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The balloons were released by the children of St. James Catholic Church.
The event was the first living rosary of what the church hopes will be many. It will start having a living rosary the first Sunday of every month at 9 a.m.
Each balloon represented a rosary bead; the children stood in the shape of a rosary and, when the time was right, the balloons were released.
Each balloon had a prayer from each of the children for St. Philomena, the patroness and protectress of the living rosary.
According to a church member, the saint is the one who brings believers closer to the Blessed Mother and Jesus Christ.
The balloons said things such as, "Pray for my family and sick people."
The living rosary was sponsored by L&S Concrete and did not cost the church members anything to partake in it.
The event was well received, and the church is planning its next one for March 3. For more information on the living rosary, call 354-004.


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Chinatown rang in the Chinese New Year with a parade through Hotel Street Saturday afternoon and the celebration lasted into the night.
It is fitting the traditional sounds of drumming welcome in the Year of the Snake, along with a day-long celebration, that featured a lot of food. After all, those born under this sign are said to love music and delicious things to eat!
Thousands snake their way through the streets of Chinatown for shopping or some good luck during lion dances.
Many residents look forward to the New Year while Chinatown shops and restaurants are looking forward to another busy year.
Businesses say this event does more than just give people a taste of Chinese food -- it also lets them sample what's new in this old part of Honolulu.
This is where the devastating 1886 Chinatown fire began, and now, new business is heating things up.
At the site of the historic fire, restaurants and stores are opening up.
"Chinatown is growing more than anything else with newer restaurants and bars, it's a new scene for the younger generation and for the older generation to come and see the new restaurants coming through," said Jesse Cruz, owner of Lucky Belly.
Old and young not only got to see the cultural activities, some also took part in the day's celebrations for the Year of the Snake.
The event attracted quite a crowd, which is something businesses in Chinatown are seeing more of.
"We get lots of Japanese tourists and First Friday has gotten very big so that brings everyone here, so yeah, it's getting exciting," said Nicole Hesslink, who works at Roberta Oaks.
The Year of the Snake officially begins on Feb. 9.

subset: commoncrawl


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Am happily flicking through all the entries so far and am kind of drawn to PoshVenus; he manages to combine looking fierce, deeply off-beat and vulnerable all at the same it. I would want to take his photo for sure. I like the way all his pictures are quite different from each other too; long hair, short hair, no hair!
Eye patch, lace veil, smiles, no smiles, fluorescent orange eye make-up, graffiti 'No' scrawled across his face. Very intriguing.
Then there is Ethan363 – and he's right, he certainly "doesn't look like all the boys". He's making me feel confused. I don't know what to think about him…I love the peroxide mop of hair but the "pure sex" mesh vest frightens me…maybe I'm not the right target audience…
Aks has chosen close-ups for all his pictures. Brave. It makes for an intense snippet into his world. He has a simple vibe, looks like he might have a read a lot of Dante.
Denis Smith is from…Venezuela…eh? Doesn't sound very Venezuelan to me but what do I know. So, I can't help but be drawn to his energy and enthusiasm. You can just sense it don't you think? He looks fun, a real sweetie and I love those glasses. Niffty little dresser too. And all that jumping – maybe he has A.D.D?


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Colonoscopy and Other Colorectal Cancer Screening Options: An Update
When I wrote about colonoscopy in 2010, colonoscopy was thought to be the best screening test for colorectal cancer because it could visualize the entire colon and could remove adenomas that were precursors of cancer. But only fecal occult blood testing (FOBT) and sigmoidoscopy had been proven to decrease colorectal cancer incidence and mortality (by 16% and 28%, respectively). Observational evidence suggested that colonoscopy would reduce the incidence and the number of deaths from colorectal cancer, but there were no randomized controlled trials, and the reduction in incidence of cancer after colonoscopy screening seemed to be restricted to left-sided colon cancers, which didn't make sense.
We still don't have any randomized controlled trials of colonoscopy, but a 2013 case-control study from Germany compared patients with and without colorectal cancer and found that those who reported having had a colonoscopy were less likely to develop colon cancer for up to 10 years after the procedure. And now two studies published in the New England Journal of Medicine in September 2013 have shed more light on the subject.


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Keyboard instruments > Piano solo
Joseph Haydn
Piano Sonatas, 3rd sequence
Editor: Georg Feder
36.00 €
Complete Edition, critical report, Reihe XVIII, Band 3, paperbound
Editor of the critical report: U. Leisinger
in preparation
Order no. HN 5493 · ISMN 979-0-2018-5493-9
Musicians throughout the world are familiar with and treasure our blue Urtext editions – top quality editions of great classical compositions. Urtext and Henle are synonymous. The musician is offered a musical text which solely reflects the composer's intentions.
- Hob. XVI:43, 33, 34; 40-42
- Hob. XVI:48, 49; 52, 50, 51


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Milford readies for 13th Black Bear Film Festival
MILFORD, PA — For more than a decade, Milford has proven to be an ideal place for a film festival. That's what Jerry Beaver, founding president of the 13th annual Black Bear Film Festival (BBFF) thought 12 years ago when he dubbed Milford the "perfect town."
This year will be no different as BBFF brings its thought-provoking, entertaining and powerful films to the newly renovated Milford Theatre and nearby Film Salon on October 12 through 14. And once again, local artists and community businesses have created unique Art Bears, which will be sold at a silent auction during the festival to raise funds for its support.
BBFF began in Milford in 2000 when a small group of individuals set out to produce an event that would support and promote innovative and independent films. The festival celebrates Milford's rich film-making heritage and conservation history tied to Gifford Pinchot, who is often referred to as the father of the American conservation movement.
The festival continues to support independent films, artistic expression, education, diversity and cultural enhancement while celebrating the region's clean air and water, abundant wildlife and natural beauty.
During one special screening on October 13 at 6 p.m. in the Milford Theatre, BBFF, in cooperation with EPIX Films, will present "Everything or Nothing: The Untold Story of 007."
Showing in Milford just eight days after its premier in New York City, the documentary focuses on three important men behind the success of the James Bond franchise: producers Albert R. Broccoli and Harry Saltzman, and author Ian Fleming.
The film offers a behind-the-scenes peek at the Bond films and the men who created the longest running film franchise in cinema history, beginning in 1962. Audience members will get an exclusive opportunity to meet Saltzman's daughter, Hilary, who will be available for questions after the film.
In addition to offerings in the main theater, a free film salon will be held nearby at St. Patrick's Social Hall (see sidebar).
Tickets and passes are available at the BBFF office at 221 Broad Street, Milford, from 1 to 5 p.m. or online at www.blackbearfilmfestival.com; [1] or visit Upriver Home, 202 Broad St. Milford, or Milford Theatre Box Office, 114 E. Catharine St. during the event. Most main stage films are $12 ($10 in advance); children's films are $5; salon programs are free. Special passes for the opening night gala dinner, featuring gourmet foods prepared by local businesses, are also available for purchase.
For more information, including the film schedule, visit www.blackbearfilmfestival.com [2] or call 570/409-0909. Learn more about the festival's history at https://vimeo.com/49505517 [3].
Black Bear Film Salon still free
BBFF will present its 2012 Black Bear Film Salon, which showcases cutting-edge short films, student productions, documentaries and more, at no charge. Throughout the weekend, guest speakers will engage in discussions with audience members on the history and production process of select films. The salon will take place at St. Patrick's Social Hall, on the corner of East High and Fourth streets in Milford, a block away from the Milford Theatre, on Saturday and Sunday from 11 a.m. to 6 p.m. Highlights include:
• "The Sky is Pink," the new anti-fracking film by Josh Fox, director of the Oscar-nominated "Gasland"
• The Young Amateur Film-Makers' Forum, featuring submissions from local middle and high school students
• "Sourlands," a new film by award-winning reporter, photojournalist and documentary filmmaker Jared Flesher on the fight for ecological sustainability
• The world premiere of "Forces of Nature," a new production from Grey Towers Heritage Association
• An award-winning documentary, "9000 Needles," presented by Worker Bee Community Acupuncture of Milford
• "Editor Uncut," a work-in-progress by Tom Hayes about his father, legendary "Esquire" editor Harold Hayes
• Guest lecturers John DiLeo, author of "Screen Savers II: My Grab Bag of Classic Movies," and Penn State film professor John Riddle's tribute to the late Chris Marker


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Chicken & white bean stew
Nutrition and extra info
- Freezable
- Dairy-free
- Gluten-free
- Healthy
Nutrition: per serving
- kcal291
- fat9g
- saturates2g
- carbs24g
- sugars9g
- fibre11g
- protein30g
- salt0.66g
- 2 tbsp sunflower oil
Sunflower oil
A variety of oils can be used for baking. Sunflower is the one we use most often at Good Food as…
- 400g boneless, skinless chicken thigh, trimmed and cut into chunks
- 1 onion, finely chopped
Onions are endlessly versatile and an essential ingredient in countless recipes. Native to Asia…
- 3 carrot, finely chopped
The carrot, with its distinctive bright orange colour, is one of the most versatile root…
- 3 celery sticks, finely chopped
A collection of long, thick, juicy stalks around a central, tender heart, celery ranges in…
- 2 thyme sprigs or ½ tsp dried
This popular herb grows in Europe, especially the Mediterranean, and is a member of the mint…
- 1 bay leaf, fresh or dried
- 600ml vegetable or chicken stock
- 2 x 400g / 14oz cans haricot beans, drained
- chopped parsley, to serve
One of the most ubiquitous herbs in British cookery, parsley is also popular in European and…
Heat the oil in a large pan, add the chicken, then fry until lightly browned. Add the veg, then fry for a few mins more. Stir in the herbs and stock. Bring to the boil. Stir well, reduce the heat, then cover and cook for 40 mins, until the chicken is tender.
Stir the beans into the pan, then simmer for 5 mins. Stir in the parsley and serve with crusty bread.
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Comments, questions and tips
Comments (129)
After reading earlier reviews I added garlic, chopped smoked bacon, extra thyme, dried herbs de Provence and bouquet garni to the pot. To give it some colour I added a tin of borlotti beans and a bag of frozen soya beans. It was devine. I didn't bother to add creme fraiche, as suggested by another reviewer, as it didn't need it in the end. I think it would have been very bland without a little additional 'help'.
After reading previous comments I fried garlic with the onions, added a bouquet garni to the casserole, lots of fresh thyme and added fried smoked back bacon rasher slivers and lots of black pepper to the dish prior to the 40 minute simmer. I used borlotti and broad beans, which gave some colour, as my local supermarket didn't have the beans listed in the recipe. After all that tinkering, it was lovely. Without the tinkering I think it would have tasted very bland and looked very beige. The end result was very tasty and I would make it again.
I love this dish and make it often as a mid-week meal that is healthy, tasty and filling. I've made it following the recipe exactly but also adapting it depending on what I have in (I often use a leek instead of an onion and sometimes use some new potatoes instead of beans). However, if you use a good quality stock, fresh veggies and nice chicken then the flavours of the ingredients sing and it doesn't need much else.
Have just cooked this and agree with the other comments that it is soup rather than a stew and it would be bland and colourless without additions. So I added garlic and coloured beans as suggested and also added baby potatoes and splash of tabasco and will now eat it but its not recipe would use again.
This is one of those recipes that's much greater than the sum of the parts. Tasty and very filling - couldn't believe how much food you get for the calories. I'm doing the 5:2 diet and this is perfect for a fast day. I used half and half flageolet and kidney beans as didn't have any haricots, but otherwise followed the recipe to the letter. I recommend using proper homemade stock if you can, but would probably still be nice with a cube.
Questions (0)
Unsure about the cooking time or want to swap an ingredient? Ask us your questions and we'll try and help you as soon as possible. Or if you want to offer a solution to another user's question, feel free to get involved…
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It's possible that you may ruin the manifold trying to restore it. Try bead/media blasting it. If it doesn't work you will have to find another manifold to send to Jerry if you want to go back to original.


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Experts: now is the time to prepare for filing tax returns
It's that time of the year to get ready to file your taxes. In less than two weeks, the IRS will begin processing returns.
Tax experts suggest people use this time to get all of their paperwork together to ease the process.
More than 80% of returns will be filed electronically and many through tax software. However, some of the details have changed after lawmakers passed legislation related to the fiscal cliff, meaning the programs may be out of date. "If you use packaged software, you want to make sure that after you install it you go through any kinds of updates that that software would have becasue there were changes to the tax laws that will effect the 2012 tax return," said the owner of Becker Tax and Bookkeeping Tammy Becker.
Also this year, the IRS is not giving a specific day for your return to show up. Instead, you should expect it within three weeks after it is processed.
Copyright 2013 by WKBT News8000. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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Women's Studies
Women's Studies is an area of study based on the understanding that gender is a fundamental category of social and cultural analysis. Women's Studies aims to:
- stimulate and promote new scholarship in Women's Studies, including work on women, gender, and other social categories
- encourage traditional departments to broaden their fields of study to include gender as a category of analysis.
The analysis of women's perspectives has enriched our understanding of historical change, social, economic, and political life, and the arts and sciences. In addition, Women's Studies highlights the necessity of considering race, socioeconomic status, sexual identity, nationality, and other social categories, particularly as these intersect with gender.
Women's Studies is an interdisciplinary field of study that draws on the arts, humanities, education, social sciences, sciences, and technology for its theories and methods.
Why Choose EIU for Women's Studies?
We believe in everything our program has to offer, but let's narrow it down to a few key reasons you should check us out.


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Bye-Bye, Boone
Aw. Aaron Boone has officially announced his retirement. Not like I didn't know this was coming. I just….well….ever since he left, I always had this slight hope that he'd return to the Yanks where he belongs. Either converting to outfield, or just being a utility guy. Anything. Like all Yankee fans, Aaron Boone holds a special place in my heart.
Aaron's health has been worsening over the years. He has had a heart condition since his childhood, but the severity recently escalated. Boone had open-heart surgery to fix the problem. It was amazing that he even played baseball after that. I can understand why he decided it was time to stop playing.
This is not a forever goodbye to Booney. Aaron plans on joining ESPN as an analyst, which would be cool. And, I'm sure, he will want to come to Old Timer's Day. He better….I miss him ♥
I always have liked Aaron Boone, even before he was a Yankee. As for so many other players, I had his baseball card and thought he was cute. I was happy when he joined the Yankees. But on October 17 of 2003, everyone (well, except the city of Boston) was glad Boone was a Yankee. In the 11th inning of this best game I have lived through, Boone forever immortalized himself in the hearts of Yankee fans everywhere.
Poor Booney didn't like facing Tim Wakefield. But in that 11th inning, Joe Torre stuck with him. Best decision ever. On the first pitch, a wiggly-jiggly knuckleball by Wakefield, Boone, who just wanted to get the bat on the ball, got the bat on the ball. Indeed he did. And he knew it. Boone was our savior that night. His magic blast sent the Yankees to another World Series, but more importantly, prolonged The Curse of the Bambino.
I need to just re-live that moment really quickly:
-Sniffle-….-Little tear-….Oh, the beauty!
I love ya, Booney.
9 Comments
I will never forget the feeling that went through me when Booney hit that homer. Chills like you would not believe! He was like, the love of my life during the 2nd half of '03. Gorgeousssss ♥ Great job as usual, Virginia! I need to get back into blog mode =l LOL.
Boone was a great player, even though he wouldn't give you 40+ bombs a year, he'd still come through in the clutch and deliver solid numbers. Nice post!!!
Do you remember his own words on what had just happened? I thought it was one of the coolest descriptions ever….
"this…this is just…SICK!!"
Most of the times when players open their mouths they tend to dissappoint. To me, those were some of the better words put together by a ball player. There's beauty in simplicity.
http://the brooklyntrolleyblogger.mlblogs.com/
….or did he use the word STUPID! Either way, it was a great line.
OMG what a night. "THIS IS STUPID!!" Sooooo good. Ugh. Thanks for the pictures, Virginia… Boonie was a cutie!~Anahttp://enternight.mlblogs.com
Aaron Boone was the man, back then, right before they decided to dump him for A-Rod. Interesting note!
Matthew T.
Boone definitely made an impact with a lot of Yankee fans… think he'll do okay with ESPN…
Outside the Phillies Looking In
i'll never forget his walk off. one of my most fondest baseball memories and i could care less about that game!
congrats on the win today


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Explore the Entrepreneurship.org Resource Center to find resources. Designed with entrepreneurs in mind, our resource center allows you to find materials to grow great ideas.
In this special lecture, mother and son serial entrepreneurs Sandra and Andy Kurtzig share smart reasons for starting companies that matter. Sandra Kurtzig outlines similarities and differences between her previous ventures and her current company, Kenandy. Andy Kurtzig discusses his company, JustAnswer, and key lessons for entrepreneurs.
Serial entrepreneur and investor Reid Hoffman encourages individuals to become the entrepreneurs of their own lives. Hoffman shares the importance of taking intelligent risks, building thoughtful networks and continually adapting your skills to navigate a fulfilling career path.
JOYUS Founder and Chairman Sukhinder Singh Cassidy says entrepreneurs should leverage trademark strengths and lean in all the way when it's time to deliver. In this lecture, Singh Cassidy explores concepts such as defining operational range, using data to support gut beliefs, and developing the big ideas teams and customers can rally around.
Thuuz Co-Founder and CEO Warren Packard appreciates how uncertainty is a constant force in the lives of entrepreneurs. Sharing stories from his career as an entrepreneur and venture capitalist, Packard captures how life is a series of decisions made without complete information. He also addresses how his current venture approaches issues of funding and strategic partnerships.
Kauffman Foundation Senior Fellow Ted Zoller challenges Stanford students to engage in entrepreneurship as a practice of action. Based on his research into dealmaker density and network development, Zoller details the power of seizing opportunities and the pathways to developing an entrepreneurial career.
Entrepreneur and business model innovator Alexander Osterwalder discusses dynamic, yet simple-to-use tools for visualizing, challenging and re-inventing business models. Osterwalder articulates how to use the visual language of his business model canvas framework, and shares stories of how this approach helps organizations of all sizes to better create, deliver and capture value.
Entrepreneur and early-stage investor Brad Feld offers advice and support to aspiring entrepreneurs. Feld, a managing partner at Foundry Group and a co-founder of TechStars, imparts personal experiences on managing your life as an entrepreneur. He also shares some of the defining characteristics his firm looks for in the entrepreneurs they invest in.
Thoughts and influences from early life continue to shape how Evernote CEO Phil Libin embraces his work. In this wide-ranging presentation, Libin shares key beliefs and provocative insights on startups, acquisitions and company exits. Based on his experiences leading multiple ventures from startup to commercial success, Libin urges entrepreneurs to chase dreams they would actually want to spend their life pursuing.
Instagram Co-Founders Kevin Systrom and Mike Krieger challenge many of the myths surrounding startups and the lives of entrepreneurs. Both former Mayfield Fellows with the Stanford Technology Ventures Program, Systrom and Krieger share their first-hand experiences of the entrepreneurial process, including identifying good problems to solve and the value in building simple solutions and minimum viable products. Systrom and Krieger also discuss aspects of their co-founder working relationship and their efforts to maintain a balance between work and life.
Entrepreneur and bestselling author Guy Kawasaki shares the secrets to being enchanting and developing influence through the "pillars of enchantment." In this funny and engaging lecture, Kawasaki examines the deep value in being likable, creating trust, and taking empowering action. He also shares keys to telling a great story, overcoming resistance, and enchanting your boss and colleagues.
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Prices, promotions, styles and availability may vary by store and online.
Action - Single Shot
Caliber - 7MM-08 Rem.
Barrel Length - 22"
Weight - 8.2 Lbs.
Sights - Bushnell Banner 3-9x40mm Scope
For generations, the single shot rifle has been the choice of the accomplished and self-assured hunter and for years, H&R has honored that choice. The Handi-Rifle's smooth, simple break actions require very little maintenance and have minimal moving parts for the utmost in reliable function. All models are equipped with H&R's Transfer Bar System that makes it one of the safest single-shot rifle platforms in the world today. This rifle features Bushnell Banner Wide Angle 3-9x40mm scope and a 22" heavy barrel. Its wood is in good condition and its metal and bore are in very good condition.


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J. Michael McWilliams, MD, PhD; Ellen Meara, PhD; Alan M. Zaslavsky, PhD; John Z. Ayanian, MD, MPP
Acknowledgment: The authors thank Katherine Swartz, PhD, for helpful comments on an earlier draft of this manuscript.
Grant Support: By The Commonwealth Fund (grant no. 20060485).
Potential Financial Conflicts of Interest:Consultancies: E. Meara (Employment Policies Institute).
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. McWilliams (e-mail, email@example.com). Data set: Available at http://www.cdc.gov/nchs/nhanes.htm.
Requests for Single Reprints: John Z. Ayanian, MD, MPP, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, email@example.com.
Current Author Addresses: Drs. McWilliams, Meara, Zaslavsky, and Ayanian: Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115.
Author Contributions: Conception and design: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Analysis and interpretation of the data: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Drafting of the article: J.M. McWilliams.
Critical revision of the article for important intellectual content: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Final approval of the article: J.M. McWilliams, E. Meara, A.M. Zaslavsky, J.Z. Ayanian.
Statistical expertise: J.M. McWilliams, E. Meara, A.M. Zaslavsky.
Obtaining of funding: J.M. McWilliams, J.Z. Ayanian.
Administrative, technical, or logistic support: J.M. McWilliams.
Collection and assembly of data: J.M. McWilliams.
McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in Control of Cardiovascular Disease and Diabetes by Race, Ethnicity, and Education: U.S. Trends From 1999 to 2006 and Effects of Medicare Coverage. Ann Intern Med. 2009;150:505-515. doi: 10.7326/0003-4819-150-8-200904210-00005
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© 2016
Published: Ann Intern Med. 2009;150(8):505-515.
Appendix: Classification of Clinical Conditions
Efforts to improve the care of cardiovascular disease and diabetes or expand insurance coverage for adults with these conditions may reduce differences in clinical outcomes.
To assess recent national trends in disease control, trends in sociodemographic differences in control, and changes in sociodemographic differences after age 65 years associated with near-universal Medicare coverage.
Observational and quasi-experimental analyses of repeated cross-sectional data.
National Health and Nutrition Examination Survey, 1999 to 2006.
Adults age 40 to 85 years with relevant clinical conditions.
Blood pressure control (<140/90 mm Hg) and mean systolic blood pressure among adults with hypertension (n = 4521); glycemic control (hemoglobin A1c levels <7.0%) and mean hemoglobin A1c levels among those with diabetes (n = 1733); and total cholesterol level control (<5.2 mmol/L [<200 mg/dL]) and mean total cholesterol levels among those with coronary heart disease, stroke, or diabetes (n = 2928). Temporal trends in these measures were compared by race, ethnicity, and education, and sociodemographic differences were compared above and below eligibility for Medicare at age 65 years.
Disease control improved significantly between 1999 and 2006 for all 6 measures (P < 0.001). These trends did not differ by race or ethnicity or by education (P ≥ 0.185 for group–time interactions), except that white–Hispanic differences in glycemic control widened (P = 0.042). Black–white differences in systolic blood pressure were smaller among adults age 65 to 85 years than among adults age 40 to 64 years (reduction in difference, 4.2 mm Hg; P = 0.009). Black–white differences in hemoglobin A1c levels were also smaller after age 65 years (reduction in difference, 0.7%; P = 0.005), as were Hispanic–white differences (reduction in difference, 0.7%; P = 0.007) and differences between less and more educated adults (reduction in difference, 0.5%; P = 0.033).
Data were cross-sectional, and estimates may have been biased by coincidental events at age 65 years, such as retirement, that may affect disease control.
Control of blood pressure and glucose and cholesterol levels has improved since 1999 for adults with cardiovascular disease and diabetes, but racial, ethnic, or socioeconomic differences have not narrowed significantly. Medicare coverage after age 65 years is associated with reductions in these differences.
The Commonwealth Fund.
Acquiring health insurance and getting better quality of care could reduce health care disparities. The relative importance of these 2 factors is unknown.
To measure changes in chronic disease control, the authors used blood pressure, hemoglobin A1c, and total cholesterol measurements that were obtained from participants in the 1999 to 2006 National Health and Nutrition Examination Survey. Disease control improved over 8 years, but gaps between white and nonwhite patients did not change. The gaps were smaller after age 65 years, when universal Medicare insurance begins.
Each annual National Health and Nutrition Examination Survey enrolled different persons.
Access to care through universal health insurance reduced disparities in chronic disease control; improved quality of care did not affect sociodemographic differences.
—The Editors
In 3 comprehensive reports since 2001, the Institute of Medicine has advanced recommendations to expand access (1), improve quality (2), and eliminate disparities in health care (3). Although widespread deficits in the quality of care have been reported in the United States (4), some evidence suggests that quality of care has improved in the past decade (5–8). More consistent efforts to provide high-quality care may also reduce racial, ethnic, and socioeconomic differences in health (9). However, quality improvement may not necessarily lead to more equitable care (5, 10, 11), especially if improvements occur among providers who serve fewer disadvantaged patients (12–18) or if new financial incentives to improve quality have unintended, detrimental consequences (18–20). Furthermore, better performance and smaller racial differences in processes of care for cardiovascular disease and diabetes have not been consistently associated with reduced racial differences in clinical outcomes, such as control of cholesterol or glucose levels (8, 21, 22). Although overall disease control in the United States may be improving for some measures (23–25), recent national trends in sociodemographic differences in control have not been comprehensively assessed.
Insurance coverage may be an important mediator of sociodemographic differences in control of cardiovascular disease and diabetes (3, 26). Racial and ethnic minorities and adults of lower socioeconomic status are much more likely to be uninsured (27), and uninsured adults are much less likely to receive basic clinical services for these conditions (28). Near-universal Medicare coverage after age 65 years has been associated with decreased racial and socioeconomic differences in self-reported general health status and receipt of mammography (29, 30). Recent longitudinal studies also suggest that acquiring Medicare coverage increases use of health services and improves self-reported health outcomes for previously uninsured adults with cardiovascular disease or diabetes (31–33). However, previous studies have not assessed the effects of increases in insurance coverage on racial, ethnic, and socioeconomic differences in clinical measures of disease control.
Our primary objectives were to assess national trends from 1999 to 2006 in blood pressure control (for adults with hypertension), glycemic control (for adults with diabetes), and cholesterol level control (for adults with coronary heart disease, stroke, or diabetes); to analyze concomitant changes in differences by race, ethnicity, and education for each of these measures; and to evaluate whether these differences narrow after age 65 years with Medicare coverage.
We analyzed serial cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative study designed to assess population health through interviews, physical examinations, and clinical testing (34). From 1999 to 2006, 41 474 noninstitutionalized adults and children were enrolled (average response rate, 81.4%), including oversamples of black adults, Mexican Americans, and adults age 60 years or older. Data have been released in four 2-year increments. Among participants who completed a standardized interview in English or Spanish, 39 352 (94.9%) had clinical examinations and testing, including 12 079 participants age 40 to 85 years.
We studied adults age 40 to 85 years who had at least 1 of the following conditions: diabetes, hypertension, coronary heart disease, or stroke (Table 1). If we assessed disease control only among those with self-reported diagnoses, improved diagnosis of less severe disease might bias estimates of time trends in disease control in a positive direction. Therefore, on the basis of relevant clinical testing, we identified and included adults with undiagnosed hypertension and diabetes so that disease control was consistently assessed among all prevalent cases (a detailed classification of conditions is in the Appendix).
Table 1.
Because the proportion of immigrant Hispanic adults varies by age and has increased over time (35) and because Hispanic immigrants experience different patterns of chronic disease care and outcomes from those of U.S.-born Hispanic adults (36), we excluded 743 Hispanic adults (53.1%) who were born outside the United States, restricting all analyses to the U.S.-born Hispanic group (hereafter referred to as Hispanic). This restriction improved comparability of Hispanic samples over time and ensured that age-related differences in outcomes were not confounded by health differences between immigrant and U.S.-born Hispanic adults. In contrast, only 5.2% of white participants and 12.7% of black participants were born outside the United States. Results were similar when we excluded white and black immigrants in a sensitivity analysis. Finally, we excluded 202 participants who were not white, black, or Hispanic because samples for other groups were too small for statistical comparisons. The Human Studies Committee of Harvard Medical School approved our study protocol.
We used dichotomous and continuous measures of disease control to compare rates of control and mean levels, respectively, across groups. We assessed blood pressure control (average systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) (37) and average systolic blood pressure readings among participants with hypertension; glycemic control (hemoglobin A1c levels <7.0%) (38) and hemoglobin A1c levels among participants with diabetes; and cholesterol level control (total cholesterol level <200 mg/dL [<5.2 mmol/L]) (39) and total cholesterol levels among participants with coronary heart disease, stroke, or diabetes. We defined comparison groups by race or ethnicity (non-Hispanic black and Hispanic each vs. non-Hispanic white) or education (high school graduates vs. non–high school graduates). We also determined age, sex, ratio of family income to poverty threshold, body mass index (BMI), current smoking status, and insurance coverage from NHANES data.
We compared trends in disease control for each measure by using a linear model (E[Yi] = β0 + β1timei + β2groupi + β3timei × groupi), in which Yi is a dichotomous or continuous indicator of disease control for the ith individual; time is a chronologic index of the four 2-year survey periods ranging from 1 (1999 to 2000) to 4 (2005 to 2006); and group is an indicator of membership in a particular racial, ethnic, or educational comparison group. Thus, coefficients for the time-by-group interaction terms represent biennial trends (average change over 2-year periods between survey waves) in racial, ethnic, and educational differences in disease control from 1999 to 2006. We estimated overall trends by using simpler models without group variables. We also calculated rates of control and mean values for each of the four 2-year periods for reporting purposes.
We adjusted all reported estimates of rates and trends for age and sex. To determine whether trends in disease control were related to changes in other population characteristics, we also estimated overall trends that were further adjusted for race, ethnicity, education, income, BMI, smoking status, and insurance coverage. We did not adjust analyses of racial, ethnic, or educational differences in disease control for factors other than age and sex, because we were interested in overall differences that could result from many individual and health care system factors, rather than attributing differences to specific mediators, such as discrimination (40).
To estimate effects of near-universal Medicare coverage on sociodemographic differences, we compared racial, ethnic, and educational differences in systolic blood pressure, hemoglobin A1c levels, and total cholesterol levels before and after age 65 years. For example, to identify changes in racial differences in systolic blood pressure associated with Medicare eligibility, we fitted a linear model predicting mean systolic blood pressure as a function of black race, an indicator of age 65 years or older, and an interaction between these 2 predictors, with white adults serving as the reference group. We fitted similar models for each racial, ethnic, and educational comparison and for each outcome. We used measured values rather than dichotomous outcomes in these analyses to identify clinically important changes with greater sensitivity.
In our study, differences in mortality rates, time-varying characteristics, and use of cross-sectional data posed several challenges to interpreting age-related changes in sociodemographic differences in disease control. Older groups may have differed from younger groups in predictors of disease control other than age or insurance coverage, and these differences between age groups may have differed by sociodemographic characteristics.
Therefore, to estimate effects of Medicare coverage more robustly, we made several prespecified modifications to improve comparability of adults age 40 to 64 years with adults age 65 to 85 years. First, we adjusted for sex because the female share of the population increases with age. Second, we restricted analyses of hemoglobin A1c and total cholesterol levels to 1091 and 1877 participants, respectively, with relevant conditions diagnosed before age 65 years so that adults who developed conditions after age 65 years did not enter comparisons without appropriate comparators before age 65 years. Third, because age at diagnosis was not reported for hypertension, we added 1562 obese participants (BMI ≥30 kg/m2) to the sample of adults with diagnosed or undiagnosed hypertension. This addition captured those who did not have hypertension but were at increased future risk, thereby better approximating an aging cohort from serial cross-sectional samples.
These refinements to the study populations reduced selection bias in comparisons of sociodemographic differences in disease control by age eligibility for Medicare. For example, if hypertension developed at later ages for white adults than for black adults and was less severe or more easily controlled early in its course, limiting comparisons to participants with evident hypertension would disproportionately select elderly white adults with comparatively lower blood pressures into analyses, biasing estimated effects of Medicare coverage on racial differences in blood pressure control toward zero. The addition of obese adults (in effect pooling hypertensive adults with those at high risk for becoming hypertensive) made it more likely that effects of aging on disease control were similar for comparison groups, thereby allowing us to separate differential changes in control due to Medicare coverage from racial differences in age of hypertension onset. Furthermore, these modifications addressed potential bias from underdiagnosis of conditions among uninsured nonelderly adults, which would have caused disadvantaged participants to be disproportionately excluded before age 65 years (41). For example, if comparisons included participants with conditions diagnosed at any age but not undiagnosed cases, and if undiagnosed cases were poorly controlled, we would understate sociodemographic differences before age 65 years relative to differences after age 65 years.
In addition, we conducted 2 sensitivity analyses to determine whether differences in blood pressure, hemoglobin A1c levels, and total cholesterol levels changed in conjunction with Medicare coverage at age 65 years or evolved gradually over earlier or later ages. First, we restricted analyses to age 63 to 67 years to ascertain differences just before and after age 65 years. Second, we varied the cutoff for the age indicator variable from 61 to 69 years by 1-year increments to determine the age at which racial, ethnic, and educational differences in disease control changed most sharply.
We adjusted all analyses for the complex survey design (42) by using SAS, version 9.1 (SAS Institute, Cary, North Carolina), and SUDAAN, version 9.0 (Research Triangle Institute, Research Triangle Park, North Carolina). We used robust variance estimators (43) appropriate to the clustered survey design to test model coefficient estimates, obtain 2-sided P values, and construct 95% CIs.
This study was funded by The Commonwealth Fund. The funding source had no role in the design, conduct, or reporting of this study, nor in the decision to submit the manuscript for publication.
Table 1 summarizes sample sizes and selected characteristics of study samples with specific conditions. The prevalence of hypertension, coronary heart disease, and stroke (data not shown) did not change over the study period (P > 0.23 for tests of trend), but the prevalence of diabetes (diagnosed or undiagnosed) increased from 11.8% (1999 to 2000) to 13.7% (2005 to 2006) (P = 0.043 for trend), which is consistent with other data on diabetes trends (44).
Age- and sex-adjusted trends indicated significant improvements in control of blood pressure, hemoglobin A1c levels, and total cholesterol levels (Figure 1). From 1999 to 2000 to 2005 to 2006, absolute improvements in control rates ranged from 10.3% for blood pressure control among adults with hypertension to 21.0% for glycemic control among adults with diabetes. Estimates of biennial trends in disease control remained essentially unchanged after further adjustment for race, ethnicity, education, income, BMI, smoking status, and insurance coverage.
Rates are plotted by survey period with 95% CIs and fitted trends from linear models. Disease control improved significantly from 1999 to 2006 for all 6 measures (all P < 0.001). A. Age- and sex-adjusted rates of blood pressure control and mean systolic blood pressure among adults with hypertension. B. Age- and sex-adjusted rates of glycemic control and mean hemoglobin A1c levels among adults with diabetes. C. Age- and sex-adjusted rates of total cholesterol level control and mean total cholesterol levels among adults with coronary heart disease, stroke, or diabetes. To convert cholesterol values from mg/dL to mmol/L, multiply by 0.0259.
Pooled over 8 years, rates of blood pressure control were significantly lower and mean systolic blood pressure was significantly higher for black and Hispanic adults than for white adults with hypertension (Table 2). Among adults with diabetes, rates of glycemic control were significantly lower and mean hemoglobin A1c levels were significantly higher for black and Hispanic than for white adults. These racial and ethnic differences in disease control did not change statistically over the study period, except that differences in glycemic control between Hispanic and white adults widened significantly from 1999 to 2006 (Figure 2). Glycemic control was significantly worse for less educated adults than more educated adults with diabetes, and mean systolic blood pressure was significantly higher for less educated than more educated adults with hypertension (Table 2). These educational differences also did not significantly change over the study period (trends not shown). Among adults with coronary heart disease, stroke, or diabetes, total cholesterol level control and mean total cholesterol levels did not differ by race, ethnicity, or education (Table 2).
Table 2.
Rates are plotted by race and ethnicity and survey period among adults with hypertension (A and B) and diabetes (C and D) with 95% CIs and fitted trends from linear models. Differences between black or Hispanic and white adults did not significantly change from 1999 to 2006 for any of the 4 measures of disease control, except differences in rates of glycemic control between Hispanic and white adults widened (P = 0.042). A. Age- and sex-adjusted rates of blood pressure control. B. Age- and sex-adjusted mean systolic blood pressure. C. Age- and sex-adjusted rates of glycemic control. D. Age- and sex-adjusted mean hemoglobin A1c levels.
On the basis of cross-sectional rates, age eligibility for Medicare was associated with increases in insurance coverage that were 6.6 percentage points greater for nonwhite than for white adults (P < 0.001) and 12.6 percentage points greater for less educated adults than for more educated adults (P < 0.001).
Most sociodemographic differences in mean systolic blood pressure, hemoglobin A1c levels, and total cholesterol levels among adults younger than 65 years were substantially smaller than those among adults age 65 years or older (Figure 3). Differences in systolic blood pressure between black and white adults with hypertension or obesity were significantly smaller among adults age 65 to 85 years than among adults age 40 to 64 years (Figure 3, A). Mean systolic blood pressure was slightly but significantly higher among less educated adults than among more educated adults before age 65 years (3.2 mm Hg [95% CI, 0.4 to 5.9 mm Hg]; P = 0.024), but this difference did not significantly change after age 65 years (data not shown). Systolic blood pressure did not significantly differ before age 65 years between Hispanic and white adults with hypertension or obesity.
All differences are displayed by age group; bars represent SEs. Higher values indicate greater disparities. Age groups are collapsed to reduce random variation, but narrower 5-year age intervals are shown adjacent to age 65 years to demonstrate notch effects. Differences among adults age 65 to 85 years were significantly smaller than those among adults age 40 to 64 years for systolic blood pressure (P = 0.009 for black–white comparison) and hemoglobin A1c levels (P < 0.001 for nonwhite–white comparison; P = 0.033 for comparison by education) and tended to be smaller for total cholesterol levels (P = 0.087 for comparison by education). Changes after age 65 years in black–white and Hispanic–white differences in hemoglobin A1c levels were equivalent, were each statistically significant, and were therefore combined into nonwhite–white differences to summarize. A. Differences in mean systolic blood pressure between black and white adults with hypertension or obesity. B. Differences in hemoglobin A1c levels between nonwhite and white adults with diabetes diagnosed before age 65 years. C. Differences in hemoglobin A1c levels between less and more educated adults with diabetes diagnosed before age 65 years. D. Differences in total cholesterol levels between less and more educated adults with coronary heart disease, stroke, or diabetes diagnosed before age 65 years. To convert cholesterol values from mg/dL to mmol/L, multiply by 0.0259.
For adults with diabetes diagnosed before age 65 years, racial, ethnic, and educational differences in hemoglobin A1c levels were significantly smaller among adults age 65 to 85 years than among those age 40 to 64 years (Figure 3, B and C).
Among adults with coronary heart disease, stroke, or diabetes diagnosed before age 65 years, educational differences in total cholesterol levels also tended to be smaller among adults age 65 years or older (Figure 3, D). Total cholesterol levels did not differ before age 65 years by race or ethnicity among adults with these conditions.
Several findings supported the robustness of these results related to the effects of Medicare. When comparisons were restricted to age 63 to 67 years, statistical trends (P < 0.100) remained for all significant reductions in group differences after age 65 years because these findings became even greater in magnitude than in comparisons of broader age groups. In addition, differential improvements in disease control for black, Hispanic, and less educated adults were greatest when group differences were compared before and after age 65, 66, or 67 years rather than other ages between 61 and 69 years.
In time–trend analyses of nationally representative data, blood pressure, glycemic, and cholesterol level control improved significantly from 1999 to 2006 for adults with cardiovascular disease or diabetes. Overall trends were not explained by changes in population characteristics, suggesting that management of cardiovascular disease and diabetes has improved considerably over this period. These improvements probably have prevented adverse outcomes, increased life expectancy, and provided considerable value to society (31, 32, 37–39, 45–52). However, improvements in disease control have not been associated with discernable reductions in racial, ethnic, or socioeconomic differences in blood pressure or glycemic control, and gaps in glycemic control between white and Hispanic adults with diabetes have widened. Therefore, to redress inequities in these health outcomes, quality improvement efforts focusing on disadvantaged groups and their health care providers or broader reforms to address social determinants of poor health are still needed (19).
In particular, because black, Hispanic, and less educated adults are much more likely to be uninsured or underinsured (27), expanding insurance coverage may be especially beneficial for these groups. With near-universal Medicare coverage after age 65 years, differences in systolic blood pressure, hemoglobin A1c levels, or total cholesterol levels reduced substantially. These reductions may substantially decrease racial and socioeconomic differences in mortality as well (53, 54). For example, 1 study estimated that eliminating racial differences in mean systolic blood pressure might reduce deaths from heart disease or stroke by more than 7500 annually among black adults (55).
Our findings are consistent with previous studies that used experimental or quasi-experimental designs to assess effects of insurance coverage on health outcomes for adults with cardiovascular disease or diabetes (32, 56–58). Thus, differences in insurance coverage before age 65 years may contribute substantially to sociodemographic differences in health. Sociodemographic comparisons of self-reported insurance coverage at the time of surveys suggested that diminished sociodemographic differences in disease control after age 65 years were due to narrowed gaps in coverage between groups. However, near-universal Medicare coverage after age 65 years probably improved disease control for greater numbers of elderly black, Hispanic, and less educated adults than these comparisons suggested because insurance status was only assessed at the time of surveys. For example, if the greater reduction in mean hemoglobin A1c levels after age 65 years for nonwhite adults relative to white adults (−0.7%) was due entirely to their 6.6% greater increase in cross-sectional rates of coverage after age 65 years, this would imply an implausibly large reduction in mean hemoglobin A1c levels (−0.7%/0.066 = −10.6%) concentrated in a relatively small group of nonwhite adults. Therefore, black, Hispanic, and less educated adults who are underinsured or intermittently uninsured may also benefit from gaining Medicare coverage (32, 59–61).
Strengths of our study included nationally representative data with standardized measurements of clinical outcomes to compare recent trends in disease control and a rigorous study design to assess effects of Medicare coverage on racial, ethnic, and socioeconomic differences in disease control. We searched the clinical literature on PubMed through October 2008 using combinations of keywords relating to health care disparities, uninsurance, and relevant clinical conditions to identify studies similar to our study. We found no previous quasi-experimental studies of the effects of Medicare coverage on sociodemographic differences in disease control. Furthermore, by comprehensively examining recent national trends in racial, ethnic, and socioeconomic differences through 2006, our study builds on previous research that found persistent or widening differences in some measures of disease control over previous decades (10, 62–64) or assessed more recent overall trends in blood pressure, glycemic, and cholesterol level control (23–25, 65).
Limitations of our study included several potential sources of bias. Because we assessed trends in disease control across serial cross-sectional samples, we could not adjust for mortality rate trends that may have differentially altered the distribution of outcome measurements for certain sociodemographic groups. For example, improved care for black adults with hypertension may have decreased cardiovascular mortality among this group with worse disease control, thereby enabling them to survive longer and possibly masking underlying improvements in disease control for lower-risk black adults. However, from 2000 to 2004, age-adjusted annual rates of death from ischemic heart disease, cerebrovascular disease, or diabetes decreased similarly for white (−48 deaths per 100 000 persons), black (−52 deaths per 100 000 persons), and Hispanic (−47 deaths per 100 000 persons) adults (35). Therefore, persistent racial differences in disease control were unlikely to be explained by differential mortality trends.
In assessing the effects of Medicare coverage on sociodemographic differences in disease control, we used a quasi-experimental design to control for racial, ethnic, or educational differences in observed or unobserved characteristics that remained fixed across age groups. This strategy assumed that predictors of disease control other than insurance coverage did not change more after age 65 years for 1 comparison group than for another. Two potential sources of bias threatened this assumption. First, sociodemographic comparison groups did not comprise the same persons at different ages. Rather, the composition of comparison groups in our study could have changed with age differently for different groups because cross-sectional samples of younger and older participants were selected on the basis of the presence of clinical conditions when surveyed. To address this limitation, we modified inclusion criteria to improve comparability across age groups and distinguish effects of Medicare coverage from differences in disease control related to age of disease onset.
Second, even in longitudinal cohorts, time-varying characteristics, such as employment, may change with age differently for different groups, and death may lead to selective attrition. Our sensitivity analyses suggest that these potential confounding effects would have to coincide directly with Medicare eligibility at age 65 years to bias our results substantially. For example, although differential premature mortality might improve average disease control among survivors in some groups, only a spike in deaths immediately before age 65 years among black, Hispanic, and less educated adults could account fully for the reduced differences in disease control associated with age eligibility for Medicare. Because mortality rates increase steadily with age, including the years surrounding age 65 years (29), such a spike in deaths is unlikely. Furthermore, events that more plausibly might coincide with Medicare eligibility, such as retirement and receipt of social security benefits, occur at similar rates for adults with different sociodemographic characteristics or previous insurance coverage (29, 32).
Our study lacked data about health care providers and organizations to explore potential mediators of improved disease management (66–75). In addition, we used self-reported diagnoses to define study populations. Previous studies have found good overall concordance between self-reports and diagnoses established from medical records or other clinical data, with self-reported measures exhibiting high specificity and moderate sensitivity (76–78). A previous NHANES analysis found self-reported hypertension to have a specificity of 90% to 95%, suggesting few false-positive diagnoses (79). By including undiagnosed cases in our study, we improved the sensitivity of these measures.
In examining trends in disease control, we selected clinical targets currently recommended by national guidelines and used to measure health system performance. However, these indicators do not reflect changes in disease prevalence. Gains in disease control may be offset by increases in disease prevalence so trends in national rates of uncontrolled disease are also important to assess. Because the prevalence of cardiovascular disease was stable over the study period, improvements in blood pressure and cholesterol level control also meant net public health gains. Despite the increase in diabetes prevalence, substantial improvements in glycemic control also lowered the rate of uncontrolled diabetes (disease prevalence × [100 − control rate]) from 7.3% in 1999 to 2000 (11.8% × [100 − 38.1%]) to 5.6% in 2005 to 2006 (13.7% × [100 − 59.1%]), which is a 23.3% relative reduction.
Our study was adequately powered to detect small overall improvements in disease control but not small changes in differences over time. In particular, the significant gap in blood pressure control between Hispanic and white adults may have narrowed somewhat, but sample sizes were not sufficient to assess an effect of this size. Nonetheless, we observed that other significant differences in blood pressure and glycemic control grew larger or remained essentially unchanged, including differences in mean systolic blood pressure between Hispanic and white adults, thereby bolstering our conclusion that national improvements in disease control were not accompanied by consistent reductions in racial, ethnic, or socioeconomic differences. Moreover, the difference in glycemic control between Hispanic and white adults significantly widened among adults with diabetes—the smallest of our 3 study populations.
Our study has important policy implications. Control of blood pressure, hemoglobin A1c levels, and total cholesterol levels has improved substantially for adults with cardiovascular disease and diabetes in the United States since 1999, which suggests that recent efforts to improve quality of care for these conditions have yielded widespread benefits. However, racial, ethnic, and socioeconomic differences in blood pressure and glycemic control have persisted or widened, suggesting that more focused efforts are needed to improve the quality of care for black, Hispanic, and less educated patients. Because age eligibility for Medicare coverage was associated with significant narrowing of differences in disease control, expanding insurance coverage before age 65 years may reduce racial, ethnic, and socioeconomic differences in important health outcomes for adults with cardiovascular disease and diabetes.
Participants were considered to have hypertension if they reported taking antihypertensive medication for high blood pressure or had a systolic blood pressure of 150 mm Hg or greater or a diastolic blood pressure of 95 mm Hg or greater when averaged over 1 to 3 readings taken during a single examination session (80). We used this higher diagnostic threshold to distinguish persons who were likely to have undiagnosed hypertension from those with isolated mild elevations. Participants were classified as having diabetes if they reported a diagnosis of diabetes or had a hemoglobin A1c level greater than 7.0%. We did not use measurements of fasting blood glucose levels to define undiagnosed diabetes because fewer than half of participants were fasting at the time of their examination. Participants reporting borderline diabetes (n = 198) were also included because 21.7% of them were taking insulin or oral medications for diabetes or had elevated hemoglobin A1c levels. Participants reporting diagnoses of coronary heart disease, myocardial infarction, or angina were classified as having coronary heart disease, and reported diagnoses were similarly used to classify participants as having a history of stroke.
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James P. Scanlan
James P. Scanlan, Attorney at Law
November 28, 2009
Article on disparities in control of cardiovascular disease and diabetes raises several measurement issues
McWilliams et al.(1) analyze changes in disparities in dichotomous and continuous measures of control of cardiovascular disease and diabetes from 1999 to 2006 and the effects of Medicare coverage on these disparities. Three aspect of their analysis warrant comment.
First, the authors analyze the size of disparities in control rates in terms of absolute differences between rates. The analysis is flawed for failure to consider the way absolute differences between outcome rates tend to change solely because of changes in the overall prevalence of the outcome -- as I have discussed with respect to similar flaws in the references nos. 8, 11, and 20-22 of the article ([2-7). See also Houweling et al. (8), which similarly recognizes the patterns of correlations between absolute differences and the overall prevalence of an outcome and the need to consider overall prevalence in appraising the meaning of standard measures of differences between outcome rates. For research of this nature to be of value, it is necessary to appraise disparities between outcome rates in terms of measures that are unaffected by the overall prevalence of the outcome, such as that described in references 9 and 10, which derives differences between means of underlying risk distributions based on outcome rates (9,10).
But, in any case, it is not useful to analyze disparities in terms of absolute difference or other measures of differences between outcome rates that are affected by the prevalence of the outcome without even addressing the measurement issues. Notably, in observing that they are building on further work that found persistent or widening healthcare disparities in recent years, the authors cite the National Healthcare Disparities Report. But the National Healthcare Disparities Report not only relies on relative differences between rates rather than absolute differences, but relies on whichever relative difference (in the favorable or the adverse outcome) is the larger. Thus, as explained in references 2, 6, and 7 (and their corrections), as well as 10-12, with regard to the appraisal of the directions of changes in the size of disparities over time, the approach of the National Healthcare Disparities Report tends toward reaching exactly the opposite conclusions of those reached by researchers who rely on absolute differences (allowing, of course, that meaningful changes may counter the patterns that are solely statistically driven)(10-12).
Second, the authors also analyze the size of disparities in terms of continuous measures, including differences between average systolic blood pressure levels and average hemoglobin A1c levels. Such an approach may well avoid the problems associated with the ways that absolute differences and other standard measures of differences between outcome rates tend to be affected by the overall prevalence of an outcome. Where available data permit, such an approach -- making use, as it does, of the actual distributions of risk factors rather than a derived difference between means of a hypothetical risk distribution -- may well be much superior to the approach discussed in references 9 and 10.
But the most useful way to measure differences between means is by deriving an effect size from the arithmetic difference between means divided by the standard deviation (either the pooled standard deviation or that of one group or the other). The authors instead simply discuss the changes in terms of changes in the arithmetic differences between means. The authors highlight what they term a "0.7%" reduction in the race or ethnic difference and a "0.5%" reduction in the education difference for subjects over 65 compared with those under 65. The former reduction was from an absolute difference between mean levels of 0.9 percentage points to one of 0.2 percentage points; the latter was from 0.6 percentage points to 0.1 percentage points. Thus, allowing that the standard deviation serving as the denominator in the effect size fractions may differ somewhat for the 45 to 64 group and the over-65 group (NHANES 2005 data, which happen to be at hand, show a standard deviation of 1.23 for the former group and 0.94 for the latter group), these figures suggest a very substantial reduction in the disparity. The magnitude of such reduction is hardly reflected in the "0.7%" and "0.5%" figures used by the authors, even if such figures reflect valid measures.
Third, while the authors generally rely on percentage point difference and percentage point changes in figures, they almost invariably describe an "x percentage point" change as an "x%" change. Whether or not the latter usage is even technically correct, most readers regard an "x%" change as a percentage change not a percentage point change. The authors themselves in endeavoring to be clear in their discussion of the implications of differential increases in insurance coverage refer to a "6.6 percentage point" difference in increases in coverage rates. The entire article would be much clearer if discussion of absolute differences between percents were invariably described as percentage point differences rather than percent differences (13).
1. McWilliams JM, Meara E., Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education, U.S. trends from 1999 to 2006 and effects of Medicare coverage. Ann Int Med. 2009;150:505-515.
2. Scanlan JP. Effects of choice measure on determination of whether health care disparities are increasing or decreasing. Journal Review May 1, 2007 (responding to Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692-700, and two other articles in the same issue): http://journalreview.org/v2/articles/view/16107620.html
3. Scanlan JP. Understanding patterns of absolute differences in vaccination rates in different settings. Journal Review Apr. 22, 2008 (responding to Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: Does managed care narrow the gap between blacks and whites? JAMA 2001;286:1455-1460): http://journalreview.org/v2/articles/view/11572737.html
4. Scanlan JP. First learn to measure healthcare disparities. Health Affairs Mar. 12, 2008 (responding to Casalino LP, Elster A, Eisenberg A, et al. Will pay-for-performance and quality reporting affect health care disparities? Health Affairs 2007;26(3):405-414):: http://content.healthaffairs.org/cgi/eletters/26/3/w405
5. Scanlan JP. Inclusion of healthcare disparities issues in pay-for -performance programs should await development of reliable means of measuring changes in disparities over time. Journal Review Feb. 16, 2008 (responding to Casalino LP, Elster A, Eisenberg A, et al. Will pay-for- performance and quality reporting affect health care disparities? Health Affairs 2007;26(3):405-414): http://journalreview.org/v2/articles/view/17426053.html
6. Scanlan JP. Understanding the ways improvements in quality affect different measures of disparities in healthcare outcomes regardless of meaningful changes in the relationships between two distributions of factors associated with the outcome. Journal Review Aug. 30, 2007 (responding to Sequist TD, Adams AS, Zhang F, Ross-Degnan D, Ayanian JZ. The effect of quality improvement on racial disparities in diabetes care. Arch Intern Med 2006;166:675-681): http://journalreview.org/v2/articles/view/16567608.html
7. Scanlan JP. Understanding patterns of correlations between plan quality and different measures of healthcare disparities. Journal Review Aug. 30, 2007 (responding to Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Relationship between quality of care and racial disparities in Medicare health plans. JAMA 2006;296:1998-2004):: http://journalreview.org/v2/articles/view/17062863.html
8. Houweling TAJ, Kunst AE, Huisman M, Mackenbach JP. Using relative and absolute measures for monitoring health inequalities: experiences from cross-national analyses on maternal and child health. International Journal for Equity in Health 2007;6:15: http://www.equityhealthj.com/content/6/1/15
9. Solutions sub-page of Measuring Health Disparities page of jpscanlan.com http://www.jpscanlan.com/measuringhealthdisp/solutions.html
10. Can We Actually Measure Health Disparities?, presented at the 7th International Conference on Health Policy Statistics, Philadelphia, PA, Jan. 17-18, 2008: Oral Presentation: http://www.jpscanlan.com/images/2008_ICHPS_Oral.pdf; PowerPoint Presentation: http://www.jpscanlan.com/images/2008_ICHPS.ppt
11. Measurement Problems in the National Healthcare Disparities Report, presented at American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, Nov. 3-7, 2007: PowerPoint Presentation: http://www.jpscanlan.com/images/APHA_2007_Presentation.ppt; Oral Presentation: http://www.jpscanlan.com/images/ORAL_ANNOTATED.pdf; Addendum (March 11, 2008): http://www.jpscanlan.com/images/Addendum.pdf
12. Scanlan JP. Study illustrates ways in which the direction of a change in disparity turns on the measure chosen. Pediatrics Mar. 27, 2008 (responding to Morita JY, Ramirez E, Trick WE. Effect of school-entry vaccination requirements on racial and ethnic disparities in Hepatitis B immunization coverage among public high school students. Pediatrics 2008;121:e547-e552): http://pediatrics.aappublications.org/cgi/eletters/121/3/e547
13. Percentage Points sub-page of Vignettes page of jpscanlan.com: http://www.jpscanlan.com/vignettes/percentgepoints.html
None declared
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text:
Officials at a Milwaukee-area Sikh temple where six people were killed last year say they aimed for fairness when they distributed the $1.1 million in donations that poured in from around the world.
The victims included a 41-year-old woman who was her family's primary breadwinner, and an 84-year-old man who retired decades ago. That raised questions about whether each family deserved equal compensation.
In the end, temple members agreed not to place values on life. Each of the victims' families got equal shares of more than $125,000.
Some of the families relocated from India after the shooting, and they've used the money for food, rent and other essentials.
Families of the wounded got lesser amounts.
Monday is the one-year anniversary of the shooting at the Sikh Temple of Wisconsin.


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Springfield, Ill. Just two and half months after being
appointed, the new Illinois State Board of Education (ISBE)
and State Schools Superintendent have reached a tentative
agreement on a four-year contract with the American Federation
of State County and Municipal Employees (AFSCME) Council 31
Local #2811. The members of AFSCME Council 31 Local #2811,
who had been working without a contract since July 1, 2004,
will vote on the contract in the next few weeks.
Were pleased that we quickly reached a contract
agreement that is both fair to State Board of Education workers
and responsible, given the states financial difficulties,
said Interim State Superintendent Randy Dunn. We believe
the agreement is a good foundation for a strong partnership
between the new State Board and our employees and I would
like to thank the men and women involved in the negotiations
for their hard work. We look forward to the contracts
The new administration at ISBE came in with a goal
to quickly reach an agreement that provides a fair and equitable
contract for both parties, said AFSCME Council 31 Local
#2811 President Sharon Hopson.
Details of the tentative agreement will not be available
until it is ratified by members of AFSCME Council 31 Local
#2811. After the Local #2811 has ratified the contract, the
State Board of Education will formally approve the agreement.
Illinois State Board of Education
100 North First Street
Springfield, IL 62777


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WEF Discussion Forums
Laboratory Management and Technical Issues
seeding high strength BOD's
Hello, we have an industrial user which uses waste potato starch in their process. They have very high BOD's. We normally don't seed their samples when performing BOD's and typically get results in the 5,000 to 10,000 range. We recently split a sample with an outside lab who did seed the samples and they got results which were about 2X higher than ours. My question is whether the reason for lower BOD's is that the our BOD dilutions are biology limited. That is there is not enough natural seed to take up the required BOD? We are seeing final DO's greater than 1 mg/l on our dilutions so this dosen't seem real possible, but just wondering.
Thank You.
I would say, yes you need to seed the samples. I think the starch will have some chemical activity of its own and oxidize even without the presence of the bugs. At the very least i would set up a batch or two of the samples with seed and without seed to compare in your facility the differences in the two. I would not put too much stock in a one time doubled result from a different lab. Interlab comparison on anything other than G:Ga (or some other stable chemical) for BOD is about as close to meaningless as you can get without being insulting.
There is a tendency to think that the BOD of a sample is somehow related to the need to seed (e.g., high BOD, no need to seed). You can have very high BOD, and essentially no seed. Consider a GGA sample that you prepared to be somewhere between 5000 and 10000 (more or less what you are testing, Donald, except that your sample contains primarily starch rather than glucose and glutamic acid). Would you seed that GGA sample? Of course you would.
The best rule to follow is that unless you KNOW the sample already has sufficient seed (for example, as a domestic influent normally does), you must seed.
So why do you get ANY oxygen depletion on the potato waste sample? There are always sufficient bacteria floating around where the sample was taken and in your lab to provide some depletion. I once inspected a lab that never seeded the GGA sample and got an average in the 180s with good precision. Doesn't say much for the cleanliness of the lab!
I see your point Perry. My opinion was always to seed these samples because the industrial process which the starch is subjected to is high temp and pressure before it is sent to our sanitary system. I just did not think it was plausible for any bacteria to survive, however because we were getting decent depletions w/o seeding we stoped seeding. Given the importance in getting a representative BOD value for which to bill this industry, I think our practice now will be to seed, however I think for the sake of curriosity I will also do what dsmith suggests and compare some seeded vs unseeded samples.
Thanks for all your help.
Please post the results of your seeded vs unseeded BODs for us. We have an ice cream plant and we never seeded the BOD for their discharge. Reading the responses here I can see that we should have.
Good plan, Donald, to compare seeded to unseeded results. If you would like to put a small wager on the outcome, let me know!
I'd be more than happy to post the results. As for placing any kind of a wager with Perry on anthing having to do with BOD results, I'd have to be nuts


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If we can get Barea, that would be nice.
Wolves GM David Kahn is in talks with the Knicks about a trade, according to Darren Wolfson of 1500 ESPN Twin Cities, though it's unclear which players are being discussed (Twitter link). Wolfson tweets his suspicion that Ronnie Brewer could be headed to Minnesota, but that appears to simply be an educated guess, as the Wolves made an offer to Brewer over the summer before he signed with the Knicks. Both teams have full rosters with 15 players, limiting flexibility, but the Knicks may be looking to add depth to their front line, while the injury-depleted Wolves could use some healthy bodies.
Wolfson speculates via Twitter that a long list of Knicks, including Carmelo Anthony, Tyson Chandler and Jason Kidd, are probably off-limits in any trade conversations. The Knicks are a taxpaying team while the Timberwolves are well below the tax line, but given that New York is in title contention while Minnesota is probably looking toward next season, I don't think the Knicks are looking to pawn off any salary. Coincidentally, the Knicks are one of a few teams that reportedly has interest in Lou Amundson, whom the Wolves just waived.
The Wolves have been shopping Luke Ridnour, according to Chris Sheridan of SheridanHoops.com, but the Knicks, like the Wolves, seem set at point guard, with Raymond Felton, Kidd and Pablo Prigioni around to man the position. The Wolves' most glaring need seems to be at the two, and while shooting guard Iman Shumpert's name has been linked to the Suns, it appears that rumor came from Phoenix's side.
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If we can get Barea, that would be nice.
I'd much rather have Ridnour over Barea, for our team. I like Barea a lot but Ridnour definitely has the superior court awareness and passing ability. We have enough dudes who can bomb 3's.
This would be a good trade for us to guard against injury, and I'm not surprised they are thinking along these lines. Felton has missed enough games already and Kidd has been banged up/tired all year. Not to mention Felton has sustained minor injuries twice since returning from his last spell on the sidelines, it's looking increasingly likely he will miss more time this year
either one, Barea or Ridnour would be an upgrade over Brewer, who has sunk
to the depths of garbage time bench. personally, I like Barea better, I think
he'd fit in well with team, with NYC, with spanish contingent, and he drives much
better into the paint and can create.
However, I believe Ridnour possesses more court smarts and is capable of
putting up bigger numbers and hitting threes, but i may be wrong, I think
Luke's just had more minutes this year. Barea was absolutely killing it last year.
I know Knicks were looking at Luke last year or year before, and you know
the garden crowd is going to love chanting LUUUUUUUUUUUKE!
go for it.
Brewer for anybody, tired at looking at his ugly FT shooting. He has to have the worst form shooting FTs in the league.
Barea with Terry in Dallas [2011] was main factor of devastation front court of Heat.
i also heard that they will add Novak anyway maybe u all not but i still like Novak not only his 3s but his ft %
Get Brewer,Novak, and Copeland the hell off this team. I don't care who for
Woody again making no rotation just STAT JR and Novak what about others where is Brewer Copeland White Thomas
they sweept Spurs twice almost same marging pts Wolves 1st time since almost 10 years there were fighting with BKN
but since last few games this is just average team.
Heat coming to town beggining of march it will be totaly tsunami of heat @ knicks floor
Ill take Barea for JR any day of the week .... Barea is an uptempo PG/SG that will look for inside scoring rather than ISO-Melo peremeter shooting. We need inside scoring, and rid ourselves of all this Damnphoney peremeter-shooting.
Brewers & Novak skills & talent as an offense/defense weapon is great to have in a postseason series.
We Knicks-Fans should not analyze Brewer, or Novak, or Shump, or Felton, or Amare's talents when u see them in a lineup that has Melo & JR .. Chuancey Billups took the Denver Nuggets to the WCF by eliminatiing the ISO-Melo/JR system
Jeremy Lin's turnovers were never mention or cared about, because Lin gave us 10 extra shots per game, plus we had more defensive-stops than all our oponents. All that stop the day we put a no-running halfcourt peremeter shooter JR.smith in the rotation. Before signing JR.smith we had a running-Novak & running-Shump playing the role JR is playing now...
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I think the praise that Woodson gets is not warranted. He has done a better job then Dantonio but again if the goal is to get to a championship he is starting to fail. We lose to these crappy teams and we do not even show up....
At the start of the season when we were hot we did not go to the MELO/Jr iso game. Now in our falling apart stage its almost everytime down the court its the samething....Ball to JR or Ball to Melo and watch them do their thing....
I think Melo is an incredible player but when he is playing ISO all the time it takes away from other aspects of his game...mainly defense.......I mean why is MELO bringing up the ball more then half the time ??
JR is and always will be a hit or miss player....Love him some games and hate him others.....THE issue is WOODSON.....As he did last year in the playoffs he coaches scared. Whenever things get rough he is afraid to make subsitiutions.....He would rather have Melo or JR just keep shooting and hope one gets hot......This takes everyone out of rythm and puts enormous pressure on MELO and JR....
Woodson needs to coach more strategically...........The issue is does Woodson have it in him....
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"Fila-boy" Makes Good
Sometimes when I get really worked up, you probably forget that I am not just a simple, hateful man. There are many things I appreciate. This is not true about Notre Dame since there is absolutely nothing redeeming about that school and I consider Rudy to be nothing more than Catholic propaganda. But, despite a dogmatic insistence on my hatred of the Yankees, let us consider them for a second.
Growing up in a small town outside of Kalamazoo, MI, I admired Derek Jeter. This wasn't true of my whole family. My brothers routinely referred to him as "Fila-boy" because for some reason he had an endorsement deal with that shoe company and always wore them. I think their dislike of him has something to do with the leftover animosity those of us who come from German descent have for the Italians totally screwing the pooch in WWII. Seriously guys, you couldn't even hold on to North Africa? But, even though he was the golden boy and could seem to do no wrong and even though my brothers hated him, I always had a special place in my heart for Jeter.
I don't know, maybe it's just me but he always seemed to hustle a little more than the other guys, to work a little harder to prove that he belonged there. Even though he was a Yankee, he didn't have that same air of entitlement that guys like A-Rod seemed to possess. And maybe that's just me projecting but when you're coming from the same area in the middle of nowhere in Michigan, it's nice to see someone who made it out.
So, I still stand by my guns and there is no way I will ever cheer for the Yankees (unless one of those guns happens to be pressed up against the side of my head). But Derek Jeter? The guy's a class act. Kalamazoo Central class of 1992, in fact. See, I'm not all bad.
12 Comments
We are trying to do our part to not be the team that gives up that record hit.
So far in this series "Fila-boy" is 0-14 against Rays pitching.
But seriously, the guy will get the record, and Kalamazoo, Michigan can be proud of its extended family son.
In reality, he is one of the guy on that pinstripe team I could root for, but do not for logical AL East reasons.
Role model, dating models, even plastic baseball models of him hitting can make some one wish they were him for a day.
And if he marries Mika……………maybe more than a week.
Rays Renegade
Alan, The Kid from Kalamazoo has done purty darn well for himself. And it's probably those core values he got in Central Michigan that have him in a funk right now as he approaches such a remarkable accomplishment… I mean, eclipsing an absolute Legend. He's probably shocked he's doing it.. ; )
Yeah Jeter! Love him….he was born not far from me in NJ. So, to have survived that AND Kalamazoo…nice job man.
Allen we all appreciate the great things,
no one can ever hate Jeter:
for it is a Cardinal Sin.//
I myself am a Yankee hater:
but will never be a Derek hater.
Jeff get em back buddy.
New post up.🙂
Indians suck!!
–Ted "TTW/T" —
It is good to see someone come out of 'nowhere' Michigan and make good. I, for one, move from 'nowhere' up north to 'BFE', Michigan where it is a lot colder and no Miejer stores. I wonder Jeter went to the K-Wings games as a kid-maybe we even played together. ????
Hilarious, but I dont think Jeter's Italian, is he? wiki says his mom is of Irish/Greman descent.
A day where D'hacks comes out of the woodwork and comments on our page is a day of celebration indeed. How ya been, Matt? That Reynolds kid sure can strike out — er, I mean, hit homeruns.
I'm sure Jeter can feel your love, Allen. And I bet he's sending it back with a huge hug. Aw, now I'm crying again.
Allan – somehow don't think you'd cheer for the Yankees even if that gun was pointed at your head! Good job to Jeter. The way he's been playing there's no wonder that the records are falling fast.
I was not aware of his roots from nowhere, Michigan :p that actually puts things into perspective much more. Always nice when a star comes from some random town and fills some great shoes.
wow! I had never seen that card and at first I was "No, that can't be Jetter!" But holy cow it is! What a cute picture!
It's a Beautiful Day for a Ballgame,
for a ballgame, today.
The fans are out to get a ticket or two
From Walla Walla, Washington to Kalamazoo!
congrats Jeter!


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The star cluster Hodge 301 is 20 million to 25 million years old. Hodge 301 is home to many aging, red supergiant stars, indicating the cluster is older. Roughly 40 massive stars already have exploded as supernovas. The expanding wave of debris is slamming into gas ejected by stars in R136, creating a ridge of star formation between the two clusters. The fledgling stars are embedded in dense gas and cannot be seen.
30 Doradus is the brightest, nearby star-forming region and home to the most massive stars in our cosmic neighborhood of about 25 galaxies. The nebula is close enough to Earth that Hubble can resolve individual stars, giving astronomers important information about the stars' birth and evolution. 30 Doradus resides 170,000 light-years away in the Large Magellanic Cloud, a small, satellite galaxy of our Milky Way.
Object Names: Tarantula Nebula, 30 Doradus, 30 Dor, NGC 2070
Image Type: Astronomical
Credit: NASA, ESA, D. Lennon and E. Sabbi (ESA/STScI), J. Anderson, S. E. de Mink, R. van der Marel, T. Sohn, and N. Walborn (STScI), N. Bastian (Excellence Cluster, Munich), L. Bedin (INAF, Padua), E. Bressert (ESO), P. Crowther (University of Sheffield), A. de Koter (University of Amsterdam), C. Evans (UKATC/STFC, Edinburgh), A. Herrero (IAC, Tenerife), N. Langer (AifA, Bonn), I. Platais (JHU), and H. Sana (University of Amsterdam)
To access available information and downloadable versions of images in this news release, click on any of the images below:


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Buy for$10.98(7 items)
The previously announced 2oth Anniversary DVD will be titled Forging The Land Of Thousand Lakes and is scheduled for relase in early June. It contains a full live concert, filmed in November 2009 at Club Teatria in Oulu/Finland.
Besides the standard version, there will be a limited Deluxe Edition, which in addition to the Oulu concert (also available in Dolby Digital 5.1) contains a bonus DVD featuring the complete Summer Breeze 2009 gig, a documentary titled Tales From The 20 Years, a collection of promo video clips and a photo gallery. Furthermore, the Deluxe Edition will include the Oulu gig in its entirety on two live CDs.
Written by Risto on 10.04.2010 at 12:41
Hahaha, "Against WINDOWS". The dangers of copy-paste...
Written by Troy Killjoy on 11.04.2010 at 03:40
Fixed... Nice eye!
Written by moe5512 on 18.07.2010 at 23:20
Got it this is actually the best live dvd ive ever seen :O
Written by NocturnalStalker on 11.04.2012 at 15:52
I only wish that the documentary had English subtitles as I don't know Finnish.
Written by Risto on 11.04.2012 at 16:00
There are English subtitles, you just have them turned off.


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He was only a dim memory until
my Aunties gave the letters to me.
A shoebox filled with weekly missives
from 1980 thru 1985
to sisters, Verna and Olive,
to be read, shared, & put in a shoebox
then tucked away in a drawer or on a closet shelf.
My Uncle Ralph never wrote to me
Each began the same,
Dear Olive & Norman,
or Dear Verna & Rowe.
Week in and week out
weather reports, 78 degrees,
from the ocean a nice breeze,
heavier than usual rains,
snow in the mountains
above 4000 ft.,
rain caused 12 car pile up
over by Del Mar,
each had a sameness
and ended with Love, Ralph & Sally
Ralph read 6 newspapers a day.
He dinna have much else to do,
what with old age and a bad knee from 1974.
He scoured each page for tidbits
to write about, to entertain his sisters,
a springboard for pages and pages of thoughts
on politicians (crooked),
world events (going to hell),
and the economy (good for the rich, but not the poor).
These were the thoughts
of an everyday kind of man who
read 6 newspapers a day.
Television was his friend.
He was on the pole at Del Mar & Santa Anita,
was in a front row seat
at a Padre's game,
instant replay for the Chargers,
and San Diego U Aztecs.
He yearned for cable tv,
he then could get all the games,
but said, "I hardly have time
to watch the games on local channels."
Television was his friend.
He was an everyday kind of guy.
Ranted and raved about crooked politicians,
kept track of cops on the take
and cops doing their duty with courage & bravery.
Sadly shook his head at conniving developers
and the ever increasing population
that clogged the streets, the freeways and malls.
He cried at man's inhumanity
that sawed off the beaks of Pelicans.
He enjoyed the annual Mother Goose Parade
as though he was yet a child.
He was an everyday kind of guy.
He was in his 80s
when he penned the last
of these boxes of kept letters,
but his memories of childhood,
family, snow storms & mountain roads
kept me enthralled.
Aunts & uncles whom I dinna know
became people with real lives.
Grandparents, who were old in my childhood
now had a history
so different than I ever imagined.
He was in his 80s when he penned these gifts.
His memories he gave to me;
he & his sister going to school,
in Madison's 5th Ward
where they had real teachers
and one who had taught their Mom too;
one room schools in Minnesota,
Grandpa driving delivery wagons,
buying and selling horses,
taking care of the children,
caring for Grandma when she was ill,
teaching her to walk again.
Memories of long treks from Wisconsin & Minnesota
to sunny California
with all their belongings tied on alongside.
These memories, and more, Uncle Ralph gave to me.
My Uncle Ralph never wrote to me
he never came to visit after my Dad was gone,
he was only a dim memory of a story long told
or mentioned at a family storytelling.
Tho my Uncle Ralph never wrote to me,
his words, more'n million handwritten words,
on thousands of pages, white, pink, blue tablet,
thin see-thru paper so "the postage dinna hurt,"
gave me a front row seat to his thoughts and memories
and came to me in shoeboxes, treasured shoeboxes,
treasured words, treasured stories.
I do believe my Uncle Ralph did write to me.
(Note: I dinna know why, but it seemed important tonite to share my Uncle Ralph with my readers/JGH)


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All public logs
From NAPwikiCombined display of all available logs of NAPwiki. You can narrow down the view by selecting a log type, the username (case-sensitive), or the affected page (also case-sensitive).
- 19:33, 6 December 2010 Lindsey.Thomas (Talk | contribs) marked revision 3210 of Espiritu Santo, Texas (1554) patrolled (automatic)


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Dr. Howard Wade Delivers Featured Speech at 39th Annual Kimball High School National Alumni Association Reunion (w/photo)
CreatedMonday, September 20 2010
Created byJim Nelson/Media Relations - (304) 327-4103 email@example.com
(Bluefield)—Dr. Howard Wade, Associate Dean of History at Bluefield State College, delivered the keynote address at the 39th annual Kimball High School National Alumni Association (KHSNAA) Reunion in Charleston, WV. More than 500 Kimball High School alumni and family attended the reunion, sponsored by the McDowell County Chapter/KHSNAA, in Charleston.
Dr. Wade's presentation, "The Legacy of Africa and African-Americans," detailed the rich history of Africa as well as its impact and importance throughout the world. "It was a genuine honor to speak at the reunion," Dr. Wade observed. "The Kimball High School National Alumni Association was envisioned and established nearly 40 years ago by several alumni living in Michigan, and it now includes chapters from 11 different states and the District of Columbia."
Ergie Smith, a well-known area teacher, coach, and administrator, received the 2010 Kimball High School distinguished alumnus award during the reunion banquet at the Charleston Marriott Town Center, September 5.
"The reunion brings together so many lifelong friends and we have the opportunity to renew those friendships," Dr. Wade continued. "The alumni association also awards scholarships to several deserving high school and college students." Dr. Louis Aikens serves as the KHSNAA vice president, and Joe N. Fitts, is the association's president. The Kimball High School "Terrors" served students and community in McDowell County from 1914-1966, establish a tradition of excellence in academics, athletics, and community.