over the network. Users have a 250MB a day cap, which helps put that total usage into perspective – remember this is only data used on the transport network and not on the city wide hotspots.
Like all the other WiFi sites located around the metro, commuters on the bus system, also known as "A re Yeng", can use up to 250MB per day on their mobiles in all its main routes
On top of using Project Isizwe to access social networks, look for jobs and watch the network's free VOD service, passengers can also get real-time access to bus schedules, maps and gate and ticket information, as they pass through the bus terminal.
Overall, the Project Isizwe has logged 14 545 547 sessions, 566 801 unique users and 61 205 monthly users since first launching in December 2013, according to stats released in April.
This is certainly a few leaps ahead of the Jo'burg-based Rea Vaya Bus Rapid Transit system which so far only had free WiFi available in nine bus turnk stations.
"Each day, thousands of people pass through transportation hubs such as airports, train and bus stations, and with business and leisure travellers carrying smartphones, tablets and other mobile devices, the demand for high capacity high performance Wi-Fi connectivity has not just become a 'nice to have' amenity, but rather an expected service, like electricity and running water," said Michael Fletcher, sales director for Ruckus Wireless sub-Saharan Africa.
"The City of Tshwane's Bus Rapid Transit system, A Re Yeng, is a perfect example of this," he added.
[Image – A Re Yeng Facebook]
A Re Yeng
Project Isizwe
Tshwane Bus Rapid Transit system
http://www.htxt.co.za
Why your business should automate its accounting processes
Gartner – Mobility took centre stage at CES 2020
A look at the technology that South African SMEs will use in the near future
SME banking, Bitcoin, stokvels & what else to expect for SA fintech in 2020
Why vocational training could be a viable alternative to Matric in the 4IR era
10 business resolutions that Gartner says CIOs should target in 2020
9 tips for matriculants looking for employment in 2019
Over 240 000 South Africans got access to electricity for the...
Submissions for A MAZE. / Johannesburg 2015 is now open
Panasonic returns to South African shelves
Dudu Mkhwanazi on winning IITPSA award and the future of Project...


text:
American College of Surgeons Media Press Releases 2019 Press Releases Medicaid expansion led to increase in screening for colorectal cancer patients in Kentucky
American Joint Committee on Cancer announces new leaders for 2020
A peer support program can help surgeons deal with adverse events that happen during surgery
ACS Commends Ways and Means Exercise of Jurisdiction over Surprise Billing
American College of Surgeons Opposes Alexander, Pallone, Walden Surprise Billing Plan
Older adults who "train" for a major operation spend less time in the hospital
Safe and effective pain control after surgery for children and teens addressed by ACS and APSA
Wichita Falls surgeon Beth H. Sutton, MD, FACS, elected Chair of the Board of Regents of the American College of Surgeons
Dr. Timothy W. Mullett is the New Chair-Elect of the ACS Commission on Cancer
New framework for humanitarian health systems to improve civilian care in conflict zones
ACS NSQIP recognizes 88 hospitals for achieving meritorious surgical patient care outcomes
Winston-Salem trauma surgeon Dr. J. Wayne Meredith is new ACS President-Elect
When a major injury occurs again in children, it's too often no accident
Five-year breast cancer survival rates at a safety net hospital rival national averages
Surgeons report that 12-hour shifts improve patient outcomes, lower costs vs. 24-hour call shifts
Gallbladder removal operation linked to better outcomes when performed soon after hospital admission
American College of Surgeons Honors Five Members with Surgical Humanitarian and Volunteerism Awards
Artificial intelligence outperforms clinicians' judgment in triaging postoperative patients for intensive care in a pilot test
Medical scribes have a positive impact on surgeons and residents
Adults 85 years and older generally fare well after colon cancer operations
ACS NSQIP surgical risk calculator accurately and reliably predicts four quality-of-life outcomes for geriatric surgical patients
Postoperative opioid prescribing and use drop significantly with no change in patient-reported pain control or satisfaction after state imposes regulations
Smartphone data can help surgeons understand a patient's recovery
General surgery residents who often experience mistreatment during residency training are at a greater risk of burnout and suicidal thoughts
Alexandria surgeon Vice Admiral Raquel C. Bono, MD, FACS, honored for inspiring women in surgery
Honorary Fellowship in the American College of Surgeons is awarded to 12 prominent surgeons
Chattanooga surgeon R. Phillip Burns, MD, FACS, honored with 2019 Distinguished Service Award of the American College of Surgeons
New York City surgeon Valerie W. Rusch, MD, FACS, is installed as the 100th President of the American College of Surgeons
American College of Surgeons Clinical Congress Convenes in San Francisco Next Week
ACS Academy of Master Surgeon Educators Admits its Second Class into Membership
Large-scale enhanced recovery program improves outcomes for bariatric surgery patients
More than 1 million people around the world have now been trained to Stop the Bleed
New risk/benefit calculator can predict possible outcomes for bariatric surgery patients
ACS comments on the continual occurrence of firearm deaths and injuries in the U.S.
Delay from breast cancer diagnosis to chemotherapy after a cancer operation may shorten survival for patients
Researchers identify four characteristics in older patients associated with an inability to return home after an operation
ACS introduces a new standardized program for hospitals devoted to high-quality surgical care for older adults
ACS and HBS Institute for Strategy and Competitiveness partner to develop value measurement tool for hospitals
MBSAQIP manual presents updated program standards for overweight and obese patients
American College of Surgeons Opposes the Lower Health Care Costs Act
Minneapolis surgeon Dr. Henry Buchwald receives 2019 Jacobson Innovation Award
National surgical care program opens enrollment for new cohort of hospitals
American College of Surgeons applauds congressional passage of PAHPAI (H.R. 269/ S. 1379)
More than half of patients in pain management study took no opioids after operations
American College of Surgeons applauds Ruiz/Roe legislative framework to address surprise medical bills
Just released: Proceedings from inaugural Medical Summit on Firearm Injury Prevention
American College of Surgeons opposes "Stop Surprise Medical Bills" legislation
Standards for quality surgical care for older adults finalized
Online tool gives surgeons and their patients probabilities for the success of their ventral hernia repair operation
May is our nation's first ever National Stop the Bleed Month
Save the date: San Francisco will host ACS Clinical Congress October 27-31
New trauma care pathway reduces delirium and likelihood of returning to the hospital
Save the date: ACS Quality and Safety Conference convenes in Washington, DC, July 19-22
Traffic accidents involving moose are 13 times more likely to result in human death
Frailty May Be a New Screening Criterion for Fitness for an Operation
Medicaid expansion led to increase in screening for colorectal cancer patients in Kentucky
Inaugural Firearm Injury Prevention Summit Held
Gallbladder Removal Operation During Pregnancy Associated with Adverse Maternal Outcomes
Kidney Transplantation to Minority Patients with a Different Blood Type Is Safe
Genetically modified virus injection into tumor can treat metastatic melanoma
African-Americans May Live Longer After Liver Transplant if Their Donors Are the Same Race
News from the American College of Surgeons
Devin Rose
Sally Garneski
Email: pressinquiry@facs.org
Medicaid expansion in Kentucky led to an increase in screening and improved survival for colorectal cancer patients
The number of low-income patients screened for colorectal cancer more than tripled after Medicaid expansion in 2014, according to study findings in the Journal of the American College of Surgeons.
CHICAGO (February 22, 2019): Kentucky is one of the poorest states in the U.S.1 However, the state has been one of the most successful in reducing its uninsured rate, which happened in part through the Affordable Care Act's Medicaid expansion that took effect on January 1, 2014.2 In the past, Kentucky has reported low rates of colorectal cancer (CRC) screening and has ranked among the highest states for incidence and mortality for the disease. One research team evaluated the impact of Medicaid expansion on the rates of CRC screening, incidence, and survival among the state's low-income population. The researchers found that the number of Medicaid patients who received screening after the expansion was more than triple the number of patients who were screened before the expansion. Additionally, CRC patients relying on Medicaid exhibited improved survival after the expansion compared to before it was implemented. The findings were published as an "article in press" on the website of the Journal of the American College of Surgeons ahead of print.
The Affordable Care Act's Medicaid expansion provided insurance coverage to those at 138 percent of the federal poverty level. In Kentucky, the expansion meant that an additional 634,807 low-income people gained access to Medicaid.2 Many people in this population have a low level of education and don't have easy access to a physician, especially the more rural Appalachian population in eastern Kentucky, said the lead study author, Avinash Bhakta, MD, a colorectal surgeon at the University of Kentucky Markey Cancer Center, Lexington. Dr. Bhakta said he began treating more and more patients from Appalachian Kentucky, and he wanted to look further into how the Affordable Care Act could be related to the increase of patients he was treating.
"For me, it was bit of a wake-up call living in our society and seeing the population that I treat in Kentucky, particularly in Appalachia," Dr. Bhakta said. "Many of these patients paved their own roads to come see me in Lexington. We didn't really see much study on the effect of the Affordable Care Act Medicaid expansion, and with our population having the leading incidence and mortality rate of CRC in the country, we felt that it was an ideal population to study this potential impact."
To conduct the study, the researchers obtained data on Kentucky's CRC screening, incidence, and outcomes from the Kentucky Hospital Discharge Database and the Kentucky Cancer Registry. The study population included 930,176 patients older than 20 years who underwent CRC screening from January 1, 2011 to December 31, 2016. A total of 408,500 patients were screened before Medicaid expansion (January 1, 2011 to December 31, 2013) and 521,676 patients were screened after Medicaid expansion (January 1, 2014 to December 31, 2016). The researchers obtained measures including demographics, insurance coverage based on information at the time of diagnosis, socioeconomics (percentage below poverty status and high school education at the county level), and clinical information (tumor grade, stage at diagnosis, and survival).
One of the most significant results from this study, Dr. Bhakta said, was that patients with Medicaid demonstrated the highest increase in CRC screening. A total of 69,328 Medicaid patients received screening after the expansion compared with 20,980 patients who were screened before the expansion—an increase of 230 percent. Additionally, 43.7 percent more Appalachian patients received screening after the expansion. When looking specifically at Medicaid patients, the researchers wrote, individuals in the 51-65 age group had the highest improvement in screening with an increase of 292.5 percent. Medicaid coverage of Appalachian patients increased by 199 percent.
From January 1, 2011 to December 31, 2016, 11,441 Kentucky patients were diagnosed with CRC. When separated by insurance, the proportion of Medicaid patients diagnosed with CRC increased by 132.4 percent after Medicaid expansion, the authors wrote. Dr. Bhakta said that increase was "a difficult number for me to swallow," because with increased screening, there should be a drop in incidence. However, Dr. Bhakta noted that this research is still young. If the researchers follow the data for another five or 10 years, he anticipates seeing a drop in incidence.
The researchers also reported that after expansion, Medicaid patients exhibited improved survival compared with patients prior to expansion. The survival differences after expansion were evident in Medicaid patients after the first year and increased each year thereafter. Appalachian patients with Medicaid coverage had significantly improved survival after expansion compared with before expansion, the researchers wrote.
"We saw that month to month post expansion, there was an improvement in survival from the pre-expansion era in our Medicaid population," Dr. Bhakta said. "We were able to follow many of these patients for up to eight years, and we are continuing to keep track of them and their recurrences and overall survival."
The most important takeaway from this study, Dr. Bhakta said, is that as more people get screened for CRC, more people will have improved survival.
"We know that with increased screening, we're able to get increased detection of earlier polyps," he said. "The Medicaid expansion allowed us to get access to a lot of near-poor patients that would have otherwise not been able to get screened."
Now that the researchers have identified the problem, they will continue to gather data and find solutions for the state's high mortality rate from CRC. "After these individuals are screened and diagnosed with colorectal cancer, are we not navigating them appropriately to surgery? After their operations, are the patients with advanced tumors not getting chemotherapy in a timely fashion?" Dr. Bhakta asked. "Finally, is this patient population that we treat at UK Markey Cancer Center resistant to traditional chemotherapeutic agents? These questions and barriers are important for us to investigate in order to continue our fight against colorectal cancer," Dr. Bhakta said.
Dr. Bhakta's coauthors were Tong Gan, MD; Heather F. Sinner, MD; Samuel C. Walling, MD; Quan Chen, DrPH; Bin Huang, DrPH; Tom C. Tucker, PhD; Jitesh A. Patel, MD, FACS; and B. Mark Evers, MD, FACS, all of the University of Kentucky.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
Study results were presented at the 130th Annual Meeting of the Southern Surgical Association, December 2018.
Data collection activities of the Kentucky Cancer Registry are supported by the National Cancer Institute Surveillance Epidemiology and End Results Program (NCI HHSN26100001), and the Center for Disease Control and Prevention National Program of Cancer Registries (CDC U58 DP005400). This study was also supported by the Markey Cancer Center Support Grant (NCI P30 CA177558) and T32 NIH Training Grant (T32CA160003). The Center for Clinical and Translational Sciences is funded through the NIH National Center for Advancing Translational Sciences (UL1TR001998).
Citation: Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky. Journal of the American College of Surgeons. Available at: https://www.journalacs.org/article/S1072-7515(19)30046-8/fulltext.
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.


Although I'm only just recently feeling like one.
Just this past week I bought face moisturizer…I don't know why this was such a monumentally adult thing to do, but even more than getting married, or having kids, or even buying our first home, using face moisturizer has made me feel like I'm really truly an adult.
…and can totally relate. Except, sadly, I've been buying facial moisturizer for years.


Frame Dimension and body Dimension: M (one hundred seventy five-185 cm).
For your convenience, convenience and protection ALL bikes bought by way of our on-line retail outlets are absolutely assembled and examined through certainly one of our certified engineers prior to being dispatched. All over the assembly process the forks, wheels, seat-post and parts are fitted. Gears and brakes are checked and altered if important, wheels are trued, tyres pumped up and all nuts and bolts tightened.
Full directions are equipped. Please apply these easy directions moderately to make sure right kind fitment.
It is extremely beneficial your bicycle be correctly assembled and checked before riding. BMW UK settle for no responsibility for harm or harm as a result of faulty assembly. For more detailed knowledge please refer on your house owners handbook and any further literature equipped together with your bicycle. In case you are in any doubt please contact your native BMW Store for help – Discover a BMW Centre here – http://www.bmw.co.united kingdom/en_GB/fastlane/to find-a-BMW-centre.html. Please note that failure to make sure your cycle is correctly assembled might result in harm and invalidate any guaranty claim. Assembly undertaken with out skilled help is on the house owners chance.


text:
St Vincent - Actor
by Benjamin Howarth
published: 7 / 6 / 2009
Fearlessly adventurous, but yet conventionally enjoyable second album from St Vincent, the moniker for American singer-songwriter Annie Clark
St Vincent is the musical identity of Annie Clark, once one of the many members of the Polyphonic Spree, and also formerly of Sufjan Steven's band. This is her second album as a soloist, following an acclaimed debut two years ago, and sees her enlisting a string section and borrowing a pair of hands from the band Midlake. 'Actor' is immediately melodic, but also quirky, surprising and subtle. I mean, of course, that it is brilliant. If, perhaps, you enjoyed Feist's magical The Reminder album a couple of years ago, then this will be right up your street as well. Actually, I have to confess that it took me a little while to get used to it. There are lots of synthesisers, and to lazy ears, it all sounds rather similar. I played it on the way to work a couple of times, and it rather washed over me. And then, suddenly, it clicked, and I realised I had found someone whose records I will be collecting for years to come. As well as the obvious touch points for all well-meaning folkie-indie types, her pretty songs are embellished by some less expected notes of reference - such as Disney soundtracks and pre-WW2 French jazz. And, this all sounds like the natural meandering of an enquiring mind, never an attempt to show off. The further away she moves from the sort of music I would normally listen to, the better she seems to get. The focus is always the songs. Her voice is light and skimpy, but this quality is counterbalanced by songs that verge on the twisted (look at the song titles, especially the creepy 'Laughing with a Mouth of Blood'). On 'Marrow', lilting choirs give way to thumping trance beats and synths, but it genuinely doesn't sound like an attempt to do anything other than fit music to a tune. 'Actor' constitutes a rare treat. It is both fearlessly adventurous, and conventionally enjoyable. Hours and hours of pleasant listening awaits.
1 The Strangers
2 Save Me From What I Want
3 The Neighbors
4 Actor Out Of Work
5 Black Rainbow
6 The Sequel
7 Laughing With A Mouth Of Blood
8 Marrow
9 The Bed
10 The Party
11 Just The Same But Brand New
https://ukstore.ilovestvincent.com/
https://www.facebook.com/St.Vincent
https://twitter.com/st_vincent
http://www.4ad.com/
https://www.facebook.com/fourad/
https://twitter.com/4AD_Official
https://plus.google.com/explore/4AD
Bush Hall, London, 30/11/2007
St Vincent, the moniker for American musician Annie Clark, has won much acclaim for her debut album, 'Marry Me'. Chris O' Toole finds St Vincent's set rewarding, but over complicated and too unpredictable at the Bush Hall in London
Daddy's Home (2021)
Thoughtful 70's retro pop on first album in four years from St. Vincent, the project of Texas-raised singer-songwriter Annie Clark
Aeon Station - Observatory


Murray Feiss Barrington Collection Light vanity fixture accommodates two 100-Watt A19 incandescent lamps. Medium socket lamp has voltage rating of 120-Volts. It features 5-Inch Dia x 5-Inch opal etched glass shade brings elegance to the home. Fixture in brushed steel finish, has a dimension of 18-Inch x 8-1/2-Inch. This fixture has 6-1/2-Inch extension from wall. Fixture power rating of 200-Watts. Fixture is damp safety rated.


"Thank you so much for the allergy and skin solutions! The Proaller, plus the Notatum alternating with the Quentans not only gave my 15 year old Maltese Beebop, relief from his respiratory and skin allergy symptoms---these amazing products helped his skin to heal completely and his beautiful hair to return so thickly, he looks like a young pup again. His ear inflammation and "gunk" cleared up and he's happy and frolicking like his "old self". He's living up to that Beebop name and wrestling with our other two Maltese, Bambi and Thumper. For the first time in years, his little tail is back up and curled as he romps around our yard. We are eternally grateful to you and continue to recommend you and your products to all of our pet-owner friends and family."
While humans often display respiratory symptoms such as sneezing and eye irritation from allergies, common symptoms of allergies in dogs and cats are excessive scratching, licking, chewing, rashes, hot spots, hair loss and even digestive upset. Generally, when a dog or cat is scratching excessively, the first thing we think of is that the pet has fleas. It is always a good idea to rule this out first by consulting your veterinarian or checking the pet's coat with a flea comb for fleas. Once you are sure it is not a flea problem, more than likely your cat or dog may have some allergies. Allergies in dogs or cats can be caused by inhaled allergens (e.g. pollen), food (e.g. dairy, eggs, etc.) and/or external allergens (e.g. exposure to chemicals in carpet, etc.). One of the fastest ways to improve your pet's health is to change your pet's diet. Many dogs are allergic to certain meat proteins (beef and eggs are common) and common allergens such as corn, soy and wheat. If possible, the optimal diet for your pet is a homemade diet using easily digestible, low-allergen foods. Allergies in dogs and cats are a symptom rather than a cause in themselves. They often occur as a result of the long-term build-up of toxins and so the goal is to detoxify the body and enhance the immune system as well as to treat the overall allergy symptoms. An air purifier can be very helpful in reducing environmental allergies. Our natural anti-infection formula can be used topically to help heal hot spots. Sometimes allergy testing and desensitization is effective, although rarely 100% effective, in eliminating allergies in dogs and cats.
1)Allergies are cumulative. In other words, a pet may have both food and environmental allergies but the symptoms only become noticeable during certain times of the year. This doesn't mean your pet doesn't have allergic reactions all the time. It just means that the situation builds up similar to a balloon that fills up with air until it pops. In your pet's case, it may mean that all of a sudden your pet has hot spots or starts chewing on its paws or rear end during the hot summer months but most likely has underlying digestive issues all year round. Is your pet "drawn" to the grass, showing signs of needing to get to the grass such as whining or pulling toward it?
2) Cats and dogs may display allergy symptoms differently. Cats may have respiratory symptoms, vomiting and other digestive disorders due to allergies as well as skin reactions. Dogs may have scratching, itching, chewing on fur, ear infections, scooting on their rear end and weepy eyes.
Special hypoallergenic diet—Keep the following ingredients out of your pet's diet. There is no "one" allergy diet that works for everyone. Each pet is different.
1) Consult your veterinarian to ensure endocrine disorders (e.g. hypothyroidism or Cushing's Disease), fleas, parasites and other health problems can be ruled out. Getting a veterinary exam is always a smart first-step as sometimes what might appear to be a minor sore, can turn out to be skin cancer once biopsied.
2) Change your pet's diet to a hypoallergenic, grain-free diet. Do not use foods that contain chemicals, byproducts or additives that are hard to digest. Avoid key allergens that contribute to inflammation, indigestion and food allergies. On the Ask Ariel order form at checkout, if you provide your pet's diet, our Nutritionist will include FREE diet tips on the packing slip with your order.


text:
Estádio Severino Cândido Carneiro – stadion piłkarski, w Vitória de Santo Antão, Pernambuco, Brazylia, na którym swoje mecze rozgrywa klub Associação Desportiva Vitória.

Linki zewnętrzne
 Templos do Futebol

Stadiony piłkarskie w Brazylii
Stadiony w Pernambuco


text:
Iraqi Militias Make Comeback Amid Surging Sectarian Violence
By Samira Ali Mandi
Frud Bezhan
There are fears that the reemergence of militias in Iraq could exacerbate a recent uptick in sectarian violence.
With the rising wave of sectarian violence in Iraq, militias that were thought to have disbanded have reemerged and new armed groups have taken root. The development has ignited fears among Iraqis that the country could descend into civil war.
As sectarian violence surges across Iraq, militias that once pushed the country to the brink of all-out civil war have reentered the scene.
Iraq has seen a sharp increase in retaliatory Sunni-Shi'ite attacks in recent months, with a wave of deadly bombings and assassinations resulting in a death toll not seen since 2008, according to the United Nations. Almost 2,000 people, mostly civilians, have been killed as a result of the violence since the start of April, and nearly 200 have died so far this month.
The return of rival Sunni and Shi'ite militias in Iraq, which comes amid escalating tensions between Iraq's Shi'ite-led government and the country's Sunni minority, has ignited fears of a civil war and a return to the intercommunal fighting of 2006-07, when thousands were indiscriminately killed each month.
Iraqis say militias and armed groups roam the streets in Baghdad, which at the height of sectarian violence was carved up between Sunni and Shi'ite militias. Locals in the capital say they have become too scared to leave their homes.
One Baghdad resident, who did not wish to reveal her name, told RFE/RL that some shops and restaurants had closed down and people were wary of travelling around the city for fear they would be targeted by militias.
"People on the street are terrified," she said. "People planning trips have postponed them. People who want to arrange or attend special occasions are postponing them. Everyone is hoping the situation will stabilize."
Another Baghdad resident, who also declined to give his name, claimed many feared a return of the death squads and revenge killings of the past.
"The return of the militias is a dangerous situation, particularly in Iraq, which has previously experienced their presence," he said. "Students are all afraid to leave their homes to attend their exams. We are in our junior year and these militias are destroying our future."
Crossing 'A Red Line'
Embattled Iraqi Prime Minister Nuri al-Maliki has pledged to clamp down on the militias and other armed groups in Baghdad. In May, Maliki announced that he had issued instructions to the country's security agencies to "strike forcefully against anyone wanting to form a force outside the frameworks of the army or the police."
"We will chase down all the illegal militias and armed gangs that want to instigate a wave of societal fighting," Maliki said. "As far as we are concerned this constitutes a red line."
Al-Qaeda's local wing, the Islamic State of Iraq, and other Sunni militia groups have reformed since the U.S. withdrawal in December 2011. Iraqi officials have suggested that Sunni extremists are joining forces to attack Shi'ite communities and symbols of government authority.
Government officials have said Sunni militant groups and Naqshbandi rebels linked to ex-officers in former Iraqi leader Saddam Hussein's army are now trying to provoke a Shi'ite militia reaction by bombing Shi'ite mosques and shrines while also targeting Shi'ite communities.
Security officials believe Shi'ite militias such as the Al-Mahdi Army, the Iraqi Hizballah Brigades, and the Asaeb Ahlul-Haq have largely refrained from joining the violence. But militia commanders have not ruled out possible retaliation.
According to Ibrahim al-Sumaydaee, an Iraqi political analyst, the main Shi'ite militias' new armed groups, consisting mostly of untrained youths, have entered the scene to avenge attacks by Sunni extremists.
"The major [Shi'ite] militia groups like Iraqi Hizballah Brigades and the Asaeb Ahlul-Haq are denying responsibility for the attacks," he says. "But what we are facing today is a third generation of Shi'ite militias that are made up of youths that are pushed to fight by their emotions."
Amir al-Taee, a member of the political wing of Asaeb Ahlul-Haq, maintains that his group has not been involved in any retaliatory attacks and denies that Shi'ite militias are regrouping. He claims that remnants of Al-Qaeda and Ba'athists in Iraq are behind the rising violence.
"What is taking place every day in the way of bombings in Baghdad and in some Iraqi provinces is carried out by Al-Qaeda together with the Ba'athists," he says. "Both of them have external agendas and are being supported by [Sunni-majority states like] Turkey, Qatar, and Saudi Arabia."
Iraq's Interior Ministry has taken a similar stance and denied the resurgence of any militias. In a recent statement made by the ministry, it has dismissed such reports as generated by the "rumor mill."
Inflammatory Remarks
The renewed bloodshed has coincided with a long-running political crisis in the government, which is made up of an unwieldy coalition of Shi'a, Sunnis, and Kurds. Critics of Maliki accuse him of being an autocratic leader who has failed to adhere to power-sharing arrangements.
Tensions between Iraq's Shi'ite-led government and the Sunni community are high, with the minority group increasingly marginalized since Hussein was overthrown by the U.S.-led invasion in 2003.
Sunnis, who have staged mass demonstrations in recent months, have accused the central government of persecution.
Independent lawmaker Qais al-Shadher, who is a member of the National Reconciliation Committee, believes the deepening political crisis and inflammatory remarks made by rival politicians has led to the reemergence of armed militias.
"We [the government] didn't fulfill the proposals outlined in the National Reconciliation program," he says. "We haven't embraced the [Sunni] tribes that supported the political process when the government called on them [to fight Al-Qaeda] in 2006 and 2007. That has led to a lack of trust and feeling of disappointment [among Sunnis]. In some cases, political interference has encouraged the former militias to take up their arms once again."
Sectarian tensions in Iraq have also been amplified by the conflict in neighboring Syria. Iraqi fighters from both sects have crossed the border to fight for opposite sides.
Syria's rebels, who are mostly Sunnis, are fighting to depose President Bashar al-Assad, an Alawite Shi'a who is backed by the Lebanese Shi'ite militant group Hizballah and Iran's Shi'ite regime.
Sumaydaee suggests that Iraq, like Syria, is fast becoming a playground for regional and Shi'ite-Sunni rivalries.
"This neighboring conflict is driving toward reigniting conflict in Iraq," he says. "I think both sides in the Syrian conflict, and those backing them, are attempting to destabilize the Iraqi political scene for their own design. The Syrian situation does not only involve Syria, but will explode to engulf the region."
Frud Bezhan is a correspondent for RFE/RL who covers Afghanistan, Iran, and Pakistan.
BezhanF@rferl.org
FOLLOW Subscribe via RSS
Bombers Target Shi'ite Mosque In Baghdad
Car Bombings Kill At Least 30 Iraqis
With Hizballah Victory In Syria, Risk Of Wider Regional War Looms
Iraqi PM Meets Community Leaders


text:
Romney, please leave "Friday Night Lights" alone
The genuinely bi-partisan TV show shouldn't be politicized
Check out this article! https://www.salon.com/2012/10/10/romney_please_leave_friday_night_lights_alone/
Willa Paskin
Mitt Romney has recently taken to using "Friday Night Lights'" super-uplifting slogan "Clear eyes, full hearts, can't lose" on the campaign trail. (To be fair, Obama has used it too, though not to the same extent.) According to the AP, before the debate, Romney's staffers tacked the slogan on the wall, and on his way out to the podium, Romney touched it, just like the Dillon Panthers used to do. And then, you know, pulled off a big upset, just like the Dillon Panthers used to do. I can admit that if President Obama was using "Clear Eyes, full hearts, can't lose" as if he was Matt Saracen I would find this adorable, but I'm glad that Romney has shown me the error of my ways. No party should get to co-opt "Friday Night Lights" for political purposes. Some things are sacred.
"Friday Night Lights" is the most genuinely bipartisan piece of art American mass culture has produced in the last decade. It's a Texas-set ode to the importance, integrity and strength of the hetero-normative family and community do-it-yourself-ism that's also a paean to public schools and public servants and the safety nets they provide for the young and underprivileged. Coach Eric Taylor is a great man, but who could say if he votes Republican or Democrat? Depending on your political persuasion it's possible to read "FNL" as a "red" or "blue" series — to extract the message you want out of it, to ascribe your preferences to its characters — but not because it is one or the other. Rather, it is truly both red and blue, deeply respectful of all of its characters, however one imagines they would vote.
Because of "Friday Night Lights'" readability, it feels almost inevitable that political campaigns would try to co-opt it. (Buzz Bissinger, who wrote the book "Friday Night Lights" on which the show is based, endorsed Romney after the debate, which may have encouraged the Romney campaign's slogan use in recent days, even though the "Clear eyes" motto is a creation of the TV show.) As James Poniewozik put it in a column the other day, the show is "a love letter to American character and community so powerful that I'm surprised today's campaigns don't use it all the time." And so now an authentically bipartisan show is being used by political parties who have to ignore one of the most contextually radical things about it, which is that it was a series about America, where — as in the real America — not everyone believed the same thing. "Friday Night Lights" went out of its way to portray all viewpoints sympathetically, and it is now being used to champion just one. Coach Taylor would not approve.
To make matters worse, the faster "Clear eyes, full hearts, can't lose" becomes a political slogan, the faster it will be leached of all eloquence. (Nothing ruins something quite like becoming part of a stump speech: The Clintons' "Don't Stop" is still the only Fleetwood Mac song other than "Oh Daddy" I can't bear to hear.) "Friday Night Lights" stopped using "Clear eyes, full hearts, can't lose" regularly in its later seasons, as if it knew overuse would make it cheesy. Anything as perfect and simple-sounding as this motto is always in danger of becoming a cliché, but there's nothing like putting it in the mouths of politicians to speed up that process.
Willa Paskin is Salon's staff TV writer.
MORE FROM Willa Paskin
2012 Presidential Debates Barack Obama Buzz Bissinger Clear Eyes Full Hearts Can't Lose Elections 2012 Friday Night Lights Mitt Romney President Obama Presidential Election 2012 Presidential Elections Television Tv
This old Trump tweet doesn't read well
Trump tries to blame Obama for 2016
Salon talks with "New Negroes" creators
Biden expected to make 2020 announcement
Last chance for impeachment


AdvantaClean of Dublin is proud to provide water damage restoration for the people of Delaware and Dublin, OH. We know that water damage can have a variety of causes. Whether rain has entered a hole in your roof, a flood has swept through your home, or a pipe has burst in the basement, our team is available 24 hours a day, seven days a week, to take on such emergencies. Below, we'll give you a quick rundown of what we can repair in your home or business.
The first thing our team will do is get your furniture, curtains, rugs, and other movables out of the water. We can then dry these and the rest of the interior using fans and dehumidifiers. When faced with major flood damage, we can pump out the standing water. This is vital because the longer the water lingers, the greater chance it will have of creating mold.
Since water damage can easily reach the walls, we'll dry them out. We know what methods to use on concrete, wood, drywall, and other types of walls. If your walls were painted with an old lead-based paint, rest assured that we can work around this hazard as we're EPA-certified for lead-safe practices. You can count on us for drywall replacement and even mold encapsulation if mold has become ingrained in the damaged wall that it can't be removed.
We'll sanitize the damaged interior and movables because you never know what the water could have been carrying. Graywater - the water that courses through our pipes - can carry harmful contaminants, and blackwater goes without mentioning. Our professionals will inspect every belonging to see if it can be salvaged or not; however, we won't throw out unsalvageable items, as these may provide the proof of water damage that you need if you're filing for flood insurance benefits.
Usually, carpets that have been suffered water damage are the first things that would be replaced, but if you wish to retain them, know that we can thoroughly clean and disinfect them. If carpets have shrunk, we'll perform stretching. The employees at AdvantaClean of Dublin are certified by the IICRC, or the Institute of Inspection Cleaning and Restoration Certification.
AdvantaClean performed water damage restoration for many basements across the country. This stands to reason because water will always seep down. Our basement treatments follow the same pattern as our other flood damage treatments, but they can also include preventative measures. For example, we can fix any leaky basement windows and even waterproof the basement. We're also certified for crawl space encapsulation.
Trust AdvantaClean of Dublin for water damage restoration and give us a call when disaster strikes. Even something relatively minor like an overflowing toilet can have unforeseen consequences, so we'll be thorough in our flood damage assessment. We serve homeowners and business owners throughout Dublin, Delaware, and everything we do is in accordance with OSHA's federal health requirements.