text:
Low usage of government healthcare facilities for acute respiratory infections in guatemala: implications for influenza surveillance.
ABSTRACT Sentinel surveillance for severe acute respiratory infections in hospitals and influenza-like illness in ambulatory clinics is recommended to assist in global pandemic influenza preparedness. Healthcare utilization patterns will affect the generalizability of data from sentinel sites and the potential to use them to estimate burden of disease. The objective of this study was to measure healthcare utilization patterns in Guatemala to inform the establishment of a sentinel surveillance system for influenza and other respiratory infections, and allow estimation of disease burden.
We used a stratified, two-stage cluster survey sample to select 1200 households from the Department of Santa Rosa. Trained interviewers screened household residents for self-reported pneumonia in the last year and influenza-like illness (ILI) in the last month and asked about healthcare utilization for each illness episode.
We surveyed 1131 (94%) households and 5449 residents between October and December 2006 and identified 323 (6%) cases of pneumonia and 628 (13%) cases of ILI. Treatment for pneumonia outside the home was sought by 92% of the children <5 years old and 73% of the persons aged five years and older. For both children <5 years old (53%) and persons aged five years and older (31%) who reported pneumonia, private clinics were the most frequently reported source of care. For ILI, treatment was sought outside the home by 81% of children <5 years old and 65% of persons aged five years and older. Government ambulatory clinics were the most frequently sought source of care for ILI both for children <5 years old (41%) and persons aged five years and older (36%).
Sentinel surveillance for influenza and other respiratory infections based in government health facilities in Guatemala will significantly underestimate the burden of disease. Adjustment for healthcare utilization practices will permit more accurate estimation of the incidence of influenza and other respiratory pathogens in the community.
- SourceAvailable from: María R López[Show abstract] [Hide abstract]
ABSTRACT: Acute respiratory infections (ARI) are an important cause of illness and death worldwide, yet data on the etiology of ARI and the population-level burden in developing countries are limited. Surveillance for ARI was conducted at two hospitals in Guatemala. Patients admitted with at least one sign of acute infection and one sign or symptom of respiratory illness met the criteria for a case of hospitalized ARI. Nasopharyngeal/oropharyngeal swabs were collected and tested by polymerase chain reaction for adenovirus, parainfluenza virus types 1,2 and 3, respiratory syncytial virus, influenza A and B viruses, human metapneumovirus, Chlamydia pneumioniae, and Mycoplasma pneumoniae. Urine specimens were tested for Streptococcus pneumoniae antigen. Blood culture and chest radiograph were done at the discretion of the treating physician. Between November 2007 and December 2011, 3,964 case-patients were enrolled. While cases occurred among all age groups, 2,396 (60.4%) cases occurred in children <5 years old and 463 (11.7%) among adults ≥65 years old. Viruses were found in 52.6% of all case-patients and 71.8% of those aged <1 year old; the most frequently detected was respiratory syncytial virus, affecting 26.4% of case-patients. Urine antigen testing for Streptococcus pneumoniae performed for case-patients ≥15 years old was positive in 15.1% of those tested. Among 2,364 (59.6%) of case-patients with a radiograph, 907 (40.0%) had findings suggestive of bacterial pneumonia. Overall, 230 (5.9%) case-patients died during the hospitalization. Using population denominators, the observed hospitalized ARI incidence was 128 cases per 100,000, with the highest rates seen among children <1 year old (1,703 per 100,000), followed by adults ≥65 years old (292 per 100,000). These data, which demonstrate a substantial burden of hospitalized ARI in Guatemala due to a variety of pathogens, can help guide public health policies aimed at reducing the burden of illness and death due to respiratory infections.PLoS ONE 01/2013; 8(12):e83600. · 3.53 Impact Factor
Article: The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review.[Show abstract] [Hide abstract]
ABSTRACT: Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers. We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low. Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes.PLoS ONE 01/2014; 9(4):e93427. · 3.53 Impact Factor
Article: Comparative epidemiology of human metapneumovirus- and respiratory syncytial virus-associated hospitalizations in Guatemala[Show abstract] [Hide abstract]
ABSTRACT: Background Human metapneumovirus (HMPV) is an important cause of acute respiratory infections (ARI), but little is known about how it compares with respiratory syncytial virus (RSV) in Central America.Objectives In this study, we describe hospitalized cases of HMPV- and RSV-ARI in Guatemala.Methods We conducted surveillance at three hospitals (November 2007–December 2012) and tested nasopharyngeal and oropharyngeal swab specimens for HMPV and RSV using real-time reverse transcription-polymerase chain reaction. We calculated incidence rates, and compared the epidemiology and outcomes of HMPV-positive versus RSV-positive and RSV-HMPV-negative cases.ResultsWe enrolled and tested specimens from 6288 ARI cases; 596 (9%) were HMPV-positive and 1485 (24%) were RSV-positive. We observed a seasonal pattern of RSV but not HMPV. The proportion HMPV-positive was low (3%) and RSV-positive high (41%) for age <1 month, whereas these proportions were similar (~20%) by age 2 years. The annual incidence of hospitalized HMPV-ARI was 102/100 000 children aged <5 years [95% confidence interval (CI): 75–178], 2·6/100 000 persons aged 5–17 years (95%CI: 1·2–5·0), and 2·6/100 000 persons aged ≥18 years (95%CI: 1·5–4·9). Among children aged <5 years, HMPV-positive cases were less severe than HMPV-RSV-negative cases after adjustment for confounders [odds ratio (OR) for intensive care = 0·63, 95% CI 0·47–0·84]; OR for death = 0·46, 95% CI 0·23–0·92).Conclusions Human metapneumovirus is a substantial contributor to ARI hospitalization in Guatemala, but HMPV hospitalizations are less frequent than RSV and, in young children, less severe than other etiologies. Preventive interventions should take into account the wide variation in incidence by age and unpredictable timing of incidence peaks.Influenza and Other Respiratory Viruses 04/2014; · 1.47 Impact Factor
Page 1
RESEARCH ARTICLE Open Access
Low usage of government healthcare facilities for
acute respiratory infections in Guatemala:
implications for influenza surveillance
Kim A Lindblade1,2*, April J Johnson3, Wences Arvelo1,2, Xingyou Zhang1, Hannah T Jordan3, Lissette Reyes4,
Alicia M Fry1and Norma Padilla5
Background: Sentinel surveillance for severe acute respiratory infections in hospitals and influenza-like illness in
ambulatory clinics is recommended to assist in global pandemic influenza preparedness. Healthcare utilization
patterns will affect the generalizability of data from sentinel sites and the potential to use them to estimate burden
of disease. The objective of this study was to measure healthcare utilization patterns in Guatemala to inform the
establishment of a sentinel surveillance system for influenza and other respiratory infections, and allow estimation
of disease burden.
Methods: We used a stratified, two-stage cluster survey sample to select 1200 households from the Department of
Santa Rosa. Trained interviewers screened household residents for self-reported pneumonia in the last year and
influenza-like illness (ILI) in the last month and asked about healthcare utilization for each illness episode.
Results: We surveyed 1131 (94%) households and 5449 residents between October and December 2006 and
identified 323 (6%) cases of pneumonia and 628 (13%) cases of ILI. Treatment for pneumonia outside the home
was sought by 92% of the children <5 years old and 73% of the persons aged five years and older. For both
children <5 years old (53%) and persons aged five years and older (31%) who reported pneumonia, private clinics
were the most frequently reported source of care. For ILI, treatment was sought outside the home by 81% of
children <5 years old and 65% of persons aged five years and older. Government ambulatory clinics were the most
frequently sought source of care for ILI both for children <5 years old (41%) and persons aged five years and older
Conclusions: Sentinel surveillance for influenza and other respiratory infections based in government health
facilities in Guatemala will significantly underestimate the burden of disease. Adjustment for healthcare utilization
practices will permit more accurate estimation of the incidence of influenza and other respiratory pathogens in the
As the 2009 influenza A (H1N1) pandemic highlighted,
surveillance for influenza is now a worldwide priority.
[1,2] At the 58thWorld Assembly in 2005, The World
Health Organization adopted a resolution calling for
Member States to fortify and coordinate national strate-
gies to prepare for an influenza pandemic, including
establishment of surveillance systems for human influ-
enza.[3] To assist with the development of standardized
influenza surveillance systems in the Americas, the Pan
American Health Organization (PAHO) and the United
States Centers for Disease Control and Prevention
(CDC) developed a generic protocol for influenza sur-
veillance incorporating two sentinel surveillance systems,
one hospital-based system for severe acute respiratory
infections (SARI) and SARI-related mortality and
another for influenza-like illness (ILI) based in ambula-
tory clinics.[4]
* Correspondence: email@example.com
1Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd., Atlanta
Full list of author information is available at the end of the article
Lindblade et al. BMC Public Health 2011, 11:885
© 2011 Lindblade et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Page 2
Sentinel surveillance for influenza can provide infor-
mation on trends in viral circulation patterns and sea-
sonality, along with virus characteristics to help guide
decisions on vaccine composition. However, healthcare
seeking behaviors can affect who accesses care at the
sentinel site, limiting the ability to gather information to
guide public health policies. Without understanding pat-
terns of healthcare seeking behavior, it is not possible to
calculate the burden of disease, generalize findings to a
larger population or identify risk groups.
Healthcare utilization surveys (HUS), one method of
determining the healthcare utilization practices for spe-
cific diseases in defined populations, have been con-
ducted in several countries. [5-12] In HUS, random
samples of the catchment population are interviewed
with respect to their healthcare seeking and treatment
behaviors during recent episodes of disease. These data
can be used in a number of ways to support the inter-
pretation of information from sentinel surveillance sites:
first, to establish correction factors for estimates of inci-
dence in the community based on numbers of cases pre-
senting at the sentinel surveillance site, including the
incidence in particular population sub-groups; second,
to describe the actual catchment population accessing
healthcare at the sentinel site to determine generalizabil-
ity; and third, to identify other healthcare providers who
may be recruited to participate in the surveillance
To inform the establishment of a surveillance system
for influenza and other respiratory infections, and the
implementation of the PAHO/CDC standard protocol
for influenza surveillance in Guatemala, we conducted a
HUS among residents of the Department of Santa Rosa,
Guatemala to describe the healthcare seeking behavior
for acute respiratory illnesses.
Study area and population
Guatemala, with a population of 12,755,366 in 2008, had
a gross national income per capita of $2680 and is con-
sidered a middle-income country by the World Bank
accessed on 1 September 2010). Guatemala is divided
into 22 departments, which are further subdivided into
10-29 municipios (similar to counties), made up of mul-
tiple communities. The Guatemalan Ministry of Public
Health and Social Welfare (MSPAS) provides free
healthcare in several different settings, including hospi-
tals, health centers, health posts, and outreach centers.
Hospitals and health centers are staffed by physicians
and nurses, whereas health posts are staffed by nurses.
Outreach centers provide preventive and primary
healthcare but are only visited by trained medical staff a
few days each month. In addition to the MSPAS
facilities, formally-employed workers who contribute to
the Guatemalan Institute of Social Security (IGSS) can
receive healthcare from IGSS hospitals and health cen-
ters, which are concentrated in Guatemala City. Other
non-governmental locations where people may seek
healthcare are private hospitals and clinics, pharmacies,
drug shops, and traditional healers and midwives. Com-
munities in Guatemala vary in their access to healthcare
depending on their size and location (e.g., urban vs.
Santa Rosa is a mostly agrarian department located in
the southeastern part of the country approximately 80
km from Guatemala City. The population in 2006 was
308,522 residing in 14 municipios with an estimated 768
communities. Cuilapa is the department's capital city. In
contrast to the country as a whole, which is almost half
Amerindian indigenous, only 3% of Santa Rosa's resi-
dents are Mayan or Xinca, and Spanish is spoken by
approximately 91% of the inhabitants. The mortality rate
of children <5 years of age for Santa Rosa is 58 per 1000
live births, significantly higher than the average for the
country (45 per 1000 live births).[13]
Government-run healthcare facilities within the
department include one hospital (the National Hospital
of Cuilapa, 176 beds), 14 health centers (one in each
municipio) and 56 health posts in the outlying commu-
nities. There is one IGGS facility that treats only
patients involved in motor vehicle accidents. Two small
private hospitals as well as approximately 133 private
ambulatory clinics are available for those who choose to
pay for healthcare. Additionally, healthcare services can
be sought from more than 114 pharmacies or drug
shops, and an unknown number of traditional healers,
midwives and community healthcare workers. Health-
care may also be accessed in Guatemala City and neigh-
boring departments.
Study design and sampling methods
We conducted a cross-sectional survey to determine
healthcare utilization patterns for acute respiratory, diar-
rhea, neurologic and febrile illnesses: we report here only
the results for acute respiratory infections. We used a
stratified, two-stage cluster sampling procedure. Commu-
nities in the 2002 Guatemalan census were stratified as to
whether or not they had a hospital or health center
located in their community. As the first stage of sam-
pling, 30 communities were selected within each stratum,
using probability proportional to the population of each
community, for a total of 60 clusters. Maps detailing
household locations were obtained from the Guatemalan
Census Bureau for these communities and 20 houses
were randomly selected for a total of 1200 houses.
Interviews were conducted in person from October 1
through December 13, 2006. All persons who had lived
Lindblade et al. BMC Public Health 2011, 11:885
Page 2 of 9
Page 3
in the house for at least six of the preceding 12 months
were considered members of the household and eligible
for inclusion, including persons deceased at the time of
the survey if they had been resident during the reference
period. Infants <6 months of age were included if they
had lived in the household since birth. Households were
excluded if a head of household or consenting adult was
unavailable after visiting the house on three separate
occasions over at least two days, or if the household
head declined to participate. Excluded households were
not replaced. If a house was abandoned or no longer
existed, another house was randomly chosen for
Human subjects
The adult respondents from each household were read a
consent statement and asked to give verbal consent for
their household's participation. The protocol for this
study was reviewed and approved by the institutional
review boards of the Centers for Disease Control and
Prevention (Atlanta, GA) and the Universidad del Valle
de Guatemala (Guatemala City, Guatemala) and
approved by the MSPAS (Guatemala City, Guatemala).
Sample size
The sample size of 600 households per strata (1200
total) was based on calculations for diarrhea, a more
common syndrome, rather than for pneumonia as infor-
mation was not available on the expected incidence of
pneumonia. However, assuming a 10% household non-
response rate, and 4.8 persons per household, a sample
of 600 households per stratum should yield between 39
and 156 persons with pneumonia, assuming an annual
incidence of between 1.5% and 6.0%, respectively. Given
a design effect of two due to the clustering of pneumo-
nia cases by community and household, this sample
would be large enough to estimate the proportion of the
population seeking healthcare outside of the house for
pneumonia with a precision of 10%, assuming 70% of
persons with pneumonia seek care for their illness.
Survey instrument
A structured survey was completed for each participat-
ing household with information on both household- and
individual-level characteristics. All household members
were enumerated and an adult proxy was interviewed
for children <15 years old or older residents not present
at the time of the interview to determine whether any
household member met any of the case definitions (mild
or severe respiratory, diarrhea, acute febrile and acute
neurologic illness) during the prescribed time period. A
clinical history was obtained for each illness episode (if
more than two episodes of the same illness were
reported, the most recent illness episode was used as
the reference) along with a history of healthcare treat-
ment seeking. Proxies of household residents who died
but met the case definition for one of the illnesses in
the relevant time period before death were also adminis-
tered the illness-specific forms.
A case of severe respiratory illness, referred to as pneu-
monia, was defined as self-reported cough and difficulty
breathing for two or more days, or a physician-diagnosis
of pneumonia; the reference period was the 12 months
prior to the interview. This case definition has been
used in several studies of self-reported pneumonia in
the community[12,14] and is based on questions that
were moderately sensitive and specific for pneumonia
from a World Health Organization verbal autopsy ques-
tionnaire.[15] Additionally, severe pneumonia was
defined for children <3 years old who met the pneumo-
nia case definition as any of the following: blue lips and/
or nails, inability to breastfeed or drink, convulsions,
unconsciousness or decreased activity. For those ≥3
years old who met the pneumonia case definition, severe
pneumonia was defined as fast breathing with confusion.
A case of mild respiratory illness, referred to as ILI,
was defined as subjective fever with either cough or sore
throat in the 30 days prior to the interview. If a respon-
dent reported both an ILI and pneumonia for the same
month, the ILI data were excluded.
Outpatient providers were defined as all sources of
healthcare that did not admit patients for overnight
stays, and included government and private ambulatory
clinics, pharmacies, drug shops, the IGSS and traditional
healers. Inpatient providers included government and
private hospitals.
Data management and analysis
Survey forms were received at the offices of the CDC-
UVG Collaboration at the Universidad del Valle de Gua-
temala for optical scanning into a database using the
Cardiff Teleform system (Vista, CA). Each Teleform
entry was checked manually with the original forms to
ensure accurate scanning and coding. Socioeconomic
status (SES) was estimated using a wealth index gener-
ated using the factor effects derived from the first prin-
ciple component of a principle component analysis of
household goods, house construction material, source of
water supply, source of cooking fuel and sanitation facil-
ity; the wealth index was categorized into quintiles with
households weighted by number of residents and sample
weights.[16,17] To account for the complex survey
design, sample weights were applied in all analyses. We
used the Wald Chi-square statistic to test for differences
between proportions and logistic regression to test for
trends related to age and SES. Analyses were conducted
Lindblade et al. BMC Public Health 2011, 11:885
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Page 4
with SAS version 9.1 (SAS Institute, Cary, NC) using
PROC SURVEYFREQ or PROC SURVEYLOGISTIC.
We approached 1200 households but residents could
not be reached at 33 (3%) locations after three visits,
and in 36 (3%), the household head declined to partici-
pate. We interviewed residents from 1131 (94%) house-
holds and gathered information on a total of 5449
persons of which 2806 (52%) were female and 586 (12%)
were children <5 years old (Table 1).
We found 323 persons (6%, 95% confidence interval
[CI] 6-7%) who met the pneumonia case definition in
the previous year. Almost all (87%) met the case defini-
tion with self-reported cough and difficulty breathing
for at least two days; 2% reported only a physician's
diagnosis of pneumonia; and 12% reported both. There
were 60 cases (11%, 95% CI 9-13%) of pneumonia
reported among children <5 years old, and 263 cases
(6%, 95% CI 5-6%) among persons aged five years or
older. Among the children <5 years old, 31 (6%, 95% CI
5-7%) met the case definition for severe pneumonia.
The proportion of pneumonia cases reported by
month increased from October 2005 through September
2006 (Figure 1.) More than half of the pneumonia cases
were reported from the last five months prior to the
There were 628 (13%, 95% CI 12-14%) persons who
reported ILI in the previous month. A case of ILI was
reported by 106 (19%, 95% CI 17-20%) children <5 years
old and 522 (12%, 95 CI 11-13%) persons aged five
years or older.
Characteristics of respondents with pneumonia and ILI
The most common symptoms reported by persons with
pneumonia were difficult breathing (100%), cough
(99%), and feverishness (88%) (Table 2). The mean dura-
tion of illness of all persons with pneumonia was 13
days (range 2-120); more than one-quarter had symp-
toms for seven days or more.
Among persons who reported ILI, the most common
symptom besides feverishness (100%) was sore throat
(97%), headache (89%) and cough (88%). Signs of lower
respiratory tract infection, such as difficult or fast
breathing and wheezing, were less common among
person who reported ILI than those with pneumonia.
The mean duration of illness among persons with ILI
was seven days (range 1-90); more than half of person
who reported an ILI had symptoms for seven days or
The age distribution of persons with pneumonia was
significantly different from the surveyed population
without pneumonia (P<0.0001), with more children <5
years and adults ≥60 years old among the persons
reporting pneumonia than among the surveyed popula-
tion without pneumonia (Table 1). Similarly, the age dis-
tribution of those with ILI was younger than the
surveyed population without ILI (P = 0.001). The distri-
bution of the person who reported ILI by household
wealth index was significantly different from those with-
out ILI (P<0.0001) with more cases among persons in
the lowest wealth category and fewer in the wealthiest
category. There was no difference in household wealth
between persons with and without pneumonia (P =
Table 1 Sociodemographic characteristics among the population surveyed, and those with pneumonia in the previous
12 months or influenza-like illness (ILI) in the previous month, Santa Rosa, Guatemala, 2006a
n (%) n (%)
Pneumonia Cases
P valueILI Cases
n (%)
P valueb
Sex, female
Age (years)
Wealth index
2844 (52)165 (50)0.51
344 (53)0.44
586 (12)
1484 (28)
1466 (27)
1439 (25)
474 (8)
60 (20)
68 (21)
68 (21)
87 (25)
40 (12)
106 (17)
170 (29)
147 (22)
150 (24)
55 (8)
832 (21)
927 (21)
1006 (20)
1141 (19)
1543 (19)
49 (20)
51 (20)
61 (21)
84 (23)
78 (15)
0.14127 (27)
127 (25)
113 (18)
127 (17)
134 (14)
aPercentages are calculated using sample weights.
bP values compare characteristics of pneumonia (or ILI) cases with those persons without pneumonia (or ILI).
Lindblade et al. BMC Public Health 2011, 11:885
Page 4 of 9
Page 5
Healthcare-seeking behavior
Among the 60 children <5 years old reporting pneumo-
nia in the last year, 55 (92%) sought care outside the
home. All subsequent analyses of healthcare-seeking
behavior are based on those who sought care outside
the home. Sixteen (27%) children sought care from
more than one source. Hospitals were consulted by 17
(25%) children <5 years old with pneumonia, and most
were government hospitals (Table 3). Nine (12%) chil-
dren <5 years old with pneumonia were admitted for at
least one night in a hospital. Outpatient care providers
were visited by 38 (75%) children <5 years old with
reported pneumonia. Overall, the most frequently
reported source of healthcare for children <5 years old
with pneumonia were private ambulatory clinics, which
attended to more than half the reported cases. More
than half (55%) of the children <5 years old with
reported pneumonia received care at least once during
their illness from government facilities, either govern-
ment hospitals or ambulatory clinics.
Among the 263 persons five years or older who
reported pneumonia in the last year, 199 (73%) sought
healthcare outside their home, with 21 (8%) seeking care
from more than one source. Among persons in this age
group who sought care outside the home, 28 (12%)
sought care at hospitals (Table 3), and 8 (4%) were
admitted for at least one night. Government hospitals
provided most of the hospitalized care. Among
Figure 1 Proportion of pneumonia cases reported by month of illness onset, Santa Rosa, Guatemala, October-December 2006.
Table 2 Frequency of symptoms in people reporting
pneumonia in the previous year and influenza-like illness
(ILI) in the previous month, Santa Rosa, Guatemala,
n (%)
n (%)
Difficult or fast breathing
Confusion or delirium
Signs of severe pneumoniac
Sore throat
Muscle aches
Runny nose
Decreased activity
Nausea or vomiting
Duration of illness ≥7 days
322 (100)
320 (99)
277 (88)
213 (77)
214 (69)
33 (12)
20 (7)
23 (7)
58 (19)
91 (29)
309 (51)
551 (88)
628 (100)
457 (77)
246 (42)
605 (98)
533 (89)
450 (76)
447 (71)
363 (60)
154 (24)
353 (56)
aNA = Not applicable
bPercentages are a proportion of non-missing data and are calculated using
sample weights.
cSevere pneumonia: children <3 years old: blue lips and/or nails, inability to
breastfeed or drink, convulsions, unconsciousness or decreased activity;
persons ≥3 years old: fast breathing with confusion.
Lindblade et al. BMC Public Health 2011, 11:885
Page 5 of 9
Page 6
outpatient care providers, the most frequently sought
source of care were private clinics, which provided care
to 65 (31%) persons with pneumonia aged five years or
older, along with government ambulatory clinics (46,
27%). A considerable proportion (16%) of persons with
pneumonia aged five years or older sought care at
Care for ILI was sought outside the home by 87 (81%)
children <5 years old, and 6 (6%) sought care from mul-
tiple sources (Table 3). Government clinics were the
source of healthcare most often consulted by children
<5 years old for ILI; 34 (41%) children <5 years old
reported seeking care at a government clinic, whereas
20 (20%) reported consulting a private clinic. Hospitals
were consulted by 6 (5%) children <5 years old for ILI,
and 4 (5%) were hospitalized for one night or more.
Care was sought at pharmacies and drug shops for
nearly one-third of children <5 years old with ILI.
Care for ILI was sought outside the home by 337
(65%) persons aged five years or older, and 13 (3%) con-
sulted multiple sources. Government clinics were con-
sulted for ILI by 111 (36%) persons aged five years or
older. Pharmacies were consulted for ILI by 110 (29%)
persons aged five years or older. One (0.1%) ILI patient
five years or older was hospitalized for more than one
Among the respondents with pneumonia who did not
seek healthcare for their illness, the perception that
their illness was not severe enough to warrant treatment
(28/69, 42%) and the cost of treatment (13/69, 20%)
were the major reasons cited for not seeking care.
Among persons with ILI who did not seek healthcare
for their illness, insufficient severity of illness (68/204,
31%), cost of treatment (37, 18%), lack of medical ser-
vices (13, 9%) and spontaneous improvement (19, 7%)
were the major reasons cited.
Sociodemographic and illness characteristics associated
with seeking treatment at government facilities
There was no significant association between sex of the
respondent and whether care was sought for pneumonia
(P = 0.34) or ILI (P = 0.15) at a government hospital or
clinic (Table 4). Children <5 years old were more likely
to receive healthcare for pneumonia and ILI at govern-
ment facilities than persons aged five years or older, but
this difference was statistically significant only for
Table 3 Healthcare providers consulted by respondents who sought care outside the home for pneumonia in the last
year or influenza-like illness in the last month, Santa Rosa, Guatemala, 2006a
Children <5 years old
Source of healthcaren (%)
Persons five years and older
n (%)
17 (25)
16 (24)
2 (1)
38 (75)
17 (31)
26 (53)
4 (6)
2 (3)
3 (7)
1 (3)
0 (0)
6 (5)
5 (5)
1 (0.3)
81 (95)
34 (41)
20 (20)
12 (13)
4 (3)
12 (17)
1 (1)
3 (3)
28 (12)
22 (11)
6 (1)
171 (88)
46 (27)
65 (31)
45 (16)
11 (7)
13 (8)
3 (2)
10 (7)
3 (0.2)
2 (0.1)
1 (0.1)
334 (100)
111 (36)
53 (13)
110 (29)
4 (2)
50 (17)
0 (0)
17 (5)
Government hospital
Private hospital
Outpatient providers
Government clinic
Private clinic
Traditional healer
Drug shop
Social Security clinic
Influenza-like illness
Government hospital
Private hospital
Outpatient providers
Government clinic
Private clinic
Traditional healer
Drug shop
Social Security clinic
aNumbers will not necessarily add up to 100% because more than one healthcare provider can be consulted in the course of an illness. Percentages are
calculated using sample weights.
Lindblade et al. BMC Public Health 2011, 11:885
Page 6 of 9
Page 7
pneumonia (P = 0.03). There was a significant inverse
trend across SES status with persons of higher socioeco-
nomic status less likely to seek care for pneumonia and
ILI at government facilities (P = 0.005 and P = 0.001,
respectively). The duration of illness was not associated
with consultation at a government facility for either
pneumonia (P = 0.37) or ILI (P = 0.25). Severity of
pneumonia was not associated with seeking care from a
government facility (P = 0.13).
We conducted a HUS to help inform establishment of a
sentinel surveillance system for pneumonia and influ-
enza-like illness in Santa Rosa, Guatemala, and found
that private clinics are the single most important source
of healthcare for pneumonia both in children <5 years
old and older persons. For more mild ILI, both children
<5 years old and persons aged five years or older are
more likely to consult government clinics than other
sources of health care. These findings suggest that in
Santa Rosa, sentinel surveillance for pneumonia in gov-
ernment hospitals will significantly underestimate the
burden of disease, by up to 75% for children <5 years
old and 88% for persons aged five years and older. Gov-
ernment healthcare clinics will underestimate the num-
ber of cases of ILI by about 59% for children <5 years
old and 64% for persons five years and older.
Our study is consistent with other studies of health-
care-seeking behavior in Guatemala and Central Amer-
ica that have found private clinics to be common
sources of healthcare. Van der Stufyt et al. reported that
more than 40% of Guatemalan families sought health-
care for their children <5 years old from private physi-
cians, compared with 26% consulting a governmental
health center.[18] Focus group interviews from three
countries in Central America found that persons consid-
ered the healthcare obtained through private physicians
and clinics preferable to public options because of
prompt attention and a perception that healthcare is
better.[19] Another study evaluating healthcare utiliza-
tion among children in rural Guatemala who reported a
diarrheal or respiratory illness found private physicians
were more likely to be consulted by households with
higher income.[20]
The population that uses government health clinics
and hospitals for respiratory illnesses in Santa Rosa is
younger and poorer than the general population. We
found a trend for decreasing use of government facilities
with increasing age and household wealth. These find-
ings should be taken into account to improve the gener-
alizability of burden of disease estimates made from
sentinel surveillance data.
The results of this study are subject to several impor-
tant limitations. We used a case definition that required
self-report or report by a proxy of an illness that
occurred up to one year prior to interview. It is well
known that such self-reports are limited by recall decay,
and recent episodes are more likely to be recalled than
earlier episodes.[21] This could be noted in our data
that demonstrated a decreasing report of pneumonia
Table 4 Association between sociodemographic and illness characteristics and consultation for healthcare at
government facilities for pneumonia or influenza-like illness (ILI), Santa Rosa, Guatemala, 2006
Pneumonia cases
Characteristic n (%)n (%)
ILI cases
n (%)
n (%)
P value
P value
Sex, female
Age (years)
Wealth index
Signs of severe pneumonia
Duration of illness <7 days
54 (22)83 (32)0.34
29 (29)
25 (31)
16 (16)
16 (14)
10 (10)
26 (21)
28 (17)
34 (22)
43 (23)
27 (17)
38 (24)
53 (26)
24 (16)
28 (20)
8 (4)
49 (18)
56 (22)
66 (21)
75 (28)
27 (10)
<0.0001 <0.0001
20 (26)
18 (22)
16 (18)
24 (21)
18 (12)
26 (27)
22 (26)
15 (14)
17 (14)
34 (25)
46 (28)
46 (18)
29 (21)
40 (23)
46 (37)
30 (24)
35 (19)
26 (16)
14 (4)
93 (60)
38 (19)
61 (30)
41 (16)
52 (15)
81 (20)
147 (56)
0.37 0.25
aNA = not applicable; percentages are calculated using sample weights.
Lindblade et al. BMC Public Health 2011, 11:885
Page 7 of 9
Page 8
with increasing time before the survey. As long as recent
illness episodes do not differ from prior episodes with
regard to patterns of healthcare-seeking behaviors, there
is no reason to believe that recall decay causes bias with
regard to these variables. Because our case definition is
based on self-report, there is substantial potential for
misclassification, especially between mild and severe
acute respiratory illness, and this can be seen in the
report of some lower respiratory tract symptoms among
respondents with ILI. However, the behaviors associated
with episodes of ILI compared to pneumonia (lower
probability of seeking care outside the home, less likely
to seek treatment at a hospital) are suggestive of a more
mild illness and we are reasonably confident that we
have described the healthcare seeking behaviors that are
broadly associated with both pneumonia and ILI. An
additional limitation is our sample size, which is too
small to permit age to be stratified into more than two
groups, restricting our ability to model healthcare-seek-
ing behaviors more precisely by smaller age groups.
Finally, it is not clear whether results from one area of
Guatemala with a significantly lower indigenous popula-
tion than the rest of the country can be generalized to
the nation as a whole.
Despite the limitations of this and similar surveys, our
findings indicate that Guatemala and other countries in
the region can improve the estimation of the burden of
influenza and other respiratory pathogens from sentinel
surveillance by taking healthcare utilization into
account. As a large proportion of the population with
respiratory disease in Guatemala does not attend gov-
ernment health facilities for treatment, this approach
could help correct government surveillance data for
missing cases and facilitate comparison of the burden of
influenza with other countries.
The authors would like to thank Olga Henao and Cindy Friedman for
assistance with the design of the survey, and Wil Clara for comments on an
earlier draft. The authors would like to acknowledge the assistance of the
Health Area of Santa Rosa for completing this survey. The Instituto Nacional
de Estadística de Guatemala kindly provided census maps and data to
developing the sampling frame. We thank the survey team for several weeks
of difficult work in challenging conditions. We would like to express our
gratitude to the population of Santa Rosa for their involvement in the study.
The findings and conclusions in this report are those of the authors and do
not necessarily represent the views of the Centers for Disease Control and
Prevention. This publication was supported in part by Cooperative
Agreement Number U50/CCU021236-05 from the U.S Centers for Disease
Control and Prevention.
The findings and conclusions in this report are those of the author(s) and do
not necessarily represent the views of the Centers for Disease Control and
Author details
1Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd., Atlanta
GA, 30333 USA.2CDC Regional Office for Central America and Panama, 18
Avenida, 11-95 Zona 15, Guatemala City, Guatemala.3Epidemic Intelligence
Service, CDC, Atlanta, GA 30333 USA.4Field Epidemiology Training Program,
Ministerio de Salud Pública y Asistencia Social, 6 Avenida 3-45 Zona 11,
Guatemala City, Guatemala.5CDC-UVG Collaboration, Universidad del Valle
de Guatemala,18 Avenida, 11-95 Zona 15, Guatemala City, Guatemala.
Authors' contributions
KAL, WA, HTJ, LR and AMF conceived of the study and wrote the protocol.
WA, HTJ, LR and NP supervised data collection. KAL, XZ and AJJ participated
in the analysis of the study. KAL and AJJ drafted the manuscript. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 11 August 2011 Accepted: 24 November 2011
Published: 24 November 2011
1.World Health Organization: Report of the WHO Consultation on
Surveillance for Pandemic Influenza; 10-12 December 2007. Geneva,
Switzerland 2009.
2.Ortiz JR, Sotomayor V, Uez OC, Oliva O, Bettels D, McCarron M, Bresee JS,
Mounts AW: Strategy to enhance influenza surveillance worldwide. Emerg
Infect Dis 2009, 15:1271-1278.
3.World Health Organization: Resolution WHA 58.5: Strengthening
Pandemic Influenza Preparedness and Response. Geneva 2005.
4.Pan American Health Organization: PAHO-CDC Generic Protocol for
Influenza Surveillance. Washington, DC USA; 2006.
5.Cayce KA, Krowchuk DP, Feldman SR, Camacho FT, Balkrishnan R,
Fleischer AB: Healthcare utilization for acute and chronic diseases of
young, school-age children in the rural and non-rural setting. Clin Pediatr
(Phila) 2005, 44:491-498.
6.Ariff KM: Preferential utilization of healthcare systems by a Malaysian
rural community for the treatment of musculoskeletal injuries. Med J
Malaysia 2000, 55:451-458.
7.Coyle CP, Santiago MC: Healthcare utilization among women with
physical disabilities. Medscape Womens Health 2002, 7:2.
8.Halder AK, Saha UR, Kabir M: Inequalities in reproductive healthcare
utilization: evidence from Bangladesh Demographic and Health Survey
2004. World Health Popul 2007, 9:48-63.
9. Lim KL, Jacobs P, Klarenbach S: A population-based analysis of healthcare
utilization of persons with back disorders: results from the Canadian
Community Health Survey 2000-2001. Spine 2006, 31:212-218.
10. Taffa N, Chepngeno G, Amuyunzu-Nyamongo M: Child morbidity and
healthcare utilization in the slums of Nairobi, Kenya. J Trop Pediatr 2005,
11. Westin M, Westerling R: Health and healthcare utilization among single
mothers and single fathers in Sweden. Scand J Public Health 2006,
12.Jordan HT, Prapasiri P, Areerat P, Anand S, Clague B, Sutthirattana S,
Chamany S, Flannery B, Olsen SJ: A comparison of population-based
pneumonia surveillance and health-seeking behavior in two provinces
in rural Thailand. Int J Infect Dis 2009, 13:355-361.
13.Ministerio de Salud Pública y Asistencia Social: V Encuesta Nacional de
Salud Materno Infantil 2008-2009, Guatemala. Guatemala City; 2009.
14.Chamany S, Burapat C, Wannachaiwong Y, Limpakarnjanarat K, Premsri N,
Zell ER, Dowell SF, Feikin DR, Olsen SJ: Assessing the sensitivity of
surveillance for pneumonia in rural Thailand. Southeast Asian J Trop Med
Public Health 2008, 39:549-556.
15.World Health Organization: A standard verbal autopsy method for
investigating causes of death in infants and children. Geneva: World
Health Organization; 1999.
16. Filmer D, Pritchett LH: Estimating wealth effects without expenditure
data - or tears: an application to educational enrollments in states of
India. Demography 2001, 38:115-132.
17.Vyas S, Kumaranayake L: Constructing socio-economic status indices: how
to use principal components analysis. Health Policy Plan 2006, 21:459-468.
Lindblade et al. BMC Public Health 2011, 11:885
Page 8 of 9
Page 9
18. van der Stuyft P, Delgado E, Sorensen SC: Utilisation rates and
expenditure for public and private, curative-care services in semi-urban
Guatemala. Ann Trop Med Parasitol 1997, 91:209-216.
Leon M: Perceptions of health care quality in Central America. Int J Qual
Health Care 2003, 15:67-71.
Goldman N, Pebley AR, Gragnolati M: Choices about treatment for ARI
and diarrhea in rural Guatemala. Soc Sci Med 2002, 55:1693-1712.
Feikin DR, Audi A, Olack B, Bigogo GM, Polyak C, Burke H, Williamson J,
Breiman RF: Evaluation of the optimal recall period for disease
symptoms in home-based morbidity surveillance in rural and urban
Kenya. Int J Epidemiol 2010, 39:450-458.
Pre-publication history
The pre-publication history for this paper can be accessed here:
Cite this article as: Lindblade et al.: Low usage of government
healthcare facilities for acute respiratory infections in Guatemala:
implications for influenza surveillance. BMC Public Health 2011 11:885.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
Lindblade et al. BMC Public Health 2011, 11:885
Page 9 of 9


text:
Celebrity Mailbag: Harry Shum Jr. Talks 'Glee' & More! (VIDEO)
Glee Does V-Day!
The cast film their Valentine's Day ep. 23 Photos »
Mailbag: Cody Simpson
Cody Simpson answers your questions! Watch »
If you watch Glee, you know that Mike Chang is pretty quiet, but the actor who plays him is ready to dish!
Harry Shum Jr. recently answered a few fan submitted questions just for Celebuzz's Celebrity Mailbag series, and you can watch what he has to say right here!
So, what were some topics of conversation?
From his wildest dance moves, to who the biggest on set goofball is, and even what music he is loving right now, check out the video above!
Visit www.harryshumjr.com for more. Also be sure to "like" him on Facebook and follow him on Twitter!

subset: commoncrawl


text:
Obstetrician & Gynecologist (OB/GYN)
37 years of experience
Video profile
Accepting new patients
37 years of experience
Video profile
Accepting new patients
111 Park St
Suite 824
Hartford, CT 06106 Phone number & directions
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A medical license is required for a doctor to practice medicine in a particular state. Requirements vary by state but most require, at a minimum, post-graduate training in the doctor's specific specialty. An NPI number is a national identifier unique to an individual health care provider and is managed by the Center for Medicare & Medicaid Services (CMS).
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Dr. William Crombleholme, MD is board certified in Maternal & Fetal Medicine.
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Dr. Crombleholme graduated from State University of New York Downstate, Brooklyn. He has 1 awards.
Dr. Crombleholme has 8 hospital affiliations:
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Home > Find an Obstetrician & Gynecologist > CT > Hartford Obstetricians & Gynecologists > Dr. William Crombleholme, MD
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text:
Pedro Martinez
Pedro Martinez wins Boston BBWAA's Fuchs Award
BOSTON (AP) Former Red Sox pitcher Pedro Martinez has won the prestigious Fuchs (fyoox) Award from the Boston chapter of the Baseball Writers' Association of America. The award
10 just isn't enough: My Hall of Fame ballot
least four candidates - first-timers Randy Johnson, Pedro Martinez and John Smoltz, plus holdover Craig Biggio, who missed by only two ..... know - who among us wants to leave a Randy Johnson or Pedro Martinez off our ballot? But if a voter's primary concern
FOX Sports Fan Vote: Who would you put into the Hall of Fame?
A trio of aces is knocking on the Hall of Fame doors in Cooperstown, NY. Randy Johnson, Pedro Martinez and John Smoltz are three of the 17 first-timers on the 2015 ballot, which will be announced on Tuesday, Jan. 6 (Inductions
25 Great Baseball Players
gotta do is scroll ... 1. Barry Bonds 2. Roger Clemens 3. Randy Johnson 4. Alex Rodriguez 5. Albert Pujols 6. Pedro Martinez 7. Ken Griffey Jr. 8. Pete Rose 9. Chipper Jones 10. Derek Jeter 11. Jeff Bagwell 12. Miguel Cabrera 13. Tim
Royals Game 2 starter Ventura wants to make Pedro Martinez proud
is the one in which his idol, Pedro Martinez , helped Boston win a championship ..... is 2004 with the Red Sox with Pedro Martinez and Manny Ramirez helping them ..... against the Giants. "For me, Pedro Martinez has always been that player for
3 Questions with Pedro Martinez | FOX Sports
3 Questions with Pedro Martinez JUL 30, 11:54pm He was one of the best pitchers of his era and always delivers an honest answer. Pedro speaks his mind on the
3 Questions with Pedro Martinez
3 Questions with Pedro Martinez JUL 30, 11:54pm He was one of the best pitchers of his era and always delivers an honest answer. Pedro speaks his mind on the
Can Hall of Fame save voters from themselves?
of every Hall of Fame voter who doesn't choose Pedro Martinez , presumably because it's Pedro's first time on the ballot ... This nonsense ..... because if you don't vote for Randy Johnson – or Pedro Martinez , I guess, although it's not impossible to argue
Merry Thanksgiving! The Hall of Fame's MEGABALLOT is here!
Hall Fame ballot Randy Johnson Pedro Martinez candidates glut | FOX Sports Menu ..... Jeff Kent, Edgar Martinez, Pedro Martinez , Don Mattingly, Fred McGriff ..... surprised if Randy Johnson and Pedro Martinez are the only ones who make it
Monday's Sports in Brief
that includes two of the last three World Series MVPs in Sandoval and David Ortiz. NEW YORK (AP) - Randy Johnson, Pedro Martinez and John Smoltz are among 17 newcomers on baseball's 2015 Hall of Fame ballot. Craig Biggio, who fell two votes


text:
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Forward features
Below you can find information about upcoming issues of Alliance including special features, areas of discussion and guest editors.
March 2015
Arts and social change
Why should philanthropists support the arts? This question will be put to ten foundations/philanthropists and ten arts organizations as part of a special feature looking at the role of philanthropists and foundations in supporting art and social change. Should they fund artists directly to create the art they want to make? Should they fund theatres and galleries to make art more available to more people? Should they fund only work that explicitly promotes social change? And what about supporting the arts in their own right? These are among the issues to be addressed in the March issue of Alliance.
Guest editors are Hania Aswad, Naseej Foundation and Fiona Ellis, Millfield House Foundation


text:
Originally Posted by macrorie
The Jupiter 12 is a fine lens. Just be careful with potential flare situations, unless you want some flare for an effect.
thanks for the tip. I still have to develop the first films from the M4, in fact I first have to finish rebuilding the darkroom...
Only dull people are brilliant at breakfast (Oscar Wilde)
My APUG Blog


text:
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text:
5846 views by 3 Nov. 2014
Featured in "Tots & Teens tees" group 3/16/13
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IF you CLICK ON the "1rst TAG" (jlh designs) it'll take you to some pages of the best of my art from all THREE of the RB sites I have. ;-)))
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text:
Hi guys
this is my first post, unfortunally with a problem
I have a Lenovo 3000 N100 and i upgrade this laptop with a T5200 Core 2 duo processor and 3GB of RAM
this laptop now are running Snow Leopard 10.6.8 with no problem
But when i try to update with Lion (with 10.7 or 10.7.4) i've got a Kernel Panic with the ACPI, when i use the -v i've got this
com.apple.driver.AppleACPIPlatform failed to resolve library dependencies
es.osx86.driver.EvOreboot failed to resolve library dependencies
couldn't alloc calss AppleACPIPlatformExpert
couldn't alloc calss es_OSx86_EvOreboot
I try the method of tonymac with ###### 1.3 and 1.5.1
Any ideas ?
Thans in advance
Install Lion on Lenovo 3000 N100 with T5200 and 3GB RAM Problem need help
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Man convicted for impersonation
By IAfrica
In Gambia
Aug 6th, 2014
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The Brikama Magistrates' Court, presided over by Magistrate Dayoh Dego Small last Tuesday, convicted one Assan Sohna for impersonation and sentenced him to a fine of D3000, in default to serve 6 months imprisonment with hard labour. Reading the judgment, the presiding magistrate informed that the court was convinced that the accused had shown remorse, but that the attitude of the accused was not correct. But he added that the court would put his mitigation into consideration. The magistrate…
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text:
Salt Lake Bees: Snyder keeps swinging hot bat, but Bees lose 2-1 to Tacoma in matinee
Tom Smart, Deseret News
SALT LAKE — Anything Salt Lake Bees catcher Chris Snyder does offensively is simply icing on the cake.
At least that's what Snyder said after Tuesday afternoon's 2-1 loss to visiting Tacoma.
"Like I tell everybody, I'm going out there and my main focus is what I do behind the plate," said Snyder. "I've been swinging the bat well, and that's fine, but No. 1 is definitely getting the pitcher through the game, controlling the running game and being solid behind there. The offense right now is just icing on the cake."
Snyder, who has a .379 batting average, seven home runs and 21 RBIs, has impressed this April.
The catcher finished Tuesday's outing 2-for-4 with a home run.
"I was looking for something out over the plate, and I got it," said Snyder.
Tuesday's solo shot moved Snyder into a first-place tie with Albuquerque slugger Scott Van Slyke for most home runs in the PCL.
Snyder currently is on the outside looking in at the Angels' 40-man roster, which means the catcher is an active player but not able to join the Halos.
Salt Lake manager Keith Johnson is hopeful the opportunity will come knocking at Snyder's door, whether it's with the Angels or some other franchise.
"I'm hoping. He came over here with an opportunity to try to make that ballclub," Johnson said. "He's been doing a great job for us, and that's all he has been trying to do— try and get himself prepared to get back into the major leagues, whether its with us or someone else.
"If the opportunity is not with us, and it's with someone else, I hope the best for him."
For Snyder, it's all about building off the confidence that comes from having positive results on the field.
"It's always good to have confidence when you step in the box. You get guys on base and in scoring position — what you've got to do is put the ball in play," said Snyder. "That confidence kind of locks you in a little bit, and I think it's helped out a lot."
NOTEBOOK: Salt Lake pitcher Matt Shoemaker put in a solid effort on the mound Tuesday afternoon, going seven innings and throwing 97 pitches — 66 of them for strikes. Shoemaker gave up 10 hits and two earned runs, striking out four Tacoma Batters.
ATTENDANCE: On a day that was deemed fit for an afternoon game, 3,590 baseball fans came out to Spring Mobile Ballpark to enjoy baseball in the sunshine.
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text: City News Thursday 24/7/2008 Brief: MCMILLCOMM Page: 39 Page 1 of 2 Section: General News Region: Brisbane Circulation: 38,801 Type: Suburban Size: 408.18 sq.cms. Published: ---T--- Necessity mother of invention Q: Where do you work? have a home I your career? MiSMo. Because the skin care office. With traffic these days I am much industry is so over serviced and has enor- more productive working from home. mous companies competing for people's Q: How did you earn your first dollar? As business. a 10-year-old chaperone for my sister and To build a new Australian business and her boyfriend, but I was easily bought off. produce what we believe to be world Q: What standard of education did you standard skin care range is very rewarding. reach? Year 10. We are still a small business, but watch this Q: What was your first full-time job? I was space. a clerical assistant in the Taxation Depart- Q: What has been your biggest regret? I ment where I met and married my husband have no regrets. We have a wonderful, at the grand old age of 18. healthy, successful family, good friends and Q: Is your current job the career you a happy life. What more could ask for? I envisaged for yourself when you finished Q: What is the most pleasing aspect of your study? No, if you had told me eight years job? I love the development of new facial ago that this is what I'd be doing I would products, then the results. It is too exciting not have believed you. for words. Q: What made you choose this career? I Q: What is the most difficult, yet necessary had developed Rosacea (facial redness and aspect? Paperwork! My paperwork skills breakouts) after a lifetime of good skin. I leave a lot to be desired, so my husband learned about a nutritional supplement, is a great help there. which is excellent for skin problems. After Q: Are you actively grooming a successor years of research and trials, MiSMo had for when you decide to step down? No, taken on a life of its own and we'd I haven't had time to think about that one developed a wonderful, effective skin care yet. range. Q: What tips do you have for people Q: How many times have you changed starting out in their careers? Be absolutely career? Five times, which include owning passionate about what you do, even in the dairy farms and a mail order fabric com- had times. Know your business inside out, pany. It was varied and interesting but I always learning something new. the good parts and the tedious. If you don't Q: Is there another career change in you? you can't pick up other people's mistakes. I hope this wonderful skin care business will Q: What tips do you have for people just see me enter old age like Helena Rubenstein beginning a business to manage staff and and love it till the end. budgets? If you are starting a new business Q: What would you do if you were forced be prepared for long hours and wearing to give up your current job? I'd seriously many hats. Don't expect to bring home a go into internet marketing. That is a whole big pay packet. Employ staff when the new world again. company can afford it. Go for success and Q: What has been the biggest success in your pay will come later. BRIEFCASE NAME: Irene McDonald DATE OF BIRTH: 8th December 1950 SUBURB OF RESIDENCE: Carindale JOB DESCRIPTION: Managing director of MiSMo Body Care: www.mismo.com.au Copyright Agency Limited (CAL) licensed copy Ref: 39196738 City News Thursday 24/7/2008 Brief: MCMILLCOMM Page: 39 Page 2 of 2 Section: General News Region: Brisbane Circulation: 38,801 Type: Suburban Size: 408.18 sq.cms. Published: ---T--- ;3p W 1, A- BEAUTY-FULL BUSINESS: Irene McDonald, founding owner of Mismo, is taking on the beauty world with her home-based business. Copyright Agency Limited (CAL) licensed copy Ref: 39196738 City News Thursday 24/7/2008 Brief: MCMILLCOMM Page: 40 Section: General News Region: Brisbane Circulation: 38,801 Type: Suburban Size: 258.89 sq.cms. Published: ---T--- Unwavering career focus Q: Where do you work? I am the a physiotherapist. Once I started manager of Revive Pilates and studying, I found my interests were BRIEFCASE Physiotherapy studios. I own one more with treating musculo- studio at Level 2, 21 Marv St skeletal injuries and then NAME: Julie Campbell Brisbane and another at Ashgrove. ultimately decided to pursue a career in Sports Physiotherapy. DATE OF BIRTH: 31.08.1963 Q: How did you earn your first dollar? Working at Woolworths on Q: What has been the biggest SUBURB OF RESIDENCE: Bar- the check-out in Ingham. don success in you career? My biggest Q: What standard of education did success has been growing Revive JOB DESCRIPTION: Manager you reach? I completed a Bachelor studios to be what they are today. of Revive Pilates and Physiotherapy of Physiotherapy at the University Travelling overseas last year with studios: www.revivestudio.com. of Queensland. the World Beach Volleyball Tour au; APA Sports Physiotherapist and Q: What was your first full-time looking after Natalie Cook and job? Physiotherapist at the Princess Pilates Clinician. Tamsin Barnett in Paris and Alexandra Hospital. Norway was a definite highlight. Q: Is your current job the career Q: What has been your biggest you envisaged for yourself when regret? I don't have any regrets. I you finished study? Yes. have I have made decisions about the been self employed for 23 years - direction of my career based on my Ihave been able to map out my family (I have two children 12 and own destiny so to speak. 9) and my desire to be a world class Q: What made you choose this sports physiotherapist, and I don't career? I originally wanted to work regret my decisions. with disabled children and decided when I was 13 that I wanted to be REVIVE: Julie Campbell from Revive Pilates and Physiotherapy in the City. Copyright Agency Limited (CAL) licensed copy Ref: 39196785


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82 of 85 people found the following review helpful
4.0 out of 5 stars Unique & Visionary
There were as many detractors as those appluading this film on it's release, but you can't please everyone. This film is cut from an entirely different cloth than most of the Hollywood dross out there these days, and shows a certain level of forward thinking from Warners to stick by Aronofsky and his vision for the film. What we get is a tight, well acted piece of...
Published on 5 Jun 2007 by N. Cannon
24 of 27 people found the following review helpful
3.0 out of 5 stars Small wonders
Certainly this film lacks the itchy paranoia of Pi or the hallucinatory / visceral power of Requiem for a Dream. The triptych of stories doesn't always mesh together and accusations of pretension are pretty difficult to deflect. Yet The Fountain contains much to recommend it, not least the sensuous photography that beautifully captures some startling images. But what...
Published on 3 Feb 2008 by customer
Most Helpful First | Newest First
82 of 85 people found the following review helpful
4.0 out of 5 stars Unique & Visionary,
N. Cannon (UK, London) - See all my reviews
There were as many detractors as those appluading this film on it's release, but you can't please everyone. This film is cut from an entirely different cloth than most of the Hollywood dross out there these days, and shows a certain level of forward thinking from Warners to stick by Aronofsky and his vision for the film. What we get is a tight, well acted piece of filmaking which literally glows and radiates an intense passion throughout the 90min screentime. It may be too open ended for most cineplex viewers, requiring a leap of imagination to absorb the tryptich of narrative as the film jumps between 3 timelines: Past, Present, Future, but for those of us prepared to invest something into the experience( and leave all that 21st century cynicism/ negativity at the door) you'll be rewarded with a beautiful, emotive, intelligent film that leaves you wanting more.
Everyone will have their own take on what the film actually means, and where and when the final timeline actually takes place? but that is the beauty of this film, it makes you think, about yourself, your loved ones and our place in the universe. If only more films did this the world could be a better place.
10 of 10 people found the following review helpful
4.0 out of 5 stars Complicated But Brilliant,
Spanning over 3 time periods, the Fountain follows the life of Tom (Hugh Jackman) a Spanish Conquistador, a Doctor trying to cure Cancer, and a lone spaceman guarding the Tree of Life.
As the Inquisator is bringing Spain to its knees, Tomas is sent by the queen to find the Tree of Life, hidden somewhere in South America, with only a few good soldiers and a wise priest, he must brave the Mayan Civilisation to reach his goal.
Whilst trying to cure cancer, Tommy's wife Izzy is slowly dying of a Brain Tumor. In her last few days, she gives Tommy a book she has been writing, and the book is called 'The Fountain'.
And in the future, Tom has the sole purpose of guarding the dying Tree of Life. He needs to rekindle its life by sending it into a new star that is being born inside a dying star.
Everyone will have a different opinion, but I can guarentee one thing, you'll be talking about it for days. If it is trying to understand it, praising it, or spreading the word of how incredibly annoying and confusing it was, you won't easily forget it.
For me, this shows the sign of a good show. Darren Aronofsky has done the ever difficult, third film in a career, wonderfully and Clint Mansell has done nothing wrong in the the dramtic and inspiring music to go with it.
Hugh Jackman and Rachel Weisz are superb and you can tell they enjoyed doing it. The special affects are amazing (inside the dying star) and both the past and present stories fit together perfectly.
The idea of a dagger being the key to a lost Mayan Temple is clever and is a different twist.
An enjoyable film to watch, but as a warning, if you like films were the bad guy does something wrong and the good guy fixes it by shooting everyone he sees, this is not the film for you.
75 of 81 people found the following review helpful
5.0 out of 5 stars You won't see a more beautiful film all year,
Mr. Od Smith "d2kvirus" (Coulsdon, Surrey) - See all my reviews
After a long wait, complete with the projects being stopped in its tracks once already, The Fountain finally reached our screens to an occasionally perplexed and/or apathetic audience on one hand, on the other to an audience that it struck an emotional chord with.
I fall into the latter, if you hadn't guessed.
This was always going to be Darren Aronofsky's difficult third movie following the mind-melting Pi and the emotional assault & battery of Requiem for a Dream, but he pulls it off with an intimate, heartbreaking story that happens to span 1000 years, only it doesn't once you think about it.
The three narrative threads (Tommy in the modern day, Tomas the Conquistador, and Tom the spaceman) may appear to jar, but they all fit into the story - not the story of the film, but the book that Tommy's dying wife Izzy is writing as her brain tumour threatens to overcome her once and for all.
The Fountain has an air of sadness that seeps from the screen: the repeated motif of Izzy asking Tommy to take a walk with her in the snow plays time and again, and takes on sadder connotations every time, while the Tommy/Tomas/Tom character(s) all face an impossible task in trying to prevent natural following it's inevitable course towards death, and how man is unable to prevent the people he loves succumbing to fate. One scene sees Tommy completely numb by bad news, walking down a street and unable to take in what's going on around him (passers-by, traffic, construction works) and we don't hear a thing until he's almost hit by a car.
As always, Aronofsky can create stunning images on screen, and as always accompanied by Clint Mansell's intimate, stripped-back score that enhances the events and the feeling of loss that is preparing to come to the fore upon all three variations of Hugh Jackman's lead character. Indeed, even when he succeeds, it ends up hurting him as he just prolonged the inevitable until it could hurt him once more.
It may not be a Friday night popcorn movie by any means, but it is a one of the finest pieces of filmmaking of recent years, and more proof that Darren Aronofsky is an underrated director that is capable of creating cinematic genius out of the meanest of circumstances, and is a film that you should see.
52 of 57 people found the following review helpful
5.0 out of 5 stars To love forever,
E. A Solinas "ea_solinas" (MD USA) - See all my reviews
This review is from: The Fountain [Blu-ray] (Blu-ray)
Darren Aronofsky has never made movies that were easy viewing. Examples? Just watch "Pi" and "Requiem For a Dream," and you'll see why this underrated director has made one of the most astounding sci-fi movies in ages.
"The Fountain" is basically a sprawling tale that is half "real," half outside the mind -- love, immortality, death, grief and a tangled plotline that may take a few viewings to get right, but is exquisite in its simplicity. Not satisfied with depth, Aronofsky also makes it an absolutely stunning visual experience.
Research oncologist Tommy (Hugh Jackman) is trying to find a cancer cure by animal testing, so he can save the life of his dying wife Izzie (Rachel Weisz), including an unsanctioned test from a mysterious tree. As she hopes for a cure, Izzie has been writing a book about a Spanish conquistador who is seeking the immortality-granting Tree of Life.
As we see in other flashbacks, that conquistador is a version of Tommy (and Izzy as Queen Isabella). And far in the future, Tommy still struggles with his wife's loss, as he travels to a distant nebula to revive the tree. But as he finally gives in to his wife's last wish, he becomes enmeshed in a mysterious rebirth that stretches through the ages.
"The Fountain" got a royal whupping from critics, and was even booed by test audiences, who presumably couldn't understand the three storylines -- or rather, one non-linear storyline, in which the lines between reality and imagination are blurred. Perhaps all of it is true, or perhaps Tommy's mind is creating the 1500 and 2500 scenarios to help him cope.
As befits a movie that tackles so many deep themes, Aronofsky weaves mythology, creation beliefs, religion and the fear of death together, and binds it together with the universal theme -- love that even death can't overcome. The dialogue tends to be more spare than the story, rather than loading it down with unnecessary ponderings.
And he does it beautifully and surreally. The whole movie is tinged in gold -- gold light, gold costumes, gold Tree of Life, gold nebula, gold deserts. The camerawork is filmed poetry: there are sweet moments like planting a seed in a grave, the Tree lit by the sun, and the sight of Tommy inside the nebula. The most exquisite moment comes when Tommy kneels before Izzy, under the Tree, with drops of golden light falling around them.
This is undoubtedly Jackman's best movie, making us feel Tom's love and sorrow for Izzy ("There's no hope for us here. There is only death"), and the lifelong struggle against death. Your heart really breaks for him. Weisz is sweet and wilting as Izzy, and the chemistry between the two leads makes their time-busting love seem entirely reasonable.
Aronofsky has made a story that is pure art, exquisite in theme, and while you might have to watch "Fountain" a few times to really "get it," but you won't regret the experience. Even if you don't like it, in an era of bland popcorn movies, its ambition is worth praising.
12 of 13 people found the following review helpful
5.0 out of 5 stars The Fountain,
Simon Mcdermott "sumerian prophet." (Devon, England) - See all my reviews
This review is from: The Fountain [Blu-ray] (Blu-ray)
This Film is absolutely stunning, and extremely profound on the concept of human mortality and the nature of impermanence.
Visually, especially in Hi-Def it looks gorgeous, and the story reaches levels of profundity on par with films like donni darko and the Matrix.
You are left at the end of it all feeling like you've awoken from an awe inspiring dream, or a psychedelic trip, as the film seems to lack a conventional paradigm.
The story its self revolves around the Mayan and biblical tree of life, and encompasses three era's past, present and future.
The past story revolves around a Spanish conquistador named Thomas,(played by Hugh Jackman) who is sent on a journey to Maya by the Spanish Queen (ratchel weisz) to discover the fabled tree of life.
The story reminded me of the film Excalibur, when Arthur's Knights are sent on the quest for the holy grail.
The Present day romance is centred around Neurologist Tommy Creo and his Wife, author Izzy Creo who is dyeing from a brain tumour.
Tommy's work is totally focused on curing brain tumour's, as he fights for a way to save his wife's life.
The third story is set in the future in a sphere glass like spaceship which circumvents the tree of life, and what appears to be a Buddhist style monk. The monk is journeying through space to take the tree of life to a dying nebula in order to save it.
What makes this film unique is that it is more like a fine work of art, or an inspiring and profound piece of poetry, in the way that it does not
tell the viewer what to think, but instead actually requires you to make up your own mind on what the film actually means.
This film will mean something different to almost every single person that views it, which in a time of brain dead Hollywood blockbusters is something very special indeed.
Interestingly When I first watched this film I was in the middle of reading a chapter in a book written by the Dalai Lama. The chapter is called 'Awareness of death', and talks about that in order for us to live we must first accept death. For it is the one thing that none of us can avoid, yet we spend our whole life either fighting against it, or trying to avoid thinking about it. This means when the time comes we are unprepaired. Unlike izzy in the film who comes to except it, and is unafraid and embraces death knowing that from death springs new life, in a never ending perpetual cycle of impermanence.
So to round it off if you are looking for a film which offers something new and will get you pondering the deeper meaning of life, then this flim is for you. On the other hand if you are looking for a Sunday afternoon
no-brainer, steer clear and rent transformers, which should provide exactly what your looking for.
11 of 12 people found the following review helpful
4.0 out of 5 stars Death and rebirth, beautiful and strange,
Hud955i "Hud" (Herts. UK) - See all my reviews
There is a rudimentary story to 'Fountain' but no real plot. The action, instead, is built around a theme. The film asks: as human beings, how do we come to terms with the death of a loved one?
There is, of course, no cure for death. We deny it and fight against it but in the end we have no choice: we have to find some way to accept it. And that, for most of us, can't be done rationally. The emotions involved and the sense of dislocation are just too big for the rational mind to cope with. Acceptance, however painful, has to achieved through metaphor or symbolism.
This is what Fountain does. Through a train of often gorgeous and fantastic images it explores the way human beings come to terms with the inevitable. Realism in film, or in any medium, is incapable of exploring psychological subjects like this in any depth. Writers and film-makers have always turned to symbolism when dealing with this kind of material.
The film locates the action in three different time frames: one past; one present; and one future - or perhaps this last belongs to a purely symbolic or psychological realm: it's hard to say and is of no importance anyway. Each of the three time-frames tells a fragment of the 'story' and connects to the others through a set of interlocking ideas which constantly deepen in meaning and in emotional power. Together, they create a sense of the universaility of death.
The part of the story which is set in the past is told dramatically. The part set in the present is told realistically. The futuristic sections belong to the realm of pure fantasy. In all three parts the two lovers struggle to cope with her death - she fatalistically and with a belief in rebirth; he, frantically believing death to be final. At no point is the action given much context, and that helps to intensify the film's focus on death itself - its real subject. Through its imagery, Fountain solves the problem it sets for itself, and it does it in a way that is deeply and recognisably human.
If you like a strong plot line or demand realism in a film then I suspect that Fountain is not going to appeal. If, on the other hand, like me, you enjoy a film that achieves its meaning symbolically, and in particular, if you have ever had to go through the emotions that it deals with, then you may find this a very powerful and perhaps recognisable piece of work. At the very least it is moving - the present-time sections directly so - the others, which are told at varying emotional distances, are more poignant or reflective, but always painful.
The camera work is often stunning, the special effects often beautfully wrought, and the sound track is haunting. The acting is generally excellent although there are one or two moments, unfortunately, when it becomes a little trite. While the contemprorary and futuristic scenes are absorbing, some of the historical ones are less succesful. Having said that, they are beautiful, and they don't descend to cliche.
4 of 4 people found the following review helpful
5.0 out of 5 stars A breathtaking super-metafictional trip to the heavens,
Inspector Gadget "Go Go Gadget Reviews" (On the trail of Doctor Claw) - See all my reviews
This review is from: The Fountain [Blu-ray] (Blu-ray)
This is probably the most difficult film to review. The Fountain isn't going to sound like much if I give you just a brief plot synopsis. But I'll give it a go. Tom Creo, a brilliant Doctor, is searching for a cure for cancer. His wife Izzy is dying and his research on monkeys only seems to mysteriously reverse the aging process. The secret ingredient to his new medicine is taken from a magic tree in South America, - the tree of life, or the fountain of youth, whatever you want to call it. As Izzy slips away, Tom becomes intrigued with her unfinished novel The Fountain. It turns out that the novel is about Tom and Izzy's past lives as a Spanish Queen and Captain in South America hundreds of years ago. And the only way Tom can finish the book is if he stays around for the future, when he can literally take the long-dead Izzy into the heavens.
Phew! That sounds disconcertingly strange, but trust me it's an amazing experience. Hugh Jackman and Rachel Weisz are brilliant, delivering multi-layered performances. The dialogue avoids soap opera clichés of dying young and instead is filled with many philosophic double meanings and a lot of undeclared emotions. I could go on for ages about how good it all is from the direction, gorgeous cinematography, beautiful score, flawless storytelling etc. But I think you get the point already.
What The Fountain mostly resembles is the most beautiful, otherworldly dream you've ever had but can barely remember. It's a hypnotic movie filled with moments that will stay with you forever. Just when you think the film has given you all that it has to offer it surprises you with more and more amazing revelations. It also works as a sort of flipside to Cloud Atlas, giving a smaller, more personal take on the human soul and the connections we share for eternity.
Smaller, but no less epic. The Fountain is unique, hypnotic experience.
The Blu-ray is in 1.85:1 1080p which presents the beautiful cinematography perfectly. It was one of the first movies to be released in the format, so the transfer may look a little dated, but it's still wonderful to look at. The DTS HD-MA sound should be cranked up loud for maximum effect. Trust me, you'll love it. There are a decent amount of extras too.
9 of 10 people found the following review helpful
5.0 out of 5 stars Marmite film,
Mr. James G. Bradford - See all my reviews
I was seriously impacted by this film! When I saw this film in the cinema I walked out blinking, not quite sure what had happened and I knew some how I had missed the whole film! So upon release I watched it again, then again, and once 2 times on one day, getting a complete difference of viewpoint and reaction completely! I was fascinated by this, some friends who saw it reacted like it was some trash Lady Ga Ga would pump out, others had profound reactions from it, never in the middle! The music, the ending build up! I needlessly go onto the film website where they have captured those emotional points.
Some said the end was sad, others said it was profound with the relisations of todays culture how " Death is a disease lets stop it" and " Death is the road to AWE" the very duality of this film! Thats reflects usually the reaction of the people too, the ones who enjoy the disease perspective were usually the ones that hated, disliked, or didn't get the film!
The extras on this film are brilliant, the closing down of the studios of its original production then huge downsizing or the story and script to get it made. The 3 different times in the making and on some of the dvds there isn't the interview done by Rachel Weiss to Hugh Jackman which is very interesting indeed!
The soundtrack also has the haunting emotional Philip Glass-like hypnotic effect that is only as clint mansell can do.
2 of 2 people found the following review helpful
4.0 out of 5 stars Beautifully Subtle,
father2 "father2" (England Europe) - See all my reviews
Verified Purchase(What is this?)
This review is from: The Fountain [Blu-ray] (Blu-ray)
Before purchasing this Blu-ray title I realised that this film is a little different from the norm and by all accounts bizarre at times. The technical quality of the film and the Blu-ray are simply superb. Personally I really loved the predominantly dark scenes on Blu-ray HD because the detail was all there, low key beauty.
Both Hugh Jackman & Rachel Weisz acted their roles beautifully and with a touchingly desperate sense of heartbreak at times. But director Darren Aronofsky does expect the audience to often fill in the gaps and leaves much untold, or told in very subtle tones, as the film flits between different times and dimensions.
I have no doubt that most people may have to watch this film half a dozen times before all the pieces slot into place, but that said your dedication will be rewarded. It's not a bad film at all, but it will have a polarizing effect: some will love it and others will fail to see the point at all. Bravo to Darren Aronofsky and his profound vision.
24 of 27 people found the following review helpful
3.0 out of 5 stars Small wonders,
Certainly this film lacks the itchy paranoia of Pi or the hallucinatory / visceral power of Requiem for a Dream. The triptych of stories doesn't always mesh together and accusations of pretension are pretty difficult to deflect. Yet The Fountain contains much to recommend it, not least the sensuous photography that beautifully captures some startling images. But what really works is the relationship between the two leads. There's a real chemistry between Jackman and Weisz that adds an emotional depth to the film that is lacking in Aronofsky's previous outings.
One of those films that will intrigue some, enrapture a few but bewilder many. Worth watching because you may be one of those it enraptures.
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The Fountain [Blu-ray] by Darren Aronofsky (Blu-ray - 2007)
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There's a long-standing belief that you can't really call yourself a car guy until you've lovingly suffered ownership of an Alfa Romeo. Well the... More
1973 Alfa Romeo GTV Coupe '73 Alfa Romeo GTV Coupe, red with black interior, excellent original car, same owner for many years, can be used... More
GR Auto Gallery is pleased to present this 1985 Alfa Romeo Spider Veloce Convertible for purchase. The Italians entered the small roadster market importing... More
1970 Alfa Romeo 1750 Round Tail Spider '70 Alfa Romeo 1750 Round Tail Spider, red with black interior, comes with a soft top frame, sitting... More
1967 Alfa Romeo Duetto '67 Alfa Romeo Duetto, white with black interior, comes with a soft top frame, excellent original car that has been sitting... More


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New York—There were many words from the wise this week, even as many retailers posted misses in net income, sales or … [Read more...]
2015 Merchants Hall of Fame
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Week in Review: Must-See News
New York—News from this week centered for the mightiest and the smallest as well. Nothing in the discount world will seem … [Read more...]
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Deadline for 2015 Merchants Hall of Fame: August 15
There's still time to submit your nominations to firstname.lastname@example.com What's the best way to honor outstanding accessories … [Read more...]
July 31, 2014 -
Week in Review: 10 Things to Know
New York—Already the most important shopping season second only to holiday, Back to School may be better than the last few seasons … [Read more...]
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Submit your nominations to firstname.lastname@example.com What's the best way to honor outstanding accessories merchants? Send in your … [Read more...]
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15 votes
"In It To Win It" Money Bomb! April 15th! Sign up and Pledge NOW!Submitted by Scanty Chunk on Mon, 04/09/2012 - 21:18
Spread this to everyone you know! They are shooting for 2 million +. They need a certain amount of people to pledge to donate.
Trending on the Web
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NOW THAT SANTORUM has dropped
This should be top priority! Let's get this on the front page ASAP, MODS, please!!!
We donate
Submitted by HerewegoHank on Mon, 04/09/2012 - 21:26. Permalink
Ten dollars a day, at least. What do you do?
10 minutes and 31 seconds ago eh?
" In Thee O Lord do I put my trust " ~ Psalm 31:1~


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