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Programs & Events Calendar
8/27/2022 August 27, 2022 - 9/10/2022 September 10, 2022
Wolves of North America
Wolf Conservation Center 7 Buck Run, South Salem, NY
Learn about the mythology, biology and ecology of wolf families and discover why it's a special time for packs in North America. Whether the wolves are living on the Arctic tundra or the woodlands of the southwest, wolf families are out searching for prey as their pups grow bigger and bolder! Guests will visit Ambassador…
August 27, 2022 @ 5:00 pm - 7:59 am
Sleeping with Wolves, the Wolf Conservation Center's (WCC) popular nocturnal adventure experience, gives guests a chance to camp out overnight with the 30+ wolves that call the WCC home! With all the howls, circling vultures, and nature's nighttime chatter, you'll feel like you're camping under the stars with wild wolves. We might not be Yellowstone,…
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Lymphedema Prevalence and Treatment Benefits in Cancer: Impact of a Therapeutic Intervention on Health Outcomes and Costs
Kimberly M. Brayton,
Affiliation Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, United States of America
Alan T. Hirsch,
Affiliation Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, United States of America
Patricia J. O′Brien,
Affiliation Hematology/Oncology Division, University of Vermont, Burlington, VT, United States of America
Andrea Cheville,
Affiliation Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, United States of America
Pinar Karaca-Mandic,
Affiliation Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
Stanley G. Rockson
* E-mail: rockson@stanford.edu
Kimberly M. Brayton Alan T. Hirsch ... Stanley G. Rockson
Lymphedema is a common complication of cancer therapeutics; its prevalence, treatment outcomes, and costs have been poorly defined. The objective of this study was to examine lymphedema prevalence among cancer survivors and to characterize changes in clinical outcomes and costs associated with a defined therapeutic intervention (use of a pneumatic compression devices [PCD]) in a representative, privately insured population.
Retrospective analysis of de-identified health claims data from a large national insurer for calendar years 2007 through 2013. Patients were required to have 12 months of continuous insurance coverage prior to PCD receipt (baseline), as well as a 12-month follow-up period. Analyses were performed for individuals with cancer-related lymphedema (n = 1,065). Lymphedema prevalence was calculated: number of patients with a lymphedema claim in a calendar year divided by total number of enrollees. The impact of PCD use was evaluated by comparing rates of a pre-specified set of health outcomes and costs for the 12 months before and after, respectively, PCD receipt. Lymphedema prevalence among cancer survivors increased from 0.95% in 2007 to 1.24% in 2013. PCD use was associated with decreases in rates of hospitalizations (45% to 32%, p<0.0001), outpatient hospital visits (95% to 90%, p<0.0001), cellulitis diagnoses (28% to 22%, p = 0.003), and physical therapy use (50% to 41%, p<0.0001). The average baseline health care costs were high ($53,422) but decreased in the year after PCD acquisition (−$11,833, p<0.0001).
Lymphedema is a prevalent medical condition that is often a defining attribute of cancer survivorship. The problem is associated with high health care costs; Treatment (in this instance, use of PCD) is associated with significant decreases in adverse clinical outcomes and costs.
Citation: Brayton KM, Hirsch AT, O′Brien PJ, Cheville A, Karaca-Mandic P, Rockson SG (2014) Lymphedema Prevalence and Treatment Benefits in Cancer: Impact of a Therapeutic Intervention on Health Outcomes and Costs. PLoS ONE 9(12): e114597. https://doi.org/10.1371/journal.pone.0114597
Editor: Gagan Deep, University of Colorado Denver, United States of America
Received: September 10, 2014; Accepted: November 10, 2014; Published: December 3, 2014
Copyright: © 2014 Brayton et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. The data consist of proprietary de-identified administrative health claims data from OptumInsight, Inc. (Eden Prairie, MN). The database was not directly accessed by the authors. Search protocols were defined and analysis conducted by Optum Insight personnel at the direction of the authors. Permission for use of the analytical results and data supporting those results was obtained from Louis Brooks Jr., Vice President, Data Technology and Marketing Analytics at OptumInsight. Requests to access the data should be directed to Louis.Brooks@Optum.com.
Funding: Kimberly Brayton, MD, is supported by Grant Number HS000028 from the NIH. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the AHRQ. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: Alan T. Hirsch, MD, serves as Chief Medical Officer of Tactile Medical, a company which manufactures a product used to treat lymphedema. This relationship has been reviewed and managed by the University of Minnesota in accordance with its Conflict of Interest policies. This relationship does not alter the authors' adherence to PLOS ONE policies on sharing data and materials. Pinar Karaca-Mandic, PhD, provides health economics consulting services to Tactile Medical, a company which manufactures a product used to treat lymphedema. This relationship is reported to the University of Minnesota. This relationship does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.
Lymphedema is a vascular disorder that, in the Western world, arises most commonly as a consequence of cancer or its treatment. This is the most prevalent form of acquired or "secondary" lymphedema [1], [2]. While several single-center cohort studies have reported estimates of the prevalence of cancer-related lymphedema among breast cancer patients [3], the existing literature fails to fully define the population-based prevalence, health outcomes, and treatment costs of this disorder [4].
The advent of lymphedema carries substantial clinical implications for the affected cancer survivors, implicating profound losses in physical and psychosocial functioning [5]–[8]. Insight into the etiology and natural history of lymphedema has improved, but there is no cure [9]. Thus, the failure to treat lymphedema is associated with major adverse clinical outcomes [10].
Several treatment alternatives can effectively reduce lymphedema symptomatology and severity. For example, specific exercises are known to enhance limb mobility [11]–[13]. Case series have demonstrated that physical interventions such as manual lymphatic massage, multilayer bandaging techniques, and application of compressive garments can effectively reduce tissue fluid volume [14]–[16]. Recently, prospectively acquired data have also confirmed the effectiveness of adjunctive pneumatic compression device (PCD) therapies in diminishing edema volume and in improving patient-reported symptoms [16]–[19].
The impact of lymphedema on health costs and the potential benefits of therapy have been inadequately characterized. Prior studies in breast-cancer populations have suggested that the development of lymphedema adds significantly to the costs of disease management [20]. However, prior investigations have evaluated neither the overall health care costs of lymphedema management, nor the impact of any available therapeutic intervention in a large, representative national population.
To address these knowledge gaps, we conducted a retrospective analysis of a large private insurance claims administrative database for calendar years 2007 through 2013. Claims data are increasingly recognized as a valuable resource, facilitating estimates of recognized disease prevalence during long durations of follow-up analysis [20]–[26]. The goals of the current investigation were: (1) to estimate, for the first time, population trends in lymphedema prevalence and outcomes in cancer; (2) to identify the association of PCD use (one of the available therapeutic interventions) with these clinical outcomes, and (3) to define the health care costs of lymphedema in the context of this form of therapeutic intervention. We distinguished those outcomes and costs that were lymphedema-related from the general outcomes and costs, based on claims coding. We used a pre/post study design and compared the rates of a pre-specified set of relevant health outcomes and costs for the 12 months before and after PCD receipt.
The IRB of Stanford University waived the need for ethical approval for our study. All the administrative health claims data was received anonymously from a de-identified Normative Health Information (dNHI) database between 2007 and 2013 for this study. The database consists of proprietary de-identified administrative health claims data from Optum Insight Inc. (Eden Prairie, MN). The database was not directly accessed by the authors. Search protocols were defined and analysis was conducted by Optum Insight personnel at the direction of the authors. There is no website ink available to the database. Permission for use of the analytical results and data supporting those results was obtained from Louis Brooks Jr, Vice President, Data Technology and Marketing Analytics at OptumInsight.
Setting and Data Source
De-identified administrative health claims data from the de-identified Normative Health Information (dNHI) database were accessed between 2007 and 2013 for this study. dNHI includes more than 34 million individuals each year, comprised of both commercially-insured and Medicare Managed Care enrollees from a large United States (US) national managed care health insurer affiliated with Optum, Inc. (Eden Prairie, MN). The enrollment database includes a geographically diverse US population (16% West, 20% Midwest, 36% South, and 27% Northeast). In addition, the age and gender distribution of the dNHI is similar to that reported by the US Census Bureau for the commercially insured and the Medicare Managed care population.
All the administrative health claims data was received anonymously from the dNHI database. The database consists of proprietary de-identified administrative health claims data from OptumInsight Inc. (Eden Prairie, MN). The database was not directly accessed by the authors. Search protocols were defined and analysis was conducted by OptumInsight personnel at the direction of the authors. There is no website ink available to the database.
The dNHI includes enrollment data, as well as medical and pharmacy claims data. Medical (facility and professional) claims include diagnosis codes recorded with International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM), procedures recorded with ICD-9-CM procedure codes, Current Procedural Terminology (CPT) codes, or Healthcare Common Procedure Coding System (HCPCS), and revenue codes.
No identifiable protected health information was accessed during this study and de-identified data were accessed in accordance with the Health Insurance Portability and Accountability Act. Therefore, institutional review board approval was not required for this study.
To estimate trends in lymphedema prevalence, we included all individuals in the analysis who had ≥1 day of medical benefit eligibility in the dNHI database during the timeframe of January 2007 through September 2013. We assigned patients to the cancer-related lymphedema cohort, based upon a primary cancer diagnosis, if they had one or more medical claims with ICD-9-CM diagnosis codes 140.xx-195.xx or 199.xx-209.xx (n = 950,033 in 2007; 1,005,372 in 2008; 1,078,822in 2009; 1,092,067 in 2010; 1,135,972 in 2011; 1,156,326in 2012; 1,188,860 in 2013). We classified individuals as having lymphedema if they had 1 or more medical claims with primary or secondary ICD-9-CM of 457.0, 457.1, or 757.0. Within the cancer cohort, in order to identify the association of PCD use with clinical outcomes and health care costs, we followed several steps of inclusion/exclusion (Figure 1). First, because we were interested in capturing pharmacy costs as well as medical costs, we required ≥1 day of pharmacy benefit eligibility during the year when the patient had medical benefit eligibility (resulting in an average exclusion of approximately 11 million individuals each year). Second, we restricted the sample to individuals who had a claim for a simple or advanced PCD identified with HCPCS codes E0651 (pneumatic compressor, segmental home model without calibrated gradient pressure) or E0652 (pneumatic compressor, segmental home model with calibrated gradient pressure) during the time period of January 1, 2008 through November 31, 2012 (n = 21,104). Third, we required the study sample to have at least 12 months of continuous medical and pharmacy insurance eligibility prior to receiving the PCD (n = 6,760). Fourth, because we wanted to focus on the first PCD, we excluded those with a claim for another PCD during the one year prior to receiving the PCD (n = 6,702). Fifth, because our primary interest was PCD users with a lymphedema diagnosis, and inasmuch as PCDs are also prescribed to treat other vascular diseases, such as chronic venous insufficiency and other diseases associated with limb edema, we further restricted the sample to individuals with at least one claim with a primary or secondary diagnosis code for lymphedema at any time during the 12 months prior to receiving the E0651/E0652 device (n = 3,415). Finally, we required individuals to have a primary cancer diagnosis in the baseline. We refer to this final study sample of 1,065 cancer patients as the PCD study sample.
Figure 1. Flow diagram depicting the selection strategy for patients included in this analysis.
Patient Demographic and Clinical Characteristics
The dNHI database included information on patient demographic characteristics such as age and gender. Specific individual level socioeconomic status data elements, including race/ethnicity and household income category, can be linked to the dNHI. The data populating the socioeconomic status elements were available for approximately 75–85% of enrollees in the dNHI and are generated by a combination of self-report, modeling, census data and a variety of other individual-level and population-level sources.
In addition, claims data were used to identify co-morbid conditions other than cancer in the PCD study sample during the 12 months prior to receipt of the PCD (baseline). Patients were identified as having baseline obesity, diabetes, hypertension or renal disease based on the relevant ICD-9-CM and CPT/HCPCS codes in their medical claims. Finally, the Charlson co-morbidity score was calculated using the diagnosis and procedure codes during the 12 months prior to receiving the PCD [24].
Lymphedema Prevalence
We calculated the annual prevalence of lymphedema in the dNHI database as the number of individuals with a lymphedema claim in a calendar year divided by the total number of individuals with ≥1 day of medical benefit eligibility and a primary cancer diagnosis in the dNHI database during that same calendar year.
Clinical Outcomes and Health Care Costs
We separately considered a pre-specified set of relevant clinical outcomes for each patient in the PCD study sample, respectively, for the 12 months before PCD receipt and the 12 months after PCD receipt. These outcomes included hospitalizations, outpatient visits, episodes of cellulitis, and courses of lymphedema physical therapy. Episodes of cellulitis were identified as the number of medical claims with a primary or a secondary diagnosis code for cellulitis. Use of physical therapy was defined as having any medical claim with a CPT/HCPCS code for physical therapy. Courses of physical therapy were defined as physical therapy cycles separated by 15 days or more.
We used the American Medical Association place of service codes provided in claims to designate costs in various health care sites for each patient in the PCD study sample, separately, for the 12 months before and after PCD receipt. The settings included home health, emergency, hospital inpatient, hospital outpatient, and office visits, with separate aggregation of durable medical equipment, laboratory, and pharmacy expenses. In the analysis of outpatient costs, we distinguished physical therapy claims (claims which included a physical therapy CPT/HCPCS code) from any other service provided in the hospital outpatient setting.
Total costs were calculated as the sum of payment by the health plan and beneficiary, facility payments, and professional service fees. All clinical outcomes and costs were designated as lymphedema-related if the corresponding claim had a primary or secondary ICD-9-CM of 457.0, 457.1, or 757.0. These diagnosis codes were chosen to capture, as broadly as possible, the subgroup of patients who were assigned a specific lymphedema diagnosis. Lymphangitis (457.2) was excluded because it represents an acute inflammatory presentation that is not limited to the lymphedema population; swelling of limb (728.91) was excluded because of its excessively non-specific nature.
The observation period for each individual patient was determined from a pre-specified "index date", defined as the first claim date at which a simple or advanced PCD (HCPCS codes E0651 or E0652) was listed. The baseline period was defined as inclusive of data obtained during the 12 months prior to the index date. The primary observation period was comprised of the baseline period plus a 12-month follow-up period after the Index Date (Figure 2).
Figure 2. Schematic of the study design protocol.
We compared the rates of the pre-specified set of relevant clinical outcomes and the health care costs per patient in each setting in the year before PCD receipt to the corresponding rates and costs in the year after PCD receipt.
Continuous variables were tested pre-PCD minus post-PCD with a paired t-test. Binary variables were tested with McNemar's test. Analyses were carried out with the SAS statistical package, version 9.2 (SAS Institute, Cary, North Carolina), with p<0.05 considered significant.
In 2007, 9,025 of the 950,333 cancer patients in the dNHI database had lymphedema, reflecting a prevalence of 0.95%. The prevalence increased slowly during each subsequent year, rising to 0.977% (9,827/1,005,372) in 2008, 1.035% (11,165/1,078,822) in 2009, 1.102% (12,029/1,092,067) in 2010, 1.127% (12,806/1,135,156) in 2011, 1.209% (13,985/1,156,326) in 2012 and 1.243% (14,775/1,188,860) in 2013.
Clinical Outcomes and Costs
The PCD study sample among patients with a cancer diagnosed comprised 1,065 individuals. The majority of patients were female (79.8%), and hypertension was a common co-morbid illness, present in 60.5% of the cohort. Obesity was relatively less common (19.0%) (Table 1).
Table 1. Demographic and clinical characteristics of the PCD study sample as of their index date (the date of first PCD claim) [n = 1,065].
Clinical Outcomes.
Health outcomes for cancer-associated lymphedema patients treated with a PCD are shown in Table 2. At baseline, patients with lymphedema suffered relatively frequent hospitalizations, with inpatient care provided to 45% of these patients in the year prior to PCD prescription. Use of a PCD was associated with a significant decline in the rate of hospitalizations (45% to 32%, p<0.0001). While lymphedema-related hospitalizations were infrequent at baseline, the rate was slightly lower during the post-PCD period; this difference was not statistically significant (3% vs. 2%, p = 0.41 cancer cohort).
Table 2. Clinical Outcomes in the PCD Study Sample (n = 1,065).
Reductions were also observed in the proportion of patients with outpatient hospital visits (95% to 90%, p<0.0001). The percentage of patients with a lymphedema-related clinic visit decreased from 47% in the baseline period to 32% in the post-PCD period (p<0.0001). The proportion of patients with cellulitis also declined in the post-PCD period (28% to 22%, p<0.0003). Finally, the proportion of patients using physical therapy declined (50% to 41%, p<0.0001). These reductions were primarily driven by a reduction in the use of lymphedema-related physical therapy (29% to 21%, p<0.0001); there was no statistically significant change in use of non-lymphedema-related physical therapy.
Health Care Costs.
Aggregate total costs per patient in the baseline 12-month period were $62,190 for the individuals with cancer-related lymphedema (Table 3). Provision of inpatient services constituted a large contribution to the total costs ($15,458) as well as the hospital outpatient services ($21,222) and office visits ($15,278).
Table 3. Health Care Costs of the PCD Study Sample (n = 1,065).
The majority of the total costs in the baseline period were non-lymphedema-related: lymphedema-related costs accounted for only 4% of the total costs ($2,243). The largest components of lymphedema-related costs were outpatient services ($1,155), office visits ($415), inpatient services ($421) and home health care ($174).
Use of a PCD was associated with a remarkable decrease in total costs of 18% ($62,190 to $50,857, p<0.0001) in the 12 months after device prescription. The largest cost decreases were achieved by a diminution of office visit costs by 36% (p<0.0001), and outpatient hospital costs by 30% (p<0.0001). Inpatient costs largely remained stable ($15,458 to 15,918, p = 0.7961).
Costs directly attributable to lymphedema care remained stable ($2,243 to $2,383, p = 0.5046). Reductions were observed in lymphedema-related costs for outpatient physical therapy ($276 to $135, p<0.0001) and other outpatient services ($879 to $563, p<0.0001).
Despite its clinical implications for affected individuals, and its high impact on both quality-of-life and functional independence, lymphedema remains a largely overlooked vascular condition in many health care delivery settings. This may reflect the fact that the clinical research community has not yet adequately characterized the population-based prevalence of lymphedema, its health outcomes, and the costs and benefits of lymphedema therapy. Limited public awareness of the condition, and, among practitioners, inadequate appreciation for the natural history and effective treatment options, can be considered to be the consequences of this knowledge gap [27].
Our study provides the first reliable estimate of the population-based prevalence of lymphedema in cancer- related settings. We demonstrate that lymphedema affects a significant and increasing segment of the cancer population. Our study population comprised of both the commercially insured and Medicare Managed Care enrollees from a large US managed care health insurer. For the lymphedema prevalence estimates, our study included an estimated 35 million enrollees of which slightly over 1 million had a primary cancer diagnosis per year. Based on estimates of the US Census and the Current Population Survey, there were about 165 million privately insured, and 13 million Medicare Managed Care enrollees in the US in 2012 [28], suggesting a cancer population of about 5.8 million individuals and among them, a lymphedema burden of 70,000 patients per year among the comparable population nationally. Inclusion of the Medicare Fee-For-Service enrollees (29 million), the Medicaid and other public insurance enrollees (54 million), and the uninsured as of 2012 (48 million) [28], increases the estimated annual prevalence estimates for lymphedema among approximately 10 million patients with primary cancer diagnosis to more than 121,000.
Prior studies have demonstrated the reduction of symptoms and partial-to-complete restoration of functional status with therapeutic interventions for lymphedema [17]–[19]; however it has not previously been demonstrated that current lymphedema treatments fundamentally alter clinical outcomes. This study was designed to focus on the therapeutic intervention of PCD use, because such devices are increasingly used, are accessible to patients when other lymphedema therapies (e.g., manual lymphatic drainage) are not, and serve as a model from which to estimate the benefits of a representative form of compressive therapy. Our data demonstrate, for the first time, the healthcare utilization patterns among cancer-associated lymphedema patients, and the association of PCD use with improvement in several clinical outcomes of interest. We observed that the use of a PCD was associated with a favorable impact on the rate of hospitalizations, clinic visits, cellulitis, and the use of physical therapy, all of which represent important clinical and therapeutic endpoints that reflect patient health status and quality of life.
The claims dataset we relied upon allows a longitudinal observation of the health economic burden associated with clinical care of the cancer population with lymphedema. Baseline health economic costs prior to acquisition of the PCD were high, with the majority of these costs found to be non-lymphedema-related. These treatment-related costs are accrued in diverse care settings, spanning home health care to inpatient sites. Our economic analysis is based on the measurement of direct costs alone, and does not include the costs of transportation to care sites, time lost from work, or losses due to the limited mobility and function that are known to be associated with lymphedema. Nonetheless, we found that economic costs decreased significantly in the year after PCD acquisition. Of note is the fact the largest component of cost reduction was reflected in outpatient care, which reduced by 36%, suggesting that there was a reduction in outpatient visits. Hospitalization costs remained relatively stable, suggesting, inferentially, that PCD was effective in reducing the health care costs of mild-to-moderate lymphedema cases, but not those of the more severely ill individuals.
Our study has several potential limitations. Claims data are derived from populations of insured individuals and thus provide only an estimate of incidence and prevalence; they do not yield information about lymphedema patients without health insurance. The attributional fidelity of coding for lymphedema when associated medical care is provided is not known, and thus we may be predisposed to significantly underestimate the actual lymphedema-related costs. Another potential limitation of this study is the potential for overlap of the pre- and post-device observations with the natural history of the cancer care, namely, a greater magnitude of cancer morbidity and cost in the earlier phases of observation. This is an unavoidable limitation of an observational study of this type, which lacks a control population. Finally, as in any observational study, this analysis is limited by the potential influence of confounding. We do not have a comparable control group of patients who were untreated, limiting the ability to draw causal conclusions.
Our study provides the first population-based estimate of national lymphedema prevalence among cancer survivors. This is almost certainly an underestimate, as not all cases are coded and evaluable in an administrative dataset. Nonetheless the estimates reflect a prevalence comparable to, or exceeding, many other disease states that have been more thoroughly investigated and supported by the medical community. These data also demonstrate that health care costs associated with a new lymphedema diagnosis are high, but that a suitable therapeutic intervention, such as PCD use, might mitigate the economic impact. The prior lack of health outcomes data of this nature has contributed to the under-recognition of lymphedema, and may have limited patient access to lymphedema treatment resources. This is particularly relevant in the cancer-survivor population, where the advent of lymphedema has a particularly profound impact on quality-of-life and general health.
The potential public health implications of these findings are substantial. The aging American population can be predicted to contribute to continued increases in disease prevalence over time. The availability of effective home care therapies is likely to become increasingly important with downward pressures on reimbursement. Further prospective studies are needed to more precisely define prevalence attributes for this disease and to quantify the nature of the potential benefit of therapeutic interventions for lymphedema.
Conceived and designed the experiments: KMB ATH PKM SGR. Performed the experiments: KMB ATH PKM SGR. Analyzed the data: KMB ATH PKM SGR. Contributed reagents/materials/analysis tools: PKM. Wrote the paper: KMB ATH PJO AC PKM SGR.
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24. Cull DL, Langan EM, Gray BH, Johnson B, Taylor SM (2010) Open versus endovascular intervention for critical limb ischemia: a population-based study. J Am Coll Surg. 210: 555–561, 561–553.
25. Eslami MH, Zayaruzny M, Fitzgerald GA (2007) The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia. J Vasc Surg. 45:55–59.
26. Hillner BE, Mandelblatt J (2006) Caring for older women with breast cancer: can observational research fill the clinical trial gap? J Natl Cancer Inst. 98:660–661.
27. Stout NL, Weiss R, Feldman JL, Stewart BR, Armer JM, et al. (2013) A systematic review of care delivery models and economic analyses in lymphedema: health policy impact (2004–2011). Lymphology. 46:27–41.
28. Current Population Survey (2012, 2013) Uninsured UIaKCoMat. Health Insurance Coverage of the Total Population. 2012, 2013: Estimates based on the Census Bureau's March 2012 and 3 Current Population Survey (CPS: Annual Social and Economic Supplements).
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NCIC descends on Maasai Maara University
The National Cohesion and Integration Commission officers have pitched tent at the Maasai Mara University probing claims of nepotism, tribalism, irregular hiring and firing of staff as well as corruption related activities.
The NCIC officers were acting on a tip-off through an
anonymous letter addressed to it and copied to the Ethics and Anti Corruption Commission, cabinet secretary ministry of Education, Governor Narok county and area MP Ole Kenta.
Under corruption related activities, the EACC is also said to be investigating the procurement of a car for the VC, Mary Waling'o at a cost of Sh12million but sources say the market value is far below the Sh12million. It is suspected that she uses the car and at the same time withdraws car allowance unlike her deputies who are using their own vehicles after it was agreed that they draw allowances.
Also under investigations is the procurement of the university bus at a cost of Sh11m but which sources say was initially to be purchased at Sh9million. Sources say the procurement of the bus did not follow the right procedure. Already, the university's tender committee is under pressure to approve procurement of a certain finance system (Enterprise Resource Planning System) at a cost of Sh20million.
The NICIC officers are said to be investigating claims of irregular hiring, promotion and firing of university staff. Of interest is one Mr Omuse who is a computer technician. Sources said in the last two years, Omuse has been promoted two times and is now in grade 12. Those who know him well say that his academic and professional qualifications do not allow him to be in grade 12.
The EACC is also said to be investigating circumstances under which Omuse took Sh990,000 in cash to pay for subscription by university to Africa association of universities and others. This money was allegedly approved by the VC and up to date, this money has never been accounted for.
It is claimed that the VC has gone tribal and creates positions for people from her ethnic community or to people who are loyal to her and who never raises queries on issues and directives and orders by the VC. The NCIC is also said to be investigating claims that most heads, chairmen and directors are appointed on tribal basis as close to 80 pc are from same ethnic community.
Already, word is out that some of her trusted and loyal lieutenants who have reached retirement age are still being retained. The officers who are said to have reached retirement age but are still in payroll are security officer, human resource officer and registrar academic affairs.
Sources say the VC has been single handedly appointing temporary staff while retrenching casuals who have worked for the university for many years on continuous basis. The VC allegedly employed Prof Oyaro's wife unprocedurally. Oyaro is the dean of Science.
The EACC, according to well-placed sources, has also been called upon to investigate an allegation that the VC is plotting on how to clear Prof David Serem of a debt of Sh9million from the suspense account. Serem is a former Principal of Maasai Mara University. When the finance officer detected the plot, he objected and was sent on forced leave. It is suspected that the VC cleared Serem during the absence of the finance officer.
On mismanagement of university funds, the letter claims that she has been visiting all over the world and financing Chinese and French to visit Narok to see the so-called botanical garden and in all her visits, there has been no impact or returns which is a clear case of misuse of university funds.
The letter further claims that the VC goes to Nairobi on Thursdays and Fridays and the trips are fully financed by the university claiming she is on official duties but investigations have revealed that she travels to Nairobi to attend classes. She is currently doing MBA at the University of Nairobi.
It is claimed that the university looses close to Sh100,000 every week through the VC's office for security purposes. Sources say whenever she travels to Nairobi; she is accompanied by a bodyguard who is paid allowances which are made in cash.
It is alleged that in all her dealings, she does not append her signature on approved documents and only puts initials (VC and the date) and rather than signing and approving the original documents, she does it on photocopies of the same documents.
The letter further alleges that the VC has hired the services of one Makokha who is a former university employee to spy on the university staff and another from Safaricom to tap other staff phones. On political patronage, she is said to have been sending emissaries to William ole Ntimama in an effort to compromise him. Sources say the VC has now employed a close relative to Ntimama in an effort to silence him.
One of the projects under investigations is the Sh15billion hospital. Stakeholders are wondering what happened to the project and if there was money allocated, where did it go? It is imperative to note that no single project has been done at the university since her appointment despite taxpayers' money channeled to the university for the last two years amounting to Sh300 million for projects.
The EACC is also said to have been investigating claims that the University Council chairman Joseph Okumu who through the influence of the VC has become an executive chairman. Records indicate that he draws a monthly allowance of close to Sh350,000 per month. The EACC sleuths are said to be pursuing documents which shows that he draws Sh80,000 responsibility allowances instead of Sh25,000.
Sources say Okumu is now performing administrative activities on a daily basis in which he addresses all deans of schools and all heads of departments and also signs letters of appointments to staff. A good example is that he signed for Ogola to act as the dean school of education.
Sources say the VC is manipulating the chairman by all means by approving and giving him allowances and honoraria on a daily basis. The two also possess some issues together without the knowledge of the full council of the university.
Part time lecturers at the Maasai Mara University are also bitterly complaining that they are never paid and are owed hundreds of thousands in unpaid salaries and allowances.
Also under investigations are circumstances under which the VC brought the Presbyterian University students to graduate at Maasai Mara University during the third graduation ceremony.
Posted by Unknown at 23:54 No comments:
Tender scam at Athi Water Services Board
With barely two months before the Athi Water Services Board CEO Malequen Miulgo proceeds for terminal leave pending end of his contract in November, details of how he manipulates the tender committee in awarding multi-million tenders have emerged.
According to sources from the tender committee, the CEO is a man obsessed with the big man syndrome and dictates on who gets what tender.
A perfect example is the augmentation of the Tigoni water supply where 28 companies submitted their tenders among them Yarrow Construction, Machiri Ltd, Oriental Construction, New Age Developers, Tisco Construction among others.
Shockingly and by order of Miulgo, the tender was awarded to Flozziz Construction Ltd which had quoted Sh121,975,587 yet it was not the lowest bidder. Sources allege the directors of Flozziz Construction Ltd offered the CEO Sh2m.
In another tender for Athi Water Boreholes Phase II, 20 companies submitted their bids. Among the companies are Insta Pumps, Prime Rigs, Njuca Consolidated, Shanxi Geological among others where the lowest bidder was Turn-O-metal which had quoted Sh197m but it was awarded to Njuaca Consolidated. Sources alleged that the company's directed gave a Sh6m bribe.
Another tender is the Oloitoktok water supply and sanitation where 14 firms submitted their tenders namely Penelly Construction (Sh845,223,494), Lee Construction (Sh895,831,031), Vaghjigai Enterprises (Sh894,940,801), Byusuff and Sons Ltd (Sh875,555,937) and Unibee Construction (Sh679,738,830) among other tenderers. Sources again allege that the CEO was allegedly given Sh200m by Byusuff and Sons Ltd and was unprocedurally awarded the tender yet it was not the lowest bidder.
To block the disgruntled tenderers from filing complaints at the Public Procurement Oversight Authority, Miulgo withholds regret letters to the unsuccessful bidders after 21 days to technically knock them out from taking the case to the PPOA for review. Sources say by the time he releases the letter, contracts are already signed making it impossible for the unsuccessful bidders to demand a review.
Section of the tender committee and staff are now appealing to the board under the chairmanship of Keen Wachira never to attempt to renew Miulgo's term which expires in November 2016. Already the tender scam allegations have been forwarded to the Ethics and Anti Corruption Commission for action. Sources say he has confided in his close allies that he has sent emissaries to the Deputy President William Ruto to sweet talk Water minister Eugene Wamalwa to give him another term. The board is expected to give him a six-month leave pending retirement beginning June 1 2016.


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Raids hit two largest hospitals in rebel-held Aleppo: NGO
Air raids hit the two largest hospitals in rebel-held parts of Syria's Aleppo early Wednesday, putting them temporarily out of service. (File photo: AFP)
AFP, Beirut Wednesday, 28 September 2016
Air raids hit the two largest hospitals in rebel-held parts of Syria's Aleppo early Wednesday, putting them temporarily out of service, the medical organization that supports them said.
"The attack happened at 4:00 am (0100 GMT). One warplane targeted both of them directly," said Adham Sahloul of the Syrian American Medical Society (SAMS).
"There are only six hospitals currently operational now that the M2 and M10 have been temporarily taken out of service," he said.
Last Update: Wednesday, 28 September 2016 KSA 12:41 - GMT 09:41
Aleppo hospitals overwhelmed by wounded
Medical supplies were running out in the besieged rebel-held sector of Aleppo, with victims pouring into barely ...
Kerry threatens to cut off Syria talks with Russia
US Secretary of State John Kerry called his Russian counterpart on Wednesday and warned him that Washington will end ...
WHO in Aleppo medivac safe route appeal
The World Health Organization (WHO) called on Tuesday for dozens of sick and wounded people in the embattled eastern ...
As Aleppo burns, US announces $364 mln in new Syria aid
With the Syrian city of Aleppo facing a new regime onslaught and Washington's diplomacy under criticism for ...
Air raids hit the two largest hospitals in rebel-held parts of Syria's Aleppo early Wednesday, putting them temporarily out of service


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Book event promotes Minnesota authors
The public had an opportunity to meet Minnesota-based authors, hear book readings and get copies of their works signed Saturday at the American...
entertainment/booksJune 19, 2019 - 12:00pm
Author David Sedaris sets show at Fargo Theatre
FARGO — Humor writer David Sedaris will appear at the Fargo Theatre for a show next year. Sedaris, known for his humorous personal essays...
entertainment/booksSeptember 12, 2018 - 4:41pm
Mooooovelous story time
The interactive, 45-minute show aims to "bring young children and books together," said Jodi Schulz, head librarian for the Park Rapids Area...
community/eventsOctober 5, 2015 - 8:39am
When muse meets her artist:Manet's favorite model inspires Maureen Gibbon's new novel
By SHANNON GEISEN sgeisen@parkrapidsenterprise.com Ah, Paree! While "living out in the woods in Osage," author Maureen Gibbon wrote...
entertainmentMarch 28, 2015 - 1:00pm
Nevis graduate publishes first book
By shannon geisen sgeisen@parkrapidsenterprise.com Author Karen Babine returns to childhood territory in her newly published book, "Water...
entertainmentMarch 1, 2015 - 9:36am
Award-winning author draws inspiration from family, history
By Shannon geisen sgeisen@parkrapidsenterprise.com A novel idea that simmered in Lin Enger's imagination for about a dozen years became...
community/eventsNovember 12, 2014 - 10:05am
Author to visit Park Rapids
Minnesotan author Lin Enger will read and sign his latest novel, "The High Divide," from 5 to 7 p.m. Saturday, Nov. 8 at Belle Caffé. The event is co-hosted with Beagle Books & Bindery. Enger grew up in Minnesota, spending most of his life in the state.
entertainment/artNovember 5, 2014 - 11:01am
The history of Polaris racing: Here comes the Midnight Blue Express
entertainment/artSeptember 9, 2013 - 7:49am
Musicians, author to engage audiences via Arts Downtown
The Arts Downtown PR series, 3rd Thursdays, continues from 5 to 7 p.m. Thursday, Feb. 21 at four locations in downtown Park Rapids. Author...
entertainmentFebruary 20, 2013 - 1:00pm
Sex, crime and betrayal: Former Wadena woman pens memoir about ex-husband's sex scandal
FARGO - Monica Lee decided to write her account of her ex-husband's sex scandal for one reason and publish it for another. "I didn't even really...
entertainmentOctober 10, 2012 - 7:54am
Local couple's book uncovers 'Little Minnesota'
Fresh out of college on the GI Bill in 1956, Jim Musburger packed up his family of four to begin his first year of teaching and coaching in Strandquist,...
entertainmentNovember 30, 2011 - 1:00pm
Merry band of rogues testify on 'criminal behavior'
A band of "armed and dangerous" mystery writers took Park Rapids library patrons captive Saturday, sharing wit and wisdom on the intricacies...
Students meet 'Shiver' author through Skype
For years, Grace has watched the wolves in the woods behind her house. One yellow-eyed wolf - her wolf - is a chilling presence she can't seem...
newsJanuary 23, 2010 - 12:00pm


RCYB Series Yueyang Dalishen Electromagnetic Machinery Co., Ltd.
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This product series links up with transferring equipments to form a complete set to remove the iron magnetic materials under weight of 0.1-25kg mixed among the non-magnetic materials.
It can be used for improving the material quality and purification as well as recovering the magnetic materials. This product series is widely applied for power industry, building industry, food industry, cement industry, coal picking-up industry, chemical industry and so on.


For the last five or six General Conferences of our denomination, I have belonged to a local church committee that prepared petitions to send to the conference. Many of these proposals were about full inclusiveness in our Church and the end of discrimination against LGBTQ (lesbian, gay, bisexual, transgender and queer) persons. Along with numerous losing efforts, there were a few small successes — most notably, perhaps, the requirement that aspiring deacons and elders promise to be in ministry to persons without regard to sexual orientation.
For the 2012 General Conference I hoped, as I know you did, that the effort to remove from the Social Principles the language that the so-called practice of homosexuality is incompatible with Christian teaching would get out of committee. Although I did not really expect that such a change would be approved by the conference as a whole, I did hope that a resolution or two on inclusiveness that my local church had submitted might actually pass. But, as you know, the legislative committee kept the language that we consider so hateful, and various resolutions died in committee.
If a General Conference cannot approve something like the Hamilton-Slaughter amendment, then it appears to me that there is little if any hope that any time in the forseeable future we shall see a change of our denominational stance against full inclusiveness.
Ironically, our loss of hope about full inclusiveness is, in part, because of a radical change that is also a sign of great hope: The rapid globalization of our Church, as represented especially by its growth in Africa. Where this change will lead our denomination is uncertain, but the vision for the Church submitted by a Liberian leader in 2008 may give us a clue. We are undoubtedly disturbed by its espousal of fundamentalist doctrine, but we can only rejoice in its prophetic call "on behalf of our impoverished brothers and sisters worldwide" for steps like "economic development, trade and property rights, electrification, industrialization, irrigation, transportation, basic health care and improved agricultural development." And, we can affirm much of its "missional priority" list; its first two items, for example, are "Fighting deadly diseases. . .while also ensuring clean water for all" and "Protecting the air, water and land while improving the standard of living for the world's poor" (petition 81562, 2008 General Conference; petition 20921, 2012 General Conference).
As we desire the best for our Church, we liberals who ardently wish for full inclusion for LGBTQ persons have, I believe, two obvious choices.
One is to stay within the denomination and continue to make our witness, hoping against hope that in another generation or two or three our views will triumph. Those of us who decide to follow this course may want to compare ourselves to the African American Methodists in the early 19th century who declined opportunities to become part of the African American Episcopal or the African American Episcopal Church Zion churches. It is difficult, I believe, to underestimate the importance of such a continuing witness.
The other choice, of course, is to leave the denomination. Individual departures occur, as we know all too well, after each General Conference. We all know long-time, loyal United Methodists who have finally reached the breaking point and have sadly withdrawn, either to leave organized religion behind altogether or to find another, more inclusive denomination. There are two ways, however, that departure can occur in a well-planned, organized way that allows inclusive congregations to stay together, and, one hopes, to thrive.
The second way was outlined in a petition that went to the 2012 General Conference but lost in committee. Since originating in a strong, conservative congregation in Mississippi, it has begun to receive support from major conservative leaders in our denomination. It allows a congregation that views itself to be "in irreconcilable conflict for reasons of conscience" with the denominational stance "on the practice of homosexuality and the blessing of homosexual unions" to withdraw and "retain full rights to its property and funds." Such a decision would have to be made by a substantial majority of "professing members present and voting at a duly called church conference" (Petition 20538). Congregations that take this step would of course be free to negotiate affiliation with another denomination.
Friends, at this stage in our denomination's history, it will do the Church and our LGBTQ-friendly congregations little good to continue the struggle as it is now playing out. There is still an important witness for many of us, including LGBTQ persons for whom there is no other church they want to call home, to make within the denomination. But others, like the Methodists who formed the AME and AMEZ churches, can no longer abide the repeated slamming of doors.
In many situations, moving on, I believe, is highly preferable to prospective scenarios that include donnybrooks every four years, numerous church trials, breakdown of respect for Church law, and even the specter of formal division. In such cases, working to facilitate transfer to another denomination or to enable disaffiliation will advance full inclusiveness, potentially strengthen a receiving denomination in many geographic areas, and permit The United Methodist Church to get on with doing some of the things that it does so well.
My liberal brothers and sisters, some of our conservative friends have extended their hands to help us depart in an amicable way. Some of us may decline the offer even as we shake their hands. For others of us, it is time, as we also shake their hands, to express our thanks, accept their help, move out, and move on.
*Martin is an emeritus professor of religion at Oklahoma City University and a retired elder in the Arkansas Conference of The United Methodist Church. He was baptized and confirmed in The Methodist Episcopal Church South; was ordained in The Methodist Church, and retired in The United Methodist Church. He traces his Methodist roots back to the 1830s.


Recent legislative changes in employment law mean that the reverse onus of proof now applies to breaches of the National Employment Standards, a modern award or an enterprise agreement as listed under section 557C of the Fair Work Amendment (Protecting Vulnerable Workers) Act 2017.
The first court proceedings involving the new reverse onus of proof laws that require employers with inadequate records to disprove alleged underpayments was launched recently by the Fair Work Ombudsman ("FWO") in the Federal Circuit Court against A & K Property Services, the operator of two fast food outlets called 'Sushi 79' and also against the company's directors personally.
Fair Work inspectors audited the Sushi 79 outlets at Brassall in Ipswich and Currimundi, on the Sunshine Coast, in 2018 as part of its auditing activity. The FWO claims nine workers employed by the two outlets were underpaid by $19,467 in their entitlements under the Fast Food Industry Award 2010. It is alleged they were not paid the minimum ordinary hourly rates, weekend penalty rates, overtime rates or superannuation, and that their annual leave and personal leave entitlements were not accrued.
The FWO also alleges the company breached workplace laws by not issuing pay slips and did not keep proper time and wages records between October and December 2017.
The company faces penalties of up to $63,000 for each contravention. The directors face penalties of up to $12,600 for their alleged involvement in the leave contraventions and one director is facing penalties of up to $12,600 for his involvement in the record-keeping and pay slip breaches.
This is the first court case by the FWO using new reverse onus of proof laws. Under these laws, employers who do not meet record-keeping or pay slip obligations and cannot give a reasonable excuse must disprove allegations in wage claims made in court instead of the FWO having to prove there was a breach.
Read more about the case in the FWO's media release which you can access by clicking here.
Do you need legal help with an employment law matter?
If you need legal advice or assistance regarding an employment law matter we can help. Call us on 07 5597 3366 or complete the 'Contact Us' form below.
Please note that this article was written by Margaret Miller, partner of Bell Legal Group, for information purposes only. It is not legal advice and should not be relied upon as such.


Orchard Cottage is a beautifully refurbished three bedroom house nestled within the peaceful one acre walled garden of Dunowen House.
This characterful old cottage, dating back to the 1800's, has been sympathetically restored to a very high standard. With three cosy bedrooms, two bathrooms, a wood burning stove and an open plan kitchen living area, Orchard Cottage offers accommodation for up to 5 guests.
Available to rent with Dunowen House to accommodate up to 23 guests or on its own as a cute tranquil hideaway for short-break or longer holiday.
Prices from €120 per night mid-week or €150 per night for weekend self-catering stays. For availability and rates call us on (023) 8869099 or contact us.


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UNIZIN-A Cloud Framework/Collaboration for Teaching and Learning
The Unizin Consortium (www.unizin.org) is universities coming together in a strategic way to exert greater control and influence over the digital learning landscape. It enables each institution, its faculty, and students to draw on an evolving set of tools to support digital learning for residential, flipped classroom, online courses/degrees, badged experiences for Alumni, or even MOOCs if desired. Unizin supports the differing missions and strategies of universities. Unizin Services are cloud-based infrastructure based on open technology standards. It will evolve to support content systems that empower faculty with full control over their owned content — store it or share it — and an analytics service to enable research to improve learning. As a university-owned service for universities, all of this will evolve within the longstanding values of the Academy. Unizin is membership-based and is being launched by a group of founding investing universities . It is governed as a not-for-profit service operator with a CEO and board of directors from its members as an Unincorporated Association at Internet2. Unizin's founding members include Colorado State University, Indiana University, the University of Florida, the University of Michigan, Oregon State University, the University of Wisconsin-Madison, and the University of Minnesota and it is extensible to other investing institutions. In our presentation, we will explain the reasons behind unizin, bring you up to date on the most recent developments, and talk about how interested universities can either join, or be sponsored. We will cover such things as the cost of joining and remaining a member, and the benefits that will accrue to members.
Bruce Maas University of Wisconsin-Madison
Amin Qazi Unizin
Supporting teaching and learning
Download paper (4 MB)


katilda.com: see katie guest blog!
i feel oh so important.
...and it was at her wedding last week.
and i totally went to her wedding reception.
....and there was great mexican food.
i just discovered your blog, via ALEXIS and I must say, I loved your guest post. you had me rolling on the ground laughing.
its so funny how we are all wired. kinda like animals. except i don't think a 'snooki' is a type of animal. just a freakish thing on mtv.
I was gonna leave an inappropriate comment about ovulation on your guest post but decided against it since I don't know that person. And then I thought about leaving it here but then I remembered that it was inappropriate so I didn't.


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Stephenson's REAMDE: perfectly executed, mammoth, ambitious technothriller
Cory Doctorow 5:46 am Wed Sep 14, 2011
REAMDE
Back in 2010, I found myself in Seattle (I was touring with my novel For the Win — a young adult science fiction novel about gold-farming), I stopped by Neal Stephenson's place for breakfast and asked him what he was working on. He said, "You ever heard of 'gold-farming?'" I couldn't help but smile.
Stephenson's one of my favorite novelists, a writer who is both very good at what he does, and who is nevertheless willing to go all the way out to the edge of his prodigious talents and take brave risks. Even when these don't fully pay off, they're always exhilarating experiments — Stephenson's imperfect results being better than most writers' best days. So while Snow Crash and Diamond Age drew critical fire for having a lot of seemingly ornamental plot-discursions that never quite paid off at the end, the insanely ambitious and enormous System of the World ruthlessly hunted down every conceivable loose end and executed it before the final page was turned. As much as I enjoyed the latter, I found that I preferred Stephenson's loose ends to the sometimes mechanical exercise of tying them all off. His next book, Anathem, solved this problem somewhat by having a lot fewer moving parts (a bit of a joke there for those of you who've read the book!) and thus a simpler, cleaner finish. As good and audacious as Anathem was, it lacked the intense, fractal plot-complexity of System, and I missed that a little.
REAMDE, Stephenson's latest novel — the "have you ever heard of 'gold-farming'" — novel is a book that represents a new kind of equilibrium in Stephenson's literary canon: a book that is simultaneously as baroque as System of the World and as cleanly and crisply finished as Anathem. It is, in other words, a triumph, all 980 pages of it.
REAMDE starts off as a clever, if somewhat straightforward technothriller. Richard Forthrast is the black sheep of a rugged, formidable midwestern family. After a checkered career of minor crime and notoriety, Richard has founded an enormous and enormously profitable multiplayer online game, called T'Rain. This has left him uncomfortably wealthy and powerful, and somewhat constrained by his corporate success. But at least he can help out his relations, like his favored adopted niece Zula, an Eritrean refugee who was raised on the family homestead in Iowa and is now putting her advanced geoscience degree to work as a technician in the T'Rain world, designing the geosystems that deposit precious metals where gold-farmers (an integral part of the T'Rain economy) can dig it up.
The story begins in earnest when Zula's foolish hacker boyfriend sells some stolen credit-card numbers to a front for the Russian mob, and then finds himself at their mercy as the bagman's entire user directory is encrypted by a piece of malicious ransomware called REAMDE (a Chinglish mangling of "Readme") that is targeted at T'Rain players (the malware also encrypts the backup). Now the mob needs to pay off the ransom — a trifling $75 worth of virtual gold — so that they can decrypt the data. Except that the in-game region where the gold-drop is to be made is now clogged with powerful griefers who waylay extortion victims and steal the gold they're bringing to the crooks.
After a bunch of wrangling and danger, Zula, her hacker boyfriend, and the Russian gangsters end up in Xianmen, China (the first two aren't there voluntarily), trying to track down the virus's author, and that's where the ambition of the REAMDE starts to kick in. You see, at this point, Stephenson is only a couple hundred pages into his thousand-page epic, and he's only marshalled a few of the many bands of characters who spend the next 700 pages embroiled in one of the most startling, exciting, white-knuckle technothrillers I've had the pleasure of losing a week of my life to.
REAMDE goes from being a story about virtual worlds to a much bigger geopolitical tale about the war on terror, filled with grace-note, high-detail technical excursions into international shipping, American survivalism, MI6 spycraft, Philippines sex-tourism, and lots and lots and lots of guns. This last part is one of the great testimonials I can make about REAMDE, because books about guncraft generally bore me down to the marrow. But Stephenson's several exquisitely choreographed shoot-outs (including an epic, 100+ page climactic mini-war) are filled with technical gubbins about guns that convey the real and genuine enthusiasm of a hardcore gun-nut, with so much verve, so much moment, that I found myself itching to find a firing range and try some of this stuff out for myself.
Combine that with a cast of characters that, while recognizably Stephensonian archetypes, are nevertheless novel, likable, and complex, and you've got a powerful, magnificent book that is worth the sizable forests that will have to be demolished to commit it to paper, and the sizable lump that it will represent in your bag or briefcase while you finish it. Here's a book that, all on its own, makes a hell of a case for buying an ebook reader, assuming you can find a DRM-free ebook edition.
Review / Colt Canyon
Colt Canyon is a sepia-toned masterpiece of pixel art, chaotic combat, and well-crafted character and weapon designs that deepen its simple but refined gameplay. All the same, its difficulty wall has me throwing my hands up in defeat. It begins with the kidnapping of your partner, establishing a classic western revenge 'n' rescue scenario. Head… READ THE REST
Susanna Clarke's new book PIRANESI is a contemplative thriller about solitude
Susanna Clarke's debut novel, Jonathan Strange & Mr Norrell, took the world by storm when it came out in 2004. The 900-page magical Victorian epic was swiftly followed by a short story collection, The Ladies of Grace Adieu, which was set in the same universe. A TV adaptation of the book came out in 2015—but… READ THE REST
Bill Gates recommends 5 "good" books to read during "lousy" times
Bill Gates has been sharing his favorite books with a summer list and a winter list for the last eight years. This year's winter reads are five "good" books – inspiring, uplifting, happy endings – "for a lousy year." They include: • The New Jim Crow, by Michelle Alexander • Range, by David Epstein •… READ THE REST
These 15 deals on flashlights and headlamps are on sale for up to 66% off
It probably sounds trite, but a quality light source in an emergency really can make the difference between life and death. While you hope to never need it, a powerful, functioning flashlight or headlamp should not only be part of your pack for any outdoor excursion, it should also be stationed in your vehicle for… READ THE REST
Industrious lets you use a fully-furnished modern office — and only pay on the days you need it
It's an option virtually every small business and freelancing professional will eventually consider — do I need to rent office space? Whether it's the result of a growing staff, growing responsibilities, or simply maturing as a company, there's usually a moment for any professional organization when getting a centralized office starts to make a lot… READ THE REST