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Book your room at Cape Bay Luxury Beach Apartments
Apartment, 2 BedroomsMax Occupancy: 4 guests (up to 3 children, 3 infants)
Penthouse, 3 BedroomsMax Occupancy: 6 guests (up to 5 children, 5 infants)
3.5-star apartment near the beach
This Cap Malheureux apartment offers direct access to the beach and is only a short distance from Bain Boeuf Beach, Pereybere Beach, and Cap Malheureux Beach. Also nearby are The Red Roof Chapel and Merville Beach.
Property Features
Guests of this beach apartment will appreciate convenient onsite amenities such as a fitness center or a children's pool.
Room Amenities
LCD televisions include digital channels. Guestrooms also feature deep soaking bathtubs, private plunge pools, and kitchens.Information missing or incorrect? Tell us!
Hotel Amenities
Hotel Amenities
In addition to an outdoor pool, Cape Bay Luxury Beach Apartments provides a fitness center and a children's pool. For a surcharge, a roundtrip airport shuttle (available on request) is offered to guests. This luxury apartment also offers a terrace, tour/ticket assistance, and multilingual staff. Onsite self parking is complimentary.
- Babysitting or childcare (surcharge)
- Airport transportation (surcharge)
- Total number of rooms - 49
- Number of floors - 3
- Fitness facilities
- Tours/ticket assistance
- Multilingual staff
- Garden
- Terrace
- Year Built 2011
- Free self parking
- Direct access to private beach
- Pool sun loungers
- Number of buildings/towers - 3
- Children's pool
- Outdoor pool
Available in all rooms: Free Wi-Fi
Free self parking
Room Amenities
- DVD player
- Separate sitting area
- Furnished balcony
- Climate control
- Access via exterior corridors
- Air conditioning
- Ceiling fan
- Phone
- Free local calls
- Coffee/tea maker
- Kitchen
- Microwave
- Limited housekeeping
- Second bathroom
- Private bathroom
- Hair dryer
- Bathtub or shower
- Deep soaking bathtub
- Rainfall showerhead
- In-room childcare (surcharge)
- Iron/ironing board
- In-room safe
- Washer/dryer
- Blackout drapes/curtains
- Separate dining area
- Dishwasher
- Full-sized refrigerator/freezer
- Stovetop
- Cookware, dishware, and utensils
- Separate living room
- Private plunge pool
- Digital TV service
- Free Wi-Fi
- Individually furnished
- Individually decorated
- Cribs/infant beds (complimentary)
Nearby Things to Do
An outdoor pool and a children's pool are on site. Other recreational amenities include a fitness center.
The recreational activities listed below are available either on site or nearby; fees may apply.
- Kayaking nearby
- Sailing nearby
- Snorkeling nearby
- Surfing/boogie boarding nearby
- Windsurfing nearby
- Scuba diving nearby
- Water skiing nearby
- Hiking/biking trails nearby
Hotel Policies
Check-in time starts at 2 PM
Special check-in instructions:
Check-out time is 11 AM
Payment types
Accepted at this hotel: MasterCard, Visa
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
No rollaway/extra beds available
No elevators
No pets or service animals allowed
- Airport shuttle fee: EUR 75 per vehicle (one way)
- Breakage deposit: EUR 300 per stay
We should mention
This property offers transfers from the airport (surcharges may apply). Guests must contact the property with arrival details 72 hours prior to arrival, using the contact information on the booking confirmation. A resort fee is included in the total price displayed. Children 18 years old and younger stay free when occupying the parent or guardian's room, using existing bedding. No pets and no service animals are allowed at this property.


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|You can observe a lot just by watching.
– Yogi Berra
|You can often measure a person by the size of his dream.
– Dr. Robert Schuller
|You can only be free if I am free.
– Clarence Darrow
|You can only be young once. But you can always be immature.
– Dave Barry
|You can only cure retail but you can prevent wholesale.
– Brock Chisholm
|You can only find truth with logic if you have already found it without it.
– Gilbert Keith Chesterton
|You can only flap your arms so much before gravity catches up to you.
– J & A Foundation
|You can only perceive real beauty in a person as they get older.
– Anouk Aimee
|You can only protect your liberties in this world by protecting the other man's freedom. You can only be free if I am free.
– Clarence Darrow
|You can only see as far as your headlights, but you can see the whole trip that way.
– E. L. Doctorow
|You can outdistance that which is running after you, but not what is running inside you.
– Rwandan Proverb
|You can overcome any obstacles by asking the right questions of the right people at the right time, then act on that advice with passion.
– Dan Surface, The One Business Book You Absolutely Must Own!
|You can pick out actors by the glazed look that comes into their eyes when the conversation wanders away from themselves.
– Michael Wilding
|You can pray for someone even if you dont think God exists.
– Real Live Preacher
|You can pretend to be serious you can't pretend to be witty.
– Sacha Guitry
|You can protect your liberties in this world only by protecting the other man's freedom. You can be free only if I am free.
– Clarence Darrow
|You can put wings on a pig, but you don't make it an eagle.
– William Jefferson Clinton
|You can realize any dream/vision/aspiration and as well attain any position/status if only you can dare to pursue, go after and work towards it unyieldingly.
– Emeasoba George
|You can rely on a steady paycheck every two weeks building another persons business or you can generate income on a daily basis building your own. I chose the latter of the two options.
– Jay Abiona
|You can reply on a steady paycheck every two weeks building another persons business or you can generate income on a daily basis building your own. I chose the latter of the two options.
– Jay Abiona
|You can rot here without feeling it.
– John Rechy
|You can say any fool thing to a dog, and the dog will give you this look that says, My God, you're RIGHT I NEVER would've thought of that'
– Dave Barry
|You can say what you like about long dresses, but they cover a multitude of shins.
– Mae West
|You can search throughout the entire universe for someone who is more deserving of your love and affection than you are yourself, and that person is not to be found anywhere. you yourself, as much as anybody in the entire universe deserve your love and affection.
– Buddha
|You can see love in war and you can also see war in love!
– Mehmet Murat ildan

subset: commoncrawl


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Blacks and the Alter
BlackBride.com President Mary Chatman is working to dismantle the idea that African Americans don't get married through her bridal expo.
October 28, 2012
We have all heard it before: Black people do not get married. And although we all may have more than a few single Black girlfriends, the idea that Black people are not tying the knot just is not true. As a matter of fact, Black people account for a large percentage of money spent in the bridal industry. This factor is the fuel behind BlackBride.com President Mary Chatman starting The BlackBride.com expo, a bridal showcase targeted towards brides of color. Taking a break from planning the expo's stop in Atlanta, Chatman spoke with Sheen about her business and the misconception that Black women are destined to be forever single.
Sheen: How did the BlackBride.com show get started?
Mary Chatman: Earlier this year, the previous owner of BlackBride.com
was approached by a film company to cross promote Jumping the Broom.
In order to do this, we came up with the idea to do a show, which we did
last April. We gained the partnership, and from there, the idea to continue
the show was born.
Sheen: Where does this idea come from that Black women do not get married?
MC: Personally, I think it's because of what is portrayed in the media, this
idea that marriage is for White people. Black women spend 1.6 billion
dollars on weddings every year.
Sheen: So how do we erase this idea?
MC: Getting the word out. We have to constantly portray a positive image of black couples and people. We have to stay positive and continue to look to the positive images that are out there.
Sheen: What sets BlackBride.com apart from other bridal websites out there?
MC: What sets it apart is that it's an online resource for brides of color. We also offer and after the aisle section for tools after marriage. This year we are also taking the show on the road. I know people are hungry for it and want it because people have come to me about it. This is proof that Black people are getting married. -HC


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Mother's milk, time-tested for millions of years, is the best nutrient for babies because it is nature's perfect food.
~Robert S. Mendelsohn
I am an International Board Certified Lactation Consultant (IBCLC), the gold standard in lactation training. I have over 14 years and thousands of hours of experience providing comprehensive breastfeeding education and assistance in a variety of settings.
I have extensive experience and special interest in working with mothers with low milk supply and babies with different types of tongue or lip tie, structural restrictions, disorganized suck, as well as providing aftercare and suck training for babies post tongue tie treatment to help normalize function and improve breastfeeding.
But I've already seen a lactation consultant, how will this be different?
There are many types of professionals who provide lactation assistance. Training can vary greatly. Some may call themselves lactation consultants or LCs, but may not be an IBCLC, which requires extensive education, years of training and a comprehensive exam. Even if you saw an IBCLC, there are different areas of specialty and levels of expertise.
A visit with me may be very different than what you've experienced before. Consultations are not just a before/after feed weigh or a quick latch evaluation. During our first consultation, we go over questions, concerns, your history, discuss your goals, I do a very thorough oral evaluation on baby looking at anatomy and function and observe 1-2 feedings to get a comprehensive picture. Most first-time visits average 2 hours.
I follow holistic practices looking at the entire mother/baby pair, not just certain parts. We may spend time discussing nutrition, emotions, attachment, natural therapies, the benefits of collaborative care with a naturopath, craniosacral treatment or other various modalities. I pride myself on working alongside a family to make a plan that best fits their comfort level and lifestyle. No guilt, just a comprehensive, personalized game plan to help you achieve your goals.
Office visits are available for families traveling from outside of Salem.
Most families schedule a minimum of 2 visits.
Payment due at time of service. I accept cash, check, credit card and most HSA cards.
I do not bill insurance; however, I will provide you with a detailed receipt that includes billing codes to submit to your insurance company.
Gift certificates are available.
Please contact me to schedule.


text:
- Actors: Jimmy Page, The Edge, Jack White, Link Wray, Bono
- Directors: Davis Guggenheim
- Producers: Jimmy Page, Davis Guggenheim, Alba Tull, Bert Ellis, Diana Derycz-Kessler
- Format: Multiple Formats, AC-3, Color, Dolby, NTSC, Widescreen
- Language: English
- Subtitles for the Hearing Impaired: English
- Region: Region 1 encoding (US and Canada only)
PLEASE NOTE: Some Region 1 DVDs may contain Regional Coding Enhancement (RCE). Some, but not all, of our international customers have had problems playing these enhanced discs on what are called "region-free" DVD players. For more information on RCE, click .
- Aspect Ratio: 1.85:1
- Number of discs: 1
- Rated: NR (Not Rated)
- Studio: Sony Pictures Home Entertainment
- DVD Release Date: December 22, 2009
- Run Time: 98 minutes
- Average Customer Review: 4.4 out of 5 stars See all reviews (358 customer reviews)
- Amazon Best Sellers Rank: #10,056 in Movies & TV (See Top 100 in Movies & TV)
- Learn more about "It Might Get Loud" on IMDb
Would you like to update product info or give feedback on images?.


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Keep in mind that whenever any sort of change is suggested by anyone there are two groups who are quick tocondemn it. NASCAR and the power teams.
NASCAR likesexclusive suppliers for two reasons. First, those companies line their pockets with loads of cash for the right to be the exclusive supplier. And second, the fewer options there are available the easier it is for poorly trained officials to regulate.
The power teams don't want anything to be allowed that might let someone catch up to them without spending a fortune to do so. And the tighter the box within which teams are allowed to operate the more money that has to be spent to catch up.
Safety is not the primary concern of either of the above mentioned entities but it is what they will say in order to keep the status quo.
I am not advocating a situation in which drivers are put at risk. I am advocating a situation in which competition is improved.


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Waitlist Process
View the waitlist PDF with the updated information and instructions.
During registration and add/drop periods, students often wish to enroll in sections that have reached their enrollment capacity and are closed. The automated waitlist process provides an opportunity for students to enroll in closed sections as space becomes available. This process also provides the schools/colleges with information for making decisions concerning their course offerings for current and future semesters.
The automated waitlist process will allow students to place their names on a waitlist for closed sections for which they are eligible to enroll. When a space becomes available, an e-mail is sent to the first student on the waitlist and he or she has until 5:59 a.m. the following day after receipt of the emailed notification to register for the course. This process continues in order of the waitlist as space becomes available.
Students are restricted to one active waitlist section per course per term, with Fall, Spring, and all summer terms each considered as one term. Some courses, including special topics courses, are excluded from this restriction.For more information, view the waitlist PDF.
The waitlist is convenient and easy to use. Students follow the normal registration process on the web via their myau.american.edu account. There is now an additional field on the Course Registration screen called "Waitlist". The default for this field is "no." Students who wish to have their names added to the waitlist for closed sections should update this field to "yes." They then receive confirmation that the course is closed and as a result have been added to the waitlist. The class schedule will confirm the status of these sections as "Waitlist".
How Does the Waitlist Work?
- Active students on a waitlist are granted permission to register as space becomes available on a first-on/firs-off basis.
- Before 8:00 a.m., eligible students receive an e-mail from the University Registrar, sent to their AU e-mail address alerting them that a space has become available in their waitlisted section.
- After the e-mailed notification is sent, students have until 5:59 a.m. the following day to claim their spot in the course.
- Should students fail to register for the waitlisted course within that period, their waitlist status expires and the space becomes available for the next eligible student.
- Student eligibility and course registration eligibility rules, such as prerequisites, are always enforced.
For more information call 202-885-2200 or email us at firstname.lastname@example.com.


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FDA Approves First Adjuvanted Vaccine for Bird Flu »
"The U.S. Food and Drug Administration today approved the first adjuvanted vaccine for the prevention of H5N1 influenza, commonly known as avian or bird flu. The vaccine, Influenza A (H5N1) Virus Monovalent Vaccine, Adjuvanted, is for use in peopl"...
Read the FDA Approves First Adjuvanted Vaccine for Bird Flu article »
There have been no reports of overdosage from administration of RELENZA.
Do not use in patients with history of allergic reaction to any ingredient of RELENZA including milk proteins [see WARNINGS AND PRECAUTIONS, DESCRIPTION].
Last reviewed on RxList: 1/12/2012
This monograph has been modified to include the generic and brand name in many instances.
Relenza FDA Prescribing Information
Additional Relenza Information
Relenza - User Reviews
Relenza User Reviews
Now you can gain knowledge and insight about a drug treatment with Patient Discussions.
Here is a collection of user reviews for the medication Relenza sorted by most helpful.
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.
Women's Health
Find out what women really need.


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Tesla is out to prove that there is not such thing as a Grinch where they are concerned. In order to show appreciation to the hundreds of people who went out and purchased the Tesla Roadster , the California-based electric car manufacturer is filling Santa's bag up with radio-controlled versions of the sports car and delivering them just before Christmas. Each owner received a Radiant Red Roadster with tan seats and a lovely Christmas card to go along with it. Now that's customer appreciation!
Of course, the RC version won't be able to hit the 0-60 mph in 4 seconds and it doesn't feature the same electric drivetrain producing 248 HP, but it's still a pretty faithful replica to the real thing, and one that can entertain the child in all of us for quite some time!


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The MG Electronics MGT24100 is a 120VAC to 24VAC power converter optimized for use with CCTV devices.
- Primary 120VAC
- Secondary 24VAC 100VA
- Open Frame Class I Transformer
- Comes with AC line cord
- UL listed
- Individually boxed
See any errors on this page? Let us know.


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a food lover's discoveries and wish list from around the web and the world
06 10 / 2013
this week I made my favorite granola recipe from love & lemons but used pumpkin pie spice instead of cinnamon. it is a good week.
28 5 / 2013
i highly recommend this granola recipe from the blog Love and Lemons (origin of the beautiful photos above), which not only tastes amazing but couldn't be easier to prepare. toss ingredients, bake in oven, enjoy. while it does taste great plain, the serving suggestion with yogurt, honey and pomegranate seeds is downright delicious and I won't deny I'm addicted. will definitely be making my own granola from here on out!
Permalink 3 notes
09 3 / 2013
Inject some grown up flavor into your mornings with this Brussels Sprouts, Chorizo and Beer Hash from Food 52. Appropriately, the recipe contributor's user name is "Brussels Sprouts for Breakfast." While the brussels sprouts might scare most people off…don't let it. It is surprisingly good and after being par-boiled and then browned in the skillet, the cabbage flavor is quite mellow. This can also be made successfully with soy chorizo (as I did this morning) meaning vegetarians can enjoy this as well!
(Source: food52.com)
Permalink 2 notes
08 3 / 2013
celebrate the onset of spring with these amazing and rather accessible donuts: baked lemon cake donuts with a meyer lemon glaze found on Prevention RD. these donuts are made with agave syrup and whole wheat flour and egg whites…so if you want a more authentic baked donut you could use the full-fat recipe from King Arthur Flour this batter was based on and just adapt it for lemons (drop the spices, add lemon zest and replace the water with lemon juice). either way, this looks like a glorious breakfast!
(Source: preventionrd.com)
09 3 / 2012
Winnie the Pooh. Wisest of us all.
Winnie the Pooh. Wisest of us all.
Permalink 5,409 notes
27 2 / 2012
caramelized onion and mushroom biscuits? absolutely.
from Joy the Baker
13 2 / 2012
apple cider donuts….from my new favorite food blog "desserts for breakfast". what better subject matter is there than that? go check it out. she's an awesome cook and the photography is arguably even more impressive.
(Source: dessertsforbreakfast.com)
Permalink 8 notes
22 12 / 2011
home-made raspberry ebelskivers with pan-fried honey-baked ham for breakfast. what a great way to start a birthday.
= )
Permalink 5 notes
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Racial Attitudes in America and the Effects on Health Disparities: A Perspective
The concept of racial differences and all that this has come to imply is perhaps the single most important social issue in the history of the United States. Since the "discovery" of America in 1492 by Columbus, the importation of the first African slaves in 1619, and the infamous Dred Scott and Plessy decisions in the 1800s that legalized separate status of African Americans, racially-based social, legal and health inequalities have persisted to the present. In fact, during the Civil Rights Movement in the mid-twentieth century, Dr. Martin Luther King famously said, "of all the forms of inequality, injustice in health care is the most shocking and inhumane."1
Dr. King was referencing a growing body of observations documenting racially and ethnically based disparities in health outcomes. Although these health disparities are associated with race, it is important to note that racial classifications are politically and socially, but not biologically, determined. In fact, contemporary genomic studies have determined that the genetic variations within a so-called racial group may reach 95%, compared to a 5% variation between so-called racial groups.2 Therefore, to explain the unequal burden of disease between whites and other groups, one must consider factors beyond biological differences such as socioeconomic level, cultural and behavior determinants of health status.
Race is, in reality, a socially and politically determined designation. It is also often a surrogate designation for more direct and authentic causes of health disparities. Conceptually, one can consider the effects of poverty and low economic status, interacting with social injustice and cultural factors (i.e. diet, tobacco use, etc.)
To determine how these factors collectively influence important health determinants such as the use of preventive services, early detection of disease, ready access to medical care for accurate diagnosis and treatment, etc. 25 Differences in these health determinants could readily explain important disparities between black and whites in terms of incidence of disease and ultimately mortality. Poverty, acting through the prism of substandard housing, inadequate information and knowledge of disease and preventive practices, risk-promoting lifestyles, attitudes, behaviors, and diminished access to health care can directly influence health status.26 Although there is a wide spectrum of wealth in minority communities, according to the U.S. Census Bureau, 35 million Americans (12% of the US population) are classified as poor, but African Americans and Hispanics comprise 24% and Hispanics 22% of this group. This compares to 8% of whites who are classified as poor.3
Disparities in health between blacks and whites are manifested in all major disease categories and occur in all clinical settings—hospitals, outpatient clinics, emergency departments, operating rooms, and nursing homes. 4-6 Examples of health disparities are shown in Table 1.
Table 1
Racially Based Disparities in Health Outcomes
Some Examples
Cancer (all sites)
Incidence, 1996-2000
561.2/100,000 white men
696.8/100,000 black men
Death Rates, 1996-2000
249.5/100,000 white men
356.2/100,000 black men
NCI Seer Data, 200319
NCI Seer Data, 200319
Cancer (lung)
Rates of Surgery for Stage I & II disease
76.7 % whites
64 % blacks
5 Year Survival
34.1 % whites
26.4 % black
Bach, NEJM, 19996
Renal Transplantation
% Evaluated for transplant
70.5% white women
50.0 % black women
76.2 % white men
53.9% black men
Ayanian, NEJM, 199916
Pain Management
Likelihood of access to opioids
74% white neighborhood
24% non-white neighborhood
Analgesics for bone fracture
Blacks 66% less likely to receive analgesics than whites
Hispanics twice as likely than whites to receive no analgesics
Morrison, NEJM, 200022
Todd, Ann Emerg Med, 200023
Todd, JAMA, 199324
The impact of these disparities is profound. A recent report observed that if differences in age-adjusted mortality between African Americans and whites were eliminated between 1990 and 2000, then approximately 890,000 African American lives would have been saved.7
A recent Institute of Medicine (IOM) study found that "although myriad sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care."8 These sources of disparity are manifest in all parts of the health care system and involve administrators as well as providers. Bias and stereotyping is likely, in most instances, to be subconscious. For example, one study found that mental health professionals who were "primed with stereotype-laden words" were more likely to evaluate hypothetical patients more negatively than when primed with neutral words.9 Another study noted that doctors rated black patients more negatively than white patients in a number of categories—intelligence, likelihood to abuse drugs and alcohol, likelihood of adherence to treatment recommendations—even after the patients' income, education and personality factors were described.10 These studies and others support a conclusion of the IOM study, which is "there is considerable empirical evidence that even well-intentioned whites who are not overtly biased and who do not believe that they are prejudice typically demonstrate unconscious implicitly negative racial attitudes and stereotypes."10(p4) In fact, conditions of clinical uncertainty accentuated by time pressures are features which promote stereotyping,8 making African American patients and their doctors facing the complexity of end-of-life decisions even more vulnerable than in other clinical settings.
The IOM study recommended several approaches to minimizing health disparities. Awareness of the extent and impact of health disparities is essential. Dissemination of cross-cultural educational programs that focus on understanding attitudes, increasing knowledge of different cultures, and acquiring skills to improve communication and caring across cultures is another essential step. More data about specific patient characteristics and outcomes, generated by standardized data collection methods is also critical to overcoming disparities. Many other strategies such as increasing availability of quality translational services; health system changes to decrease care fragmentation and the more widespread utilization of evidence-based clinical practice guidelines must also be incorporated with these core educational and clinical recommendations to have a truly durable impact on improving racially based disparities.8
Death and Dying in Contemporary American Society
Definitions of hospice and palliative care, and current rates of hospice utilization.
Palliative care is a relatively new term, particularly in the United States. There are many published definitions, but essentially all encompass the terms included in the 2002 World Health Organization description of palliative care which is " an approach which improves quality of life of patients and their families facing life-threatening illness .through the prevention and relief of suffering ... by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."11 This definition is attractive because it emphasizes the comprehensive approach to assessment and care, focuses on the need to attend to suffering, and is does not restrict the need for this type of care exclusively to dying patients.
Hospice care can be considered as subtype of palliative care applied to dying patients and their grieving families. Palliative and hospice care comprise an array of services at the core of which involve around the clock availability of a interdisciplinary team typically consisting of a physician, nurse, nurse aide, chaplain and social worker. The services provided by high-quality palliative care and hospice teams include ongoing communication and care coordination, expertise in symptom assessment and treatment, anticipatory guidance, crises prevention and early management, the provision of spiritual care and advance care planning, and bereavement support for the family. Hospice is a proven model of palliative care delivery for dying patients. Much of palliative care delivered in hospitals and outpatient clinics and offices are delivered by teams of doctors and nurses which are not a part of community-based hospice programs, although there are exceptions. By contrast, more than 90% of hospice care delivered to dying patients is done in the home or nursing home setting. In hospitals and physician offices, most palliative care is delivered by clinicians who are usually not part of community-based hospice teams.
In 2006, there were approximately 2.4 million deaths in the United States, and about 2 million of these can be anticipated. In theory, these 2 million deaths would be appropriate for hospice care. In 2004, there were approximately 3,600 hospices in the United States, and about 1.6 million individuals, representing nearly 60% of eligible patients and families.12 This number has grown by about 44% since 2002 and is likely to increase given the aging of the United States population. Cancer was by far the most common diagnosis associated with hospice entry, accounting for 45% of patients, followed by heart failure, dementia, lung, and kidney disease.
It is worthwhile noting, however, that non-cancer diagnosis accounts for much of the increase in hospice utilization over the past five years. This very respectable growth in hospice services is tempered by the relatively short lengths of stay in hospice care. Under the Medicare Hospice Benefit, patients may enter the hospice up to six months prior to death if two physicians confirm that the individual has a terminal prognosis, and the patient is willing to elect the benefit. Despite this, the median length of stay in hospice programs across the United States in 2004 was only 22 days.
Fewer than 10% of patients utilizing hospice in 2004 were African American, even though they make up more than 13% of the U.S. population, suffering a disproportionately higher mortality than whites.12 The reasons behind this disparity are complex and incompletely understood but will be described in more detail in an accompanying chapter in African American Perspectives in Pain and Palliative Care. The gaps in hospice utilization between blacks and whites persist across age groups.13
End-of-life "movement" in USA in latter 20 th Century
In the past 25 years, in part spurred by the highly publicized "right to die" cases Karen Ann Quinlan in 1985 and the publication of the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) studies in 1995, there has been a remarkable increase in attention to the needs of seriously ill and dying patients.14 This attention has become manifest in several ways. Hospital-based palliative care teams have increased by 90% from 1998-2003, according to the American Hospital Association (AHA) annual survey of hospitals.15 Hospice programs are growing and seeking to expand access to previously underserved ethnic minority populations and to dying children.
The education of physicians, nurses, and social workers to improve their skills and confidence in the practice of palliative medicine has received increased attention, and there are formal curricula available for clinicians which have been endorsed by the major professional organizations representing these disciplines. Physicians can now earn certification in palliative medicine from the College of Hospice and Palliative Medicine,16 and formal designation of the specialty of Palliative Medicine by the American Board of Medical Specialties is anticipated within the next five years.
We have an emerging consensus on the essential aspects of quality end-of-life care, based on evidence obtained from well-designed studies surveying patient and families and health-service research critically evaluating relevant parts of the health care system. A high quality health system should practice patient-centered care at its core, emphasizing and attaining the correct medical diagnosis and customizing evidence-based therapies, particularly pain and symptom management, and should provide non-fragmented treatment, which anticipates and prevents crises whenever possible.
Care should acknowledge and respect the role of the patient in family and community.
The overriding goal is to help the patient live as fully as possible, with the highest possible quality of remaining life. Thus the key domains for quality care at the end of life as emphasized by several researchers and the National Hospice and Palliative Care Association (NHPCO) include pain and symptom management, shared decision making, a focus on patient satisfaction, and coordinated, non-fragmented care, ultimately leading to safe and comfortable dying, self-determined life closure and effective grieving for the family left behind.17
Realities of death and dying for African Americans
Given the background detailed in the prior section, we can now place the contemporary circumstances of African American patients and families in perspective. An undeniable reality of the legacy of societal and medical racism and its lingering effects into the 21st Century is the persistent gap in death rates and life expectancy between blacks and whites in the United States. Although deaths rates from all causes fell consistently for blacks and whites in the second half of the twenty century, blacks continued to die at 1.5 times the rate as whites (see Table 2).
Table 2
Mortality Rates-All Causes, 1950-1998
In 2003, the age-adjusted death rate for the black population was still 30% higher (1.3 times greater) than the white population.18 There are many reasons for this persistent gap, including differences in rates of health insurance, which are critical to access to health care services; a greater likelihood of advanced stages of cancer and HIV-AIDS in blacks vs. whites at time of presentation for medical care; higher rates of tobacco and alcohol use in blacks vs. whites; and generally lower rates of utilization of health-promoting lifestyles and use of preventive measures. As indicated earlier, these socioeconomic circumstances and health behaviors have at their root complex interactions between race, culture and poverty.
For example, cancer death rates for the years 1996-2000 were 356 per 100,000 African American men, compared to 249 per 100,000 white men.19 It is also true that poor Americans, irrespective of race, have a 10% to 15% lower 5-year cancer survival than wealthier Americans.20 Many African Americans share a similar cultural background, if culture is defined by characteristics such as a shared communication system, similar physical and social environments, common beliefs, values, traditions, and world view leading to similar lifestyles, attitudes, and—most importantly—behaviors.25 Acting additively or synergistically, the factors of poverty and culture influence the social environment in which one lives as well as access to information and knowledge and may be associated with the engagement of risk-promoting behaviors (e.g., tobacco use, consumption of high-fat diets). When one then adds greater probability of diminished access to health care, it is not difficult to understand how these circumstances could lead to higher cancer incidents and decreased survival.
Superimposed on the above are the effects of unequal treatment documented in the IOM report.8 Thus the manifestation of these profound health inequalities occurs, in part, because health care providers see their patients (consciously and subconsciously) through the powerful lens of race. This often leads to false assumptions that result in serious harm. The unequal burden of disease in our society is a challenge to our scientific and medical abilities, vision, and presents a profound moral and ethical dilemma for our society.
Concluding Thoughts—Disparities & Implications for End-of-Life decision-making
The greater mortality rates from almost all diseases for blacks compared to whites must be considered in clinical and health policy considerations concerning end-of-life care and decision-making. Almost all frameworks that evaluate the quality of end-of-life care include the components of symptom management, spiritual and personal growth, death in a familiar setting, surrounded by family and loved ones; understanding information to guide decision-making and planning; confidence that one will not be a financial, emotional or physical burden, and the right of self-determination and control of treatment decisions and choices.21 The effects of racism and poverty and the associated marginalization compromise the attainment of quality caring in these domains of end-of-life care. The challenge for clinicians and policy makers is to overcome this ultimate of inequalities in health care.
1. Luther ML Jr. Quoted by: Kucinich D. A Prayer For America. New York, NY : Thunder's Mouth Press/Nation Books; 2003.
2. Smedly A, Smedly BD. Race as biology is fiction. Racism as a social problem is real: anthropological and historical perspectives on the social construction of race. Am Psychol. 2005;60 (1):16-26.
3. US Census Bureau, Current Population Survey. 2003-2004 Annual Social and Economic Supplements, Table 4.
4. Bonham VL. Race, ethnicity and pain treatment: striving to understand the causes and solutions to the disparities in pain treatment. J Law Med Ethics. 2001;29(1):52-68.
5. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patient's preferences on racial differences in access to renal treatment. N Engl J Med. 1999;341(22):1661-1669.
6. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in treatment of early stage lung cancer. N Engl J Med. 1999;341(16):1198.
7. Wolf SH, et al. The health impact of resolving racial disparities: an analysis of US mortality data. Am J Public Health. 2004;94:2078.
8. Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC : The National Academies Press; 2003.
9. Abreu JM. Conscious and non-conscious African American stereotypes: Impact on first impression and diagnostic rations by therapists. J Consult Clin Psychol. 67(3):387-393.
10. van Ryn M, Burke J. The effect of patient race and socio-economic status on physician's perceptions of patients. Social Science and Medicine. 2000;50:813-828.
11. World Health Organization. Cancer. WHO Definition of Palliative Care. Accessed May 9, 2006.
12. The National Hospice and Palliative Care Organization.
13. Greiner KA et al. Hospice use by minorities in the last year of life. JAGS. 2003;51:970-978.
14. Life Tree. Two Decades to an American Culture of Death. Accessed May 10, 2006.
15. Center to Advance Palliative Care. Accessed May 10, 2006.
16. van Gunten C. Development of a medical subspecialty in palliative medicine: progress report. J Palliat Med. 2004;7(2):209-219.
17. Connor SR, Tecca M, LundPerson J, Teno J. Measuring hospice care: the National Hospice and Palliative Care Organization National Hospice Data Set. J Pain Symptom Manage. 2004;28(4):316-328.
18. Hayert DL, Heron MP, Murphy SL, Kung H-C. Natl Vital Stat Rep. 2006;54(13):1-20.
19. Surveillance, Epidemiology, and End Results Program, 1975-2000. National Cancer Institute, Division of Cancer Control and Population Sciences; 2003.
20. Freeman H. Cancer in the Socioeconomically Disadvantaged. American Cancer Society; 1989.
21. Lunney JR, Foley KM, Smith TJ, Gelband H, eds. Describing Death in America : What We Need to Know. National Academy of Sciences ; 2003.
22. Morrison RS, Wallenstein S, Natale, DK, Senzel, RS, Huang, Lo-Li. "We Don't Carry That"—Failure of Pharmacies in Predominantly Nonwhite Neighborhoods to Stock Opioid Analgesics. N Engl J Med. 2000; 342(14):1023-1026.
23. Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity and analgesia practice. Ann Emerg Med. 2000;35(1):11-16.
24. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537-1539.
25. Freeman, HP. Commentary on the Meaning of Race in Science and Society. Cancer Epidemiol. Biomarkers Prev 2003;12 (Suppl): 232-236
26. Freeman, HP. Race Poverty and Cancer. J Natl Cancer Inst. 1991;83(8).


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The National Highway Traffic Safety Administration is investigating reports of engine fires in the Chevrolet Cruze and Jeep Wrangler.
Reports indicate the fires began while the vehicles were moving. GM and Chrysler Group say they know of no accidents or injuries arising from the incidents…and are cooperating with the investigation.
Credit card processor Global Payments says less than 1.5 million charge cards in North America were affected by a recent data breach.
If your account was affected, Visa and Mastercard have already notified you of the potential for identity theft and illicit charges because of the breach. But cardholder names, addresses and social security numbers were not obtained.
An update to the VISA system caused a 45-minute network outage yesterday, causing some transactions to be rejected at the register. Your card should work this morning.
Groupon had difficulty getting its financials correct before its IPO and it's in trouble again: Revising both its Q-4 20-11 and full-year numbers to show $14.3 million less income and increased expenses.
So what happened?
Groupon beefed-up its refund-reserve accrual because of the company's fourth-quarter deal-mix and higher price-point offers — which have higher refund rates. Groupon shares fell over six percent.
TaxMasters and its CEO, Patrick Cox, must pay $195 million in restitution and penalties for defrauding customers and violating the Texas Deceptive Trade Practices Act 110,000 times.
The latest regulatory filings indicate the company has $4.9 million in assets and $21.6 million in liabilities.
Farmers are planning to plant more corn this season to cash in on higher prices.
Reuters says corn crops will be at a seven-year high, pushing prices down, and the price of wheat and soybeans will be higher, as less of those crops are sown.
Wall Street finished a winning month — and a winning quarter — with the S&P, Dow, and Nasdaq showing a mixed finish on Friday.
The Dow up 66-points.
The S&P up 5-points.
The Nasdaq down 4-points.
Crude oil added 24 cents to close at $103.02 a barrel.
Natural gas down a penny at $2.11.
Gold closed up $17 at $1,671.90 an ounce….silver up 26-cents at $32.35.
Copper climbed 3-cents to $3.82/pound.


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This was not made by me. It was fan-made. I just loved it and wanted to share it with my friends.
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text:
Confession time: I just can't get through "The Hunger Games." I give up. I fold. I surrender. I'm SORRY. Please don't berate me.
People sure are excited for the movie, though. Truth be told, the trailer makes it look pretty good, and I will probably see it because at this rate there is no other way I'm going to get the story, aside from reading about it on Wikipedia. Apparently there's a lot of dead kids in it! And ROMANCE sustained by the extreme stress of the situation in which these maybe-soon-to-be-dead kids find themselves! God, it's just like high school.