The 'Perception of Anti-Coagulant Treatment Questionnaire' (PACT-Q) was developed to assess patients' expectations of, and satisfaction with their anticoagulant treatment. This questionnaire needs to be finalised and psychometrically validated.
The PACT-Q was included in the United States, the Netherlands and France into three phase III multinational clinical trials conducted to evaluate efficacy and safety of a new long-acting anticoagulant drug (idraparinux) compared to vitamin K antagonist (VKA). PACT-Q was administered to patients with deep venous thrombosis (DVT), atrial fibrillation (AF) or pulmonary embolism (PE) at Day 1, to assess patients' expectations, and at 3 and 6 months to assess patients' satisfaction and treatment convenience and burden. The final structure of the PACT-Q (Principal Component Analysis – PCA – with Varimax Rotation) was first determined and its psychometric properties were then measured with validity of the structure (Multitrait analysis), internal consistency reliability (Cronbach's alpha coefficients) and known-group validity.
PCA and multitrait analyses showed the multidimensionality of the "Treatment Expectations" dimension, comprising 7 items that had to be scored independently. The "Convenience" and "Burden of Disease and Treatment" dimensions of the hypothesised original structure of the questionnaire were combined, thus resulting in 13 items grouped into the single dimension "Convenience". The "Anticoagulant Treatment Satisfaction" dimension remained unchanged and included 7 items. All items of the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions displayed good convergent and discriminant validity. The internal consistency reliability was good, with a Cronbach's alpha of 0.84 for the "Convenience" dimension, and 0.76 for the "Anticoagulant Treatment Satisfaction" dimension. Known-group validity was good, especially with regard to occurrence of thromboembolic events within 3 months from randomisation.
The PACT-Q is a valid and reliable instrument that allows the assessment of patients' expectations and satisfaction regarding anticoagulant treatment, as well as their opinion about treatment convenience of use. Its two-part structure – assessment of expectations at baseline in the first part, and of convenience, burden and treatment satisfaction in the second – was validated and displays good and stable psychometric properties. These results are not sufficient to recommend the use of satisfaction as primary endpoint in clinical trials; further validation work is needed to support the interpretation of PACT-Q dimension scores. However, this first validation makes the PACT-Q an appropriate measure for use in clinical and pharmacoepidemiological research, as well as in real-life studies.
(ClinicalTrials.gov numbers, NCT00067093, NCT00062803 and NCT00070655).
Oral vitamin K antagonists (VKA) are effective and commonly used anticoagulant agents for the secondary prevention of venous thromboembolic disease and the prevention of systemic embolism in patients with atrial fibrillation . However, because of patients' monitoring requirements, their inherent limitations in daily life (e.g. diet and activities) and the considerable inter-individual variability in pharmacodynamic effect, the burden of VKA on patients' daily life is highly significant, especially when given as long-term therapy [2–4]. Together with possible side effects such as bleedings, anticoagulant treatment may negatively affect patients' health-related quality of life (HRQoL) and treatment satisfaction, which in turn is likely to result in the decrease of the treatment effectiveness and ultimately in its failure [5–9]. Patients' satisfaction with treatment mainly depends on their previous experiences of similar treatment to which they compare their new treatment, as well as on their expectations . Thus, especially when clinical outcomes regarding treatment efficacy and tolerance are rare and undistinguishable between different treatments, information about patients' satisfaction with their treatment and HRQoL is highly valuable. Surprisingly, despite the large use of VKA, no specific questionnaire was available to assess patients' satisfaction with their treatment and to evaluate their unmet needs. Therefore, the Perception of Anti-Coagulant Treatment Questionnaire (PACT-Q) was developed  as a means to investigate the burden of disease in patients with deep venous thrombosis (DVT), pulmonary embolism (PE) or atrial fibrillation (AF), with specific focus on patients' satisfaction with anticoagulant treatment and treatment convenience. The questionnaire was administered in the United States, the Netherlands and France during international phase III clinical trials in patients with DVT, PE or AF. These studies aimed at evaluating the efficacy and safety of the new anticoagulant drug -idraparinux- injected subcutaneously once a week, compared to VKA. The trials were multicentre, international, randomised in two arms (VKA versus idraparinux), open-label and assessor-blind.
In order to be fully acceptable as a meaningful endpoint in clinical trials, the structure of a questionnaire has to be validated, its scoring rules established and its psychometric properties demonstrated. In this paper, we present the finalisation, i.e. scoring and validation of the original structure of the questionnaire. The psychometric validation of the resulting dimensions is also presented.
The original PACT-Q consists of two parts and contains 27 items : the PACT-Q1, composed of a single dimension (7 items), covering the expectations of patients regarding their anticoagulant treatment, is to be administered before treatment initiation; the PACT-Q2, composed of 3 dimensions covering the convenience of use of the treatment (11 items), burden of disease and treatment (2 items) and satisfaction with the anticoagulant treatment (7 items) as perceived by the patient, is to be administered to patients once the treatment is ongoing . All the items of PACT-Q1 and PACT-Q2 parts are to be answered on a 5-point Likert scale. The questionnaire was simultaneously developed in French, American English and Dutch following a rigorous development process, in which the data collected from the patients were given particular importance . It was further translated and adapted into 11 different country-specific versions following recommended linguistic validation procedures that included forward and backward translations by native speakers .
The PACT-Q was administered during phase III clinical trials (DVT Clinical Study Protocol 64717/EFC3491; PE Clinical Study Protocol 64714/EFC 3484; AF Clinical Study Protocol 64720) as secondary endpoint in multicentre studies conducted in Europe (Austria, Belgium, Czech Republic, Denmark, France, Germany, Italy, the Netherlands and Poland), North America (Canada and the United States) and Oceania (Australia and New Zealand), with patients with DVT, AF or PE. All three trials were randomised, open-label and assessor-blind, and were conducted in accordance with the principles stated in the Declaration of Helsinki. Patients who provided an oral consent prior to their inclusion participated in the study. At Day 1, patients were asked to complete the PACT-Q1 part of the questionnaire; at 3 month (M3) and 6 month (M6), patients were asked to complete the PACT-Q2 part.
Patients included in the analyses had at least one PACT-Q1 and one PACT-Q2 completed and assessable (i.e. 50% of items completed) at Day 1 and M3, respectively, and did not violate the protocol for PACT-Q administration along the whole study (Figure 1). As the PACT-Q was originally developed in French, American English and Dutch, only patients from France, the United States and the Netherlands were included in the study populations. In order to control learning bias and for the purpose of the validation , two populations were pre-specified: the "scoring and initial validation" population subset was constituted of 452 patients with either DVT, AF or PE and from either the United States, the Netherlands or France; the "robustness" population subset was constituted of 200 AF patients from either the United States or the Netherlands. The "pooled" population (n = 652), corresponding to the "scoring and initial validation" population subset combined with the "robustness" population subset, was used to determine the PACT-Q psychometric properties. Patients who answered at least 50% of the PACT-Q2 items at M6 were included in the responsiveness analysis of PACT-Q2 ("responsiveness" population subset).
Flowchart of the population included and participating in the study.
One should note that although the clinical trial was open-label, statistical analyses were blind to treatment attribution, i.e. no distinction was made between the treatment arms that patients were randomly allocated to.
Principal Component Analysis (PCA) with Varimax Rotation is often used to assess the hypothetical structure of an instrument, by observing how the different items are spontaneously grouped into factors . In our case, PCA was performed to check whether the factorial structure of PACT-Q reproduces the number and the type of dimensions that were hypothesised during the development step. Multitrait analysis (MA) defining the item convergent validity criterion (correlation between each item and its own dimension is considered satisfactory if it achieves ≥ 0.40) and the item discriminant validity criterion (each item should have a higher correlation with its own dimension than with the other dimensions) was performed to ascertain the consistency of the dimensions .
The internal consistency reliability of the dimensions , i.e. the extent to which individual items are consistent with each other and reflect a single underlying construct, was assessed by the determination of Cronbach's alpha coefficient . A value of 0.70 or above is recommended for group comparisons . A Multiple Factorial Analysis (MFA) was carried out to analyse the relationship between PACT-Q1 and PACT-Q2 . MFA assesses several sets of variables defined on the same set of individuals, and allows computation of a summary statistic referred to as the RV coefficient (vector correlation coefficient) . RV value ranges from 0 to 1; the closer to 1 the RV, the more similar the configuration of the two sets of variables.
Validity is the degree to which the instrument measures what it is supposed to measure [21–23]. Several types of validity were assessed. The validation of the conceptual model was assessed by performing MA with description of item convergent and discriminant validity . Scale-scale correlation was evaluated in order to test the construct validity of the questionnaire. Floor and ceiling effects were measured to check that there was no issue related to a high percentage of patients having the lowest or the highest possible score on any one scale. Clinical validity evaluates the extent to which the questionnaire is able to detect variability amongst patients with different clinical severity levels. Known-group validity can be evaluated when differences in scores are expected between groups of patients that differ on relevant variables. Clinical and known-group properties were assessed amongst groups of patients defined according to age, gender, international normalized ratio (INR – patients at risk of embolism, INR < 2; patients with less risk of embolism, INR > 3), prior medication, thromboembolic events within the 3 months following randomisation, and time they spent in the 2–3 INR range between randomisation and M3.
Internal consistency reliability of the dimensions of the PACT-Q was again evaluated, by determination of the Cronbach's alpha coefficient . Responsiveness refers to the ability of a questionnaire to detect important changes over a period of time ; it was assessed for the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions of the PACT-Q2 over M3 and M6, by determining the Effect-Size (ES) and Standardised Response Mean (SRM) [25–27]. A Wilcoxon signed rank test was performed in order to compare the change to 0. A Kruskal-Wallis test was performed to test the hypothesis that the change in scores was significantly different across the different groups of patients. The PACT-Q responsiveness was tested for groups of patients defined according to the primary efficacy outcome (i.e. thromboembolic event within 3 months from randomisation consisting in stroke or a non-central nervous system systemic embolism for AF patients, and a PE or DVT event for PE and DVT patients respectively) and the time spent in the 2–3 INR range between randomisation and M6 visits. The threshold for statistical significance was set at 0.05.
MFA was performed using SPAD Software. All the other data processing and analyses were performed with SAS Software for Windows (Statistical Analysis System, version 9).
Socio-demographic and clinical characteristics of the "pooled" population set that was used in the analyses are summarised in Table 1. The "pooled" population consisted of 652 patients, amongst whom 234 were from the United States, 309 from the Netherlands and 109 from France. Of these 652 patients, 426 patients had AF, 87 had DVT and 139 had PE. The mean age was 65 years, patients with AF being the oldest population (mean = 68 years-old). Overall, males were more represented than females, with the greatest difference observed within the AF population (70% men).
The analyses were performed with the "scoring and initial validation" population subset (n = 452), including patients with AF (n = 226), DVT (n = 87) and PE (n = 139) from France (n = 109), the Netherlands (n = 209) and the United States (n = 134).
The PCA with Varimax Rotation and MA were conducted on the PACT-Q1 completed at Day 1. The PCA performed on the 7 items of PACT-Q1 resulted in the definition of 2 factors with eigenvalues greater than 1, accounting for only 23% (Factor 1, containing items A3, A5 and A7) and 18% (Factor 2, containing items A1, A2, A4 and A6) of the total variance. Correlations between the 7 items were very low, with Pearson coefficients ranging from -0.068 to 0.268, indicating that the items were non-redundant. Cronbach's alpha was low (0.43). Item-dimension correlation coefficients ranged from 0.12 to 0.29, reflecting low item convergent validity criteria. Taken together, these data indicated that the "Treatment Expectations" dimension was not unidimensional. Each of the items of this dimension will therefore be analysed separately.
Following PCA analysis with Varimax Rotation conducted on the PACT-Q2 part completed at M3, four factors were retained based on an eigenvalue greater than one, representing 53% of the total variance. Factor 1 contained all items of the original "Convenience" dimension (i.e. B1 to B9), except B10 and B11; factor 2 contained items D4 to D7 of the original "Anticoagulant Treatment Satisfaction" dimension; factor 3 the items B10, B11 of the "Convenience" dimension and the items C1 and C2 of the "Burden of Disease and Treatment" dimension; factor 4 the items D1, D2 and D3 of the original "Anticoagulant Treatment Satisfaction" dimension. MA results showed good item convergent validity criteria for all the items within their own respective dimension, except items B10 and B11 ("Convenience" dimension) and items D2 and D3 ("Anticoagulant Treatment Satisfaction" dimension). All items reached the discriminant validity criterion, i.e. all items shared a higher correlation with their own dimension than with the other dimensions of the questionnaire. Cronbach's alpha was satisfactory for the "Burden of Disease and Treatment" dimension (0.66), and good for the "Anticoagulant Treatment Satisfaction" and the "Convenience" dimensions (0.79 and 0.82, respectively). No ceiling effects were reported, whereas a floor effect was observed for the "Burden of Disease and Treatment" (57%) and "Convenience" (26%) dimensions.
To improve the measurement model of the PACT-Q2, several alternative models were further tested for their structure, amongst which one model was retained as it displayed the most satisfactory and stable properties. The retained model included 2 dimensions ("Convenience", containing all B and C items, and "Anticoagulant Treatment Satisfaction" dimension, containing all D items). All the items within each of the PACT-Q2 dimensions met the convergent validity criterion (ranging from 0.42 to 0.66), except items B10 and B11, and items D2 and D3. All items met the item discriminant validity criterion. A floor effect was still observed for the "Convenience" dimension; no ceiling effect was noted for the 2 dimensions. The respective Cronbach's alpha values were 0.83 and 0.79 for the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions. The correlation coefficient between the 2 dimensions was low (-0.25), confirming that they clearly covered two separate concepts.
Thus, the final PACT-Q2 was constituted of 2 dimensions: the "Convenience" dimension, comprising items B1 to B11 (from the original "Convenience" dimension) combined with items C1 and C2 (from the original "Burden of Disease and Treatment" dimension), and the "Anticoagulant Treatment Satisfaction" dimension containing items D1 to D7 (Figure 2). The structure, dimensions and detailed contents of the items of the final version of PACT-Q are reported in Table 3.
Conceptual framework of the final PACT-Q.
The final PACT-Q1 remained similar to the original version, i.e. containing 7 items, each individually scored from 1 to 5; for items A1, A2, A4 and A5, the higher the score, the higher the patients' expectations of their treatment; for items A3, A5 and A7, the lower the score, the higher the patients' expectations of their treatment (Table 2). Within the PACT-Q2, items B and C are reversed, summed and rescaled on a 0–100 scale to obtain the "Convenience" dimension score (Table 2). The higher the score, the higher the convenience and the lower the burden as perceived by the patient for their treatment. Items D are summed and rescaled on a 0–100 scale to determine the "Anticoagulant Treatment Satisfaction" dimension score (Table 2); the higher the score, the higher the patient satisfaction with their anticoagulant treatment.
Pearson correlation coefficients between PACT-Q1 and PACT-Q2 (final structure) were below 0.20 for the majority of the items, indicating a weak relationship between the "Treatment Expectations" items and those assessing the "Convenience" and "Anticoagulant Treatment Satisfaction". RV coefficients between PACT-Q1 at Day 1 and PACT-Q2 at M3 were also low, ranging from 0.032 to 0.040, showing weak links between the dimensions of the two PACT-Q parts.
MA was first conducted with the "scoring and initial validation" population subset (n = 452). In order to use a subset of patients that had not been used for the scoring, the robustness of the PACT-Q structure was then validated with the "robustness" population subset (n = 200). A further analysis with the "pooled" population set (n = 652) allowed the validation to be consolidated.
Regardless of the country, the quality of completion of PACT-Q1 at Day 1 was good in the "pooled" population, with 1.1% missing data. For PACT-Q2, completion was still good though slightly lower, with 2.4% missing data at M3, and 1.5% missing data at M6.
Percentages of responses allocated to each of the response choices at Day 1 for the "Expectations" items are represented on Figure 3. The majority of patients answered "A lot" or "Extremely" for items A1, A2, A4 and A6. The majority of patients answered "Not at all" or "A little" for items A3, A5 and A7. Scores of the "Convenience" and "Anticoagulant Treatment Satisfaction" at M3 and M6 are summarised in Table 4. "Convenience" scores decreased from 91.3 at M3 to 90.6 at M6; "Anticoagulant Treatment Satisfaction" scores slightly increased from 68.9 to 70.6, respectively.
c percentage of patients with the lowest possible score (i.e. 0), that is patients who answered the least favourable response choice to all items of the dimension.
d percentage of patients with the highest possible score (i.e. 100), that is patients who answered the most favourable response choice to all items of the dimension.
Description of the percentage of patients per response choice to the "Expectations" items at Day 1 (N = 652).
Item convergent validity, floor and ceiling effects and internal consistency reliability of the PACT-Q2 dimensions obtained for these two subsets of population and the "pooled" population are summarised in Table 4.
Overall (i.e. in the "pooled" population), all the items within the "Convenience" dimension, except items B10 and B11, met the item convergent criteria and ranged from 0.33 to 0.64. All the items within the "Anticoagulant Treatment Satisfaction" dimension met the convergent criterion, except items D2 and D3, and ranged from 0.33 to 0.63. All the items of the 2 dimensions reached the item discriminant validity criterion.
The correlation coefficient between the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions of the PACT-Q2 was moderate (0.29), reflecting a fair relationship and no redundancy between the 2 dimensions.
No floor effect was observed for either dimension of the PACT-Q2. No ceiling effect was noted for the "Anticoagulant Treatment Satisfaction" dimension, contrary to the "Convenience" dimension (percentage of patients at the highest possible score = 22%).
Good internal consistency reliability was displayed within each of the PACT-Q2 dimensions, with Cronbach's alpha values of 0.84 for "Convenience", and 0.76 for "Anticoagulant Treatment Satisfaction".
Scores of items A2, A4, A5 and A7 within the "Treatment Expectations" dimension at Day 1 (PACT-Q1), and the "Convenience" and "Anticoagulant Treatment Satisfaction" dimensions at M3 showed significant differences when compared according to the age of the patients: the highest scores of "Treatment Expectations" items were observed for patients under 60 years of age (data not shown). Patients aged between 60 and 65 displayed higher "Anticoagulant Treatment Satisfaction" scores than younger and older patients, this difference being significant (p = 0.028). For the "Convenience" dimension, the highest score was observed for patients aged between 65 and 75 years (p < 0.0001). Only the A2, A3 and A7 item scores of "Treatment Expectations" were significantly different between females and males, while other scores were similar over the 2 groups. When compared according to experience of prior medication, scores of the "Convenience" dimension were significantly higher for patients who did not have prior medication than patients who did (score of 92 versus 89, respectively; p = 0.01). A higher score was reported at item A2 ("Treatment Expectations" – symptom relief) for patients with no prior medication experience than for patients with experience (3.3 versus 2.8, p = 0.0044). In contrast, a significantly higher score for item A3 ("Treatment Expectations" – side effects) was observed for patients with prior experience of medication than patients with no prior medication (2.9 versus 2.4, p = 0.0003). Scores in the "Anticoagulant Treatment Satisfaction" dimension were higher for patients who reported no events within 3 months of randomisation than for those who reported having had an event (69 versus 41, respectively; p = 0.005).
When compared between groups of patients defined according to their baseline INR level at Day 1 (i.e. < 2, [2;3], > 3), scores of most items of PACT-Q1 (item A2, "symptom relief"; item A3, "side effects"; A4, "ease of use"; A5, "making mistakes"; and A7, "cost of the treatment") were significantly higher for patients with INR < 2 than for patients with INR = 2. Regarding PACT-Q2 at M3, the "Anticoagulant Treatment Satisfaction" score was the lowest for patients with an INR > 3, and significantly increased as INR decreased (scores ranging from 61 to 69). These results at M3 concerned only patients treated with VKA as the INR was not available after Day 1 for patients treated with the new anticoagulant treatment. None of the other differences observed between scores of the PACT-Q2 dimensions or PACT-Q1 items were significant.
Similarly, score differences reported between groups of patients defined according to the time they spent in the 2–3 INR range (4 groups defined: < 50%, between 50% and 60%, between 60% and 70%, and ≥ 70%) were not significant. In other terms, the time spent in the 2–3 INR range between randomisation and M3 does not have a statistically significant impact on scores. Again, these results concerned only patients treated with VKA, as those treated with idraparinux did not have INR monitoring during the study.
Overall, no significantly different changes in the "Convenience" and "Anticoagulant Treatment Satisfaction" scores were observed from M3 to M6, whether compared between groups of patients defined according to their report of a thromboembolic event (or not) within 3 months of randomisation, the time they spent within the 2–3 INR range between randomisation and M3, and M3 and M6, or the impact of the INR control status deterioration or improvement. Most of the changes in scores observed within each group were not significantly different to 0 (p-signed rank test > 0.05).
The PACT-Q was included as a secondary endpoint in phase III clinical trials in order to assess the expectations and satisfaction of patients suffering from DVT, PE or AF and treated with a new long-acting anti-thrombotic drug injected once a week subcutaneously, in comparison with an oral VKA treatment. The finalisation and psychometric validation steps of the questionnaire were performed using the patients of the clinical trials.
Regarding the PACT-Q2 part, the exploratory PCA performed on the original PACT-Q revealed a structure very close to the proposed original structure , with 4 factors covering treatment convenience (items B1 to B9), treatment satisfaction (items D4 to D7), burden of disease and treatment and convenience of use (items C1 and C2 and items B10 and B11, respectively), and patients' anticoagulant treatment satisfaction (items D1 to D3). The overall good homogeneity of the PACT-Q2 dimensions, as reflected by the Cronbach's alpha values of 0.79 ("Anticoagulant Treatment Satisfaction" dimension) and 0.82 ("Convenience" dimension), confirmed the well-founded hypothesis of the original structure of the questionnaire. The lower value (0.66) reported for the "Burden of Disease and Treatment" dimension is perfectly acceptable as it contains only 2 items. As for the PACT-Q1 part, the weak correlations between each of the items and their low item convergent validity criterion, together with the low internal consistency reliability of the "Treatment Expectations" dimension, strongly suggests that the items of PACT-Q1 cannot be thought of as one single concept.
The last series of PCA and MA led to the conclusion that the 7 items of the "Treatment Expectations" of PACT-Q1 were to be scored individually. This is not surprising as expectations cover heterogeneous concepts, each of them being measured by a single item. After the last finalisation step, the PACT-Q2 was reduced from 3 to 2 dimensions covering treatment "Convenience" (13 items) and "Anticoagulant Treatment Satisfaction" (7 items). The number of items in the 2 dimensions is quite high, and one could wish to reduce the PACT-Q to a short form. However, no items were removed as they were all relevant for the purpose of the questionnaire and the concepts were shown to be pertinent and well-accepted by patients. The use of PACT-Q in further clinical studies would be needed to definitively confirm their relevance. The reliability of these findings is increased by the use of separate subsets of population for the scoring and initial validation and for the psychometric validation.
The good quality of completion and returns of both PACT-Q1 and PACT-Q2 in all of the countries reflected the good acceptability of the questionnaire. The PACT-Q2 structure was further confirmed by a good item convergent and discriminant validity criterion and excellent internal consistency reliability of both dimensions. No floor or ceiling effects were observed for the "Anticoagulant Treatment Satisfaction" dimension; in contrast, a ceiling effect (22%) was reported for the "Convenience" dimension. While a ceiling effect is not recommended when measuring quality of life aspects , it is easily conceivable and acceptable that a majority of patients report no inconvenience of use in their treatment, particularly in clinical trials.
Known-group validity showed that PACT-Q dimensions were able to discriminate between groups of patients presenting different disease experiences and characteristics. In particular, patients who had had no previous experience of anticoagulant treatment were significantly more demanding in terms of symptom relief, while patients who had already been treated with anticoagulants expected more side effects than those who had not, and could therefore possibly be more realistic. These findings agree with Oliver's work, who proposed that patients' expectations are considerably influenced by previous experiences and knowledge that they have acquired of their disease and treatment . As expected, patients' satisfaction was greater if they did not have a thrombolic event within the period of time that they were under treatment. In addition, one should point out that although a few patients only (n = 4) experienced an event within these 3 months, this had a noticeable impact on their satisfaction, thus indicating that PACT-Q is sensitive to events that are meaningful to patients. Lastly, patients at risk of embolism (INR < 2) at Day 1 of the study expected much more from their anticoagulant treatment in terms of cost, ease of use, side effects, worries about making mistakes and symptom relief, when compared to patients with lower risk of embolism (INR > 3). After 3 months of anticoagulant treatment, patients with an INR > 3 (i.e. with less risk of embolism) were the most satisfied with their treatment compared to patients with a higher INR. Interestingly, no correlation could be drawn between patients' expectations from the anticoagulant treatment at baseline and their satisfaction after 3 months of treatment. This can be explained by the theoretical model of Oliver et al., in which the authors propose that patients derive their satisfaction from the comparison between their expectations before starting the treatment and the performance they eventually perceive from it after being treated . Therefore, in order to study the link between expectations and satisfaction, it would be necessary to assess it according to the treatment patients are receiving, which could not be performed as the statistical analyses were blind to the treatment attribution.
The good psychometric properties demonstrated by the PACT-Q in this paper support its use as secondary endpoint in trials. However, one should note that key validation criteria still need to be assessed before considering its use as a primary endpoint; in particular, the assessment of the responsiveness and test-retest reliability properties of the questionnaire and the estimation of the value for the minimal important difference.
Given the design of the phase III clinical trial, test-retest reliability of the PACT-Q was not assessed. For similar reasons, it was difficult to assess the responsiveness of the questionnaire. Indeed, as the PACT-Q2 aims to assess patients' satisfaction with their treatment and treatment convenience, the largest difference that one could expect should be between patients treated with VKA and patients treated with the new anticoagulant drug. However, the scoring procedure had to be established blinded to treatment groups; comparison of patients' satisfaction between these groups could therefore not be made in this present study. Changes in satisfaction and treatment convenience, are more likely to be assessable from the treatment effect longitudinal study; these data of which will be further presented in another publication.
The PACT-Q is a valid and robust instrument that allows patients' expectations and satisfaction with anticoagulant treatment to be assessed. The good acceptability and psychometric properties of the questionnaire have been demonstrated with patients with various conditions including DVT, PE and AF, suggesting the PACT-Q's suitability for thromboembolic pathologies in general. Its multi-language validated versions will facilitate and widen its use in international studies.
This instrument could be helpful for clinicians to identify patients' expectations, either positive or negative, of their anticoagulant treatment. Together with a better knowledge of how patients perceive their treatment, the questionnaire could therefore contribute to facilitate physicians' decision about the most appropriate medical care for their patients; this would probably result in a better compliance from patients, and ultimately in a better control of the disease.
PACT-Q© is protected by copyright with all rights reserved to Sanofi-Aventis, France. Do not use without permission. For information on, or permission to use PACT-Q©, please contact the Mapi Research Trust, 27 rue de la Villette 69003 Lyon, France. Tel: +33 (0)4 72 13 65 75 – E-mail: trust@mapi.fr – website: http://www.mapi-trust.org.
We would like to thank Benoit Arnould (Mapi Values) for his input in the questionnaire development and data interpretation, and for reviewing the manuscript; Aude Roborel de Climens (Mapi Values) for her input in the statistical reports from which the manuscript has been written. We would also like to thank Prisca Leguet (Sanofi-Aventis) for her contribution to the development of the project. The manuscript has been reviewed for its English by Nicola Barnes, whom we would like to include in our acknowledgments.
The present work was funded by Sanofi-Aventis, Research and Development. The phase III trials were initiated by Sanofi-Aventis, Research and Development. The work on the PACT-Q was investigator-initiated. SR Kahn is supported by a Senior Clinical Investigator Award from the Fonds de la Recherche en Santé du Québec. Hélène Gilet, Isabelle Guillemin are paid consultants to Sanofi-Aventis, Research and Development. Sylvie Gabriel is an employee of Sanofi-Aventis, Research and Development. The other authors have no conflict of interest.


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Shadows of The Last Stand Part 1
July 1, 2019 July 13, 2020 Dragonofyang	6 Comments	Literary Critique, S7E7 The Last Stand Part 1, S8E2 Shadows, Video, Voltron Legendary Defender
A TPL Reconstruction
Slides Transcript:
[Slide 1]
Welcome to Team Purple Lion's reconstruction of Voltron Legendary Defender Season 7. We are educators, researchers, and analysts using our knowledge of literary analysis to reconstruct Seasons 7 and 8 of Voltron Legendary Defender. This project aims to reconstruct a cogent, thematically appropriate story for all ages and educate viewers on the nuts and bolts of creative writing and literary analysis.
This episode is Season 7 Episode 7 The Last Stand Part 1. In our reconstruction, we combine scenes from Season 8 Episode 2 Shadows to create better narrative flow and sustained dramatic tension in the last half of Season 7.
Summary: "The Last Stand" centers on the Holt parents and their search for children Matt and Katie/Pidge while developing adequate Earth defenses against the Galra. Contrasting this is Honerva's loss of and search for her son Lotor while managing what remains of the Empire.
The juxtaposed scenes demonstrate a distinction between healthy familial love and the toxic dynamic of an abusive household while building sympathy for Lotor and creating dramatic tension toward a shocking reveal that will be seen as S7E13's true cliffhanger. The title suggests Earth's last stand against the Galra, the Holts' last stand in finding their children, and Honerva's last stand in avenging her son – once she learns of his fate.
Color and Theme: The juxtaposed scenes from "The Last Stand" and "Shadows" use complimentary colors to demonstrate an opposing diametric between the love demonstrated by the Holt and Galra families.
Color and Theme: While the Earth scenes are mainly colored in the yellow-orange, yellow, and yellow-green hues, the Shadows scenes are mainly colored in the blue-violet, violet, and red-violet hues, signifying joyfulness, light, and life for the Holt family and mystery and darkness for the Royal Galra family.
Color and Theme: Although it is actually part of the cliffhanger in S7E13, of special note is the color scheme of Ven'tar's planet: yellow, yellow-green, and green, suggesting that at that point of the story Lotor had come from a place of darkness into a place of love, light, and life, connecting his love for the planet with the love we associate with the Holt family.
Team Purple Lion used scene connectors to piece together which scenes should be paired.
Scene connectors are images and phrases that help the audience make a thematic connection between two scenes. For instance, a character might mention a person, place, or thing that is mentioned again in the next scene. Or a visual motif, such as a recurring object, may appear across scenes.
As you watch The Last Stand Part 1a, be on the lookout for scene connectors.
[episode plays]
You made it to the end! Time for a pop quiz. Dis you find all the scene connectors? Pause the video and list as many as you noticed.
Pidge's love for her father contrasts with Honerva being rejected by Lotor.
Honerva's declaration "I will find you, my son" connects with Colleen Holt's declaration "This is the only family I have left. You'll get me the clearance."
Colleen's statement "I thought you were dead" connects with Honerva's line about Lotor, "He pierced the veil".
Sam's explanation of Zarkon and Quintessence connects to Zarkon asking Honerva if she can bring him Quintessence.
Zarkon's recorded mentioning of the Druids, played during the military briefing, connects with Honerva abandoning the Druids.
Matt's mention of Lotor and his statement of love for his parents connects with Lotor's troubled birth to parents who rejected him.
Thank you for joining us for The Last Stand Part 1a. Our efforts continue on The Last Stand Part 1b.
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Shadows of the Last Stand Part 2 →
Season Seven's Corrected Cliffhanger
July 10, 2019 July 13, 2020 Dragonofyang	5
Chasing the Ghosts of Season 8
December 18, 2018 July 13, 2020 LeakingHate	2
The Heroine with a Thousand Faces
June 13, 2019 July 13, 2020 Dragonofyang	2
6 thoughts on "Shadows of The Last Stand Part 1"
Amazing work again! I am curious as to how/why Team Purple Lion decided to use scene connectors to reconstruct "Shadows" within S7's narrative, and if there were other instances of scene connectors similar to the ones found here in previous seasons
Hi Anon, thanks for such a great question!
The scene connectors actually weren't what we started with. To give you a glimpse into our process, I tend to work from big picture elements like theme backward into the smaller narrative details. I actually hadn't watched S7 since it first aired last year but started rewatching the last two episodes of S7 after listening to music tracks from them that contained Lotor's theme and noticed something I wasn't looking for: The end scenes of "Shadows" are what should be the actual cliffhanger of S8 because they are what the dramatic tension set up in the early half of S8 pulls toward. I then began rewatching S7 as a whole to back myself on that and again noticed something completely unanticipated: The rest of "Shadows" fits thematically into "The Last Stand" nearly scene by scene. LeakingHate and I figured "Shadows" was dispersed throughout S7 originally but I didn't expect it to be such a neat fit into that particular episode. It makes sense though because "The Last Stand" is where most of the MFE stuff, which wasn't originally there, was added. After that, I began pairing scenes based on thematic content, primarily using dialogue. Crystal then broke up the episodes in question into smaller chunks for me to play around on the order. I broke some down further and moved them around based on dialogue and flow. I started noticing the more visual scene connectors as I was arranging them. Actually, once I had spliced them together it was a visual scene connector that solidified for me I was on point about the original cliffhanger — the DotU Lotor bathelm shape that appears in both the reworked S7 and the original S7 cliffhanger.
I'd have to go through and watch all the seasons again to make any kind of comprehensive list of scene connectors within and between episodes, which would be extensive. It's an incredibly common tool in fiction writing. Some of the scene connectors I can recall off hand are in Season 6. Shiro/Kuron and Keith's arc toward the end mirrors the dialogue common to Lotor, Allura, and Keith. For example, Lotor states that things didn't have to end this way, but the paladins made their choice. Keith mirrors this line when he tells Allura "Lotor made his choice". Another example is when Keith tells Kuron "I'll never give up on you", mirrored in Allura's insistence "we can't just leave him!"
Thanks again for interacting with us! I hope this was helpful in understanding some of our reverse engineering process.
So if I'm reading this right: 'The Last Stand' + 'Shadows" are the original Season 7 finale. But if 'The Last Stand' is the finale then does that mean 'The Last Stand Part 2' and the rest of the season are also out of order? Or is it just these two particular episodes? And how would that fit chronologically? Wouldn't that mean that Season 7 would end in a flashback with Luca heading to Earth?
We're working on getting the chart of S7's layout and the other two episodes I patched up on the site to accompany this video. If you want to rewatch S7 with our estimated corrected layout it is:
S7E1 A Little Adventure
S7E2 The Road Home
S8E4 Battle Scars
S7E3 The Way Forward
S8E5 The Grudge (minus garrison content)
S7E4 The Feud (this was not originally there, but consider it bonus content)
S7E5 The Ruins
S7E6 The Journey Within
S7E7 The Last Stand Part 1 (edited with scenes from Shadows, minus MFE stuff)
S7E9 Know Your Enemy
S7E10 Heart of the Lion
S7E11 Trial by Fire
S7E12 Lion's Pride Part 1
S7E13 Lion's Pride Part 2 (corrected cliffhanger includes last ~6 minutes from Shadows)
Basically it goes in the same order, but The Feud and anything to do with the MFE pilots were not part of the originally envisioned plot. Yes, the end scene would be Luca headed to Earth in a flashback, but it comes after we see her mech in the hanger during Lion's Pride Part 2. There should be a moment of horror for the audience when we see Lotor was telling the truth about Ven'tar's planet and then realize his mother plans to try and bring him back and she has an entire army of mechs ready to destroy Voltron. Luca headed off toward Earth is a sort of "and now it begins" moment. Hopefully this will make more sense once we get the other two vids up.
-Felix
Ahhhhhh, I get it now! Thank you for clearing that up! Between reading so many fix-it fics and writing my own I get all the events of the episodes mixed up hehehe. I always assumed that The Grudge was supposed to be in Season 7 because of how out of place it was. It did nothing to drive the main plot forward besides the whole 'Honerva might be in Oriande time to punch the wormhole BIG TIME'. And as an artist/beginner animator/keen-eyed observer of animation, the art styles flip faster than the writers. And of course in 'Genesis' Ezor is just 'Allura on Helium'.
…You know for a show with 8 seasons all of their problems would've been solved if they just said 'We're gonna go on a hiatus for a while to get our shit together.'
Oh wow! Thank you so much on the insight into the team's process!! It's pretty wicked to see all the parallels – visually, aurally and narratively – that occur in this series. They really explain *why* VLD became a favorite of mine; it's quite thrilling to find all the pieces that fit neatly together. (And you're right, a comprehensive list of scene connectors found in VLD would be extensive, I really appreciate the ones that you did share offhand! Before S8's heavy blow, I had ambitions to write on the parallels found in the series…maybe one day…eventually…)
I have noticed that Allura and Keith tend to share a lot of narrative beats between each other and in relation to Lotor and Shiro (that could also be bias speaking on my part, considering these four are my absolute favorites, plus Hunk).
Looking forward to the second part of the reconstruction! Absolute kudos to Team Purple Lion for your dedication and sharing your (evidence-supported!!!!) findings!

redpajama_set_name: RedPajamaCommonCrawl


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WA News
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Enterprise Bargaining Simplified
Enterprise Bargaining
As we come out of our first month of the New Year, many workplaces are getting into Enterprise Bargaining.
For most Union members this is known to be a standard process every three years or so, often with many delegates taking part.
United Voice members are always at the table, because Union members know what they want and how working together gets the best results.
And whilst this occurs at many different workplaces all through the year, the process can be confusing.
That's why we're going to simplify it for you.
Often known as your 'Agreement', a federal Enterprise Bargaining Agreement (EBA) is made in two key steps:
The first step is at the 'bargaining table' where employees and employers negotiate the terms and conditions of employment for a new Agreement.
The negotiation meetings take time, and allow for both parties to openly and freely discuss proposed conditions and offers.
Workers who take part in negotiations as part of their Union bargaining team are often delegates, or groups of delegates who collectively form a bargaining committee.
To prepare for negotiations, Union members - with assistance from officials - devise a 'log of claims' which consists of items the workers are seeking in their new Agreement. The employer can and often will prepare one too.
Negotiations may take several meetings of back and forth, with workers often presented with proposals or offers by the employer which are not popular. This can lead to lengthy disagreements, and some times to workers taking protected Industrial Action.
At any stage during negotiations the employer can put a new Agreement out to a vote. Sometimes employers put out an Agreement to a vote, before Union members at the table think the employer's offer is good enough.
The more union members there are in a workplace, the less likely it is that an employer will try use this strategy. When union membership is strong at a workplace, the employer will usually stay at the bargaining table until terms are agreed.
All workers who will be covered by the new Agreement can take part in the vote, but it is not compulsory.
A majority vote will decide whether bargaining continues (a 'No' vote) or whether the Agreement is made (a 'Yes' vote) and can be lodged with the Fair Work Commission for approval.
Being on the Bargaining Committee
To be part of the bargaining committee is an honour and while it can get stressful and heated at times, it's an exciting experience. Zoe, a Disability delegate, is part of her workplace bargaining committee for the first time.
"Sitting in on my first EBA negotiations is exciting and is an experience I would suggest all members be party to," she said.
Another member taking part in negotiations is Ben, a Health member, who wants the chance to positively change his workplace rights.
"To be part of these negotiations means we get to influence the direction our workplace rights are going," he said.
There are many negotiations taking place in 2018, making the number of members in a workplace more important than ever.
The greater number of members - The better the outcome.
That's why it's so important to be a union member.
If you know somebody who should be a United Voice member, send them this link and ask them to join today: http://www.unitedvoicewa.org.au/join
Union Western Australia United Voice Fair Work Commission Bargaining Enterprise Agreement EBA wa_featured_news
Join the union
United voice is a union of workers organising to win better jobs, stronger communities, a fairer society and a sustainable future.
Connect with United Voice
Member contact: 1800 199 890
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Rachael.Osborne@unitedvoice.org.au
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The Representative is a condo community overlooking Pentagon City and the Potomac Valley in Arlington VA. Its location near Prospect Hill Park puts it in very close proximity to the Pentagon. It's sited between Prospect Hill Park and Hopper Memorial Park not far from I-395 on Arlington Ridge Road. The Representative is located where Arlington Ridge Road terminates at 1101 Arlington Ridge Road. The road here makes a hairpin-turn on a promontory overlooking I-395, Crystal City, Arlington, the Pentagon and Washington DC.
The Arlington Ridge Road here makes a hairpin-turn alongside the Representative to climb a promontory overlooking I-395, Crystal City, Arlington, the Pentagon, and Washington DC. This location gives the Representative superb views of the Potomac and Northern Virginia and puts the Representative near the heart of the action, and at the same time a little off the beaten track.
Are you considering selling or renting-out your condo at The Representative?


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Sport Cycling Cadel Evans confirmed for national road race
10:17am, Jan 9, 2014 Updated: 3:00pm, Jan 9
Cadel Evans confirmed for national road race
Cadel Evans has confirmed he will start in Sunday's elite road race at the Australian road cycling championships at Ballarat in Victoria.
The 2011 Tour de France champion gave the nationals a major boost late last month when he registered for the road race, but made it clear at the time he would not make a final decision on starting until much closer to race day.
"My training has been very focused in the last few weeks and I feel that I'm at a level that should hopefully enable me to be competitive on Sunday," Evans announced on Thursday.
"I know it's going to be hard work going up against the larger teams, but it will be interesting to see how the race unfolds and I'm looking forward to a good, solid hitout."
It will will be the first time since 2005 that Evans has competed at the road nationals.
Evans' racing program this year will focus on the May Giro d'Italia rather than the July Tour de France, resulting in an earlier start to his schedule.
Evans had earlier confirmed he would race from January 19 in the Tour Down Under in Adelaide.
He last competed in that race four years ago, after his breakthrough 2009 world road title.
The elite men's road race on Sunday will feature a world-class field including fellow Tour de France stars Simon Gerrans and Richie Porte, along with Nathan Earle, Luke Durbridge, Simon Clarke, Matthew Goss, Matthew Hayman, Rohan Dennis, Steele von Hoff, Lachlan Morton, Jonathon Cantwell, Will Clarke and Jack Anderson.
The race is set to attract a capacity crowd as Evans joins more than 150 riders in the 183.6km event over 18 laps of the 10.2km Buninyong circuit.
Gerrans after third Tour Down Under title


The giant Tyrannosaurus rex pulverized bones by biting down with forces equalling the weight of three small cars while simultaneously generating world record tooth pressures, according to a new study by a Florida State University-Oklahoma State University research team.
In a study published today in Scientific Reports, Florida State University Professor of Biological Science Gregory Erickson and Paul Gignac, assistant professor of Anatomy and Vertebrate Paleontology at Oklahoma State University Center for Health Sciences, explain how T. rexcould pulverize bones — a capacity known as extreme osteophagy that is typically seen in living carnivorous mammals such as wolves and hyenas, but not reptiles whose teeth do not allow for chewing up bones.
Erickson and Gignac found that this prehistoric reptile could chow down with nearly 8,000 pounds of force, which is more than two times greater than the bite force of the largest living crocodiles — today's bite force champions. At the same time, their long, conical teeth generated an astounding 431,000 pounds per square inch of bone-failing tooth pressures.
"It was this bone-crunching acumen that helped T. rex to more fully exploit the carcasses of large horned-dinosaurs and duck-billed hadrosaurids whose bones, rich in mineral salts and marrow, were unavailable to smaller, less equipped carnivorous dinosaurs," Gignac said.
The researchers built on their extensive experience testing and modeling how the musculature of living crocodilians, which are close relatives of dinosaurs, contribute to bite forces. They then compared the results with birds, which are modern-day dinosaurs, and generated a model for T. rex.
From their work on crocodilians, they realized that high bite forces were only part of the story. To understand how the giant dinosaur consumed bone, Erickson and Gignac also needed to understand how those forces were transmitted through the teeth, a measurement they call tooth pressure.
In current day, well-known bone crunchers like spotted hyenas and gray wolves have occluding teeth that are used to finely fragment long bones for access to the marrow inside — a hallmark feature of mammalian osteophagy. Tyrannosaurus rex appears to be unique among reptiles for achieving this mammal-like ability but without specialized, occluding dentition.
The new study is one of several by the authors and their colleagues that now show how sophisticated feeding abilities, most like those of modern mammals and their immediate ancestors, actually first appeared in reptiles during the Age of the Dinosaurs.


Willow. . Wallpaper and background images in the Buffy the Vampire Slayer club tagged: buffy the vampire slayer willow alyson hannigan.
This Buffy the Vampire Slayer fan art might contain hip boot, thigh boot, tights, leotards, stocking, and pantyhose.
That's photoshopped her head onto someone else's body, isn't it?


Applications for the 2017 A&R Academy are now closed and placements confirmed.
Expressions of interest for the 2018 program will open in December 2017.
Sony Music Entertainment Australia has launched the Sony Music A&R Academy – a unique and Australian industry-first initiative for the development and mentoring of future A&R talent.
The A&R Academy allows talented, passionate and exceptional tertiary education graduates to join Australia's leading A&R team in Sydney and Melbourne and be part of a structured program that will see them work in the company full-time for 12 months.
"I am really excited to announce the launch of the Sony Music A&R Academy. A&R is the heartbeat of the music industry and Sony Music Entertainment Australia has always been committed to the signing and development of artists that can succeed at home and overseas.
This program will allow tomorrow's A&R leaders to learn and excel as part of the thriving entrepreneurial, innovative, creative and risk taking culture of Sony Music Entertainment Australia. They will learn from the best in the business and at the end of the program, be equipped to become industry leaders in A&R.
undergo general skill development necessary to succeed in today's music industry.
The recruitment process is rigorous as positions are very limited. Applicants will apply by video message and resume through a purpose built website.
Candidates must be a recent graduate, and be nominated by, one of Sony Music's partnered universities or colleges, including the Australian Institute of Music in Sydney and Melbourne, the Queensland University of Technology, RMIT University and Melbourne University.
At the conclusion of the 12 month program, A&R Academy interns will either be offered a permanent position with the company or potential for Sony Music to invest in them as entrepreneurs.
"The Sony Music A&R Academy is an excellent initiative that recognises that learning does not stop at graduation, particularly in such a dynamic field as A&R. As such, it presents an excellent opportunity for today's students to gain the practical hands-on experience and expert mentorship that will help them become the successful music industry talent of tomorrow.


We are financing a condo purchase in Newport Beach and the appraisal came in $13,000 over the contract price. This was a big surprise, given the strength of the current market.
This is just a reminder that, for loan-to-value purposes, lenders always correlate to the lower of the appraised value or contract price. An appraisal that comes in over the contract price does not affect financing options at all.
Investment Property Financing; 75%; 80%; 85%; 90% LTV??


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Money / Financial Planning
What To Do When You or Someone Else Is Left Out of a Loved One's Will
laflor / Getty Images
Sadly, a loved one has recently passed away. While sorting through their affairs, you've discovered their will didn't include everyone you expected.
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Namely, someone close to the deceased was excluded — possibly even you.
It's only natural to have feelings of disappointment, betrayal and loss if you're left out of a loved one's will, said Maryanne Parker, founder of Manor of Manners, an etiquette consulting firm based in San Diego.
"On many occasions we were warned by many red flags or simply by the person who was creating the will," she said. "If we were big spenders during our younger years and the family was paying for our expenses, college or helped us with a business and there is an understanding that we won't be included in the will, we should accept it accordingly, the way it was discussed, be gracious and move on."
If you feel you were unfairly excluded, Parker said it's easy to dwell on this emotion, which can be truly difficult.
"Most of the time the rest of the family is not even aware of the situation and unfortunately they will be on the receiving end of our emotions," she said. "We should carefully monitor our reaction and remember that even after the disappointment of the will, we will be living, communicating and carrying on as a family and our reaction might make or break the future relationships."
She said it's common for people left out of a will to jump to conclusions, which doesn't end well when paired with hurt feelings.
"If we assume the will was disproportionately created based on malice and some kind of family conspiracy, sometimes sincere conversations with siblings and relatives might serve us very well, in terms of healing the loss, overcoming the disappointment and moving forward as a family," she said.
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Of course, she said it's also possible in some unfortunate situations that a family might purposely exclude a loved one from the will for a variety of reasons.
"If we find it truly unfair and we certainly believe that we should be getting a part of it and something went wrong and the will was done incorrectly, then we should take legal action and move away from the family," she said. "Sometimes the circumstances are deeper and darker just to be handled by a regular etiquette approach."
It's also possible that you were included in the will but a loved one was not. Parker said she actually finds this scenario more difficult than being excluded from a will yourself, as it could unknowingly create a huge division between siblings and relatives.
In this case, Parker said you need to carefully examine the situation before deciding how to proceed. If the deceased family member has already decided how to divide the estate, she said they had their reasons.
"If we decide that our brother, sister or a relative needs financial assistance — and in general help — we can make a personal decision based on our own family relationships," she said. "This can be very difficult, because in some cases the sibling we want to help might be standing in her own way and the help might be even more detrimental than helpful — especially if they have certain questionable lifestyles."
However, she said if the person is truly down on their luck, lending a helping hand can be the ideal scenario.
"We cannot have a simple recipe for every single situation, because every life story is different," she said. "The bottom line is to read the room every single time we make a big decision."
Ultimately, she said it's also important to decide how valuable your relationships are with the family. This will help you decide if you want to work toward moving on in a positive direction or deal with grudges the rest of your life.
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Jennifer Taylor is a West Coast-based freelance writer with more than a decade of experience writing about anything and everything. Since earning her MBA, personal finance has been her favorite topic, as she's passionate about writing stories that educate, inform and empower. Specifically, she specializes in budgeting, debt repayment, savings and retirement.
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Ranking House GOP members demand accounting from Biden admin for COVID relief funds
January 5, 2022 By Jon Brown
FIRST ON FOX: Ranking House Republicans sent a letter to President Biden on Wednesday requesting an accounting of how his administration has spent trillions in COVID-19 relief funds as the administration is reportedly planning to ask Congress for more.
House Budget Committee Republican Leader Jason Smith of Missouri, House Energy and Commerce Committee Republican Leader Cathy McMorris-Rodgers of Washington, and House Ways & Means Committee Republican Leader Kevin Brady of Texas signed the letter, which claims the Biden administration has failed to account for how, when, and where the money intended to address COVID-19 was distributed.
The lack of transparency, they said, has continued despite multiple requests from Congress for information.
Smith, Rodgers, and Brady noted recent reports and statements from the administration indicating that they are planning to ask for more money from Congress for supposed COVID-19 relief, despite dozens of publicly reported examples they cite in the letter documenting tens of billions worth of misused federal taxpayer dollars.
The letter explicitly mentions the billions of COVID-19 funds that the administration repurposed to deal with the crisis on the U.S. southern border, which included housing illegal immigrants.
The letter comes as the daily number of COVID-19 cases in the United States has surged to its highest level while the country faces a critical shortage of testing kits.
President Joe Biden prepares to remove his face mask in the South Court Auditorium of the White House complex Dec. 23, 2021, in Washington, D.C. (Photo by Drew Angerer/Getty Images)
"Hundreds of billions of dollars have been used to bail out state governments, to build bike trails, new high school weight rooms, apartment buildings, and golf courses, to name just a few examples," the members wrote.
"Simply put, this Administration's first request to Congress for COVID-19 dollars has resulted in multiple, easily predicted instances of non-COVID related spending. What's worse, when asked to account for these taxpayer dollars or answer questions about their use, your Administration has remained silent," they continued.
The Biden administration did not respond to Fox News' request for comment in time for publication.
President Joe Biden removes his face mask to speak about gun violence prevention in the Rose Garden at the White House, Thursday, April 8, 2021, in Washington. (AP Photo/Andrew Harnik)
"American taxpayers deserve an honest and detailed accounting of where the $6 trillion in COVID-19 relief passed by Congress has been spent and how much remains," the letter said. "Your Administration has misused taxpayer dollars to spend on items unrelated to COVID-19 and repurposed funds for the southern border crisis of your own creation.
"The American people deserve transparency and answers to these important questions from their government before being asked to further foot the bill for another attempt by your White House to spend hundreds of billions or even trillions more in the name of 'combating COVID-19.' A permanent pandemic narrative cannot be used by your office to avoid this responsibility," they added.