Category — Health News
In March of 2012, 17-year old high school student Mariah Edwards entered a local surgical center for a tonsillectomy, a procedure performed by physicians for decades. Philadelphia’s WPVI reports that what should have been an uneventful stay turned into an unimaginable nightmare for the family when the young girl died. With the ever increasing advancements in knowledge and technology occurring in the medical field, many procedures now occur on an outpatient basis. However, while modernization increases, statistics indicate that the quality of care patients receive remains on a steady decline.
A surgeon performed Edward’s tonsillectomy in under an hour without encountering complications. Medical staff informed the relieved family. Medical staff transferred the girl to the facility recovery room. Attached to an array of monitors designed to continually assess a patient’s status and alarm staff when that status changes, the girl lay unconscious from the effects of anesthesia and a powerful narcotic pain medication. At some point during her expected recovery, Edward’s respiratory rate and vital signs began declining. Personnel staffing the recovery area did not respond to the emergency situation because sometime after Edward’s admittance, a nurse pulled the curtain around the girl’s bed and muted the alarms on the monitors. Staff admitted not checking the status of the patient for a period of 25 minutes.
Hospital Errors Cause Alarmingly High Number of Fatalities
In the aftermath of this tragedy, the medical facility implemented a policy ensuring a higher degree of patient care that included prohibiting staff from silencing monitors. A negligence lawsuit remains pending. According to a report published by the Institute of Medicine , between 44,000 and 98,000 patients die annually in America’s hospitals because of human error. These numbers do not take into account the number of fatalities occurring in outpatient clinics, outpatient surgery centers, dental offices, nursing homes or other patient care facilities. The report goes on to declare that medical error related fatalities outnumber deaths incurred secondary to motor vehicle accidents and terminal disease conditions.
Equally alarming is the fact that when evaluating individual states, the Institute of Medicine claims that medical errors contributed to more than 50 percent of fatalities occurring in hospitals in some regions. The organization notes a number of factors contributing to these statistics including communication errors, diagnostic errors, human errors and manufacturing errors. The medical community prefers not taking punitive measures against employees responsible for committing errors for fear of creating an environment void of transparency or a willingness to openly confess mistakes.
Considerations for Improvement
The Institute of Medicine and the Quality Interagency Coordination Task Force propose that standardizing medical equipment and incorporating safeguards decreases the risk of error. Other recommendations include improving work environments for medical personnel by limiting shift hours or preventing understaffing. Facilities must also implement methods and technologies that reduce errors concerning medications or documentation. The organizations also hope to develop a national error reporting database that increases the quality of care by performing routine analysis of situations. From studying individual or multiple scenarios, new methods of prevention may develop. The IOM and the QuIC task force also suggest that patients take a more active approach in their health care.
February 26, 2013 No Comments
Hospice care is a service provided for patients nearing the end of their lives. Its goal is to help people feel the most comfortable during the final weeks of their lives, and to provide support services for families and caregivers during that time. As described on the Elder Care page of the Department of Health and Human Service’s web site, the decision to utilize hospice care is highly personal for both the patient and the family, and there are many factors to consider, from physical and emotional concerns, to financial and even spiritual matters.
A Study on Hospice Care
WebMD describes a recent study done on hospice care and how it’s been used over the last several years. The study included information about duration of hospice use and how it was used in conjunction with visits to the ICU. The study concluded that the length of time hospice services are in use has declined drastically over the last several years. With the shorter time in hospice care, the positive and beneficial impact on the patients and their families is minimal.
The study also showed that between 2000 and 2009 fewer people died in the hospital, but the use of the ICU during the same time period increased in the last month of life. The use of hospice also increased during the same time period. Although the use of hospice care increased overall, 28.4% of the hospice care used was for no more than three days. 40% of those cases followed directly after a stay in an ICU.
Reasons For the Decline
There seem to be many contributing factors in play here. One of them is that people are only considering hospice care as a last resort, and this usually happens too late. Doctors are not paid to sit down and discuss these services with their patients, so they don’t often do so unless they are approached about it directly. When families and patients are better informed about hospice and learn about it further in advance, they tend to have more time to acquire the services faster and benefit more from the psycho-social support that is offered to them.
Another reason that people are only receiving hospice care for short amounts of time might be because of a sudden decline in their health. They might lack the time to prepare for hospice services. Additionally, the fact that it is much harder to get hospice care than it is to stay at a hospital or in the ICU may also play a role in patients and families putting off its use. Filling out 25 pages of forms is much harder than being admitted to the ICU.
There are things that can be done to make it easier for people to get the hospice care they need when it will benefit them the most. Some of these things include informing patients about hospice services earlier, and making it easier to acquire them. This can have a positive and far reaching impact on the patients and their families.
February 18, 2013 No Comments
A recent article by CBS Chicago reports indicates that the Chicagoland area is experiencing an increasing need for nurses. The Illinois Department of Employment Security (IDES) reports that in Illinois, job demand for registered nurses is expected to grow 16.3 percent for 2020 from employment in 2010. Vocational and licensed practical nurses are expected to see a 9.1 percent growth during the same period.
Basic Supply and Demand
The high demand for nurses is reflected in the availability of jobs. In December 2012, the Economic Information and Analysis Division of IDES found over 5,200 online job postings for registered nurses in Illinois. Several factors contribute to the increase in demand for healthcare workers. The baby boomer generation is now requiring more long term care. The retirement rate among nurses who are from the baby boomer generation is also creating more job openings, according to the American Association of Colleges of Nursing. The influx of younger nurses coming into the profession is currently not keeping up with the rate of nurses who are retiring. Currently, nursing is one of the top 25 occupations with the most vacancies in Illinois.
Another factor that is contributing to the increased demand for nurses is the financial pressure hospitals are now feeling. Hospitals are more inclined to release patients as early as possible, which means the patients may require home care or a subsequent stay in a long term care facility. This pattern is creating more job openings for nurses in settings outside of traditional hospitals.
Healthcare providers are also expanding their services in Chicago. According to the Chicago Tribune, Rush University Medical Center is expected to hire 40 to 50 nurse practitioners in 2013 while NorthShore University HealthSystem is expected to expand and augment their service offerings. The expansion of health services by local hospitals should drive the demand for nurses. A concern expressed by the American Association of Colleges of Nursing is that a nursing shortage could lead to increased stress, which could cause nurses to leave the profession. It is believed that a nursing shortage could eventually negatively impact the quality of care patients receive at a given hospital or other facility.
While nursing is a profession that already requires specialized education, licensing, and training, educational requirements for nurses may increase in the near future. Currently, many nursing jobs require an associate or bachelor degree. However, the Institute of Medicine is working to increase the number of nurses who hold a bachelor degree to 80 percent by the year 2020. As of now, approximately 50 percent of nurses have a bachelor degree. In addition to having a degree, nurses are also required to have a nursing license and to regularly complete continuing education courses to renew their license and keep their skills current. By doing so, nurses are sure to be able to rest secure in job stability if nursing jobs are as readily available as they currently are in the greater Chicago area.
February 14, 2013 No Comments
An interesting study conducted by the Mayo Clinic, cited at WebMD, suggests that the US may be facing a shortage of primary care physicians in the near future.
According to the Bureau of Labor Statistics, there were approximately 46,740 primary-care physicians employed in 2011. The American College of Physicians indicates the demand for primary care physicians will skyrocket as the population ages, health care needs increase due to increasing number of people becoming insured under the affordable care act, and increasing demand for acute, chronic, and long-term care. Even if the current number of internists remains constant, the ACP indicates, there would not be enough physicians in the future to meet the increased demand.
Medical Students Bowing Out
But the numbers of medical students choosing to become internists is not projected to rise, or even to remain constant. In fact, fewer and fewer physicians are choosing a career in general internal medicine. The first inkling of a shortage was suggested by a 1992 study that reported only about half of the students graduating from a general internal medicine program maintained a practice in general internal medicine. The ACP also cited a subsequent 2010 report that predicted the nation would be short by 45,750 internists by 2020.
A new study conducted by the Mayo clinic presents a comprehensive, if dark picture. Among 17,000 third-year medical students surveyed at the time of their exams, 21.5 percent stated they planned to pursue general internal medicine. Even among those students already enrolled in a general internist program between 2009 to 2011, only 40 percent said they planned to stick with internal medicine. Adding insult to injury, only about 20 percent of those enrolled in a traditional “categorical” program, planned on pursuing internal medicine.
Where Are They Going?
Colin West, MD, PhD, the Mayo study’s chief researcher, speculated on a number of causes for the shortage. West thinks that doctors today are seeking a better work-life balance than what is generally afforded to internists, who must work when their patients are sick, rather than sticking with convenient office hours. Many of the specialty medical practices offer part-time hours, flexible schedules and more control over office-visits hours than does a general internist practice.
Another potential cause is the almighty dollar. A simple economic fact is that doctors pursuing a specialty earn about twice as much as primary-care physicians. The 2011 BLS survey reported a mean annual salary of $189,210 for internists compared to cardiologists, who made $321,080.
One of the hardest to empirically measure but still important factors luring physicians away from a career in internal medicine is cachet. Martha S. Grayson, MD, senior associate dean at the Albert Einstein College of Medicine, found in her research that medical students are being enticed by the glamor of specialty medicine. It appears specialists such as neurosurgeons, radiologists and even toxicologists are more highly valued by society than are internists.
January 9, 2013 No Comments
When a typical American imagines a drug-abusing culture, they picture young street people ruining their lives by shooting heroin or cocaine. But the face of drug abuse across America is changing. The new drug epidemic doesn’t involve teenagers using street drugs. It involves their parents abusing prescription medications.
The orphan-making epidemic is particularly acute in areas such as Rockcastle County, Kentucky, where authorities are reporting one drug related death per week. Tragic cases abound such as 16-year old Avery Bradshaw who lost his father to a drug overdose on Oxycontin and 17-year old Sean Watkins who lost his mother at the age of ten to the same drug. Bradshaw and Watkins are not isolated cases. According to the 2010 census, over 86,000 children in Kentucky are currently being raised by someone other than a biological parent. Read their stories and others here: Prescription drugs ‘orphan’ children in eastern Kentucky.
Bradshaw and Watkins are more fortunate than other children impacted by this tragedy, however, as they both are living in stable homes with their grandparents. Other children who have been made orphans by prescription-drug abuse are being shuffled from house to house in sometimes dangerous and unstable living situations. The Centers for Disease Control and Prevention has declared the problem to be an epidemic with someone dying of a prescription drug-related overdose every 19-minutes across the US.
In addition to Kentucky, states most impacted include Washington, Utah, Florida, Louisiana, Nevada and New Mexico. The epidemic is so difficult to stop because the drug of choice and the users keep changing. Organizations such as UNITE lobby to fight each narcotic villain. Founded by US Representative Hal Rogers in 2003, UNITE’s initial efforts were focused on getting pushers to quit selling drugs to children. But, just as UNITE began to make headway on this front, the face of drug-abuse changed necessitating a new war. UNITE has adapted to the change and now focuses its efforts on educating and counseling children orphaned by this tragedy.
It’s difficult to focus on one drug as the drug of choice keeps changing. Street drugs such as heroin and cocaine were replaced by powerful prescription narcotics, such as vicodin. When vicodin became harder to find, addicts switched to oxcontin, a powerful and addictive narcotic-pain killer whose effects are amplified by crushing the pills and snorting or injecting them and/or combining medication use with alcohol. Oxycontin’s manufacturer responded in 2010 by reformulating their drug so it was almost impossible to crush.
The drug of choice then became opana, whose main ingredient is oxymorphine. In 2010 in Kentucky, toxicology reports found oxymorphine in only 2% of all drug-related deaths. By 2011, the prevalence has skyrocketed to 23%. Although this drug’s manufacturers have also reformulated a non-crushable version of their medication, this formulation will not be released until 2013. Upon its release, drug czars are expecting another medication to quickly take its place.
Tough economic times may be attributing to the shift in demographic use patterns from children to their parents, especially in impoverished rural areas such as the Appalachians. In fact, one major source of the drugs is senior citizens, who are selling them to pushers to supplement their social security incomes. One thing is sadly sure, regardless of age or demographic, the war on drugs is far from over.
January 8, 2013 No Comments
Hoarding, which is defined as the compulsive urge to acquire and retain a large number of possessions that appear to be useless or of limited value, is estimated to effect two million people in the United States alone. New research reported on at NBC News suggests a brain malfunction may be responsible, at least in part, for the disorder.
My Stuff, Your Stuff
David Tolin, adjunct associate professor of psychiatry at the Yale University School of Medicine and director of the Anxiety Disorders Center at The Institute of Living in Hartford, Connecticut, noticed during his extensive experience working with hoarders that people who tend to hoard become abnormally nervous when asked to discard objectively rather useless possessions. He questioned whether this high level of anxiety has a biochemical basis. His research team completed brain scans on 43 hoarders, 31 patients with obsessive-compulsive disorder and 33 control subjects with no evidence of either OCD or hoarding to see if there were significant biochemical differences in brain functioning between these groups when asked to discard clutter from their homes.
Tolin’s group had each research subject bring into his laboratory all the papers from their countertop, which he put in a box labelled, “my stuff.” He then had the researchers themselves bring in their own personal junk mail, which he put into another box labelled “your stuff.”
While each subject’s brain responses was scanned, a researcher went through each item in both boxes, asking the subject if the item could be shredded. Subjects were told no items would be thrown out without their consent. Hoarders had significantly different brain patterns during this exercise than did OCD patients or “normal” controls.
Significant differences in the insula and the anterior cingulated cortex of the hoarders’ brains were noted. There was significantly lower activity in these areas when the researchers were going through other people’s items as opposed to when they were going through the hoarder’s personal items. During these occasions, brain activity in the insula and anterior cingulated cortex skyrocketed.
Tolin speculates that increased activity in these brain areas is unpleasant for the hoarders, who respond by avoiding decision-making activities altogether. Similarly, hoarders may not notice clutter in their homes as their brain shows low activity in these brain areas when they aren’t asked to throw items out. Tolin is unsure if his hoarders’ brain patterns are genetic or environmental. Cognitive-behavioral treatment, as well as pharmacotherapy with drugs like Paxil, however, is targeted toward changing these brain patterns, no matter their origin.
In cognitive-behavioral therapy, the hoarder is systematically desensitized to decision-making with regard to throwing away his junk. He is shown an item, is asked to make a decision about whether to keep it or throw it away, and his thinking patterns are shared with the therapist. Maladaptive thinking patterns are eliminated and replaced with more adaptive ways of thinking as a way of teaching the hoarder to manage his high levels of anxiety.
According to Science Daily, Sanjaya Saxena, M.D., Director of the Obsessive-Compulsive Disorders (OCD) Program at the University of California, San Diego (UCSD) School of Medicine, has conducted his own research, which supports the neurological hypothesis about hoarders. He found that Selective Serotonin Re-uptake Inhibitors, such as Paxil, might be effective in the treatment of hoarding. His small study found that 32 patients with compulsive hoarding syndrome responded favorably to SSRI medications. Results are promising and warrant further investigation.
December 29, 2012 No Comments
Managing even a minor crisis becomes more difficult if you let small things build up, according to Jane Brody in a blog for the New York Times.
Brody noticed herself getting stressed out over small things when she was in the midst of preparing to take a holiday trip this year, despite being an expert speaking on the subject of managing anxiety. She became less effective in terms of her personal problem-solving, simply because her mind was on many other small details. Brody writes that one of her neighbors had to put the issue in perspective for her, helping her to re-prioritize her “to do” list before the trip.
It’s All About Perspective
Brody uses this personal analogy to highlight what experts in anxiety management has long since discovered through scientific research. In the words of Pennsylvania stress and anxiety psychologist Tamar E. Chansky, “everyday stresses add up.” Chansky believes all of us lose perspective at times when stress mounts. The problem becomes more acute, however, when anxiety is a way of life. People can sometimes lose so much perspective on a daily basis that anxiety becomes chronic and life-crippling.
Chansky advises not sweating over the small stuff, letting go of what she terms “extraneous catastrophes.” Sometimes by letting go of minor issues, or problems over which we have no control, we can better manage our baseline level of stress. The less we worry about, the better we are able to handle real crises when they emerge. Chansky advocates positive thinking, focusing on what can be done to alleviate a problem, rather than fretting about how bad the problem is, or how it cannot possibly be solved.
Brody finds these suggestions very helpful, and employs a kind of informal “self-help group” while she’s walking with her friends. Everyone shares a problem, she relates, and inevitably someone with a more neutral perspective will offer a workable solution.
Chansky offers other valuable solutions, including taking a break when you find yourself getting worked up and practicing breathing slowly and calmly. Deep breaths help slow the heart beat and respiration and will help calm you down, she explains.
Re-Direct Your Focus
Therese J. Borchard, Associate Editor of PsychCentral, agrees with many of the tips offered by Chansky, and offers a few additional pointers. She suggests focusing on a sound or object in your environment instead of the issue that is stressing you out. This kind of break can help calm you, enabling you to more objectively evaluate the situation.
If you are overwhelmed by the big picture, Borchard finds that focusing just on a small task, or a small unit of time each as short as a minute, can help you get through the crisis. If you can make everything “fine” for just one minute, you are more likely to continue this positive spiral for longer and longer periods of time, until you have successfully resolved the crisis.
All of these writers advocate a common theme which is to learn from anxiety, rather than be swallowed whole by it. Feelings of anxiety are a sign that something in your life, either an external event or even an internal thought trigger, need to be changed to become more adaptive. In the words of Borchard, “Bite off less professionally and invest more energy into finding good help for the kids and housework. Because [we] can’t do it all.”
December 27, 2012 No Comments
Hospitals and healthcare centers are places of intended cleanliness and health. As such, tradition has held that in the planning and construction phases of erecting a new facility, a very prime piece of real estate must be chosen; a place of cleanliness that has had a proven history of a more idyllic nature. Naturally, this is logical thinking for such an important establishment.
Today though, that long-standing trend is being turned upside down. Healthcare establishments are now finding that the more imperfect the land, the better. Why, you may ask. The answer lies in previously little-known, or at least little-exploited laws and regulations.
According to the well-versed, recent New York Times article, the trend of such establishments purchasing and using troubled land and property is growing rapidly. Hospitals and healthcare centers are buying up such property and enjoying massive tax credits and incentives for taking on the burden. Valuable grants and even H.U.D. lending is extended to a buyer when the property being purchased is in a bad state. The same article cites individual credits of up to $500,000 having already been issued.
What Makes a “Brownfield”
In short, the start-up capital gleaned from all the available incentives overcomes the expenses of even the worst property reparations. But what exactly qualifies a property as problematic, or a “brownfield” property? The Environmental Protection Agency actually provides valuable resources on the subject right from its website. According to the EPA, any number of circumstances can see a property considered a brownfield. Deep structural decay, toxic wastes, solid wastes, waste water accumulation, and other property ailments all can draw a brownfield label. From here, the prospective buyer assesses what is needed to make the site usable, and weighs it against the many financial incentives to be gained. In most cases, the reparations are well worth the benefits. Subsequently, the purchase is made and work starts.
This arrangement is not only beneficial to the incoming healthcare establishment, but is also greatly helpful to the community. Generally, these distressed properties are in lower-income, depressed parts of the municipality. With no other potential buyers, an incoming health facility cleans up the particular property and its problems single-handedly. In addition, the area is provided with localized healthcare, often desperately needed.
With such a mutually beneficial outcome, it is little wonder that this trend is just at its beginnings, with much more soon to come. As of now, this “Brownfield Buying Extravaganza” is mainly taking place in Florida, its birthplace, but is expanding quickly to many other states. Look for upcoming legislature that makes this a friendly process in many more jurisdictions. The only question now – which other industries will be the next to try to and jump on board.
December 23, 2012 No Comments
While you may have heard that living alone doesn’t necessarily make you lonely, a new research study reported on by CNN indicates that only about one in five elderly persons who live alone are lonely and that loneliness was associated with memory loss. So, living alone is not necessarily problematic for the elderly, however being lonely can present a serious impediment to quality living.
Tjalling Jan Holwerda, lead researcher from the Free University Medical Center in Amsterdam, studied over 2,000 persons over 65-years old, who were living in the Netherlands, for this research. None of the study participants showed any signs of dementia at the beginning of the research, and none were in assisted living circumstances. Holwerda’s team studied the cohort longitudinally, following up with them twice yearly over a three year period. Even when results were adjusted for demographics such as age, lonely people in her study were 64 percent more likely to be to manifest symptoms of dementia.
Study Corroborates Previous Findings
Holwerda’s research builds on the results of previous studies that found that having a supportive social network was correlated with factors such as good psychological and physical well-being. Some of this research suggests being lonely can be lethal — as this risk factor was correlated with higher blood pressure and increased risk for heart disease and stroke.
Holwerda’s research replicates a 2007 study conducted in the US that was published in the Journal of the American Medical Association. In this study, 823 elderly persons free of dementia were recruited from senior citizen facilities in the Chicago, Illinois area. Each research subject was asked to rate his perceived loneliness on a scale of 1 to 5, once at baseline and once a year over the next four years. After research subjects passed away, a postmortem was conducted to quantify Alzheimers/Dementia pathology in their brains. In total, 76 subjects had some clinical evidence of AD, with lonely people being about twice as likely to manifest these signs. As in Holwerda’s research, it was the subjective experience of loneliness, not being socially isolated, that was associated with a higher incidence of AD.
The Power of Perception
Caution is warranted when reviewing research results reporting a correlational relationship between factors, because, as any first year statistics student will tell you, correlation does not imply causation. Just because loneliness is associated with depression, does not mean that loneliness causes dementia. In fact, persons with dementia may separate themselves from others, or a third factor, such as poor social skills, may account for both loneliness and dementia.
In any event, this study provides convincing evidence of the power of perception. That a person’s belief that they are lonely is related to the likelihood that they will show some signs of dementia over time is an amazing, important outcome of this research.
December 20, 2012 No Comments
Summarizing a report originally published in “The Lancet,” Great Britain’s leading medical journal, The New York Times reports that worldwide life expectancies have increased dramatically in the last two decades. Representatives from over 300 public health agencies and institutions contributed to the British report, which contains mortality and life expectancy data for over 180 countries.
Treatment and Prevention Initiatives are Working
Public health officials credit developing nations’ aggressive immunization, food distribution and safe water initiatives for the most significant gains. “Times” health correspondent Sabrina Tavernise reports, throughout the developing world, improvements in sanitation, access to food, and medical services, and the success of widespread vaccination programs have produced striking results: Between 1990 and 2010, infant mortality decreased more than 50 percent, and malnutrition, formerly the world’s No. 1 health threat, has fallen to No. 8 on the worldwide rankings.
Data in the World Health Organization’s 2012 Snapshot of Global Health generally corroborates the British study. WHO reports, “In 2000, an estimated 9.6 million children under five years old died worldwide. The biggest killers were pneumonia, prematurity, diarrhea, malaria, measles, and HIV/Aids. By 2010, annual child deaths had been reduced to 7.6 million.” United Nations researchers especially noted a 74 percent reduction in worldwide measles deaths. In New York recently, WHO officials issued a formal statement saying that much of their data matches information in “The Lancet’s” report, but it cannot confirm all the numbers, because only 34 nations keep reliable cause-of-death records; British researchers prepared information on the other 146 countries by statistical modeling. Therefore, some data from United Nations agencies differs substantially from figures published in “The Lancet.”
Increases in “Rich Countries’ Diseases”
The British report highlighted significant increases in what worldwide health experts call “rich countries’ diseases”—obesity, diabetes, heart disease and some cancers. A few health researchers correlate these increases with rapid industrialization of some developing nations which improves overall standards of living but also increases risks from environmental carcinogens. “The New York Times” quoted University of Pennsylvania professor Ezekiel Emanuel, who asserts that increases in heart disease, diabetes and cancer “are, in a strange way, good news. They show that developing nations have overcome infectious and communicable diseases, and therefore people in those nations are living better and longer.”
American women conformed to worldwide trends in obesity, diabetes, heart disease, stroke and cancer, but their life expectancies remained approximately the same as they were in 1990. Although some baby-boomers realistically may anticipate living beyond 100 years old, the average American woman’s life expectancy is up only two percent in twenty years, rising from 78.6 to 80.5 years. The United States ranks 36th in worldwide life expectancies, down 14 places from 1990, and falling behind several nations still considered members of the “third world.”
“Third World U.S.A.”
Esperanza Canez, researcher at the University of California, San Diego, expressed her continuing concern for disadvantaged children in the United States. “Although this country has the world’s most advanced healthcare technology and offers exceptional care to people who can afford it, families below the poverty line have almost the same rates of disease, malnutrition and infant mortality as their counterparts in developing nations.” Canez says she looks forward to some improvement when reform legislation takes effect in 2014, but she insists, “Whatever people’s political positions, one way or another this country must find means for nourishing, vaccinating and caring for all of its children regardless of their ethnic origins and social classes.” Canez laments, “Right now, the gap between upper-middle-class and poor children stretches wider and goes deeper than the Grand Canyon.”
December 18, 2012 No Comments