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Novellas in November, Part 1
This is my second year of joining Laura (Reading in Bed) and others in reading mostly novellas in November. I've trawled my shelves and my current library pile for short books, limiting myself to ones of around 150 pages or fewer. First up: four short works of fiction. (I'm at work on various 'nonfiction novellas', too.) For the first two I give longer reviews as I got the books from the publishers; the other two are true minis.
Swallowing Mercury by Wioletta Greg
(translated from the Polish by Eliza Marciniak)
[146 pages]
I heard about this one via the Man Booker International Prize longlist. Quirkiness is particularly common in indie and translated books, I find, and while it's often off-putting for me, I loved it here. Greg achieves an impressive balance between grim subject matter and simple enjoyment of remembered childhood activities. Her novella is, after all, set in Poland in the 1980s, the last decade of it being a Communist state in the Soviet Union.
The narrator (and autobiographical stand-in?) is Wiolka Rogalówna, who lives with her parents in a moldering house in the fictional town of Hektary. Her father, one of the most striking characters, was arrested for deserting from the army two weeks before she was born, and now works for a paper mill and zealously pursues his hobbies of hunting, fishing, and taxidermy. The signs of their deprivation – really the whole country's poverty – are subtle: Wiolka has to go selling hand-picked sour cherries with her grandmother at the market even though she's embarrassed to run into her classmates; she goes out collecting scrap metal with a gang of boys; and she ties up her hair with a rubber band she cut from an inner tube.
Catholicism plays a major role in these characters' lives: Wiolka wins a blessed figure in a church raffle, the Pope is rumored to be on his way, and a picture of the Black Madonna visits the town. A striking contrast is set up between the threat of molestation – Wiolka is always fending off unwanted advances, it seems – and lighthearted antics like school competitions and going to great lengths to get rare matchbox labels for her collection. This almost madcap element balances out some of the difficulty of her upbringing.
What I most appreciated was the way Greg depicts some universalities of childhood and adolescence, such as catching bugs, having eerie experiences in the dark, and getting one's first period. This is a book of titled vignettes of just five to 10 pages, but it feels much more expansive than that, capturing the whole of early life. The Polish title translates as "Unripe," which better reflects the coming-of-age theme; the English translator has gone for that quirk instead.
A favorite passage:
"Then I sat at the table, which was set with plates full of pasta, laid my head down on the surface and felt the pulsating of the wood. In its cracks and knots, christenings, wakes and name-day celebrations were in full swing, and woodworms were playing dodgeball using poppy seeds that had fallen from the crusts of freshly baked bread."
Thanks to Portobello Books for the free copy for review.
A Field Guide to the North American Family by Garth Risk Hallberg
[126 pages]
Written somewhat in the style of a bird field guide, this is essentially a set of flash fiction stories you have to put together in your mind to figure out what happens to two seemingly conventional middle-class families: the Harrisons and the Hungates, neighbors on Long Island. Frank Harrison dies suddenly in 2008, and the Hungates divorce soon after. Their son Gabe devotes much of his high school years to drug-taking before an accident lands him in a burn unit. Here he's visited by his girlfriend, Lacey Harrison. Her little brother, Tommy, is a compulsive liar but knows a big secret his late father was keeping from his wife.
The chapters, each just a paragraph or two, are given alphabetical, cross-referenced headings and an apparently thematic photograph. For example, "Entertainment," one of my favorite stand-alone pieces, opens "In the beginning was the Television. And the Television was large and paneled in plastic made to look like wood. It dwelled in a dim corner of the living room and came on for national news, Cosby, Saturday cartoons, and football."
This is a Franzen-esque take on family dysfunction and, like City on Fire, is best devoured in large chunks at a time so you don't lose momentum: as short as this is, I found it easy to forget who the characters were and had to keep referring to the (handy) family tree at the start. Ultimately I found the mixed-media format just a little silly, and the photos often seem to bear little relation to the text. It's interesting to see how this idea evolved into the mixed-media sections of City on Fire, which is as epic as this is minimalist, though the story line of this novella is so thin as to be almost incidental.
Favorite lines:
"Depending on parent genotype, the crossbreeding of a Bad Habit and Boredom will result in either Chemistry or Entertainment."
"Though hardly the most visible member of its kingdom, Love has never been as endangered as conservationists would have us believe, for without it, the Family would cease to function."
Thanks to Vintage Books for the free copy for review.
The Comfort of Strangers by Ian McEwan
[100 pages]
This is the earliest McEwan work I've read (1981). I could see the seeds of some of his classic themes: obsession, sexual and otherwise; the slow building of suspense and awareness until an inevitable short burst of violence. Mary and Colin are a vacationing couple in Venice. One evening they've spent so long in bed that by the time they get out all the local restaurants have shut, but a bar-owner takes pity and gives them sustenance, then a place to rest and wash when they get lost and fail to locate their hotel. Soon neighborly solicitude turns into a creepy level of attention. McEwan has a knack for presenting situations that are just odd enough to stand out but not odd enough to provoke an instant recoil, so along with the characters we keep thinking all will turn out benignly. This reminded me of Death in Venice and The Talented Mr. Ripley.
First Love by Gwendoline Riley
[167 pages – on the long side, but I had a library copy to read anyway]
Neve tells us about her testy marriage with Edwyn, a Jekyll & Hyde type who sometimes earns our sympathy for his health problems and other times seems like a verbally abusive misogynist. But she also tells us about her past: her excess drinking, her unpleasant father, her moves between various cities in the north of England and Scotland, a previous relationship that broke down, her mother's failed marriages, and so on. There's a lot of very good dialogue in this book – I was reminded of Conversations with Friends – and Neve's needy mum is a great character, but I wasn't sure what this all amounts to. As best I can make out, we are meant to question Neve's self-destructive habits, with Edwyn being just the latest example of a poor, masochistic decision. Every once in a while you get Riley waxing lyrical in a way that suggests she's a really great author who got stuck with a somber, limited subject: "Outside the sunset abetted one last queer revival of light, so the outlook was torched; wet bus stop, wet shutters, all deep-dyed."
Other favorite lines:
"An illusion of freedom: snap-twist getaways with no plans: nothing real. I'd given my freedom away. Time and again. As if I had contempt for it. Or was it hopelessness I felt, that I was so negligent? Or did it hardly matter, in fact? … Could I trust myself? Not to make my life a lair."


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After almost five month's of dithering, Indonesia's two-year forest moratorium started this month. President Susilo Bambang Yudhoyono faced a choice between two options: one version of the moratorium would have prevented new concession in all forests and peatlands; another version applied only to primary forests and peatlands. Yudhoyono chose the second.
The fact that the moratorium was welcomed by Asia Pulp and Paper, a company with one of Indonesia's worst records for forest destruction, indicates just how little companies will have to change from business as usual as a result of the moratorium.
There was the possibility that existing concessions (of which there are a very large number in Indonesia – many of which overlap and many of which are illegal) could be, at least, reviewed. It seems extremely unlikely that this will now happen. An indicative map is part of the presidential instruction that brings the moratorium into force (or farce as one commentator puts it). The indicative map shows the area of primary forest and peatlands that is to be protected for the two-year period of the moratorium. Huge white areas are carved out of green area representing primary forest, particularly in Papua – these represent existing concessions. Two national parks in Sumatra are completely omitted from the map.
The already weak moratorium is filled with loopholes. Existing concessions are specifically excluded from the moratorium, as are concessions that have already "received approval in principle" from the Minister of Forestry and the extension of existing permits. "National development" projects are excluded – the presidential decree includes a list: geothermal, oil and gas, electricity, land for rice and sugar cane.
The moratorium is part of Norway's US$1 billion dollar REDD deal with Indonesia. Norway has also promised US$250 million to Guyana and US$1 billion to Brazil.
In March 2011, members of civil society and members of parliament in Guyana wrote to Norway's Minister of the Environment and International Development, Erik Solheim. The letter listed "eight key problems with the operation of the Memorandum of Understanding between the governments of Guyana and Norway". Part of the problem is that deforestation is increasing in Guyana and the first project in President Bharat Jagdeo's Low Carbon Development Strategy is a controversial hydropower dam in the middle of the rainforest. Construction of the access road has started, but is way behind schedule and the project is plagued with allegations of corruption and mishandling of funds.
The letter generated a large amount of discussion inside and outside Guyana. Almost two months after receiving the letter, Solheim replied, but wrote that, "It will not be possible to go into the details of your letter here". Now Solheim has received another letter, requesting that he provides a detailed reply to the eight problems.
In Brazil, things are looking even worse. The rate of deforestation, which had fallen in recent years, shot back up this year. In March and April, nearly 593 square kilometres of forest were cleared – an increase of 470 per cent compared to the same two months last year.
One possible reason for the dramatic increase is that the increase in deforestation is the fact that the government has been discussing dramatically weakening the country's forest code. Ranchers are clearing forest anticipating that the weakened forest code will be passed and that an amnesty will be granted for previous illegal logging. On 24 May 2011, Brazil's House of Congress approved the amended forest code. It now goes to the Senate and, if approved there, requires the approval of Brazil's president Dilma Rousseff.
The debate surrounding Brazil's Forest Code (see article in this issue) reveals one of the perverse incentives of REDD. Governments with good laws in place, with good governance and with decreasing rates of deforestation stand to gain little from REDD. But with deforestation soaring, Brazil might just do very well out of REDD.
Meanwhile Brazil continues to push ahead with the Belo Monte hydropower dam, that has been opposed for 20 years by the indigenous peoples living in the Xingú watershed. Brazil is also pushing to include "forests in exhaustion" in the clean development mechanism – a proposal that amounts to no more than a subsidy for industrial tree plantations.
Two great videos came out recently in Europe, highlighting different problems with the way REDD is currently developing. The first, produced by a Dutch TV programme, Keuringsdienst van Waarde, looked into carbon offsets and found that they could buy an area of Brazil's rainforest for as little as one cent per square metre. The programme is fascinating, in turns shocking and funny, and raises a series of problems with the idea of carbon offsets.
For the second video, journalists from the London-based magazine Don't Panic went undercover to see just how far Conservation International would go to help greenwash polluting corporations. Their first problem was that CI already works with a list of Corporate Partners that looks like a who's who of planetary destruction, including ArcelorMittal, BHP Billiton, Cargill, Chevron, Goldman Sachs, Kimberly-Clark, McDonald's, Monsanto, Rio Tinto, Shell and Wilmar International.
Don't Panic's journalists pretended to be representatives of Lockheed Martin, the world's biggest arms manufacturer. Conservation International's representative didn't see any problems and suggested a "carbon offset strategy" and that "Lockheed Martin" could "offset" its polluting and deadly operations by buying a forest in Madagascar, Asia or Africa. Don't Panic wanted to find out whether Conservation International is "any more than a green PR company?" The answer, clearly, is no.
By Chris Lang, http://chrislang.org

subset: commoncrawl


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As little Zuzu Bailey once said, "Every time a bell rings, an angel gets its wings." Apparently, there are a ton of bells ringing: nearly 70 percent of Americans believe that angels actually exist.
According to a recent Pew survey, 68% of Americans "either 'completely agree' or 'mostly agree' that angels (and demons) are active in this world." Colleen Hughes, editor of Angels on Earth told CBS News that she believes most people believe in angels "because too much stuff happens to us that we can't explain. There are coincidences that we're willing to chalk up to coincidence, and there's too much that we aren't, because we have this feeling that it was something else."
Tom Elliott believes in angels, though he's not sure that all angels are the winged, trumpeted variety. After promised tickets to a baseball game fell through, Elliot and his young son, who were attempting to carry on a family tradition shortly after the death of Elliott's father, found themselves out of luck until a stranger approached with two tickets. "He said, 'I've got 2 tickets for you here. I want your young son to see the game,' and he just handed us two tickets. And as we looked down at the tickets, he turned around and walked away. Before we could barely even say 'thank you.'"
Elliot and his son were able to see the game from the best seats in the house, and Elliot's son noted that one seat next to them was left empty; a sign, he believed, that his grandfather was with them. Was it an angel that delivered those tickets? Edward Grinnan, the editor of Guideposts, says it's all a matter of perception: "I mean, it's the interpretation of Tom and his son that really does matter. And to them, that man was an angel. He performed an angelic deed, if you will. And his actual origins I don't think are as relevant as the effect that that deed had on those two people."
As we saw in the comments of our Saturday Night Nostalgia post yesterday, several commenters were visited by "angels" who left gifts and holiday meals on their doorsteps. They didn't come from some otherworldly place, but from the same neighborhoods, same streets, same towns. Maybe it's easier to assign goodwill to "angels" when the world often makes it difficult for us to trust or see the goodness in one another, but you don't need wings and a halo to give someone a gift of kindness. You just have to have a heart.
Do Angels Exist? [CBS News]


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By NATHAN KING Associated Press
AUBURN, Ala. (AP) — Bo Nix threw for 207 yards and a touchdown, No. 10 Auburn ran for 172 yards after amassing just 20 in the first half and the Tigers' defense dominated in a 24-6 victory over Tulane on Saturday night.
With a broken game clock already making for a slow and low-energy start to the game, the teams combined for 86 yards of offense across the first nine drives, with Tulane kicking a field goal on its opening series and Auburn (2-0) losing a fumble on its second.
After Tulane's first scoring drive, Auburn's defense locked down the Green Wave (1-1), allowing minus-3 yards over the next four possessions.
Making his first home start after leading the Tigers to a last-second victory over Oregon last week in Texas, Nix found Will Hastings for a 31-yard touchdown pass two minutes into the second quarter to give Auburn the lead. The Tigers scored on back-to-back drives, with Nix's 40-yard completion to Seth Williams setting them up for a 4-yard touchdown run by Eli Stove.
Nix was 19 for 37, tying the fifth-most passing attempts in a game by a freshman quarterback in program history.
After Auburn's running backs combined for 42 rushing yards on 13 carries late into the third quarter, starter JaTarvious Whitlow carried the ball eight times for 54 yards — including a 14-yard touchdown run — on Auburn's third scoring drive of the night.
Whitlow had 121 yards from scrimmage, but fumbled three times and lost two of them.
Tulane quarterback Justin McMillan — an LSU transfer — completed 10 of 33 passes for 103 yards and an interception by Auburn safety Jeremiah Dinson. McMillan also led the team in rushing with 54 yards.
Auburn: The rushing stat line improved mightily in the second half, but that's two straight games with slow starts on the ground behind an offensive line that has struggled to get push early.
Tulane: While the Green Wave offensive was ultimately stifled when it mattered, it rushed for over 100 yards for the 42nd straight game — an ongoing school record.
Williams and Hastings, both starters for Auburn, sustained injuries in the win. On Williams' 40-yard reception, Tulane cornerback Willie Langham landed hard on Williams' left shoulder.
In the third quarter, Hastings was hit in the helmet going up for a reception by Tulane's Macon Clark, who was then ejected for targeting. Hastings walked off under his own power.
Neither player returned to the game. With sophomore Anthony Schwartz still recovering from offseason hand surgery, Stove is Auburn's only healthy starter out wide.
Tulane: At Missouri State next week.
Auburn: Host Kent State next Saturday.


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We've been a having a lot of rain lately and well…honestly… it's getting a little tiresome but I am taking great pleasure in witnessing the slow bloom of all the flowering trees. Dogwoods, cherry blossoms, camellias. I'll take them! Give me some brightness and beauty amidst the gray!
This weekend, I plan on going out into the garden and bringing in some of these gorgeous flowering branches. They make the most beautiful display. Inexpensive, dramatic and inspiring you can't help but want them in your home. Check out these gorgeous images via Style and Home.com…
Don't you love the deep shades of navy, teal and amethyst and how they contrast against the lightness of the blooms? So lovely!
What spring blossoms are you enjoying where you are?


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A Grade 12 student in Salmon Arm is hoping for the return of her handmade grad dress, which was stolen from a vehicle during the early hours of April 11.
According to James Lidstone, a friend of the dress owner Taryn Bottcher, the dress was handmade for her by her grandmother for her upcoming high school graduation. He said while it may not have value to others, it is priceless to Bottcher because of the sentimental value.
|Taryn Bottcher, a Grade 12 student in Salmon Arm, spent three months helping her grandmother sew her the perfect dress for her upcoming graduation. Her friend James Lidstone said after the dress was stolen, she broke down. (Image from Facebook)
"It was a long haul because it took three months to make, and it's completely handmade," said Lidstone. "She didn't want to just buy a dress, she said if she was going to have a dress she was going to get one that she wanted. And her grandmother is a seamstress so they worked together on it.
"(Taryn) is not the type of person to get emotional, but after it was stolen she just broke down."
Lidstone said the family made a police report and that the dress was not the only item taken from the vehicle. He said the dress is the only thing the family is concerned with having returned.
"We just want the dress back. We don't even care about the wallet and the other personal items that were taken," said Lidstone.
Lidstone said they have been overwhelmed with the support from the surrounding community, with his Facebook post about the stolen dress being shared nearly 2,000 times. He said many people have called offering their own dresses for Bottcher to wear on her big day, but he said the generosity was greatly appreciated but not necessary.
"We've kind of already lost hope because it's been nearly four days and we haven't heard anything, so they've already started making another one," said Lidstone, noting that the grad ceremony is at the end of June so Bottcher and her grandmother still had time to create another gown.
If anyone has information relating to the dress, they are asked to call James Lidstone at 250-463-1101.
To report a typo, email: firstname.lastname@example.com.
Jordyn Thomson | Reporter
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I have no intention of making my blog all about dogs. I mean, I could, there's plenty of material. In fact, if I wanted to solely focus on the Life of Dogs, on Dogs Being Dogs, I could probably gain quite a following. There are a lot of dog lovers in the world. Maybe I could even make some coin.
But that's probably not only true about dogs, it's probably true about a lot of things. If I made my blog exclusively anti-Trump ("Idiot Clown Presidents Being Idiot Clown Presidents") I would probably blow up with followers by dissecting the stupid things daily that the stupid commander-in-chief does daily. Those wise enough to already have seen through the deceptions of the Lord of Lies would greatly enjoy it, and those looking to pierce through to the truth could find me for that reason. It would also be a great place for trolls to come and play.
That isn't what I want to do, though.
One time, at a family gathering, a niece of mine told me "Uncle Tommy, your Facebook is ALL about dogs and beer and superheroes and politics and selfies and …" and I stopped her right there. It's true, I told her, my Facebook is all about a bunch of different things, the same as I. At any given time I am thinking a lot about dogs and beer and superheroes and politics and love and family and friendship and science and math and money and football. To name a few. I think a lot, and I am always thinking about that one thing called everything.
So I don't want to make my blog all about dogs, or any specific topic. I want to make it about Tom, and what is on his mind at any given time.
That being said, all I have going on right now is all about dogs. Specifically, all about Marvel who, like I said, steals all my blog time. I'll be back, but in the meantime…
Here's more pictures of dogs. 😏


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Decomposition analysis for pediatric perforated appendicitis rates in black patients (A) and Latino patients (B) compared with white patients. The horizontal bars represent the percentage of the difference in perforation rates between black (A) or Latino (B) and white children explained by racial differences in the listed factor. Bars to the right of the zero line contribute to the higher perforation rate observed in minority children. Those to the left of the line are associated with a reduced risk of perforation in minority children.
eTable 1. HCUP Definitions for hospital size.
eTable 2. Numbers of patients in study and perforation rates for appendicitis. The numbers represent the absolute counts of cases in each category found in the HCUP databases for 2002-2008 for acute and perforated appendicitis.
eTable 3. Mean values representing appendicitis perforation rates for each of the factors assessed that could influence appendiceal perforation.
eTable 4. Logistic regression for perforated appendicitis on all the variables that might influence pediatric appendicitis perforation rates.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Livingston EH, Fairlie RW. Little Effect of Insurance Status or Socioeconomic Condition on Disparities in Minority Appendicitis Perforation Rates. Arch Surg. 2012;147(1):11–17. doi:10.1001/archsurg.2011.746
© 2023
To estimate how much of the gap in appendicitis perforation rates between minority and white children is explained by differences in socioeconomic and insurance factors.
Observational analysis of hospital discharge information.
The Healthcare Cost and Utilization Project database.
Appendicitis perforation rates determined from the Healthcare Cost and Utilization Project database of hospital discharges from 2001 to 2008.
Main Outcome Measures
The proportion of the gap between perforation rates explained by various patient- and hospital-level variables.
There were no disparities observed in adult appendicitis perforation rates. The perforation rate for white children was 26.7%; black children, 35.5%; and Latino children, 36.5%. Gap analysis showed that only 12.0% of the difference in perforation rates between black and white children was explained by insurance status and only 12.7% of the difference between Latino and white children was explained. Income level only accounted for 7.2% of the gap for black children and 6.1% for Latino children. Age explained one-third of the gap for Latino children and one-third was not accounted for by measurable variables. Two-thirds of the difference between appendicitis perforation rates between black and white children was not explained by measurable factors.
A very small amount of the gap between minority and white children's appendicitis rates is explained by the proxy factors for health insurance and poverty status that might relate to health care access. Appendicitis perforation rates are not an appropriate indicator of health care access.
One of the great medical discoveries of the late 19th century was that appendiceal rupture caused many cases of lethal pelvic infection. Carefully studying a large series of autopsies, Reginald Fitz1 postulated that the appendix became inflamed and eventually gangrenous, with subsequent perforation causing pelvic sepsis. In this earlier time before antibiotics and fluid resuscitation were available, pelvic sepsis was usually lethal.2 The lethality of perforated appendicitis led surgeons to advocate emergency appendectomy once a diagnosis of appendicitis was suspected.3 Prevention of appendiceal rupture is believed to be a race against time, with appendectomy performed immediately once a diagnosis of appendicitis is established.
Quiz Ref IDAssuming perforation is the inevitable fate for untreated appendicitis,4 perforation rates are considered a reliable marker for access to health care systems. Numerous reports of minority patients, the impoverished, and those who are underinsured have concluded that patients from these groups with inadequate health care access have higher appendicitis perforation rates.5-14 These analyses have relied on descriptive statistics or regression analyses without quantifying how much of an effect any individual factor has on perforation rates. More recent epidemiological studies have questioned the inevitability of perforation when appendicitis is present.15,16 A growing body of literature suggests that appendicitis does not need emergent treatment because perforation rates are not impacted by delayed treatment.17,18
Quiz Ref IDIf perforation is not an inevitable consequence of delayed treatment, there must be an explanation for why several large-scale investigations concluded that there was an association between race, ethnicity, and socioeconomic factors and appendicitis perforation rates. We hypothesize that this apparent relationship results from not considering the relative magnitude of socioeconomic and health care access factors to perforation rates above and beyond simple statistical significance. We further hypothesize that gap analysis will show that the reason there was an apparent socioeconomic effect on perforation rates resulted from incomplete consideration of uncontrolled residual confounding variables. To fully evaluate the potential for racial, ethnic, and socioeconomic disparities to influence appendicitis perforation rates, we used gap decomposition techniques to quantify how much these factors contribute to perforated appendicitis outcomes. This analysis will also quantify the degree to which unmeasured confounding factors contribute to appendicitis perforation rates.
Quiz Ref IDThe Healthcare Cost and Utilization Project (HCUP) databases for 2001 to 2008 were combined. The HCUP database is composed of administrative state-level discharge records that account for 20% of all US nongovernment hospital admissions. A subset of this database was created by inclusion of records that had International Classification of Diseases, Ninth Revision diagnostic codes of 540.0 to 543.9 (appendicitis) in any of the 15 diagnosis entries or if any of the 15 procedure codes ranged from 47.0 to 47.99 (operations on the appendix). Perforated appendicitis was considered present if any diagnostic code was 540.0 (rupture of the appendix) or 540.1 (appendicitis with peritoneal abscess). Nonperforated appendicitis was considered present if any diagnostic code ranged from 540.0 to 543.9 exclusive of the 2 earlier-cited perforation codes.
Race/ethnicity was obtained from the HCUP database core elements file and encoded as white, black, and Latino. Because of relatively small numbers, other racial ethnic categories were not considered for more detailed analysis. The HCUP database is missing race data in its entirety in records from Georgia, Illinois, Kentucky, Maine, Minnesota, Nevada, Ohio, Oregon, Washington, and West Virginia. Race information is missing from some California records. A combination variable of white, black, and Latino was created to test the distribution of perforation rates as a function of various demographic features between the missing data and the combination variable. This was done to determine if the population of patients with missing race information was similar to that for which race was designated in HCUP. As a sensitivity analysis, records with missing values were randomly assigned race designations in proportions equivalent to the known race population. The randomly assigned variables were studied alone and also following combination with the records from patients with known race.
Because the spectrum of appendicitis perforation rates differs greatly between adults and children, the analytic data set was segregated into an adult population (≥18 years old) and children (<18 years old). The HCUP database also contains medical insurance information. Socioeconomic status was estimated from the average income for the zip code region where the patient lived. Poor was defined as income less than $36 000 to $39 000 per year for 2001 to 2008 (the exact threshold changes annually in the HCUP core data elements file); lower middle-class incomes were $36 000 to $39 000 to $46 000 to $49 000 annually; upper middle class, $46 000 to $49 000 to $62 000 to $64 000; and "rich" if the annual salary exceeded $62 000 to $64 000.
Patient insurance status and hospital-specific characteristics were obtained from the HCUP database. Hospital size was obtained from the variable Hosp_Bedsize in the HCUP hospital file data elements (http://www.hcup-us.ahrq.gov/db/vars/hosp_bedsize/nisnote.jsp). The definitions used for small, medium, and large bed size are presented in
eTable 1. The variable Hosp_Control was assessed to determine the relationship of hospital ownership to appendicitis perforation rates. Teaching status and hospital environment were obtained from the hospital file variables Hosp_Teach and Hosp_Location, respectively. The number of appendectomies performed in each hospital per year was calculated.
Multivariate logistic regression was used to assess the impact race, ethnicity, poverty, and insurance status had on pediatric appendicitis perforation rates. Regressions were nested to examine the effect addition of variables had on each other.
Factors that contribute to the differing appendiceal perforation rates between white and minority patients were assessed by gap decomposition. The differences in perforation rates are composed of measured factors that contribute to some portion of the difference and an unmeasured component that is unexplained by the information available for analysis. Patient- and hospital-level factors were assessed to quantify how much they contribute to the higher perforation rates observed in minority patients.
represents the mean perforation rate for white patients. For binary data, the mean value is the same as the perforation rate. Similarly,
is the appendicitis perforation rate for black (or any other minority) patients.
is the gap between white and minority patient appendicitis rates. The first term in brackets on the right side of the equation determines the explained portion of the group difference (ie, gap). The second term determines the proportion of the gap that is unexplained by the variables used in the analysis. This second term is not reported in this article. For logistic regression, the following definitions are used:
represents the average probability for perforation in the white cohort as determined by summation of each patient's predicted probability for perforation (determined by solution of the logistic regression equation) for appendicitis perforation divided by the number of white patients.
is a vector of individual values for the explanatory variables for white patients (eg, age, sex, and insurance type). Substituting the distribution of individual values for black patients
into the regression equation using the estimated regression coefficients for white patients
facilitates estimation of the amount of the overall difference in appendicitis perforation rates attributable to the factors entered as independent variables in the regression equation.19 Greater detail regarding gap decomposition and the R and SAS codes used to perform this analysis is presented in the eAppendix.
Briefly, a logistic regression equation was estimated for all potential racial, ethnic, and patient- and hospital-level explanatory variables. An individual white patient's estimated risk for perforation was calculated by entering the explanatory variables into the regression equation. This individual was paired with a black patient whose explanatory variables were entered into the same regression equation that used the same estimated coefficients. This was done 1 variable at a time, and on subtracting the estimated probability for the black patient from the white patient, an estimate of the explained portion of the perforation rate gap was obtained. This process was repeated for all the explanatory variables, resulting in a set of gap estimates for each variable. Because there were more white patients than minority patients in the sample, they were randomly matched 1:1 with a minority patient in each iteration of the estimation process. One thousand iterations were performed with rerandomization of the white patient–matching cohort and the mean contribution to the gap for each variable was calculated. During this analysis, variables were grouped together into similar categories. For example, all variables indicating a patient's type of insurance were grouped into a single "insurance" category such that the amount of the perforation rate gap that can be explained by any difference in medical insurance status was reflected in this single variable.
The variables were assembled into 11 groups: (1) sex, (2) age and age × age, (3) income level derived from zip code information, (4) region of the country, (5) insurance type, (6) elective or emergent hospital admission status, (7) hospital size (see HCUP definition in the
eTables), (8) hospital ownership and teaching status, (9) urban or rural location of the hospital, (10) total hospital volume and annual appendectomy volume and the square of these variables, and (11) year of the surgery.
The study cohort included 526 925 cases of appendicitis contained in the HCUP database between 2001 and 2008. When we evaluated perforation rates for the entire population, there were no clinically important differences between racial categories. Adult appendicitis perforation rates were very similar among white, black, and Latino patients (eTable 2). Disparities were evident between children, with white patients having a 26.7% perforation rate. The pediatric appendicitis perforation rate was 35.5% for black children and the perforation rate was highest in Latino children at 36.5%. The racial, ethnic, and socioeconomic and insurance status for children with perforated appendicitis is presented in Table 1. Approximately one-third of all records either did not have racial or ethnic information or those patients were categorized as belonging to a group other than white, black, or Latino. Because many states contributing to HCUP do not supply race information, we compared the patient- and hospital-level appendicitis perforation rates for data with missing race information with a combination variable of white, black, and Latino. The distribution is very similar, suggesting that race information is missing in a way that is equivalent to being random and that exclusion of data with missing race information from subsequent analysis should not impact our results.
In general, children with Medicaid insurance had higher perforation rates than those with private insurance or those who were classified as "self-pay." Too few minority children had Medicare insurance to include in this analysis. Similarly, children in families with lower incomes had higher appendicitis perforation rates than their counterparts in higher-income families.
Quiz Ref IDRegional differences in pediatric appendicitis perforation rates were small for white and black children. In contrast, there was a 27.9% perforation rate for Latino children living in the Northeast and a 40.5% perforation rate for those living in the western United States. Differences in hospital size had little effect on perforation rates. Pediatric appendicitis perforation rates were lower (27.2%) for black children in private, investor-owned facilities as compared with the 34.7% rate in private nonprofit hospitals. Perforations were more common in urban environments and were more common in teaching hospitals. This may be related to differences in racial and ethnic compositions at these facilities. Teaching hospitals are enriched with black patients, with 6.7% of all appendicitis cases being black in teaching hospitals compared with 3.6% in nonteaching facilities. The same is true for Hispanic patients, with 23.7% of appendicitis cases being Hispanic in teaching facilities compared with 18.4% in nonteaching hospitals. Similarly, more black individuals were treated in urban than rural facilities (5.4% vs 2.7%) and substantially more Hispanic individuals were treated at urban hospitals (23.2% vs 7.1%). Perforation rates were higher in high-volume hospitals.
Nested logistic regression analysis reported in Table 2 showed independent effects of black race or Latino ethnicity compared with white race, poverty, and the use of Medicaid insurance on pediatric appendicitis perforation rates. Each variable remained significant after addition of the other variables into the regression equation, suggesting that race, ethnicity, poverty, and Medicaid insurance status each had independent effects on perforated appendicitis rates. Further exploration of the contribution of each factor on perforation rates was performed by decomposition analysis.
eTable 3 shows the mean values for all variables entered into the regression used for decomposition analysis. eTable 4 presents the results of the regression. Decomposition analysis for the black-white gap in pediatric perforated appendicitis rates is shown in the Figure, A. Because black children's perforated appendicitis rate was 0.355 and for white children, it was 0.267, the difference to be explained was 0.088. Of this, only 7.2% of the 0.088 difference was explained by difference in income groups among these children. Twelve percent of the difference was explained by insurance status, 7.8% by teaching status, and 5.5% by age differences. Approximately two-thirds of the 0.088 difference in perforated appendicitis rates was not explained by any of the patient- or hospital-level factors we studied. Higher appendicitis case volume was associated with a lower perforation rate but volume only explained 2.3% of the gap.
Age explained nearly one-third of the 0.099 difference in perforated appendicitis rates between Latino and white children (Figure, B). This difference was driven largely by Latino children at risk of perforation being younger than white children at risk. Only 6.1% of the perforation rate difference between Latino and white children was accounted for by income level; 13.6%, by regional differences; 12.7%, by insurance type; and 2.7%, by hospital teaching status. One-third of the 0.099 difference in appendicitis perforation rate between Latino and white children could not be accounted for by the factors assessed in this analysis. Being in the northeastern United States was associated with a higher risk of perforation for black children but less for Latino children. Large hospital size was associated with higher perforation rates in black children relative to white children but only explained 0.7% of the gap, whereas large hospitals were associated with few perforations for Latino children but hospital size only explained 0.2% of the observed white-Latino gap in perforation rates.
Logistic regression analysis is one of the most common statistical methods used to assess the contribution of factors to a dichotomous outcome variable in observational studies. Results are reported as odds ratios that are interpreted as the odds of an event occurring relative to the odds of it not occurring if the factor is present or absent. Using logistic regression, we found an odds ratio of approximately 1.50 for appendicitis perforation rates for black children relative to white children. This means that the odds of a black child having perforated appendicitis are 50% higher than for a white child. When Medicaid insurance status was entered into the regression equation, the odds ratio for insurance status was approximately 1.25, suggesting that Medicaid insurance status accounts for a 25% increased risk for perforation in black children independent of their race. Expression of the results as a percentage of increased risk in odds ratio makes the impact of the risk factor on an outcome appear larger than is merited by the actual, raw numbers.
Analysis by simple logistic regression can also overestimate the effect a variable has on an outcome. Unmeasured or nonincluded factors (confounders) affecting an outcome that are correlated with a variable included in the regression equation cause the appearance of a larger effect on the outcome than really exists. For example, obesity and diabetes mellitus are highly correlated. If one examined the relationship between obesity and mortality without inclusion of diabetes in the regression, a very strong association between obesity and mortality might be found that would be lessened if diabetes had been controlled for.20 This situation is known as having residual, unmeasured confounders. Another problem with logistic regression is that if the prevalence of some factor is small, it will only contribute a small amount to the explained variance of an effect, yet it, by itself, may have a strong association manifested by a large odds ratio.21
Numerous studies have reported that minority children have higher appendicitis perforation rates than do white children (Table 3). In many of these studies, logistic regression was performed to determine the contribution of insurance and socioeconomic factors to the higher perforation rates observed in minority children (Table 4). The proportions of patients with perforation and the results from regression analysis in most of these studies are very similar in magnitude to those we obtained by similar analysis of the HCUP database. Analyses in this manner led the investigators of the prior published studies to conclude that socioeconomic factors independently contributed to appendiceal perforation rates. This was first observed for adults whose insurance status was shown to be an independent risk factor for appendiceal perforation independent of race and socioeconomic status, leading to the conclusions that insurance-related delays in treatment were a significant health policy issue.5,24 Subsequent studies focused on children, with a number of them highlighting apparent racial disparities in perforation rates that might be related to inadequate health care access.9-11,13,14 All of these studies relied on logistic regression analysis as outlined earlier and arrived at the same conclusion.
We also performed a similar logistic regression analysis and obtained virtually identical results of prior published studies (Table 4). Further exploration of the regression models by gap decomposition suggested different interpretations than may be obtained from simple logistic regression. Decomposition of the difference between minority and white patients' perforated appendicitis rates demonstrated that insurance and socioeconomic factors account for a small fraction of the disparity. Using logistic regression, we found that the adjusted odds ratio for appendiceal perforation for black children was 1.24 for Medicaid insurance and 1.30 for Latino children. Black and Latino children had an approximately 9% higher perforation rate than white children and decomposition analysis showed that insurance status only accounted for 12% of this difference. The finding that insurance type accounts for only 12% of the increased perforation rate between minority and white children demonstrates that insurance status contributes only minimally to appendiceal perforation in children, a fact that is not evident from consideration of odds ratios alone.
Minority children have higher appendicitis perforation rates than white children. Why this occurs is unknown, but in general, minority patients are in lower socioeconomic categories and have less access to health care insurance, factors that might contribute to perforated appendicitis because of delayed treatment. In our analysis of a large database that incorporates 20% of all US hospital admissions, we found no differences in perforation rates for adult white, black, or Latino patients. In an analysis of similar data from 1979 to 1984, Addiss et al25 observed that the appendicitis perforation rate for nonwhite patients was 21.8% compared with 18.2% for white patients. Our more contemporary data showed that the perforation rates for white and nonwhite adults were about the same at 25% to 29%. Racial and ethnic differences in appendicitis perforation rates seem to be limited to the pediatric population.24,26
Quiz Ref IDHigher appendicitis perforation rates were observed for black and Latino children compared with white children. Consistent with prior observations, these minority patients had, on average, lower socioeconomic status and were more frequently underinsured or uninsured.5 Most of the gap between perforation rates in black and white children was not explained by the factors we studied, demonstrating the large effect of residual confounding in these sorts of analyses. Age accounted for nearly one-third of the gap between Latino and white children but socioeconomic or hospital-level factors explained little of the gap in perforation rates. Given the minimal contribution of insurance status to the gap, we conclude that any delays in treatment that might accompany inadequate health insurance coverage do not substantively contribute to appendicitis perforation rates. This conclusion is consistent with our prior epidemiological studies that suggest a disconnect between acute appendicitis and perforated disease.15,16 If perforation is an inevitable consequence of biological factors and not related to the duration of acute appendicitis, there would be minimal impact of socioeconomic factors on perforation rates, as we found in the current study. Indeed, there is biological evidence that immunological factors such as interleukin 6 activation determine the propensity to perforate.27,28 If this is the case and biologically driven differences could determine appendicitis perforation, exogenous factors such as poverty or inadequate insurance would not substantially contribute to the racial/ethnic gap in perforation rates. However, the large amount of unexplained gap could result from residual confounding that is not accounted for by the variables available in an administrative database. Thus, one cannot definitively conclude that any biological, patient, or hospital characteristic accounts for the disparity in childhood appendicitis perforation rates.
In addition to the substantial amount of unexplained confounding in this study, it is also limited by the large number of patients who did not have racial or ethnic information designated in HCUP. The HCUP database is created by collating hospital discharge information that is collected by individual states. Each state has different reporting requirements such that several of them either do not collect or transmit race or ethnic information to HCUP. Since this occurs in a systematic way that is independent of the outcome, it is likely that these missing data are missing in a way that is equivalent to being random and should not affect our analysis or conclusions.29 We found the distribution of patient and hospital factors in the missing data to be similar to that for the aggregated data in which race/ethnicity was present, supporting the notion that this is the case.
As is the case with most analyses from administrative data sets, we used zip code–level approximations for income level. It is conceivable that there is significant heterogeneity of income levels within a zip code region that could contribute to error in our analysis. This error might understate the contribution from racial gaps in income levels.
Correspondence: Edward H. Livingston, MD, Division of Gastrointestinal and Endocrine Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Room E7-126, Dallas, TX 75390-9156 (email@example.com).
Accepted for Publication: July 11, 2011.
Author Contributions:Study concept and design: Livingston and Fairlie. Acquisition of data: Livingston. Analysis and interpretation of data: Livingston and Fairlie. Drafting of the manuscript: Livingston and Fairlie. Critical revision of the manuscript for important intellectual content: Livingston and Fairlie. Statistical analysis: Livingston and Fairlie. Obtained funding: Livingston. Administrative, technical, and material support: Livingston.
Financial Disclosure: None reported.
Funding/Support: This study was supported in part by the Hudson-Penn endowment.


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This gallery contains 21 photos.
Most vehicles fall into standard categories in the automotive world. There are Vans, Pickup Trucks, SUVs, Sedans, Coupes, Wagons, etc. Granted, there are usually sub-sections within these categories to better define a vehicle. However, one look at the majority vehicles and there is no mistaking what it is. Continue reading


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Yamaha's new TSX-140 desktop audio player has a simple, soothing schtick: If you use it as a musical alarm, it will gradually awaken you with a host of audio options. Let's explore!
As the image betrays, the unit is obviously compatible with the iPod touch and iPhone 3g/3GS/4, as well as MP3s played from a USB stick or your FM/AM dial.
Two 3.5 inch speakers provide the tunes, which can be delivered in the aforementioned "slow to rise" manner described above. Called IntelliAlarm, the system lets you select the audio source and then awaken gradually thanks to some proprietary high frequency filtering technology and volume management. Eventually, should you not rise (but are still alive), the system beeps.
Additional details, via a press release from Yamaha this afternoon:
The TSX-140 offers a USB mini-B connector that facilitates iPod/iPhone syncing to a computercwhile charging in the dock. In addition to the illuminated buttons oncthe top panel, three front panel controls give access to source, volume, radio presets, alarm clock and equalizer functions. LED indicators show which function has been selected for simple, fast tuning. A brightness sensor automatically adjusts all display LEDs to suit the ambient light level.
Apple MacBook Air Laptop
Powerful performance
The M1 chip delivers 3.5x faster performance than the previous generation all while using way less power. Get up to 18 hours of battery life.
The unit will set you back $400 and can be purchased in black, brick or gray.


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Shahn, Ben
Shahn, Ben (Benjamin Shahn), 1898–1969, American painter and graphic artist, b. Lithuania. Shahn emigrated to the United States in 1906. After working in lithography until 1930, his style crystallized in a series of 23 paintings concerning the Sacco-Vanzetti trial, among them The Passion of Sacco and Vanzetti (Whitney Mus., New York City). Shahn dealt consistently with social and political themes. He developed a strong and brilliant sense of graphic design revealed in numerous posters. His painting Vacant Lot (Wadsworth Atheneum, Hartford, Conn.) exhibits a poetic realism, whereas his more abstract works are characterized by terse, incisive lines and a lyric intensity of color. The Blind Botanist (Wichita Art Mus.) is characteristic of his abstractions. Shahn's murals include a series for the Bronx Central Annex Post Office, New York City. From 1933 to 1938 he worked as a photographer for the Farm Security Administration, producing masterful images of impoverished rural areas and their inhabitants. Shahn's later works are concerned with the loneliness of the city dweller.
See his writings, ed. by J. D. Morse (1972); biographies by his wife, B. B. Shahn (1972), and H. Greenfeld (1998); studies by J. T. Soby (1947 and 1957); K. W. Prescott, The Complete Graphic Works of Ben Shahn (1973).
The Columbia Electronic Encyclopedia, 6th ed. Copyright © 2023, Columbia University Press. All rights reserved.
See more Encyclopedia articles on: American and Canadian Art: Biographies


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Article Text
AIMS To investigate the effects of small for gestational age (SGA) in very low birthweight (VLBW) infants on growth and development until the fifth year of life.
METHODS VLBW (< 1500 g) infants, selected from a prospective study, were classified as SGA (n = 115) on the basis of birth weight below the 10th percentile for gestational age and were compared with two groups of appropriate for gestational age (AGA) infants matched according to birth weight (AGA-BW; n = 115) or gestation at birth (AGA-GA; n = 115). Prenatal, perinatal, and postnatal risk factors were recorded, and duration and intensity of treatment were computed from daily assessments. Body weight, length, and head circumference were measured at birth, five and 20 months (corrected for prematurity), and at 56 months. General development was assessed at five and 20 months with the Griffiths scale of babies abilities, and cognitive development at 56 months with the Columbia mental maturity scales, a vocabulary (AWST) and language comprehension test (LSVTA).
RESULTS Significant group differences were found in complications (pregnancy, birth, and neonatal), parity, and multiple birth rate . The AGA-GA group showed most satisfactory growth up to 56 months, with both the AGA-BW and SGA groups lagging behind. The AGA-GA group also scored significantly more highly on all developmental and cognitive tests than the other groups. Developmental test results were similar for the SGA and AGA-BW groups at five and 20 months, but AGA-BW infants (lowest gestation) had lower scores on performance intelligence quotient and language comprehension at 56 months than the SGA group. When prenatal and neonatal complications, parity, and multiple birth were accounted for, group differences in growth remained, but differences in cognitive outcome disappeared after five months.
CONCLUSIONS Being underweight and with a short gestation (SGA and VLBW) leads to poor weight gain and head growth in infancy but does not result in poorer growth than in infants of the same birth weight but shorter gestation (AGA-BW) in the long term. SGA is related to early developmental delay and later language problems; however, neonatal complications may have a larger detrimental effect on long term cognitive development of VLBW infants than whether they are born SGA or AGA.
- small for gestational age
- very low birth weight
- growth
- development
- cognitive development
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Very low birthweight infants (VLBW) are at increased risk of poor long term growth1-3 and cognitive and language deficits.4 Those VLBW infants born small for gestational age (SGA) have been suggested to be at double jeopardy because of their shortened gestational period as well as intrauterine growth retardation.5 ,6 A higher incidence of prenatal and perinatal complications, as well as lower cognitive scores and poorer growth during the first years of life, has been reported in SGA infants compared with those with an appropriate weight for gestational age (AGA).7-10
However, the relative significance of growth retardation, low birth weight, and gestation on the development of very preterm infants remains controversial. Spinillo et al 11 found the significance of lower than expected birth weight as a predictor of neonatal outcome to be lower than that of gestational age. In contrast, Hutton et al 5 found birthweight ratio but not gestation to predict cognitive ability at 8–9 years of age.
Methodological factors and sample characteristics have been speculated to account for differences in reported outcomes, such as the definition of SGA, size of sample, range of gestational ages and birth weights in the sample, and the duration of follow up.12 In addition, AGA comparison groups often differed in either birth weight or gestation, therefore it was unclear whether the neurological and cognitive impairment of the SGA group was due to shorter gestation or impaired prenatal growth.
Recently two studies compared the growth and development of low birthweight SGA infants with those of both gestational age matched and birthweight matched low birthweight AGA infants. McCartonet al 12 compared a large sample (n = 129) of low birthweight (< 2000 g) SGA (< 3rd percentile) infants with AGA infants grouped either by birth weight or gestation. Poorer cognitive scores and neurological deficits up to 6 years of age were more likely in SGA infants than in AGA infants of comparable gestation. There were no differences in neurological or cognitive outcomes at any age when grouped by birth weight. Sunget al 13 compared a smaller sample (n = 27) of VLBW (< 1500 g) SGA (< 10th percentile) infants with two groups of VLBW AGA infants matched for either gestation or birth weight up to the age of 3. As in the previous study, SGA infants scored lower on developmental tests than the gestation matched AGA group, but had similar scores to the AGA infants matched according to birth weight. However, at 3 years of age, SGA infants had lower weight and height than both comparison groups. Sunget al 13 conclude that intrauterine growth retardation in VLBW infants has a significant long term impact on growth, but extreme immaturity (short gestation) has significant effects on neurodevelopmental outcome that surpass the effects of intrauterine growth retardation.
About half of all SGA infants are born to mothers with obstetric complications, and as many as 65% of SGA infants, compared with AGA infants, experience perinatal problems.14 Uncertainty remains about whether complications during pregnancy, at birth, and during the neonatal period, as well as parental smoking during pregnancy, parity, and multiple birth may account for the long term developmental outcome in VLBW SGA infants.
The present study investigated the influence of birth weight and gestation on growth and cognitive development of a large group of VLBW SGA infants until the 5th year of life by adopting the design of Sunget al 13 and matching two distinct groups of AGA infants according to gestation and birth weight. It was further determined whether any effects of gestation or birth weight remained on growth and general and cognitive development after controlling for prenatal and neonatal complications, parity, and multiple birth.
Children were selected from the subject pool of the Bavarian longitudinal study (n = 7505), a prospective population study of all infants born and admitted to one of 16 children's hospitals in South Bavaria, Germany in the first 10 days of life during the period 1 February 1985 to 31 March 1986.3 ,4 ,15 ,16 The selection criteria were: participation in all assessments at five, 20, and 56 months; absence of blindness, deafness, or severe cardiopulmonary or other major congenital anomalies, chromosomal defects, or intrauterine infections.
The SGA group consisted of 115 VLBW infants with a birth weight of < 1500 g who were identified as having birth weights below the 10th percentile for gestational age on sex specific standards. Gestational age was determined from maternal dates of the last menstrual period, serial ultrasound examination during pregnancy, and Dubowitz examinations.17 When gestational age estimates from these methods differed by less than two weeks, maternal dates were used; when the difference between the three methods was greater than two weeks—for example, uncertain dates—then Dubowitz examination results alone were used to determine gestational age.
After the SGA infants had been identified, they were matched with two comparison groups of AGA infants: AGA-GA, 115 infants born AGA were matched with the SGA group according to gestation at birth (within exact day); AGA-BW, 115 infants born AGA, who were not included in the AGA-GA group, were matched with the SGA group according to birth weight (± 100 g). As a result, the two AGA groups were distinct in membership—that is, none of the children belonged to both groups. Sex was balanced accordingly (58 boys, 57 girls in each group).
A cohort specific normative sample (n = 432) of infants representative of Bavarian children born in 19853 ,18 was concurrently studied to standardise sex specific norms of anthropometric (weight, length, and head circumference) and cognitive (intelligence quotient (IQ) and language comprehension) assessments at five, 20 and 56 months.
Parents in the Bavarian longitudinal study were approached within 48 hours of the infant's admission to hospital; the study aims were explained, and the parents were asked to give written consent to participate.
Prenatal data were coded from the medical histories in the obstetric units, while perinatal and neonatal data were collected prospectively. The information was summarised into three scales of complications during pregnancy (14 complications), birth (13 complications), and the neonatal period (21 complications). Presence of a complication was scored as 1 and absence as 0; the scores were then totalled separately for pregnancy, birth, and neonatal period as previously described.3 ,15 ,16 ,18 ,19 Information on parity and multiple birth was obtained from hospital records.
Daily assessments of care level, respiratory support, feeding dependency, and neurological status such as mobility, muscle tone, and neurological excitability were carried out from day one after birth. Each of the six variables were scored daily on four point rating scales (0–3) by the method of Casaer and Eggermont.20 The duration of intensive neonatal treatment index (DINTI) was computed as the number of days until the infant reached a stable clinical state (total daily scores < 3 for three consecutive days), and the intensity of neonatal treatment index (INTI) was computed as the mean of daily ratings during the first 10 days of life or until a stable clinical state was reached, depending on which occurred sooner.15 ,16 Socioeconomic data and information on smoking (pregnancy, current) were obtained by standard interviews with the infants' parents in the first 10 days of life and at each follow up visit. Socioeconomic status was computed as a weighted composite score of maternal highest educational qualification, paternal highest educational qualification, and occupation of the head of the family.15 ,21
Body weight, length, and head circumference were measured at birth, five and 20 months corrected for prematurity, and at 56 months by specially trained research nurses during follow up visits in the assessment centres (hospitals) using a predefined protocol: weighing on standard scales in underwear only; standard application for head circumference measurement. At five and 20 months of age corrected for prematurity, general development was assessed with the German version of the Griffiths scale of babies abilities22 and expressed as developmental quotients (DQs). At 56 months, children were administered the following tests: (a) the Columbia mental maturity scales (CMM),23 ,24 an assessment of performance IQ; (b) the AWST,25 a vocabulary assessment similar to the Peabody picture vocabulary test used to determine verbal intelligence; (c) the LSVTA subscale,26 an assessment of comprehension (the child is given a set of standard materials and asked to perform sequences of actions given verbally by the examiner). The CMM, AWST, and LSVTA were standardised as 100 (15) (SD) according to the normative sample.18
All cognitive assessments were carried out by specially employed paediatricians and research nurses in specially equipped assessment rooms attached to the childrens' hospitals in South Bavaria. All investigators were trained in the assessment procedures and were unaware of the infants' neonatal course and previous test results.
Ethical approval was obtained from the University of Munich Children's Hospital, and the Landesärztekammer Bayern (Health council of Bavaria) was fully informed.
Data were analysed by computer using the SPSS statistical package. Group differences in anthropometric and DQ/IQ scores were analysed using one factorial analysis of variance. The effects of prenatal and neonatal complications, parity, and multiple birth on group differences in anthropometric and DQ/IQ scores were investigated using analysis of covariance. χ2 analysis determined overall group differences in cognitive impairment. Follow up tests included a priori contrasts and comparisons for categorical data.
Table 1 shows that group matching according to either birth weight or gestation achieved comparable groups. Those matched according to birth weight (AGA-BW v SGA) differed significantly (by more than three weeks) in gestational age, duration of care, and intensity of care, but were very similar in head circumference and length at birth. The AGA-BW group had higher complication scores neonatally, but did not differ in complication scores during pregnancy or at birth. They took longer to reach medical stability (DINTI), had higher treatment intensity scores (INTI), longer duration of ventilation and parenteral nutrition, but did not require more time until discharge from hospital than the SGA group. In addition, the AGA-BW group contained fewer firstborns and more multiple births than either of the other groups.
The groups matched according to gestation (AGA-GAv SGA) differed in birth weight, head circumference, length at birth, duration of care, and intensity of care. The AGA-GA group had fewer risk factors during pregnancy, at birth, and during the neonatal period, and took significantly less time to reach medical stability (DINTI), had lower treatment intensity scores (INTI), shorter duration of ventilation and parenteral nutrition, and required less time until discharge from hospital than the SGA infants. In addition, the AGA-GA group contained fewer firstborns than the SGA group.
There were no significant differences among the three groups in socioeconomic status, marital status, age, or education of the mother (table 1).
Table 2 shows a comparison of groups with regard to individual complications that were included in the complication scores and occurred with sufficient frequency during pregnancy, birth and neonatally. No group differences in prevalence of maternal or paternal smoking were found. During pregnancy, mothers of SGA infants had a higher incidence of pre-eclampsia than the mothers in the two AGA groups. SGA infants were more often born by caesarian section than AGA infants. In the neonatal period, all three groups differed in the incidence of complications (table 2).
Significant differences between the three groups in body weight, length, and head circumference remained at five, 20, and 56 months (figs 1-3).
Infants in the AGA-GA group remained heavier and longer with a larger head at five, 20, and 56 months than those in the SGA and AGA-BW groups. The SGA infants were lighter at five and 20 months than the AGA-BW infants, but caught up with the AGA-BW group with regard to weight at 56 months. The SGA infants were also shorter with a smaller head circumference than the AGA-BW infants at five months, but these differences had disappeared at 20 and 56 months.
Group differences were found in early developmental assessments (Griffiths) and later IQ and language performance (CMM, AWST, LSVTA) (table 3). AGA-GA infants overall scored higher in the Griffiths assessment at five and 20 months, the CMM, the AWST, and the LSVTA at 56 months than the other two groups. In the Griffiths scales, the AGA-BW group did not differ from the SGA group at five and 20 months. However, at 56 months, the AGA-BW had lower scores on the CMM and LSVTA than the SGA group, but had comparable scores in the AWST. The AGA-GA group scored higher in the AWST and LSVTA than the SGA group but showed similar scores in the CMM.
IQ scores were recoded to distinguish between no impairment (> −1 SD below the mean), mild impairment (−1 to −2 SD below the mean), and serious impairment (< −2 SD below the mean). Overall group differences were found for the CMM and LSVTA: the AGA-GA group had the lowest and the AGA-BW group the highest incidence of serious impairment in the CMM and LSVTA (table 4). Post hoc comparisons showed that the only significant difference between the SGA and AGA-GA group was for the CMM.
When complications (during pregnancy, at birth and neonatally), and parity and multiple birth (covariates) were accounted for, group differences in weight, length, and head circumference remained significant up to 56 months (all p < 0.001). Differences between groups in general development were only found in the Griffiths scales at five months, after adjustments for complications were made; no other group differences remained. Table 5 shows adjusted group means for general and cognitive outcomes. Complications during pregnancy were found to be a significant covariate for scores on the CMM, AWST, and LSVTA at 56 months. Neonatal complications were found to be a significant covariate for all cognitive assessments up to 56 months, whereas complications at birth had no effect on group performance at any age. Parity was a significant covariate for scores on the AWST. Post hoc comparisons showed that firstborns scored higher on the AWST than children born later in a family. Multiple birth covaried with group scores on the Griffiths scales at five months. Post hoc comparisons showed higher Griffiths scales scores for single than multiple births but no differences in cognitive scores at later ages.
The significance of growth retardation, low birth weight, and gestation on growth and cognitive outcome of very preterm infants was investigated in this study by comparing VLBW SGA infants with AGA infants matched for either birth weight or gestation. In agreement with the results of Sung et al,13infants in the gestation matched AGA-GA group were heavier and longer with a larger head than those in the other two groups. In their study, however, the groups did not differ in weight and length at one year, but at three years, the SGA group was lighter and shorter than the other two AGA groups. They concluded that increasing growth lags in SGA compared with AGA infants occur with increasing age. In our study, we find the opposite trend: the SGA group was lighter and shorter, and had smaller head circumference at five months than both AGA comparison groups. However, at 20 months the SGA group had caught up with the birth weight matched AGA group in length and head circumference and at 56 months in weight also. Therefore, we come to the opposite conclusion with regard to the growth of VLBW SGA infants: growth lags in SGA compared with AGA infants decrease with increasing age.
Studies on long term cognitive outcome in SGA compared with AGA infants matched according to either gestation or birth weight12 ,13 have found no difference in cognitive ability up to five years between SGA infants and birth weight matched AGA infants. In our study, however, we found that at 56 months, the SGA infants are actually performing better in IQ and language related tests than the birthweight matched infants. In addition, we found a tendency for the AGA-BW group to display more severe cognitive deficits than the other two groups; however, the difference from the SGA group did not reach statistical significance. The AGA-BW group in the study of Sunget al 13 also displayed the most neonatal complications and displayed the lowest cognitive performance of all three groups. The fact that the difference between the AGA-BW and the SGA group did not reach significance in that study may have been due to the small sample size (n = 27) per group. Our findings support the tentative conclusion of Sung et al that "extreme immaturity (short gestation) at the time of delivery has significant effects on cognitive development that surpass the effects of IUGR".
Several studies that have shown long term cognitive differences between SGA and AGA infants have neglected to control for neonatal complications and sociodemographic factors.5 ,6 ,13 In this study, the SGA and AGA groups were highly comparable with regard to sociodemographic factors. Thus differences in growth and general and cognitive development cannot be accounted for by differences in social factors. In contrast, the three groups differed in complications, with the AGA-BW group experiencing the most neonatal complications.
We found that even when the influence of prenatal and especially postnatal complications was controlled for, the group differences in growth remained significant up to five years; however, the differences in cognitive outcome disappeared after five months. This indicates that neonatal complications are more closely associated with early gestation, and have a larger impact on long term cognitive outcome than on long term growth. Neonatal and pregnancy complications are the major factors explaining individual differences in cognitive scores in VLBW children.4 ,27
This study unfortunately has no assessments of abnormal fetal heart rate, abnormal umbilical artery waveforms, or fetal cerebral arterial Doppler assessment.28-30 However, it is not yet clear whether cerebral redistribution (brain sparing) is a healthy adaptation to stress or a warning sign for long term developmental problems. Furthermore, maternal or paternal smoking did not differ between groups.
Higher parity was linked to lower language scores at 56 months (also reported in preterm infants by Largo et al 31). Once complications and parity were controlled for, all differences in language disappeared. Further studies may clarify the role of parity on the language development of VLBW SGA infants—that is, whether VLBW infants born later in a family are less stimulated in their language development.32 In conclusion, our findings suggest that, for VLBW infants, complications during pregnancy and especially neonatally have a larger detrimental effect on long term cognitive development than whether they are born SGA or AGA.
Key message
Differences in growth between SGA and AGA VLBW infants were found to persist up to 5 years of age, independently of prenatal and postnatal complications. In contrast, complications during pregnancy and the neonatal period had a larger effect on infant cognitive development than size for gestation (SGAv AGA).
The research was supported by the Bundesministerium für Forschung und Technologie (Federal Government of Germany, Ministry of Science and Technology) programme grants PKE 4 and JUG 14 (FKZs 0706224, 0706564, and 01EP9504) to K R, D W and B O. Thanks are due to the 16 special care baby units in South Bavaria, the paediatricians, psychologists, and psychometric assistants who carried out the assessments, and especially the parents and children who participated.


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1 Maschil of Asaph. {N}
Give ear, O my people, to my teaching; incline your ears to the words of my mouth.
2 I will open my mouth with a parable; I will utter dark sayings concerning days of old;
3 That which we have heard and known, and our fathers have told us,
4 We will not hide from their children, telling to the generation to come the praises of the LORD, {N}
and His strength, and His wondrous works that He hath done.
5 For He established a testimony in Jacob, and appointed a law in Israel, {N}
which He commanded our fathers, that they should make them known to their children;
6 That the generation to come might know them, even the children that should be born; who should arise and tell them to their children,
7 That they might put their confidence in God, and not forget the works of God, but keep His commandments;
8 And might not be as their fathers, a stubborn and rebellious generation; {N}
a generation that set not their heart aright, and whose spirit was not stedfast with God.
9 The children of Ephraim were as archers handling the bow, that turned back in the day of battle.
10 They kept not the covenant of God, and refused to walk in His law;
11 And they forgot His doings, and His wondrous works that He had shown them.
12 Marvellous things did He in the sight of their fathers, in the land of Egypt, in the field of Zoan.
13 He cleaved the sea, and caused them to pass through; and He made the waters to stand as a heap.
14 By day also He led them with a cloud, and all the night with a light of fire.
15 He cleaved rocks in the wilderness, and gave them drink abundantly as out of the great deep.
16 He brought streams also out of the rock, and caused waters to run down like rivers.
17 Yet went they on still to sin against Him, to rebel against the Most High in the desert.
18 And they tried God in their heart by asking food for their craving.
19 Yea, they spoke against God; they said: 'Can God prepare a table in the wilderness?
20 Behold, He smote the rock, that waters gushed out, and streams overflowed; {N}
can He give bread also? or will He provide flesh for His people?'
21 Therefore the LORD heard, and was wroth; {N}
and a fire was kindled against Jacob, and anger also went up against Israel;
22 Because they believed not in God, and trusted not in His salvation.
23 And He commanded the skies above, and opened the doors of heaven;
24 And He caused manna to rain upon them for food, and gave them of the corn of heaven.
25 Man did eat the bread of the mighty; He sent them provisions to the full.
26 He caused the east wind to set forth in heaven; and by His power He brought on the south wind.
27 He caused flesh also to rain upon them as the dust, and winged fowl as the sand of the seas;
28 And He let it fall in the midst of their camp, round about their dwellings.
29 So they did eat, and were well filled; and He gave them that which they craved.
30 They were not estranged from their craving, their food was yet in their mouths,
31 When the anger of God went up against them, and slew of the lustieth among them, {N}
and smote down the young men of Israel.
32 For all this they sinned still, and believed not in His wondrous works.
33 Therefore He ended their days as a breath, and their years in terror.
34 When He slew them, then they would inquire after Him, and turn back and seek God earnestly.
35 And they remembered that God was their Rock, and the Most High God their redeemer.
36 But they beguiled Him with their mouth, and lied unto Him with their tongue.
37 For their heart was not stedfast with Him, neither were they faithful in His covenant.
38 But He, being full of compassion, forgiveth iniquity, and destroyeth not; {N}
yea, many a time doth He turn His anger away, and doth not stir up all His wrath.
39 So He remembered that they were but flesh, a wind that passeth away, and cometh not again.
40 How oft did they rebel against Him in the wilderness, and grieve Him in the desert!
41 And still again they tried God, and set bounds to the Holy One of Israel.
42 They remembered not His hand, nor the day when He redeemed them from the adversary.
43 How He set His signs in Egypt, and His wonders in the field of Zoan;
44 And turned their rivers into blood, so that they could not drink their streams.
45 He sent among them swarms of flies, which devoured them; and frogs, which destroyed them.
46 He gave also their increase unto the caterpillar, and their labour unto the locust.
47 He destroyed their vines with hail, and their sycamore-trees with frost.
48 He gave over their cattle also to the hail, and their flocks to fiery bolts.
49 He sent forth upon them the fierceness of His anger, wrath, and indignation, and trouble, a sending of messengers of evil.
50 He levelled a path for His anger; He spared not their soul from death, but gave their life over to the pestilence;
51 And smote all the first-born in Egypt, the first-fruits of their strength in the tents of Ham;
52 But He made His own people to go forth like sheep, and guided them in the wilderness like a flock.
53 And He led them safely, and they feared not; but the sea overwhelmed their enemies.
54 And He brought them to His holy border, to the mountain, which His right hand had gotten.
55 He drove out the nations also before them, and allotted them for an inheritance by line, {N}
and made the tribes of Israel to dwell in their tents.
56 Yet they tried and provoked God, the Most High, and kept not His testimonies;
57 But turned back, and dealt treacherously like their fathers; they were turned aside like a deceitful bow.
58 For they provoked Him with their high places, and moved Him to jealousy with their graven images.
59 God heard, and was wroth, and He greatly abhorred Israel;
60 And He forsook the tabernacle of Shiloh, the tent which He had made to dwell among men;
61 And delivered His strength into captivity, and His glory into the adversary's hand.
62 He gave His people over also unto the sword; and was wroth with His inheritance.
63 Fire devoured their young men; and their virgins had no marriage-song.
64 Their priests fell by the sword; and their widows made no lamentation.
65 Then the Lord awaked as one asleep, like a mighty man recovering from wine.
66 And He smote His adversaries backward; He put upon them a perpetual reproach.
67 Moreover He abhorred the tent of Joseph, and chose not the tribe of Ephraim;
68 But chose the tribe of Judah, the mount Zion which He loved.
69 And He built His sanctuary like the heights, like the earth which He hath founded for ever.
70 He chose David also His servant, and took him from the sheepfolds;
71 From following the ewes that give suck He brought him, to be shepherd over Jacob His people, and Israel His inheritance.
72 So he shepherded them according to the integrity of his heart; and lead them by the skilfulness of his hands. {P}


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Landsmöde is Denmark's biggest event in the energy sector. The Danish District Heating Associations national convention gathers more than 2,000 people in the industry to debate and exchange experiences.
We will be presenting the highest capacity brazed plate heat exchangers for District Heating with capacities of up to 10 MW.
You are welcome to meet us on stand: BL
To book a meeting please contact:
Christer Frennfelt
Consultant and Utility Business Manager
HUB Northern Europe
Read more about the event here


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Six RoundsBy Caitlin Corrigan
January 24, 2014
On the day we call the cops on him, L. tells me he's always been a fighter.
No guns, though. He looks up at me from where he's hunched, a skinny kid sitting on a rickety chair. Not before what happened.
What happened before was L. was riding his bike and some bad boys shot him in the spine. He wasn't supposed to walk again. He walks fine now. He swaggers. His khaki pants are too big and he cinches up his belt higher than the other boys. I don't think he can handle wrestling with the constant creep of a sagging waistline.


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Perspective: 5 myths about swing states
Swing states: Pundits love to talk about them, and candidates lavish attention on them. Sometimes it seems that the nominees are running for president of the United States of Ohio, Pennsylvania and Florida, and that the rest of us are just spectators. But much of what we think we know about these key states, which switch party allegiances with some frequency, has been knocked down by political science research - and sometimes, by recent history. Here are a few misperceptions about these in-demand states.
1. Swing-state polls are the key to predicting the winner.
In fact, the opposite is true, especially this far from November. Generally, elections are determined by a "uniform swing." That is, if the Republican candidate does a little better overall, then he's going to do a little better in close states such as Ohio and Nevada, too. So even though the candidates will spend most of their time and money in the states they expect to matter most, it won't make much difference.
Any candidate who wins the popular vote by at least three percentage points is certain to win the electoral college, and any candidate who wins the popular vote by as much as a full percentage point is overwhelmingly likely to win the electoral college. So the best way to follow the election is to read the national polling averages. National polls have a key advantage: There are a lot more of them, so we're less likely to be fooled by the occasional outlier. And the frequency of national polls, conducted by the same handful of firms, means informed readers can catch any obvious partisan tilts in the results and interpret them accordingly.
Granted, political junkies like me won't be able to stop themselves from peeking at what the Des Moines Register thinks is happening in the Hawkeye State. But if we're smart, we'll look at the national polls to find out what's really going on.
2. A vice presidential candidate should appeal to key groups in swing states.
We hear this every election cycle. The National Journal's latest Veepstakes rankings, for example, say that former Minnesota Gov. Tim Pawlenty makes sense as a possible running mate for Mitt Romney because "in an election that could be decided by Rustbelt battlegrounds, it couldn't hurt to have a guy capable of matching VP Biden's blue-collar appeal."
This sort of thinking is probably what led to John McCain's selection of Sarah Palin in 2008; his campaign thought she would neutralize Barack Obama's advantage among female voters. And supposedly, Joe Biden was picked to help Obama with white working-class voters in the swing states of Ohio and Pennsylvania. The problem is that there's no evidence that vice presidential candidates have that kind of impact.
The exception, research has found, is that a popular running mate might help by a couple of points in his or her home state. But even if a candidate knows what the swing states are, it's a lot harder to figure out where, exactly, the campaign could most use that two-point boost. And home-state popularity isn't transferable. So whatever folks in Duluth or St. Paul might think of Pawlenty, he might not appeal to voters in Dayton.
3. Ignore the national economy, and focus on swing-state economies.
Ever since political scientists showed that the economy is a major factor in presidential elections, they have struggled to determine what exactly that boils down to. Is it voters' personal experience? What their friends and neighbors believe? The answer matters a lot. If the local economy is the deciding factor, then it would make sense for the candidates to focus on how the economy is doing in, say, Dade County, Fla., or Hamilton County, Ohio.
It turns out, however, that impressions of the national economy are what really move votes. As one recent study of voting and the economy concluded: "Evidently, voters believe the president has little effect on their local economy, and they do not form their evaluation of the national economy based on surrounding conditions. . . . People form their opinions of the national economy based on non-local factors, such as the national media."
4. Once a swing state, always a swing state.
It's true that some states will perpetually be competitive, but over time, some experience significant changes. West Virginia, for instance, went from being one of the strongest Democratic states in 1980 to being one of the strongest Republican states now. It's very hard to know in advance, certainly until the last few weeks of the campaign, what the key swing states - the ones that will truly determine the winner - will turn out to be.
The best illustration of that is to note which states have been closest to the national margin of victory in the past few elections. For example, when Obama won by seven percentage points in 2008, which state results most closely matched that number? Those states would have determined the winner, had the electoral college count been very narrow. The five states closest to the overall margin of victory in 2008 were Virginia, Iowa, New Hampshire, Florida and Minnesota. In 2000, they were Oregon, Iowa, New Hampshire, New Mexico and Florida; and in 2004, they were Pennsylvania, Nevada, Ohio, Michigan and Minnesota. That's 11 states over three cycles, including completely different sets in 2000 and 2004.
Sure, we don't expect solidly Republican Wyoming or solidly Democratic Vermont to be competitive. But the past three cycles show that we can't know right now whether the state that puts Romney or Obama over the top will be Colorado, Ohio, or any of a dozen or more possibilities.
5. Republicans can't win without Ohio.
You'll hear plenty of similar pronouncements every election season. The Republicans have never won without Ohio, therefore they can't win without Ohio. Or: There is a "blue wall" of states that the Democrats have captured consistently since 1992, so the party has a built-in minimum in the electoral college. That could mean that any poll showing a strong Republican tilt in one of those states indicates that Obama is doomed - or that Gov. Scott Walker's recall victory in "blue wall" Wisconsin shows that Democrats are in trouble.
Forget all these "rules." When Republicans won three consecutive presidential elections in the 1980s, pundits became convinced that the GOP had an electoral college lock. That view lasted exactly as long as the party's national vote lead did; as soon as Bill Clinton took the national lead in 1992, it turned out that some of the Republican "lock" states were swingers after all. Sure, if Romney wins Democratic California, he's going to win the election, but that's because if Romney wins California, he's going to be in the process of a huge national landslide.
The United States has national elections, and what matters almost every time is the national results. Yes, a candidate must find 270 electoral votes in order to win. But in most years, the electoral college margin will be much larger than the popular vote difference. And the rare times, such as in 2000, when the popular vote is very close, it's not possible to guess in advance which states will be the one or two that really make a difference. So the campaigns will put their resources into those states they expect to be close, because it certainly doesn't hurt, but our elections are much more national than our obsession with swing states implies.
Jonathan Bernstein is a political scientist who contributes to the Washington Post blogs Plum Line and PostPartisan.


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Curly (Type 3)
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Tide be runnin' the great world over:
'Twas only last June month I mind that we
Was thinkin' the toss and the call in the breast of the lover
So everlastin' as the sea.
Heer's the same little fishes that splutter and swim,
Wi' the moon's old glim on the grey, wet sand:
An' him no more to me nor me to him
Then the wind goin' over my hand.
Charlotte Mew (1869-1928): Sea Love, from The Farmer's Bride, 1916
Te Arii Vahine (The Queen of Beauty): Paul Gauguin, 1896, watercolour, 172 x 229 mm (private collection)