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What explains the success of California? Fear of the apocalypse.
Fear of a publishing apocalypse, to be precise. Most of us never would have heard about Edan Lepucki's debut novel, "California," about a post-apocalyptic Golden State, except for a battle between Amazon and book publishers. California's publisher, Hachette, rejected the giant retailer's pricing demands, so Amazon made it more difficult to order Hachette books on its website. Comedian Stephen Colbert protested Amazon's behavior by asking the public to buy a previously obscure Hachette novel: "California."
For all the attention this brought the book, precious little has been said about what's in it. Which is too bad. Because "California" has a lot to say about California — and especially the state of our thinking about how the state might end.
The apocalypse, and what comes after it, is serious business here. Hollywood has minted billions by telling post-apocalyptic stories. Silicon Valley spins happier, "creative" tales of destruction, reveling in its ability to create technologies that wipe out pre-existing industries. We twice elected a governor best known for his performances as a robot from the post-apocalyptic future. More recently, Los Angeles Mayor Eric Garcetti announced a new position, chief resilience officer, to prepare L.A. better for natural disasters and other existential threats.
Perhaps Armageddon requires bureaucratic oversight. But it also requires imagination — at least as much as disaster preparation. And Lepucki's novel is just one of many cultural offerings that suggest that California is losing its edge in post-apocalyptic thinking.
Movies and TV, once reliable for bringing forth new end-of-the-world narratives, are recycling the same tired apocalyptic scenarios: aliens, zombies, robots, nuclear war, mad scientists, oil shortages, climate change, asteroids, viruses, aliens with viruses, and so on. This summer, "Dawn of the Planet of the Apes" — a film sequel to a remake — offers a vision of a collapsing human race overtaken by smart apes building a superior civilization in Marin County. Since Marin residents already are a more advanced form of primate — just ask them — the premise feels derivative, at best.
In its future vision, Lepucki's "California," while beautifully written, feels dated. Her post-apocalyptic world of tomorrow seems driven by fears that come from the California of the 1970s and 1980s: overpopulation (today's state has flat immigration and falling birthrates), food shortages (when cheap, obesity-boosting food is all too available), and crime (despite today's record low crime stats). Lepucki connects those fears to today's hot buttons: climate change, terrorism, and income inequality seem to have wiped out many cities and people. Amid chaos, the main characters leave L.A., cross through the Central Valley, and struggle to survive in what appears to be North State forests.
This post-apocalyptic California has little reliable electricity, no Internet, and no public universities. Governance and politics remains messy (since Lepucki is silent on the question, I'm assuming that Prop 13 has survived the apocalypse), though the public does seem more engaged than it currently is. Someone cares enough about the post-apocalyptic governor's race to kidnap a candidate, then release him after 16 days, naked except for a paper party hat.


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TV and radio appearances by Nation writers and editors, big Nation announcements.
On Sunday, Anthony Weiner's campaign manager quit amid new revelations that Weiner continued to engage in sexually explicit online communications after he resigned from Congress. And while Weiner's imploding candidacy for New York City mayor has made good headlines, the story has been a distraction from the real scandals—increasing inequality, discriminatory policing practices—that must be addressed in this election.
Please support our journalism. Get a digital subscription for just $9.50!
Nation editor Katrina vanden Heuvel joins a panel on ABC's This Week to discuss Weiner's prospects going forward, but also to refocus the debate away from "Carlos Danger" and towards the issues that truly matter to New Yorkers.
—Jake Scobey-Thal
In Defense of Carlos Danger.

subset: commoncrawl


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Comment: Re:Lets kill facebook! Here is how: (Score 1) 314
by robyr (#35125688) Attached to: Internet Is Easy Prey For Governments
I actually like this idea, and if you are serious about possibly setting up a project, get with me. I have some great ideas in this area, and have been thinking about it since the rise of the so-called "Social Media" sites.


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- Introduction
- Ancient Latin literature
- Medieval Latin literature
- Renaissance Latin literature
Satura meant a medley. The word was applied to variety performances introduced, according to Livy, by the Etruscans. Literary satire begins with Ennius, but it was Lucilius who established the genre. After experimenting, he settled on hexameters, thus making them its recognized vehicle. A tendency to break into dialogue may be a vestige of a dramatic element in nonliterary satura. Lucilius used this medium for self-expression, fearlessly criticizing public as well as private conduct. He owed much to the Cynic-Stoic "diatribes" (racy sermons in prose or verse) of Greeks such as Bion; but in extant Hellenistic literature he is most clearly presaged by the fragments of Callimachus' iambs. "Menippean" satire, which descended from the Greek prototype of Menippus of Gadara and mingled prose and verse, was introduced to Rome by Varro.
Horace saw that satire was still awaiting improvement: Lucilius had been an uncouth versifier. Satires I, 1–3 are essays in the Lucilian manner. But Horace's nature was to laugh, not to flay, and his incidental butts were either insignificant or dead. He came to appreciate that the real point about Lucilius was not his denunciations but his self-revelation. This encouraged him to talk about himself. In Satires II he developed in parts the satire of moral diatribe presaging Juvenal. His successor Persius blended Lucilius, Horace, diatribe, and mime into pungent sermons in verse. The great declaimer was Juvenal, who fixed the idea of satire for posterity. Gone was the personal approach of Lucilius and Horace. His anger may at times have been cultivated for effect, but his epigrammatic power and brilliant eye for detail make him a great poet.
The younger Seneca's Apocolocyntosis was a medley of prose and verse, but its pitiless skit on the deification of the emperor Claudius was Lucilian satire. The Satyricon of Petronius is also Menippean inasmuch as it contains varied digressions and occasional verse; essentially, however, it comes under fiction.
With Lucilian satire may be classed the fables of Augustus' freedman Phaedrus, the Roman Aesop, whose beast fables include contemporary allusions.
Iambic, lyric, and epigram
The short poems of Catullus were called by himself nugae ("trifles"). They vary remarkably in mood and intention, and he uses iambic metre normally associated with invective not only for his abuse of Caesar and Pompey but also for his tender homecoming to Sirmio. Catullus alone used the hendecasyllable, the metre of skits and lampoons, as a medium for love poetry.
Horace was a pioneer. In his Epodes he used iambic verse to express devotion to Maecenas and for brutal invective in the manner of the Greek poet Archilochus. But his primary aim was to create literature, whereas his models had been venting their feelings. In the Odes he adapted other Greek metres and claimed immortality for introducing early Greek lyric to Latin. The Odes rarely show the passion now associated with lyric but are marked by elegance, dignity, and studied perfectionism.
Martial went back to Catullus for his metres and his often obscene wit. He fixed the notion of epigram for posterity by making it characteristically pointed.
The elegiac couplet of hexameter and pentameter (verse line of five feet) was taken over by Catullus, who broke with tradition by filling elegy with personal emotion. One of his most intense poems in this metre, about Lesbia, extends to 26 lines; another is a long poem of involved design in which the fabled love of Laodameia for Protesilaus is incidentally used as a paradigm. These two poems make him the inventor of the "subjective" love elegy dealing with the poet's own passion. Gallus, whose work is lost, established the genre; Tibullus and Propertius smoothed out the metre.
Propertius' first book is still Catullan in that it seems genuinely inspired by his passion for Cynthia: the involvement of Tibullus is less certain. Later, Propertius grew more interested in manipulating literary conventions. Tibullus' elegy is constructed of sections of placid couplets with subtle transitions. These two poets established the convention of the "soft poet," valiant only in the campaigns of love, immortalized through them and the Muses. Propertius was at first impervious to Augustan ideals, glorying in his abject slavery to love and his naughtiness (nequitia), though later he became acclimatized to Maecenas' circle.
Tibullus, a lover of peace, country life, and old religious customs, had grace and quiet humour. Propertius, too, could be charming, but he was far more. He often wrote impetuously, straining language and associative sequence with passion or irony or sombre imagination.
Ovid's aim was not to unburden his soul but to entertain. In the Amores he is outrageous and amusing in the role adopted from Propertius, his Corinna being probably a fiction. Elegy became his characteristic medium. He carried the couplet of his predecessors to its logical extreme, characterized by parallelism, regular flow and ebb, and a neat wit.
Other language and literary art forms
Rhetoric and oratory
Speaking in the forum and law courts was the essence of a public career at Rome and hence of educational practice. After the 2nd century bc, Greek art affected Latin oratory. The dominant style in Cicero's time was the "Asiatic"—emotional, rhythmical, and ornate. Cicero, Asiatic at first, early learned to tone down his style. Criticized later by the revivers of plain style, he insisted that style should vary with subject. But in public speaking he held that crowds were swayed less by argument than emotion. He was the acknowledged master speaker from 70 bc until his death (43 bc). He expounded the history of Roman oratory in the Brutus and his own methods in the De oratore.
The establishment of monarchy robbed eloquence of its public importance, but rhetoric remained the crown of education. Insofar as this taught boys to marshal material clearly and to express themselves cogently, it performed the function of the modern essay; but insofar as the temptations of applause made it strained and affected, it did harm.
In the De oratore, Cicero had pleaded that an orator's training should be in all liberal arts. Education without rhetoric was inconceivable; but what Cicero was proposing was to graft onto it a complete system of higher education. Quintilian, in his Institutio oratoria, went back to Cicero for inspiration as well as style. Much of that work is conventional, but the first and last books in particular show admirable common sense and humanity; and his work greatly influenced Renaissance education.


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Benefit Remove It Makeup Remover, 177ml
Product information
Oil-free eye makeup remover
Removing your makeup is as important as applying it. Remove it makeup remover! Effectively removes eye makeup, including long-wearing & waterproof formulas, with an oil-free, no-rinse formula.
How to use: Apply Remove It makeup remover to a clean cotton swab to instantly correct mascara or eyeliner mistakes.
- Brand
- Eligible for International Delivery
- Skin Type
- All Types
Brand Story
Once upon a time in a small Indiana town, a baby was born... No, wait a minute... make that two babies. As the identical twins grew, they developed rather peculiar habits.
The one known as Jean wore spaghetti in her hair and used the glowin' behinds of fireflies to create elaborate face paintings. Jane, on the other hand, spent hours counting Raisinettes, biting them in half, then trading the smaller versions to her younger cousins for real-size M&Ms. "Miraculous," said the townsfolk. "Jean has a right brain, Jane has a left... together these two just might do something crazy!"
And they did! In 1976, the Ford twins created a unique San Francisco beauty boutique with a whimsical candy store atmosphere. "Who says makeup has to be serious to be good?" they said. The shop grew famous for delivering quick fixes for every gal's peskiest beauty dilemmas, and with a "double" dose of wackiness mixed with know how, the twins successfully built Benefit Cosmetics into a global beauty brand. The "friskiest luxury brand" now has over 2,000 counters in more than 30 countries.
Jean's daughters and Jane's nieces, Maggie and Annie Ford-Danielson, are Benefit's next generation, brand ambassadors and global trend artists in their own right, eager to infuse the brand with eclectic tastes. The fab four are guaranteed to keep the creative juices flowing, ensuring that Benefit continue to deliver feel-good products for every woman.
Click & collectFree from John Lewis or Waitrose shops for collection tomorrow from 2pm
369 participating John Lewis and Waitrose shops
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Collect + from a local shop from Thursday - postcode exclusions apply for Collect+ deliveries5000+ participating Collect+ shops
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Standard delivery in 5 working days
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- £9.95
International delivery not available
We want you to be happy with your purchase. If you're not, depending on the type of product, you can make free returns in the UK via John Lewis shops, Royal Mail, Collect+, or MyHermes. If you need to arrange collection of large or heavy items, call us on 03456 049 049. For international returns queries, call us on +44 1698 545 454. Find out more about returns.
You'll find returns information on your delivery note. Unless faulty, we'd like you to make your return within 90 days of purchase. Exceptions apply to certain products - find out more about our refund policy.
Q & As
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text:
Showing How Much I Care
Stacey Hayes got her start in the Medical Records Department, but found her home when she took a position as a patient services coordinator in the Addiction Medicine Clinic. For more than 12 years she has helped support and encourage those struggling with the disease of addiction. "Our clinic is like a family," said Stacey. "The patients are part of that family too." Every day she offers a warm welcome and smile when they check in, making sure to listen carefully and remember special details. "It means a lot to remember something a patient says and then ask about it a couple days later. It shows patients you are really listening to them and care about their lives." For Stacey, each patient provides an opportunity to show how much she cares.


text:
Next, you'll be asked to connect with Twitter. Rest assured, we will never send a tweet from your account
without your permission.
We will send you an email with an invite soon.
RT @NickKellet: #Twitter don'ts for newbies 1. No Auto DM's 2. Don't DM if it can be public (don't thank in private) 3. Don't thank & share links to like
Follow @BridiesTyping on Twitter


text: Im going to be putting some larger tires (4") on my summit so im going to gear down. Now flipping the tranny gears is going to greatly reduce my top end even though im putting on bigger tires because the tires are not that much bigger than stock. Its not a huge difference like on the merv. So im wondering if anyone has messed around with this on the summit yet? Im thinking either get a smaller pinion or larger spurr to gear down, or flip the tranny gears and get a slightly larger pinion to make up for some of the loss in top end. I have a 18 tooth pinion now so I think I will take the 16 tooth out and throw that on and flip the gears and see how it drives when I get my tires later this week. Im basicaly looking to keep the same top speed but gear down for the slightly bigger tres. Also I run 3s lipo.


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Prairie Creek Estates Apartments100 Prairie Creek Dr, Brownsville, TN 38012 View On Map
Prairie Creek Estates Subdivision is a 48-unit property located on South Washington Avenue, in Brownsville, Tennessee. The subdivision consists of 48 3 bedroom units containing between 1,145 and 1,250 approximate square feet. Each unit will have a garage, private entry and front and back porch.Each unit is equipped with a stove, vent hood, refrigerator, dishwasher, disposal, microwave oven, central heat and air conditioning, washer and dryer hook-ups and ceiling fans.The exterior is constructed of brick and/or vinyl siding. The property is made up of 24 buildings with 2 units in each building. The property includes a community facility for the exclusive use of the residents. The Prairie Creek Estates Subdivision was built to cater exclusively to large families. The rent structure of the property is governed by the IRS Section 42 rules and is restricted to residents earning at or below 60% of the area median income. Please call for an appointment today.
Prairie Creek Estates is located in Brownsville, TN in the 38012 zip code. View this apartment on a map.
Pricing & Floor Plans
|Floor Plan
|Price Range
3 Bed 2 Bath
|Contact Us
|Check Availability
Office Hours
- Tuesday: 8:00 am - 5:00 pm
- Thursday: 8:00 am - 5:00 pm
Features & Amenities
- Brick and/or vinyl siding
Floor Plan Features & Amenities
- Air Conditioning
- Dishwasher
- Microwave
- Private Patio
- Washer/Dryer Connections
- Balcony
- Disposal
- Patio
- Refrigerator
- Ceiling Fans
- Large Closets
- Private Balcony
- Satellite TV
Maps & Directions
About Us
Professionally Managed By: Ledic Management Group
General Policies
12 months


text:
Property Details
Condo, 3 Bedrooms, 2 Baths, 10 Sleeps
Incredible Ocean Front Penthouse offers breath taking views,
romantic sunsets, local fine dining, entertainment or absolute
relaxation. This massive 2,500sq. ft. 3 bedroom 2 bath, open floor
plan comes fully furnished with modest décor. After an exciting
day at the beach come back to the penthouse and watch the sunset on
our 900sq.ft roof top patio, which offers a bar area, bbq and plenty
of seating when entertaining your guest or simply enjoying a
romantic evening in. When ending your evening step into our private
sauna and wash away your worries. We also have a fully stocked
kitchen with cooking utensils and complete dish set, linens provided
& for your longer stays we have a convenient separate laundry room.
Penthouse allows smoking on the spacious patio deck - No smoking is
permitted within the penthouse. To view the virtual tour email a request.
Recent Review
Photo doesn't do this rental justice!Photo doesn't do this rental justice!
About the Owner
2 Reviews
2 traveler reviews
Photo doesn't do this rental justice!Photo doesn't do this rental justice!
Perfect For Our Large Family!
Activity and Interests
Actives and Attractions include a five minute walk to restaurants,
24hour grocery store/wine deli, Belmont Plaza Swimming Center, wind
surf center, water taxis, exciting night life, Belmont Fishing
Pier. A 3 minute walk to beach, fishing...1 minute walk to catch
the local bus to the heart of Belmont Shores, downtown Long
Beach/Queen Mary/Aquarium of the Pacific/Performing Arts Center and
Catalina Express Terminals...10-20 min to 3 Freeways...15-45 min to
3 International Airports.
We hope to make your trip completely memorable and enjoyable.
Contact us today with your desired dates and party details and we
will get started on your booking right away.
Rental rates
- Weekly Rate: $2250 - $3000
Monthly Rate: $3500 - $5500
The Penthouse is available YEAR ROUND
Weekley Rates
$2,250 (October 1st - May 1st)
$2,550 (May 2nd - September 30th)
Also, "Grand Prix Special" 3 days 2 nights $1,500.
RENTAL FEES: 50% of the balance is required and due within 5 days of
the verbal agreement
Balance paid in full in advance
$250 Non-Refundable Cleaning fee.
Security Deposit $500 - refundable upon inspection.
- 12
- Available
- 12
- Unavailable
- 12
- Today
Property Type
- condo
- Adventure
- Family
- Romantic
- pets not allowed
Location Type
- Beach View
- 2 Bathrooms
- Bathroom 1
- Bathroom 2
- 3 Bedrooms, Sleeps 10
- Bedroom 1
- Bedroom 2
- Bedroom 3
- From the penthouse you are a short drive away from Southern California's most popular destinations; just 25 minutes to Disneyland, 35 minutes to Downtown Los Angeles. 1 Queen bed2 Twin (bunkbed) 1 Twin Daybed with 1 Twin pull out trundle underneath 1 pull-out full size sofa bed Portable cribs and inflatble matresses available upon request 52" Big Screen TV Fully equipped kitchen w/ microwave, blender Linens, towels, wash clothes, etc. Outdoor BBQ grill 2 Unique Fireplaces Beach chairs Large supply of beach towels Washer and dryer


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Non-typeable Haemophilus influenzae (NTHi) and Streptococcus pneumoniae are major causes of bacterial acute otitis media (AOM). Data regarding AOM are limited in Latin America. This is the first active surveillance in a private setting in Venezuela to characterize the bacterial etiology of AOM in children < 5 years of age.
Between December 2008 and December 2009, 91 AOM episodes (including sporadic, recurrent and treatment failures) were studied in 87 children enrolled into a medical center in Caracas, Venezuela. Middle ear fluid samples were collected either by tympanocentesis or spontaneous otorrhea swab sampling method. Standard laboratory and microbiological techniques were used to identify bacteria and test for antimicrobial resistance. The results were interpreted according to Clinical Laboratory Standards Institute (CLSI) 2009 for non-meningitis isolates. All statistical analyses were performed using SAS 9.1 and Microsoft Excel (for graphical purposes).
Overall, bacteria were cultured from 69.2% (63 of the 91 episodes); at least one pathogen (S. pneumoniae, H. influenzae, S. pyogenes or M. catarrhalis) was cultured from 65.9% (60/91) of episodes. H. influenzae (55.5%; 35/63 episodes) and S. pneumoniae (34.9%; 22/63 episodes) were the most frequently reported bacteria. Among H. influenzae isolates, 62.9% (22/35 episodes) were non-capsulated (NTHi) and 31.4% (11/35 episodes) were capsulated including types d, a, c and f, across all age groups. Low antibiotic resistance for H. influenzae was observed to amoxicillin/ampicillin (5.7%; 2/35 samples). NTHi was isolated in four of the six H. influenzae positive samples (66.7%) from recurrent episodes.
We found H. influenzae and S. pneumoniae to be the main pathogens causing AOM in Venezuela. Pneumococcal conjugate vaccines with efficacy against these bacterial pathogens may have the potential to maximize protection against AOM.
Keywords:Acute otitis media; Non-typeable Haemophilus influenzae (NTHi); Pneumococcal conjugate vaccine
Acute otitis media (AOM) is one of the most frequently diagnosed bacterial infections in children following nasopharyngeal colonization [1]. It results in frequent pediatric visits both in the developed [2] and developing world [3]. Approximately, three in four children develop at least one episode of AOM by 3 years of age, [4] with peak incidences observed among 6-18 month-old children [2]. A report on the epidemiology of AOM by Block and colleagues [5] showed that 64% of children had experienced their first episode by 6 months, and 86% by 1 year of age; 31% had > 3 episodes in < 12 months of age. AOM is, thus, one of the main causes of childhood morbidity in both developed and developing countries [6]. The estimated annual disease burden of AOM ranges between 8,200,000-12,900,000 cases among children < 5 years of age in Latin America and the Caribbean [7]. In Venezuela, approximately 100,000-130,000 AOM cases per year (2004-2007) are reported in children < 5 years of age (Ministerio del Poder Popular para la Salud. Gobierno Bolivariano de Venezuela, Personal communication, 2010).
AOM is a multi-pathogen disease [8]. Streptococcus pneumoniae (S. pneumoniae) and non-typeable Haemophilus influenzae (NTHi) have consistently been reported as the two major bacterial pathogens responsible for AOM, [9-11] identified in up to 80% of cases. Other regularly reported bacterial pathogens include Moraxella catarrhalis (M. catarrhalis) and Streptococcus pyogenes (S. pyogenes) [11]. S. pneumoniae has been shown to be responsible for 43.8%-61.4% of all bacterial AOM cases in Latin America [12-14]. H. influenzae has, however, emerged as the most frequently recovered bacterial pathogen in recent studies [13,15]. AOM caused by NTHi has been particularly associated with older age groups and recurrent disease [11]. Recurrent to chronic AOM may predispose to chronic suppurative otitis media (CSOM) in a third of cases [16]. Globally, 65-330 million people may suffer from CSOM [17].
Recurrent disease in children has important implications for AOM treatment. Although some cases resolve spontaneously, the majority require antibiotic treatment for early recovery. AOM constitutes the primary motive for the prescription of antibiotics in children [18]. The increasing use of these antibiotics may be acting as a selective pressure driving antibiotic resistance [19]. AOM is the primary cause of antibiotic consumption in Latin America and the Caribbean [20]. Antibiotic consumption in Latin America is highest in Argentina and Venezuela [21]. High prevalence of drug-resistant pathogens like penicillin-resistant S. pneumoniae and β-lactamase producing or other ampicillin-resistant H. influenzae have become major factors in complicating the management of AOM [22]. Efforts to prevent infectious diseases through vaccination may be able to reduce the demand for antibiotics in the community and the selective persistence of nasopharyngeal bacterial pathogens [23].
Pneumoccocal conjugate vaccines (PCVs) have been shown to be safe and effective in preventing invasive pneumococcal disease (IPD) in children [24,25]. The 7-valent pneumococcal vaccine (PCV-7; Prevnar™/Prevenar™, Pfizer/Wyeth, US) was introduced into the US public immunization strategy in 2000 and has demonstrated noticeable efficacy against IPD [26,27]; 57% (95%CI: 44-67) efficacy against vaccine-type pneumococcal AOM [28] and overall 7% (95%CI: 4.1-9.7) efficacy against clinical AOM episodes [24]. Wide use of PCV-7 led to a relative shift in the proportion of pathogens causing persistent AOM was observed (decrease in S. pneumoniae and an increasing predominance of NTHi) [10]. Furthermore, with widespread vaccination, the predominant cause of remaining cases of pneumococcal disease became non-vaccine serotypes of S. pneumoniae [29,30], due to changing antimicrobial resistance patterns and secular trends. There are two new PCVs licensed recently in Venezuela. The 10-valent pneumococcal/H. influenzae protein D conjugated vaccine (PHiD-CV, Synflorix™, GlaxoSmithKline [GSK] Biologicals, Rixensart, Belgium) has 8 of the 10 serotypes conjugated to a recombinant form of protein D of H. influenzae. A randomized, double-blind study with an 11-valent prototype vaccine relying on the protein D carrier provides evidence that proteinD-containing vaccines may offer additional protection (35%) against AOM episodes caused by both pneumococcus and H. influenzae [31]. A 13-valent pneumococcal vaccine formulation (PCV-13) is also available.
In Venezuela, Haemophilus influenzae type B was introduced into the expanded program of immunization in 2000 [32]. Pneumoccocal conjugate vaccines are not indicated for universal vaccination, however since 2004, PCV-7 has been gradually introduced into private practice. Data on AOM in Latin America are limited and no there are no data on AOM etiology in Venezuela. This study thus provides novel data on the bacterial etiology of AOM and the associated serotypes in Venezuelan children. This study assessed the microbiology of AOM cases, antibiotic susceptibility pattern of the middle ear pathogens obtained from these cases, and the proportion of AOM episodes that may be vaccine-preventable with new pneumococcal vaccines recently licensed.
Study design and subjects
We conducted a prospective epidemiological study within a routine, private clinical setting in a medical center in Caracas, Venezuela from December 2008 to December 2009. Children ≥3 months and < 5 years of age, visiting physician/pediatrician clinics for AOM and for whom a MEF sample was available, were enrolled in the study. We included children presenting with one of the general signs of otalgia/irritability, conjunctivitis, fever and either Paradise's criteria (bulging, diffused or localized inflamed tympanic membranes) or spontaneous otorrhea (< 24 h). Exclusion criteria included: children hospitalized at the time of the diagnosis or treatment of AOM, presenting with a new episode of AOM but having received antibiotic treatment in the previous 72 h for a different illness, those who had received antibiotic by the physician/ear, nose and throat (ENT) specialist prior to tympanocentesis and those with otorrhea for > 24 h or with otitis media with effusion (not AOM).
Two specific groups of children were eligible for study recruitment: - Children with a new episode of AOM (< 72 h of onset) who were yet to receive antibiotic therapy for the episode, and - Children with a diagnosis of AOM within 48-72 h before study enrolment, who had received antibiotic therapy, but remained symptomatic at the time of study entry (treatment failures).
A child could be enrolled multiple times in the study whenever he/she reported a new episode. A case was considered as a new episode if there was a 30-day symptom-free interval since the resolution of the first episode. A recurrent AOM episode was the third or greater new episode within the last 6 months or the fourth or greater new episode within the last 12 months.
The primary endpoints were occurrence of H. influenzae, S. pneumoniae, M. catarrhalis and S. pyogenes isolated from MEF samples. Secondary endpoints were occurrence of H. influenzae and S. pneumoniae specific serotypes from MEF samples and antimicrobial susceptibility of all bacterial pathogens isolated from MEF samples.
Written informed consent was obtained from the parents/guardians of participating children before conducting any study-related procedures. We collected demographic information including age and sex assuring confidentiality for subjects enrolled.
Bacterial identification and characterization
Samples of MEF from all children were collected by an ENT specialist by performing tympanocentesis or by careful sampling of spontaneous otorrhoea (removal and cleaning of the ear canal material and deep aspiration of the MEF material via needle insertion).
MEF samples were inoculated into Amies transport medium with charcoal [33], sent to the study laboratory (Laboratorio Metropolitano) within 16-48 h, inoculated onto chocolate and blood agar and incubated at 37°C in a 5% CO2 atmosphere. For identification, standard guidelines described by the American Society of Microbiology were used and confirmed by using NH and GP cards VITEK-2 compact system (bioMérieux™).
Clinical feature
A detailed medical history including symptoms, seasonality, vaccination status for PCV and HiB, AOM episodes characteristics including recurrency, A clinical examination was performed recording all data in the study database.
Antibacterial susceptibility
Antimicrobial susceptibility was done using AST-P68 (bioMérieux™) for S. pneumoniae, standard methods for H. influenzae and M. catarrhalis were according to Clinical Laboratory Standards Institute (CLSI-M100-S19) 2009 and for quality control, S. pneumoniae ATCC 49619 and H. influenzae ATCC 49247 y 49766 [34] strains were used. Serotyping for S. pneumoniae was done at the national reference laboratory, Laboratorio de Microbiologia del Instituto Nacional de Higiene "Rafael Rangel" using Quellung reaction following SIREVA II guidelines [35]. H. influenzae isolates were confirmed by polymerase chain reaction (PCR) procedures and β-lactamase testing (nitrocefin disk) was performed.
Statistical analyses
We performed the analyses only on the ATP cohort (subjects meeting all eligibility criteria, complying with the protocol-defined procedures, with no elimination criteria during the study and for whom laboratory results of the MEF samples was available). The study results were presented as episodes of AOM.
We calculated the proportions of AOM caused by S. pneumoniae, H. influenzae and other bacterial pathogens. Distribution analyses of S. pneumoniae and H. influenzae serotypes by age, procedure and pneumococcal vaccination status according to age (fully vaccinated, partially vaccinated and unvaccinated) for AOM cases were performed. We also determined seasonality of AOM cases and other isolates. Qualitative variables, including symptoms and vaccination, were compared to explore differences among capsulated and non capsulated H. influenzae status with the Fisher exact test. All tests were 2 sided, and the level of significance was set at p < 0.05.
All statistical analyses were performed using Statistical Analysis System (SAS) version 9.1 (or higher) and Microsoft Excel (for graphical purposes).
The study was conducted according to Good Clinical Practice guidelines, the Declaration of Helsinki and the local rules and regulations of the country. All the study-related documents were reviewed and approved by the local Independent Ethics Committee/Institutional Review Board and the study adhered to applicable local guidelines.
Demographic characteristics and sample description
We collected data on 92 episodes of AOM reported from 87 enrolled children. Ninety-one episodes were retained in the ATP (according-to-protocol) cohort due to one child being enrolled more than once for the same AOM episode. Only one of these episodes was classified as a treatment failure. Of the 87 children included in the ATP cohort, 84 reported a single episode, two reported two episodes and one child reported three episodes. Any consecutive episode occurred with an interval of > 30 days after the previous episode.
The mean age of the children for all episodes was 28.3 months; the proportion of females was 51.6% (47/91 episodes) (Additional file 1: Table S1).
Additional file 1. Table S1. Demographic characteristics with bacterial etiology of episodes by age and gender (ATP Cohort).
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The majority of the episodes (57.2%; 52/91) were reported in the 1-3 years age group; 30.8% (28/91 episodes) and 26.4% (24/91 episodes) occurred in the 12-23 months and 24-35 months age groups, respectively.
We collected one MEF (middle ear fluid) sample from each of the 91 episodes. Most samples (90.1%; 82/91 episodes) were collected by tympanocentesis, while nine samples (9.9%) were collected from spontaneous otorrhea episodes. Of the nine episodes with spontaneous otorrhea, 18.2% (2/11), 17.9% (5/28) and 8.3% (2/24) were distributed in the 3-11 months, 12-23 months and 24-35 months age groups, respectively.
Bacterial etiology of episodes
We observed pathogenic bacterial growth in 67.1% (55/82 episodes) and 88.9% (8/9 episodes) of samples collected by tympanocentesis and spontaneous otorrhoea, respectively. Overall, bacteria were cultured from 69.2% (63) of the 91 episodes; one treatment failure episode of AOM did not show any bacterial growth. Overall, 65.9% (60) of the episodes yielded positive cultures for at least one of the four pathogenic bacteria. The most commonly isolated bacteria among MEF samples with bacterial growth were H. influenzae and S. pneumoniae, detected in 55.5% (35/63) and 34.9% (22/63) of episodes, respectively. Only 3.2% (2/63) episodes were positive for S. pyogenes, and 1.6% (1/63 episodes) for M. catarrhalis. No single episode was positive for both S. pneumoniae and H. influenzae.
The highest number of positive episodes for at least one of the four pathogenic bacteria under study was in the 3-11 months age group (72.7%; 8/11 episodes); the lowest number of positive episodes was found in the 24-35 months age group (58.3%; 14/24 episodes). The most frequently isolated bacteria across all age groups were H. influenzae and S. pneumoniae (Figure 1).
Figure 1. Bacterial etiology of episodes by age (ATP Cohort). The simple bars represent the percentage of bacterial episodes in each age group.
Among episodes with spontaneous otorrhea, S. pneumoniae was isolated in three episodes, S. pyogenes in two, H. influenzae in one episode; the remaining two episodes corresponded to other agents.
Recurrent AOM episodes were reported for 5.4% (14/91 episodes) during the study. We obtained bacterial cultures from samples from 71.4% (10/14) of these recurrent episodes. Of these, 6/10 were positive for H. influenzae; 3/10 for S. pneumoniae and 1/10 was positive for M. catarrhalis.
Bacterial etiology by serotype
Most H. influenzae strains were non-capsulated (NTHi: 62.9%; 22/35 episodes). This was followed by serotype d (17.1%; 6/35 episodes), a and c (each accounting for 5.7%; 2/35 episodes), and f (2.9%; 1/35 episodes). Two samples (5.7%; 2/35 episodes) were reported as unknown serotype.
Serotype 19A was the most frequently isolated S. pneumoniae serotype (40.9%; 9/22 episodes) followed by serotypes 6A, 11 and 15 (each accounting for 9.1%; 2/22 episodes), and 23 F and 7 C (each accounting for 4.5%; 1/22 episodes). Five samples (22.7%; 5/22 episodes) were reported as unknown (Figure 2).
Figure 2. Bacterial etiology by serotypes (ATP Cohort). The stacked column bars represent the number of serotypes for each bacterial positive episode.
A similar trend of serotype distribution was observed across the age groups for both H. influenzae and S. pneumoniae.
Of the six H. influenzae positive samples from recurrent episodes, NTHi was isolated in four samples (66.7%; 4/6 samples). The remaining two samples corresponded to types c and a. The three S. pneumoniae positive samples from recurrent episodes corresponded to serotypes 7 C, 23 F and one was reported as unknown. Of the 14 recurrent AOM episodes, the highest numbers of episodes were reported in the 24-35 months and 36-47 months age groups (5 episodes each); three episodes were reported in the 12-23 months and one episode in the 3-11 months age groups.
Common symptoms reported
Fever (65.9%; 60/91 episodes) and ear pain (57.1%; 52/91 episodes) were the most common symptoms reported before the study visit and also during the study visit (49.5%; 45/91 episodes and 56%; 51/91 episodes, for fever and ear pain respectively). We did not observe significant differences between capsulated and non-capsulated H. influenzae for fever (68.2% vs. 72.7%; p = 0.78) and pain (45.5% vs. 54.5%; p = 0.62).
Seasonal distribution of bacterial etiology of episodes
AOM episodes occurred throughout the year; the highest numbers of episodes were recorded for children enrolled in 2009 (July: 14 episodes; March: 10 episodes). The highest number of H. influenzae positive episodes was in children enrolled in April and July (14.3% each; 5/35 episodes). At least one S. pneumoniae positive episode was reported for most months of the year - between January and April, and July and December, inclusive, the highest number of episodes being enrolled in July (22.7%; 5/22 episodes) (Figure 3).
Figure 3. Seasonal distribution of AOM episodes (ATP Cohort). The blue stacked line graph shows the number of AOM episodes enrolled in each month and the simple bar graph shows the number of H. influenzae and S. pneumoniae episodes isolated each month.
Vaccination status
About 80.2% (73/91 episodes) of episodes occurred in children who received at least one dose of the PCV-7. About 97.1% (34/35) subjects testing positive for H. influenzae received at least one H. influenzae type b vaccine dose.
The percentage of episodes with positive cultures for at least one of the four study bacteriawas 69.6% (32/46 episodes) in fully vaccinated children, 63% (17/27 episodes) in partially vaccinated and 57.1% (8/14 episodes) in unvaccinated children.
More specifically for S. pneumoniae, the percentage of culture positive episodes was 30.3% (10/33 episodes), 35.3% (6/17 episodes) and 40.0% (4/10 episodes) in the fully vaccinated, partially vaccinated and unvaccinated children, respectively. The percentage of H. influenzae culture positive episodes were 63.6% (21/33 episodes) in the fully vaccinated children, 52.9% (9/17 episodes) in partially vaccinated and 40.0% (4/10 episodes) in unvaccinated children, respectively. We did not find significant differences between capsulated and non-capsulated H. influenzae or between fully vaccinated and partially/unvaccinated groups (p = 0.38).
Antibacterial susceptibility
Among the 35 H. influenzae positive samples, 94.3% (33/35) were sensitive to amoxicillin/ampicillin, 5.7% (2/35) were resistant to amoxicillin/ampicillin and 2.9% (1/35) showed intermediate resistance to cefuroxime. 25.7% (9/35) samples showed resistance to trimethoprim/sulfamethoxazole. The two isolates resistant to amoxicillin/ampicillin and susceptible to amoxicillin/clavulanate were tested for β-lactamase activity with positive results (n = 2).
Among the 22 S. pneumoniae positive samples, 77.3% (17/22) were sensitive, 18.2% (4/22) and 4.5% (1/22) of samples were intermediate and resistant to penicillin, respectively (Figure 4). All S. pneumoniae isolates tested except three were sensitive to amoxicillin and ampicillin (86.4%; 19/22). Erythromycin resistance was reported in 33.3% (7/22) samples; 35% (7/22) of samples were resistant to tetracycline and 45.5% (10/22) to trimethoprim/sulfamethoxazole.
Figure 4. Penicillin resistance for S. pneumoniae isolates (ATP Cohort). Susceptibility of each S. pneumoniae serotype to penicillin for categories viz; sensitive, intermediate and resistant.
Of the nine samples positive for S. pneumoniae serotype 19A, 77.8% (7/9) were sensitive to penicillin and intermediate resistance was observed for 22.2% (2/9) samples. No resistance to penicillin was noted for this serotype. No antibiotic resistance was observed to cefotaxime, chloramphenicol or levofloxacin.
This is the first study to investigate the bacterial etiology of AOM in a private setting in Venezuela. Our findings are novel in that we identified non-capsulated and capsulated H. influenzae as the main pathogens causing AOM in Venezuela. Among the episodes reported,H. influenzae (55.5%) and S. pneumoniae (34.9%) were the most commonly isolated bacteria. This is in-line with other studies who have reported these bacteria to be frequently isolated in other Latin American countries including Argentina [36], Chile [13], Costa Rica [12,37], Mexico [38] and Colombia [39]. Following the introduction of PCV-7 and the inclusion of the vaccine into the universal immunization program in the United States, a significant decrease in the proportion of S. pneumoniae and an increase in H. influenzae proportion among MEF isolates have been reported (2003-2006) [40]. A similar pattern was observed in the present study and has been observed in previous studies [10,41] following introduction of the PCV. An increase in the occurrence of non-PCV-7 S. pneumoniae serotypes has also been described previously [42].
In the current analysis, we show that H. influenzae isolated in Venezuelan children was most commonly NTHi (62.9%). NTHi has previously been reported to be associated with a history of recurrent AOM episodes, treatment failure and AOM within two weeks of completing a course of any antibiotic [43]. The high prevalence of NTHi in this private setting could be explained by the fact that vaccine coverage for PCV was considerably high (63.6%). In this previous study, the authors showed that NTHi was not only the most prevalent cause of recurrent episodes of AOM but also of new cases and was detected across all age groups [44]. This finding differs from earlier reports of NTHi in children 2 years or older [11]. In our present study, most of the episodes we reported were in children younger than 24 months; NTHi was the most prevalent type among all age groups, including 3-11 month olds, who showed an equal distribution with S. pneumoniae.
We also report the isolation of capsulated H. influenzae including types d, c, a and f, which has not been reported previously. These were not only isolated in all age groups, but also reported in recurrent episodes. In a recent systematic review for Latin America, capsulated types were not confirmed in MEF samples from AOM etiology studies except for b type. This was also consistent with the results from other studies in Europe, such as France, where H. influenzae isolates were identified as NTHi. This could be explained by the fact that nasopharyngeal colonization of encapsulated H influenzae is uncommon, occurring only in 2-5% of children [45,46]
We found serotype 19A to be the most commonly isolated S. pneumoniae serotype (40.9%) from children who were fully vaccinated with the PCV, suggesting that PCV-7 vaccination does not offer a high level of cross-protection against 19A. Recently, in the US and other countries the non-vaccine serotype 19A has been associated with an increase in the proportions of IPD and AOM [10,26,28,41,47]. Other less commonly found bacterial pathogens in this present study were S. pyogenes (2.2%) and M. catarrhalis (1.1%), similar to other studies [36,48].
We observed a seasonal pattern of AOM in the present study that was similar to that observed in a recent study in Colombia [39]. We found that AOM episodes were reported throughout the year, with the highest number of episodes reported in July, corresponding to the rainy season in Venezuela.
An increased use of antibiotics has been observed in Latin American countries, predominantly in Venezuela [21]. Antibiotic resistance to S. pneumoniae and H. influenzae has become a serious public health issue, more so in Latin America due to increased S. pneumoniae resistance to penicillin and other antibiotics [7]. Seven of nine S. pneumoniae 19A isolates were sensitive to penicillin in our study, highlighting the low prevalence of penicillin-resistant serotype 19A. In the H. influenzae isolates reported, 25.7% were resistant to trimethoprim-sulfamethoxazole and 5.7% to amoxicillin/ampicillin. We did not observe antibiotic resistance to amoxicillin/clavulanate, cefotaxime, chloramphenicol and tetracycline. A limited occurrence of amoxicillin resistance has been previously detected in another multinational study [49]. Hence, amoxicillin and amoxicillin/clavulanate continue to be considered as appropriate treatment options for AOM in children [50]. Reducing antibiotic use by maximizing vaccination uptake may be a useful strategy to eradicate antibiotic-resistant serotypes.
PCVs could be an important tool in reducing the AOM burden. Besides offering protection against the vaccine serotypes, previous studies suggest that PCV7-CRM provides cross-protection against the non-vaccine serotype 6A for IPD and AOM [28,51] and that PCVs with different conjugation methods or carrier proteins may provide modest (though non-significant) protection against 19A disease [52]. Antibiotic resistance and selection pressures are also likely to have an impact on the efficacy of PCVs. Vaccines that may protect against non-capsulated and capsulated H. influenzae serotypes may also play an important role to reduce the number of AOM episodes. Efficacies of 35.6% and 35.3% have previously been shown [31] against all H. influenzae and NTHi otitis media episodes with a prototype pneumococcal vaccine conjugated to the H influenzae protein D. This protein is present in capsulated and non-capsulated isolates and hence may potentially protect against AOM episodes caused by these agents. The proportions of pathogens causing AOM and potentially targeted by each vaccine formulation would be 55% for PHiD-CV and 19% for PCV-13. However, it is important to note that no efficacy or effectiveness data exist for either formulation. Additionally, previous studies with the precursor vaccines (PCV-7; 11-valent pneumococcal protein D conjugate PHiD-CV predecessor vaccine) have demonstrated efficacy of < 100% against the targeted pathogens [28,31]. The precise magnitude of protection is therefore unknown.
This study is limited by a small sample size which affects the precision of the estimates. In addition, the enrolled children were recruited from a private center and thus may not truly represent the Venezuelan population. This is particularly important given the potential differences in exposure and risk factors for otitis media across the country.
In summary, this was the first active surveillance for AOM etiology in Venezuela in a private setting in a highly PCV vaccinated population. NTHi was the most prevalent etiological agent, suggesting that protection against NTHi is crucial for AOM prevention. Reduced antibiotic use and vaccine with efficacy against H. influenzae (beyond type b) and S. pneumoniae could be effective strategies for preventing AOM disease among children in Venezuela.
AOM: acute otitis media; ATP: according-to-protocol; CI: confidence interval; CLSI: Clinical and Laboratory Standards Institute; CSOM: chronic suppurative otitis media; ENT: Ear: nose: throat; GSK: GlaxoSmithKline; H. influenzae: Haemophilus influenzae; IPD: invasive pneumococcal disease; M. catarrhalis: Moraxella catarrhalis; MEF: middle ear fluid; NTHi: Non-typeable Haemophilus influenzae; PCR: polymerase chain reaction; PCV: pneumococcal conjugate vaccine; PHiD-CV: pneumococcal non-typeable Haemophilus influenzae protein-D conjugate vaccine; S. aureus: Staphylococcus aureus; S. pneumoniae: Streptococcus pneumoniae; S. pyogenes: Streptococcus pyogenes; SAS: Statistical Analysis System
Competing interests
LN and JAS received honoraria/paid expert testimony/travel grants from the commercial entity that sponsored the study.
MMC, RDA, EO-B and REC are employees of GlaxoSmithKline Biologicals.
EOB and REC have stock ownership; MMC, and RDA have stock options.
FS, AC, ES, NR, OA, FB and NM: No conflict.
Authors' contributions
LN and JAS were involved in all processes related to enrolling patients, contributed to study design, interpretation of data, review and comments on all drafts of this paper and gave final approval to submit for publication. FS was the ENT who performed all tympanoscentesis, interpretation of data, review and comments on all drafts of this paper and gave final approval to submit for publication. AC, ES, NR, OA, FB and NM, worked actively in isolation and serotyping all samples, interpretation of data, review and comments on all drafts of this paper and gave final approval to submit for publication. RDA, EOB, REC and MMC contributed to study design, interpretation of data, review and comments on all drafts of this paper and gave final approval to submit for publication.
Financial support was provided by GlaxoSmithKline, Inc. GSK (Latin America). The authors would like to thank the infants and their families for participating in this study. They also wish to thank Dr. Elizabeth Paradzik and Yorane González for providing their expertise as ENT specialists, Dr. Zaira Ron for study coordination, to all pediatricians from Policlínica Metropolitana for referring subjects for this study, and the GSK CARICAM team (Marianela Rojas, Helena Guerra and Diana Campo) for contributing and supporting the co-ordination and monitoring activities for this study. The authors would also like to acknowledge Mohammed Najeeb Ashraf for providing technical assistance in the preparation of this manuscript, Dr. Camilo Moreno and Jessica Mattos for management and coordination of this publication and Gunasekaran Ramakrishnan for helping with the statistical analysis (all employed by GSK Biologicals).
Synflorix is a trademark of the GlaxoSmithKline group of companies; Prevnar/Prevenar is a trademark of Pfizer/Wyeth, USA.
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Lawyers hoping to resurrect a decade-old securities class action against Pfizer Inc. will make their case to the Second Circuit on Tuesday.
Arnold & Porter's Lisa Blatt didn't fare any better than White & Case in fending off New York's efforts to block a "forced switch" to a new version of Actavis' Alzheimer's drug Namenda.
After wresting billions from Wall Street, the departing New York regulator is steering clear of the big law firms that cater to the banking industry. But whether he remains in private practice or shoots for public office, it's a good bet we'll all be hearing from him again.
The two Skadden transactional lawyers advised Endo Pharmaceuticals on its $8.05 billion buy of generic drug maker Par Pharmaceuticals from private equity firm TPG Capital.
A rundown of the key figures in the Dewey trial.
Gregory W. Sutton joined Montgomery McCracken Walker & Rhoads as a partner in the Philadelphia office.
CMO Bill Piwonka says the company's focus is on e-discovery and investment in products.
Subrogation Complaint Dismissal on Collateral Estoppel Grounds Should Have Been Denied
Complaint Facially Sufficient; Constitutional Challenge Rejected, Dismissal Denied
Stark & Stark announces that Jeffrey Hall has joined the firm as a partner in the Lawrenceville office.
A civil rights case over a raid on a Florida barbershop has settled for $125,000, leaving unresolved a federal appeals question about whether law enforcement officers can be liable for constitutional violations committed by other officers.


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Medicare at 40: Midlife Crises Threaten Successful Program
Aging Baby Boomers, rising costs will stretch its resources, experts say
On July 30, 1965, Lyndon Johnson was still savoring his landslide election as president, and he drew upon that broad support to sign an ambitious public health-care plan called Medicare into law.
But the battle to create the program "was intensely fought, and it didn't pass by a wide margin," said Karen Davis, president of the Commonwealth Fund, an independent research foundation focused on health and social issues.
Conservatives in the South opposed the program because it meant the end of racial segregation in hospitals, and the American Medical Association fought it because many doctors worried Medicare would impinge on physician autonomy, she said.
"Medicare's number-one goal was to provide financial protection to elderly people and their adult children," Davis said. Before Medicare, many newly retired Americans found themselves both uninsured and uninsurable after losing their employer-based health coverage.
"The potential of being wiped out financially by any kind of hospitalization was very real," Davis said. "Not only wiping out the assets of the elderly, but also those of their children, who of course felt like they had to help pay those bills."
Now, 40 years later, most experts — and Medicare beneficiaries — agree the program has succeeded in meeting its goals. In fact, Davis pointed to one 2003 Commonwealth Fund survey that found that the bulk of the 42 million Americans covered by Medicare were actually more satisfied with their coverage than younger people insured through the private sector.
"They are much more likely to say that they get care when they need it and are much less likely to report having to change their way of life because of medical bills," she said.
John Rother, director of policy and strategy at AARP, agreed that "Medicare has really achieved what it set out to do." And he believes all players have benefited, with the program "providing a stable source of financing to doctors, hospitals and other health-care providers."
That's not to say Medicare can't be improved or doesn't face serious challenges ahead.
"Ultimately, we're going to have twice as many people in the program when the Baby Boomers retire as we do today," Rother pointed out. "We're going to have to find some source of revenue to finance all that."
Rother believes the rising cost of drugs, new medical technologies, and other elements of health care pose the biggest threat to the program. "There are certainly many challenges facing Medicare, but most of them are facing our entire health-care system," he said. "You can't solve Medicare's problems without really looking at the system in which it is embedded."
In a survey released Tuesday, the Commonwealth Fund asked 230 experts drawn from various segments of the health-care spectrum to weigh in on Medicare. While the overwhelming majority labeled the program an overall success, most wished it could also use its clout to improve the quality of care for beneficiaries.
"It's imperative that Medicare look for any opportunities to improve care and lower costs," Davis said. "There are certainly some ideas that look promising."
For example, she said, the Commonwealth Fund is sponsoring a study looking at whether advanced-practice nurses can save the system money by helping heart-failure patients better manage their illness after they return home from the hospital. "That way, they're much less likely to wind up back in the hospital, which costs so much money," she explained.
Another key area for improvement centers on information technologies. Davis imagines a new Medicare where data on each beneficiary — all their medications, test results and history — is kept on one secure, centralized e-file that's available to patients and their doctors. Rother supports such a move, noting that "none of the private-sector health plans have the clout that Medicare does to really push forward in this area."
Then there are innovative financing schemes, such as Medicare "buy-ins" for younger Americans. In such an arrangement, a 50-year-old worker could earmark a small percentage of his or her income toward a "Medicare savings plan" that would help pay for any future medical expenses not covered by the program. Sixty-five percent of experts responding to the Commonwealth Fund survey said they would support such a plan.
However, Rother said that while buy-ins "make sense," they remain little more than a "Band Aid" solution to Medicare's future fiscal woes. "The fundamental problems are going to be deeper than that," he said.
AARP's 35 million members are increasingly concerned about the future of Medicare and health care in general, Rother said. "Right now, their concerns are focused on prescription drug costs, but I think the cost of health care generally is likely to be the biggest problem people face in their retirement," he said. "Because they see that costs are going up much faster than their incomes."
For her part, Davis said she remains optimistic. "When I look at the high satisfaction level of beneficiaries covered by Medicare, it's clear it works for people — far more so than for employer coverage, which you're never sure is going to be there. You can be sure that Medicare is going to be there."
More information
For more on Medicare at 40, head to the Commonwealth Fund.


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Thanks for checking out my QRZ.com bio! I started down this long, addictive path called Amateur Radio at the age of 13 when my father gave me a CB radio for my birthday. My older and more technically savvy brother began telling me of something called "Ham Radio", and suddenly I wanted much more than my Radio Shack Mini-23 could give me! The following year found me sitting in front of a stern-faced examiner at the Federal Building in Baltimore, Maryland taking my first Amateur Radio exam. For a while I was very active, then I discovered girls, and cars, and college, and work, and marriage, and kids, and divorce, and remarriage, and they all conspired against an active ham career! Throughout that time, though, I never let my license lapse or lost the passion for Amateur Radio (I stayed somewhat active on 2 meter FM). Around 2000 I picked up an old Tempo One HF radio and a trap vertical and rediscovered the "magic"! I've not looked back since.
My current station consists of a Yaesu FT-920 and a TenTec Omni VI Plus, with an Ameritron AL-80A amplifier feeding RF to a Mosley CL-33 for 10-15-20 meters, a rotatable dipole for 12 and 17 meters, a Hustler 6BTV vertical for 10, 15, 20, 30 and 40 meters, and a GAP Voyager for 40, 80 and 160 meters. Six meter operation is accomplished using the FT-920 and a Diamond DP-GH62. For VHF and UHF FM I use a Yaesu FT-8900R with a Diamond V-2000 antenna. (I am also on 60 meters using a MonoGAP antenna, which has so far been very impressive!)
When not on the air I serve as an ARRL VE and have been known to help teach some Technician classes. I am the immediate past President of the Vero Beach Amateur Radio Club and a past ARES EC for Indian River County, FL. Oh, and somehow in all that I find time to pursue gainful employment... :^)
I occasionally operate some HF digital modes. My original intent was to operate on digital long enough to get the ARRL Triple Play Award (which I did accomplish), but I discovered that I enjoy the various modes enough to keep using them. I primarily use RTTY, JT65 and JT9, and have earned WAS on each mode.
For those who may need them, some of my membership numbers are: QCWA: 32076; OMISS: 4211; 3905CC: 40m-2081 75m-2352; 10-10: 72779; FISTS: 13027; NAQCC: 4229; SKCC: 3639; 30MDG: 3884; EPC: 18751; DMC: 05762. I am a Life Member of ARRL, QCWA and INDEXA, a member of the Florida Contest Group and the Florida East Coast DX Club, and actively support several other Amateur Radio organizations. I hold 8BDXCC, 8BWAC, DXCC Challenge, WAZ, WPX Mixed (Honor Roll), CQ DX SSB, Triple Play #763, WAS Phone-CW-Digital, 5BWAS (all on Phone), 50 MHz VUCC, and the IARU Region 1, 2 and 3 Awards, plus the ARRL Diamond DXCC Award.
I wholeheartedly endorse the DX CODE OF CONDUCT. If you are unfamiliar with it, please take a moment to click on the link below.
See you on the bands!
73, Vince K4JC
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John Varvatos Star U.S.A.
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Kobarid gastronomic circle
Kobarid gastronomic circle contains five top restaurants of the Kobarid area.
LTO Soto�je TIC KOBARID Trg svobode 16, SI 5222 Kobarid tel.: +386 (0) 5 38 00 490 fax: +386 (0) 5 38 00 491 e-mail: email@example.com www.lto-sotocje.si THE KOBARID GASTRONOMIC CIRCLE De honesta voluptate et valetudine On true pleasure and good health PUBLISHED BY: LTO Soto�je, 2009; TEXT BY: Ana Ros; PHOTOGRAPHS: Janez Puksi�; TRANSLATION: Amidas d.o.o.; MAPS: Mateja Sirk Fili; DESIGN: Ivana Kadivec; PRINTED BY: Gorenjski tisk "De honesta voluptate et valetudine" "On true pleasure and good health", or even better "true pleasure is good health". In 1467, the philosopher Bartolomeo Platina gave this title to his treatise on healthy food. He quoted Maestro Martino de Rossi, who was chef to the fifteenth century Patriarch of Aquileia and the So�a region, and hence had links to Slovenia, Ludovico Trevisano. In contrast to the very medieval approach to food of their time, the chef and the philosopher preferred to base their cuisine on a moderate, cultural and healthy way of eating. History today counts them as pioneers of the institutions of starter, main course and final course. So the people of the So�a Valley have known about and enjoyed good food for a very long time. The traditions have passed from generation to generation, in written form and orally. Today every housewife knows how to prepare the famous local dessert "kobariski struklji" (a delicious dessert made from dough stuffed with walnuts, raisins and such like), to which the culinary grandees of the town even dedicate a festival. Yet, beware, history and tradition do not reign absolutely, for every strukelj is different. And diversity is indeed a special feature of the restaurants of Kobarid, eateries that feature great variety yet with enough in common to have created the intriguing, enticing KOBARID GASTRONOMIC CIRCLE. The circle has no beginning and no end. There is no champion, no winner; the circle remains ... The "Kobariski strukelj" is a pastry with a signature. Every housewife from Kobarid prepares hers in a slightly different way and "signs" it with her fingerprint in the middle of the "strukelj". Once upon a time it served as a fortifying snack during the summer mowing, but today it is the star attraction on the dessert menus of restaurants in the Kobarid area. INGREDIENTS: steamed dough, walnuts, cinnamon, bitter chocolate, butter, breadcrumbs and raisins. Gostisce Jazbec You might start at Jazbec , a real Slovenian gostilna or inn, where you will always enjoy the delicious aromas of home-made polenta, real alpine cheese, the cottagecheese-like skuta, and Tolmin the foods our forebears enjoyed that today are zelodec sausage, often neglected or even seen as something to be ashamed of. Gostis�e - Pizzerija Jazbec Idrsko 56, SI 5222 Kobarid tel.: +386 (0) 5 38 99 100, +386 (0) 41 570 126 fax: +386 (0)5 38 91 402 e-mail: email@example.com www.jazbec.eu OPEN: fl every day from 12:00am till 10:00pm fl closed: in winter time on Mondays, Tuesdays and Wednesdays Bostjan Jazbec Gostilna Breza Monika and Nina Petrica You might then move on to Gostilna Breza , a petite, attractive gostilna where, despite the high Poso�je mountains that surround Kobarid, you will enjoy tastes and flavours from the Dolenjska hills and Bela Krajina, two of Slovenia's more south-easterly lying regions. And the goodness of food at Gostilna Breza is matched by its almost heavenly interior. Gostilna Breza Mu�eniska 17, SI 5222 Kobarid tel.: +386 (0) 5 38 90 041, +386 (0) 31 617 501 e-mail: firstname.lastname@example.com OPEN: fl every day from 11:00am till 03:00pm & from 06:00pm till 10:00pm fl closed: Wednesday and Thursday Restavracija Kotlar Within the extremely original interior of Restavracija Kotlar , you'll be seated at a table so richly laden that it almost mocks the best restaurants fresh and imaginatively prepared is the fish they offer. on the coast, so Restavracija Kotlar Trg svobode 11, SI 5222 Kobarid tel.: +386 (0) 5 38 91 110, +386 (0) 41 612 763 e-mail: firstname.lastname@example.com www.kotlar.si OPEN: fl every day from 12:00am till 03:00pm & from 06:00pm till 10:00pm fl closed: Tuesdays and Wednesdays Debora von Kastelmur Restavracija Topli val Nearby, in their family hotel complex, is the home of the doyens of Kobarid cuisine, the Hvala family. Some decades ago their restaurant, Topli Val , became famous for its exceptionally fresh sea food; it retains that reputation to this day as a meeting place of the mountains and the sea, the Alps and the Adriatic, with its wonderful meat dishes and deliciously prepared fish. And finally you might come full circle. Or is that just beginning again? Hotel Hvala - restavracija Topli val Trg svobode 1, SI 5222 Kobarid tel.: +386 (0) 5 38 99 300 fax: +386 (0) 5 38 85 322 e-mail: firstname.lastname@example.com www.hotelhvala.si OPEN: fl every day from 12:00am till 10:00pm fl closed: February and November Tanja and Ales Hvala, Vesna and Gorazd Marksl Hisa Franko Ana Ros and Valter Kramar Hisa Franko , like a philosopher or artist withdrawn into the silence of the Kobariski Stol foothills, takes from the past while offering the future. At Hisa Franko they are nurtured by the environment in which they live and work, creating a new culture and a new milestone in history. And so we return to 1467. The circle turns, and never comes to a close. Hisa Franko Staro selo 1, SI 5222 Kobarid tel.: +386 (0) 5 38 94 120 fax: +386 (0) 5 38 94 129 e-mail: email@example.com www.hisafranko.com OPEN: fl every day from 11:00am till 11:00pm fl closed: in winter time on Mondays and Tuesdays, in summer time on Mondays Of course, Kobarid's wonderful VILLACH KLAGENFURT cuisine is not the only reason for paying a visit to the town. Anyone with an interest in history would Tarvisio the Kobarid First World War Museum, appreciate a visit to which was awarded the European Museum of the Year Award in 1993. Tolmin KRANJ UDINE Cividale The Kobarid history trail LJUBLJANA offers an attractive and informative GORIZIA NOVA GORICA trip for young people, families and TRIESTE KOPER The emeraldgreen So�a River and the older visitors alike. exceptional countryside around the town offer a challenge to anglers, kayakers and rafters, walkers, hikers and climbers, paragliders and cyclists. And what better way to end the day than at a good restaurant in the company of friends?


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Pausing With God
California 32003
Website: http://www.pausingwithgod.com/
Sheri is well aware that menopause is a natural and inevitable time in a woman's life. She didn't realize that there was a way to walk through this season VICTORIOUSLY until she had to struggle with the symptoms herself. Sheri believes that no matter whether you are premenopause, perimenopause, menopausal, postmenopause or too young to even think about it, we hope to serve as a powerful source of encouragement. Our sincere hope is that this book provides the reader with... Full Bio


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Dallas Museum of Art Exhibition Records
What's Inside this Collection.
The Dallas Museum of Art (DMA) has presented over 1,500 exhibitions throughout its distinguished history. Approximately 500 exhibitions were organized by the DMA from 1903-1983, reflecting the development of both the Museum and the city of Dallas, documenting a progression of cultural, social, and political environments throughout eight decades. Exhibition documentation is a primary resource for researchers of Contemporary Art, American Art and Texas Regionalist Art, African Art, Asian, South Pacific, Ancient Art, and European Art. Additional information about exhibitions may be found in the Dallas Museum of Art Archives, Exhibition Records collection.
This project is made possible by a grant from the National Endowment for the Arts.


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Bowel Diversion Surgery Ileostomy, Colostomy Center - Ames, IA
WebMD Physician Directory
Ames, Iowa
Bowel Diversion Surgery: Ileostomy, Colostomy, Ileoanal Reservoir, and Continent Ileostomy
What Is Bowel Diversion Surgery?
Bowel diversion surgery allows stool to safely leave the body when (because of disease or injury) the large intestine is removed or needs time to heal. Bowel is a general term for any part of the small or...
Read the Bowel Diversion Surgery: Ileostomy, Colostomy, Ileoanal Reservoir, and Continent Ileostomy article »
Other Related Bowel Diversion Surgery Ileostomy, Colostomy Articles
Emergency Contact for Ames
Nearby Ames Hospitals *
Mary Greeley Medical Center
Story County Medical Center
Boone County Hospital
Woodward Resource Center
VA Central Iowa Medical Center
Dallas County Hospital
Broadlawns Medical Center
Mercy Franklin Center
Iowa Lutheran Hospital
Mercy Medical Center Des Moines
Blank Children's Hospital
Iowa Methodist Medical Center
Van Diest Medical Center
Mercy Medical Center West Lakes
Methodist West Hospital
*Provider Directory Terms of Use:
The WebMD 'Provider Directory' is provided by WebMD for use by the general public as a quick reference of information about Providers. The Provider Directory is not intended as a tool for verifying the credentials, qualifications, or abilities of any Provider contained therein. Inclusion in the Provider Directory does not imply recommendation or endorsement nor does omission in the Provider Directory imply WebMD disapproval.


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The 2015 Movie Geek Art Show!
All original movie-themed artwork!
Friday, June 26th
At Nancy's Bagel Grounds
2101 Frankfort Ave.
6PM til 10PM
During the F.A.T. Friday Trolley Hop!
Plus live music, food and lots of other fun!!
Previous Events...
Meltdown Macabre
Thank you to everyone who came out to the live show! Bermudan was awesome!! We had great original music, a cool movie and people even seemed to enjoy the weird cartoons! Plus we had an interesting conversation built around the movie afterwards (which should be coming up on the show in the near future). All around, a really fun night. Thanks to everyone who came out and even bigger thanks to those who helped put it together! ( Jacqueline,Nick, Alisha, Sterling and everyone else who pitched in!)
Movie Meltdown presents
The Second Annual Halloween Event...
Meltdown Macabre
This year includes a showing of the silent movie adaptation of
Edgar Allan Poe's classic
"The Fall of the House of Usher"
featuring a LIVE performance
of an original score by
Plus the first act of the evening is a special feature - the
Cavalcade of Creepy Cartoons!!
Saturday, October 18th
Nancy's Bagel Grounds
2101 Frankfort Ave.
Louisville, Ky.
Show starts at 7:00PM, music starts at 8:00PM
Plus... this event is FREE!
(But we will be accepting donations to fund our upcoming regular movie nights!)
Plus we'll wrap up the evening with a "live" recording of an episode of "Movie Meltdown", featuring a group discussion of our reaction to this version of "The Fall of the House of Usher" as well as other adaptations of Poe's work in film.
Don't miss this evening of spooky fun!!
Cryptid Carnival!
THANKS to everyone who came out to the Cryptid Carnival!
Friday, July 25th
Movie Meltdown presents...
Cryptid Carnival
featuring the
Tales from the Crypids
Art Show!
Original Cryptid-themed artwork!
Movie Meltdown's "Cryptid Carnival" will feature LIVE performances from... Sweatermeat
and The Formalities!!
We'll be showing Ron Schildknecht's film
"The Legend of the Pope Lick Monster"
after dark! And we'll have the director on-hand to ask him some questions
about his connection to the legend and about making his movie.
Live Music!
Belly Dancing!
LIVE Cryptids!
AND... we'll be recording an episode of Movie Meltdown
right there in the middle of the show!!
Mark your calendars now people!!
Friday, July 25th
Nancy's Bagel Grounds
2101 Frankfort Ave.
Louisville, Ky.
6pm - ???
Don't miss your chance to see... the Cryptids!
Listen to our coverage of the event on episode 281: http://moviemeltdown.libsyn.com/281-welcome-to-the-cryptid-carnival
and on episode 282:
The Return of the Yeti Spaghetti Show
THANKS to everyone who came out to "The Yeti Spaghetti Show"! It was a great turnout, and as promised - it was a hell of a lot of fun!
The Yeti Spaghetti Show is back! And it's bigger and better then ever! Now featuring the terrific pasta of "The Old Spaghetti Factory"!! So clear out the evening of Feb. 22nd for great spaghetti, a bad Yeti movie, ice cream and even a new drink special available at the bar... "The Drunken Yeti". Beware!!!! And like last time, we'll be recording an episode of "Movie Meltdown" after the feature... where YOU can weigh in on the movie!
When: Saturday, February 22nd
Where: The Old Spaghetti Factory - 235 W Market Street - Louisville, Ky.
Time: 8:00 PM
What do you get: Your choice of "The Old Spaghetti Factory" signature dishes either Spaghetti or Fettuccine as well as a soft drink AND ice cream!
Spaghetti : Rich Meat Sauce Ground beef sautéed with onions and celery then
simmered with tomatoes and Italian spices.
Fettuccine Alfredo: Our own version of this classic dish - fettuccine
noodles in a butter cream sauce with shredded Romano cheese.
ALL that for only $15! Tickets will be available at the door at "The Old Spaghetti Factory".
Plus we'll be watching a terrible movie, hanging out and taking pictures with a live YETI and recording an episode of "Movie Meltdown"! And all that entertainment comes FREE!!!
Seating is limited, so tickets will be sold in advance (plus you get the discount price IF you buy your tickets early)!!
Tickets are available NOW at:
The Old Spaghetti Factory - 235 W Market St.
So get yours TODAY!!
Plus don't forget about... "The Drunken Yeti"!
Yes, we will be featuring our own special drink at the bar, so come out and try the infamous Drunken Yeti! (Mixed drinks will be available for the show, but they are not included with the ticket price... you pay for your own booze people.)
Listen to our coverage of the event on episode 264:
(Scroll down to see photos from the previous Yeti Spaghetti Show!)
(The 1st) Meltdown Macabre
Thank you to everyone who joined us for "Meltdown Macabre"!!
Movie Meltdown's horror movie DOUBLE FEATURE!!
Saturday, October 12, 2013
at The Alley Theater - 1205 E Washington St.
* 7PM - The EXCLUSIVE Louisville area showing of "CHASTITY BITES".
Starring starring Allison Scagliotti of "Warehouse 13".
* 9PM - The classically horrendous flick "MAMA DRACULA".
Starring Oscar-winner Louise Fletcher.
* And we conducted a "live" version of "Movie Meltdown", featuring a full group discussion of "Mama Dracula" after the movie! We had quite A LOT to say about that movie.
Listen to that coverage on episode 249: http://moviemeltdown.libsyn.com/249-wirgins-and-wampires
Thanks to everyone who came out!
Thank you to all the terrific artists who contributed to this show. And thank you to "Hilltop Tavern" for hosting this event!!
Thank you to everyone who came to the opening of "The Movie Geek Art Show!" It was a fun night!
Movie Meltdown presents...
at "Hilltop Tavern"
1800 Frankfort Ave, Louisville, KY 40206
And check out the write up in LEO!!
Listen to our coverage on episode 242: http://moviemeltdown.libsyn.com/242-the-movie-geek-art-show
and episode 243: http://moviemeltdown.libsyn.com/243-portrait-of-a-podcast
The (1st) Yeti Spaghetti Show!
Thanks to everyone who came out to
"The (1st) Yeti Spaghetti Show"! It was a lot of fun!
Listen to episode 202 for all the goings-on!!


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Appendix B National Science Foundation Funding for Solar Physics Currently solar physics research is supported by three divisions in two separate directorates within the National Science Foundation (NSF). Originally the Astronomical, Atmospheric, Earth, and Ocean Sciences Di- rectorate provided support for solar physics within a single directorate. In 1986 the Division of Astronomical Sciences was moved to the Mathematical and Physical Sciences Directorate, and at the same time NSF formed a new Geosciences Directorate consisting of the Atmospheric Sciences, Earth Sci- ences, and Ocean Sciences Divisions, plus the Division of Polar Programs. The Geosciences Directorate now provides a major source of funding for solar physics. GEOSCIENCES DIRECTORATE Grant support to individual scientists for solar physics research is pro- vided by the Atmospheric Sciences Division, which also supports studies of solar activity as it relates to an understanding of the solar influences on the Earth's upper atmosphere and near-space environment. In addition, support is provided for the High Altitude Observatory (MAO) of the Na- tional Center for Atmospheric Research. The HAO is one of the largest solar research institutions in the United States, with a permanent staff of approximately 15 PhD scientists and the addition of about a dozen visiting scientists each year with substantial funding from other agencies. In addi- tion, a small number of grants for solar physics research conducted in the 57
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58 polar regions is provided by the Division of Polar Programs. Each divi- sion also has a Facilities Section with separate responsibility for supporting necessary facilities, maintenance, and instrumentation. MATHEMATICAL AND PIIYSICAL SCIENCES DIRECTORATE The Astronomical Sciences Division provides grants to individual sci- entists for research in solar physics and the solar-stellar connection. In addition, solar physics support is provided by an NSF contract to the Association of Universities for Research in Astronomy, Inc. (AURA) for the National Optical Astronomy Observatories (NOAO), which manages and provides funding support for the National Solar Observatory (NSO), Tucson, Arizona, also one of the largest solar research institutions in the United States, with 15 PhD scientists and 10 affiliated PhD scientists funded by non-NSF sources. NATIONAL SCIENCE FOUNDATION BUDGET FOR SOLAR PITYSICS Table B.1, a summary of the NSF budget for solar physics for FY 1985 through FY 1988, shows the breakdown of support for grants and for centers and initiatives. Able B.1 shows that solar physics funding for both the HAO and the NSO has declined in teas of constant dollars (1982 = 100) from FY 1985 through FY 1988. The subtotal for grants has increased for these same years, although the significant part of that increase has come from the Division of Atmospheric Sciences. Overall, NSF support for the field of solar physics has remained approximately level in terms of constant dollars from FY 1985 through FY 19~, except for the funding for the Global Oscillations Network Group (GONG) initiative, included as part of the NSO budget. However, when the GONG program is completed, if not before, both the HAO and NSO, which have already sustained budget cuts, will need significant funding to retain their vital roles as national centers.
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so TABLE B.1 NSF Summary Budget Breakdown of Support for Solar Physics Research (millions of dollars, corrected for inflation, FY 1982 = 100*) Fiscal Year 1985 1986 1987 1988 Grants** ATM 1.40 1.52 1.43 1.75 ASM 0.64 0.62 0.98 0.72 DPP 0.09 0.09 0.09 0.25 Subtotal grants 2.13 2.23 2.50 2.72 Centers and initiatives** HAO/NCAR 3.36 3.10 2.95 2.86 NSO/NOAO 2.67 2.50 2.60 2.61 NSO/GONG initiative 0.22 0.31 0.90 0.93 Subtotal centers and initiatives 6.25 5.9 ~6.45 6.40 Total solar physics 8.38 8.14 8.95 9.12 SOURCE: Personal communication, NSF program directors: grants ATM, Dennis Peacock; grants ASM, G. Siegfried Kutter; grants DPP, John Lynch; HAO/NCAR, Giorgio Tesi; NSO/NOAO and NSO/GONG, Seth Tuttle. *Inflation adjustments (tailored to fiscal year basis using quarters 4, 1, 2, 3) from Table 7.4, Implicit Price Deflators (1982 = 100), Survey of Current Business Vol. 68, No. 7, July 1988, p. 90, U.S. Department of Commerce, Bureau of Economic Analysis, Washington, DC 20230. Personal communication, Shelby Herman, for final quarter, 1988, final estimate. FY 1985, 108.5; BY 1986, 110.6; BY 1987, 111.5; BY 1988, 114.5. **ATM--Atmospheric Sciences Division; ASM-Astronomical Sciences Division; DPP-Division of Polar Programs; HAO/NCAR~High Altitude Observatory, National Center for Atmospheric Research; NSO/NOAO--National Solar Observatory, National Optical Astronomy Observatories; NSO/GONG-National Solar Observatory, Global Oscillations Network Group.


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MEA responds to Right-to-Work complaints
By Current State
Michigan's new right-to-work law triggered a dispute last week. The conservative Mackinac Center Legal Foundation filed a complaint with the state over what it claims is harassment by the Michigan Education Association toward a member.
There are eight complaints against the union, but the main one involves a kindergarten teacher from West Michigan. Miriam Chanski alleges interference and harassment after notifying the MEA of her intent to stop paying dues.
Doug Pratt, the MEA's Director of Public Affairs, joins us to share his organization's views on the complaint.
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