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Brockton area fights back against potent heroin additive, overdoses
In January, Heather Kennedy started hearing from people that a bright white, hard- and fast-hitting batch of heroin was going around that left users with a longer high.
She also started hearing about more overdoses and overdose deaths.
Kennedy, who works for Community Outreach, Prevention and Education in Brockton, received a health advisory from the state Department of Public Health warning that the prescription painkiller fentanyl may be finding its way into local batches of heroin. Fentanyl is a powerful painkiller that is often prescribed to terminally ill cancer patients.
Now Kennedy and others in the region are looking to fight back against fentanyl and the rising surge of overdoses.
"We immediately started enrolling as many people as possible and giving out as many doses of Narcan as possible," Kennedy said. Narcan is a brand name for the drug naloxone, used to reverse the effects of an overdose.
She said COPE has also been expanding its services in Brockton, Stoughton and Carver since January.
In Whitman on Wednesday night, the Brockton Mayor's Opioid Overdose Prevention Coalition met with drug prevention groups from Whitman, East Bridgewater and Rockland. Police officers, members of town government and addiction treatment workers discussed upcoming plans, including what to do about fentanyl.
Hillary Dubois, coalition coordinator, who was at the meeting Wednesday, said they have seen an increase in recent months of people who are looking for resources and information.
Dr. Joseph Shrand, who is the medical director of CASTLE (Clean and Sober Teens Living Empowered), part of the High Point Treatment Center in Brockton, said they are actively trying to educate people about "just how dangerous the stuff on the streets is now."
"We have a very active overdose prevention group," Shrand said.
In Rhode Island there were at least 22 fatal overdoses in January in which the deadly concoction was believed to have been used, according to the Boston Public Health Commission. In Pennsylvania at least 17 deaths were linked to the mixture in recent weeks.
Reports from Signature Healthcare Brockton Hospital and South Shore Hospital have indicated that overdose numbers are up in recent months.
In 2012, South Shore Hospital in Weymouth saw an average of 31 overdose patients per month, hospital spokeswoman Sarah Darcy said. In 2013, the hospital saw that number increase to an average of 40 per month.
Darcy said that number is not going down this year. "We're not seeing a trend that's dropping," she said.
South Shore Hospital has programs to train area EMTs how to administer Narcan. They also have a program where loved ones of addicts can be taught how to use Narcan, as well.
Darcy said the programs that they have in place are vital in combating the high rate of overdoses.
Benjamin Paulin may be reached at email@example.com.
READ MORE about drugs in Brockton.

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Today's News: Our Take - Scandal Scoop: Will Harrison Succumb to Guilt?
Olivia Pope and her associates have done some shady things to protect their clients, but when one of their own is messed with, there's no limit to what they'll do to protect them - even if that ultimately means causing them pain.
That's what Scandal's resident smooth talker Harrison (Columbus Short) has been dealing with after having to plant information that David (Joshua Malina) had abused his former girlfriend in order to get Abby (Darby Stanchfield) to break up with him. But really, he was saving her life!
Is speed the new suspense on TV?
"He didn't put a clause on what he said to Olivia," Columbus Short tells TVGuide.com, recalling when Harrison offered his services to Olivia (Kerry Washington) by saying he'd do anything for her. "It was whatever she asked him to do. So when she asked him to do that, it puts him in a precarious position because Abby is really his family. It hurts him to see her hurt."
Short was coy about whether the guilt would ultimately get to Harrison, but he did say, "I don't want to know what happens when Abby finds out. She'll go crazy." Regardless, Short says Olivia's faithful follower would never turn against her, but he is starting to understand her more. "Now he's realizing how much Olivia lives in the gray," he says. "Her life is not black and white. He knows there's something she's actually protecting him from. Harrison understands embodying that position and that it is ugly and you have to get your hands dirty. Olivia's hands are dirty a lot."
It isn't just Harrison who's noticed the gray areas. "Are these good people? I battle with that on the daily," Short says. "Our moral ambiguity is such a weird dichotomy, but I do feel Harrison is capable - under the disguise of that suit is his gladiator armor - to handle the gray."
TV's Sophomore Class Report: Which shows are working? Which are slumping?
That's exactly why Olivia will be handing the reins over to Harrison in the coming episodes as she deals with more pressing matters. "Things in Olivia's personal life and on the White House side of things are getting a little out of control," Short says. "She can't handle her job. It leaves him to step in and take over for her and she has complete confidence in him."
However, Harrison will be dealing with issues within the walls of OPA when Quinn (Katie Lowes) begins digging into the reasons behind the surprising dismissal of the charges against her in the bombing case. "It affects the office," Short says. "Things are unraveling more and more and the rabbit hole is beginning to go very, very deep. Abby already has a sneaking suspicion, and Harrison has never asked, but has a clear idea of how it all went down."
During all of this, an event will rock the world of OPA (and beyond) in the final three episodes before the midseason finale, which include what is arguably one of the biggest episodes to date, "Happy Birthday, Mr. President." Keen fans have likely already deduced what goes down based on the promo, but Short would only offer this tease: "I don't think that has been done on network television."
Any guesses?
Scandal airs Thursdays at 10/9c on ABC.
View original Scandal Scoop: Will Harrison Succumb to Guilt? at TVGuide.com
Other Links From TVGuide.com


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Making Energy Efficiency Emotionally Appealing
One of the critical jobs for a consumer product marketer is to make an emotional connection with potential customers, to create a desire to buy that isn't based on a reasonable evaluation of the costs and benefits of the product. How else does Apple convince everyone to upgrade iPhones every year, when each new version has just a few cool new features but costs just as much as the previous one? Or buy the new iPad 2, when by most accounts, it's pretty much the same thing as the original iPad?
Now take our industry -- home energy efficiency. With a rational consumer evaluation of the costs and benefits, we've got a great product, compared to Apple. The problem is that consumers don't make buying decisions rationally. So what can we do to sell our product -- home energy retrofits -- based on its emotional appeal?
Plenty. We've done some early work on applying the lessons of behavioral economics to selling home energy retrofits, but in this article, we're going to focus on what works and what doesn't in visual design, specifically, the design of energy efficiency reports.
A/B Testing
The ongoing pilot tests of the new national Home Energy Score being developed by DOE offered a great opportunity for some research in what works to create an emotional engagement with homeowners when it comes to energy efficiency. Over the past several months, EnergySavvy has worked with DOE to conduct an online test of potential design elements for the new national Home Energy Score, to determine which ones exert an emotional tug that makes homeowners think about getting home energy upgrades.
DOE released the basic framework of the Home Energy Score design in November 2010. It consists of a scale from 1 to 10 that compares your home with other homes in the area, and projects where you could be with various upgrades.
We set up an online A/B test (a type of test used in marketing to compare an original sample to a variety of single-variable samples), which used 12 different variations of the original design to isolate the engagement rate differences associated with relatively minor variations. These variations included emphasizing the dollar savings number over the score difference number (or vice versa), personalizing the language used in the scale, and changing colors used in the design, among others. People who took the test were directed to a simple landing page with the caption How Efficient Is Your Home? and a prominent display of the design. In some cases, it was the original design, while in others it was one of the variations. Although there were relatively subtle differences among many of the variations, there were significant differences in the conversion rates. A conversion was defined as a click-through on a button next to the visual labeled "Take the Survey," implying that there would be some effort associated with the next step. The idea was to see which variations had enough emotional appeal to encourage viewers to take this next step.
What We Learned
The variations that had the highest conversion rates had the following characteristics:
Personalized language. By making the language and design of the visual more personal, through changes such as using "Your Home" instead of "Current Score," or by adding friendly home icons (see Figure 1), we showed statistically significant increases in conversion rates.
Estimate energy savings over several years. Showing a five-year dollar savings calculation instead of an annual dollar savings calculation increased conversion rates significantly (even though the five-year number was just the one-year number multiplied by 5). See Figure 2.
Simplify the result. Showing an estimated dollar savings alone, without also showing a target score, significantly increased conversion rates.
These are all very small differences, but each one produced statistically significant differences in engagement rates. Presenting a house's energy score is just one way to engage (or disengage) a customer's interest in a home energy efficiency program.
learn more
For more information on the methodology used in this test, or to ask other specific questions, contact Scott Case at firstname.lastname@example.com.
To learn more about the EnergySavvy programs, go to www.energysavvy.com/programs.
To read Sheena Iyengar's article, "The Fewer The Better—Streamlining Your 401(k) Plan's Fund Choices Can Improve Employees Participation And Decision-Making," visit www.columbia.edu/~ss957/media_ref_pages/thefewer.htm.
What Programs Can Learn—and Apply
To generalize what we learned from the quantitative A|B tests on the DOE Home Energy Score design, we've drawn a few conclusions that can be applied to visual design and copy for all home energy efficiency programs.
Keep it simple. Simpler, friendlier language and fewer data always won out on our A/B test cases. In an industry full of building science nerds (and we use that term affectionately), we've all got to fight the urge to overwhelm homeowners with technical details. Research by Columbia University professor Sheena Iyengar showed a correlation between the number of 401K plan choices that employees at a company had and the rate at which they participated in any plan. The more plan choices they had, the lower the participation rate was for every option.
Personalize. Through visuals and language ("Your Home" and "Efficient Homes in Your Neighborhood" for example) we can invoke the social proof effect. This effect, which comes from social psychology, means that the actions that other people have taken in the past can influence people in the present to believe that those actions represent correct behavior. The social proof effect has been widely seen in persuading hotel guests to reuse their towels, for example.
Make it long term. Given that most energy efficiency improvements are intended to last for many years, it seems legitimate to show at least a five-year savings estimate. While studies in behavioral economics often show that people aren't always motivated more when they are given more money, the fact that the people in our tests were more motivated by the five-year savings number than they were by the equivalent annual savings number is consistent with the findings of other studies in social psychology.
Scott Case is the vice president of Product Management at EnergySavvy. Scott holds an MBA from MIT and a BA degree in political science and economics from Williams College.
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I would agree with you if it wasn't for one thing. What could you give paladins instead of designing the class around FoL, that the other healers don't have?
I would probably buff Seal of Light heavily. Something like this:
Seal of Light
14% of base mana
Instant cast
Fills the Paladin with divine light for 2 min, healing up to 5 friendly party or raid members for [A * AP * WS + B * SPH * WS] with each melee attack. Only one Seal can be active on the Paladin at any one time.
Unleashing this Seal's energy will heal the friendly party or raid member with the highest threat for [C * AP + D * SPH] over 20 sec. (Does not stack. A, B, C, D are values such that the ability is balanced and worthwhile)
Effectively, meleeing with Seal of Light takes over the mundane maintenance healing that we use Flash of Light for. We use the Judgement to maintain a solid HoT on the tank with duration matching the duration of the Judgement effect. We have Holy Shock, Sacred Shield, and Holy Light for responsive healing. I'm not really sure where Beacon of Light would fit in.
Actually, it might be interesting to use Beacon of Light like a focus target. If you cast Beacon on someone, your Judgement of Light HoT automatically targets them, and maybe something similar happens with Holy Shock (Shock hits the enemy and heals the Beacon target). Beacon would have to go much lower in the tree though.
Essentially a normal paladin would have somewhat undirected healing, but a Holy paladin would be able to focus her healing through Beacon of Light. I'd have to think about it a bit more, but I think there are some possibilities with this scheme. It fits nicely with our niche as a single-target, tank healer. Effectively we're duplicating WAR's defensive target scheme on a small level. It's not a true defensive target, but it would be enough to get some of the same style as the warrior priest mechanics (which I've praised in the past).


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Walter Isaacson's forthcoming biography of Steve Jobs is on a kind of crypto-PR tour, having magically landed in the hands of a gaggle of journalists well in advance of its publication. Said journalists are furiously typing with one hand and flipping pages with the other, bringing us glimpses of the year's most anticipated biography of a recently deceased mega-icon of technology. Yesterday, for instance, it was revealed that Jobs regretted delaying potentially life-extending surgery in the very early days of his diagnosis with pancreatic cancer. Now in a wide-ranging survey of the biography, the AP reports that Jobs' disdain for Android was much greater than that for any other competitive product.
According to Isaacson, Steve Jobs' reaction to the January 2010 unveiling of the HTC smartphone lineup was fury. Calling it "a great theft," Jobs supposedly proclaimed, "I will spend my last dying breath if I need to, and I will spend every penny of Apple's $40 billion in the bank, to right this wrong... I'm going to destroy Android, because it's a stolen product. I'm willing to go thermonuclear war on this."
Jobs meant it. Apple would kick off the lawsuits shortly thereafter, and the company hasn't been ignored itself. Countersuits have been filed, and as we have reported on Ars, just about everyone is suing everyone else.
Of course, lawsuits are usually made to be settled, but Jobs was having none of it. Meeting with then-Google CEO Eric Schmidt, a man who for years sat on Apple's board before Android made that no longer possible, Jobs told Schmidt that money wasn't going to make it right. "I don't want your money. If you offer me $5 billion, I won't want it," Jobs reportedly said. "I've got plenty of money. I want you to stop using our ideas in Android, that's all I want." And with that, the door to any possible settlement was slammed shut. We wonder if Jobs' passing will open the door to lawsuit settlements down the road.
Isaacson's book, Steve Jobs will hit store shelves on Monday, October 24, and the Ars review of the book will be up shortly thereafter, so keep an eye out for it.


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All items for sale are subject to Massachusetts laws. Not all items will be available for purchase by MA residence.
Welcome to the New Troy City Tactical.com
We hope that you enjoy your online shopping experience with us. If you're local to the area we encourage you to come by and say hi. Please have a great day and we'll look forward to serving your firearms needs.


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Front Runners List: Click to see list completion progress by climbers that log their climbs using Peakbagger.com.
Compare Climbers: Click to compare ascents of up to 5 climbers working on this list.
This list shows the highest points of the 50 largest counties in the US outside of Alaska. All but four of them are in nine western states. There is one each in Texas, Nebraska, Minnesota, and Maine.
Thanks to John Hasch for suggesting the addition of the Area column, greatly improving the usefulness of this list.
= Peak with Rank #1 on List;   = Other Peaks
This page has been served 733224 times since 2004-11-01.


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Police: No inconsistency in Pistorius account of killing
- Oscar Pistorius%27 bail hearing will continue for a third day
- Police say they have witnesses who say they heard arguing at Pistorius%27 house
- Police claim testosterone found in bedroom%3B defense says %22herbal substance%22
JOHANNESBURG, South Africa -- In a blow to the prosecution, a detective testified Wednesday that the police have found nothing inconsistent with how South African Olympic and Paralympic runner Oscar Pistorius has described shooting and killing his girlfriend on Valentine's Day.
In the second day of a bail hearing in nearby Pretoria, new details in the case emerged as Pistorius' defense team argued that the shooting of Reeva Steenkamp was an accident. Pistorius, charged with premeditated murder, said he mistook Steenkamp for an intruder when he fired through the toilet door.
The prosecution said Pistorius and Steenkamp had argued before she locked herself in the toilet. They say he fired four shots, with three hitting Steenkamp and killing her.
"I believe that he knew that Reeva was in the bathroom, and he shot four shots through the door," detective Hilton Botha said Wednesday.
But asked if the police found anything inconsistent with the version of events presented by Pistorius, Botha responded they had not.
The hearing will continue for a third day Thursday as chief magistrate Desmond Nair decides whether Pistorius is eligible for bail. Botha also testified that Pistorius is a flight risk after a "memory stick" was found with details of the athlete's offshore bank accounts, according to the BBC.
In making its case for why Pistorius should not be granted bail, the prosecution said two boxes of testosterone and needles were found in his bedroom. Defense lawyer Barry Roux countered that police found an "herbal substance," not a steroid and or banned substance.
Medupe Simasiku, the spokesman for South Africa's National Prosecution Agency, told The Associated Press that it was too early to identify the substance as it was being tested at a lab. He said it was not known if the product was legal.
DAY 1: Pistorius disputes premeditated murder charge
Botha said there were witnesses who heard arguing prior to the shooting.
"(Witnesses) heard talking that sounded like non-stop fighting from two to three in the morning," said Botha, who also said Steenkamp had wounds on her head, hand and hip.
Police also told the court that witnesses heard the shooting in two rounds, 17 minutes apart, that Steenkamp was wearing shorts and a vest with no shoes and that the holster for the gun was on her side of the bed. In his affidavit, Pistorius said that he thought Steenkamp was in bed when he fired his gun.
Botha also testified that the trajectory of the bullets showed the gun Pistorius used was fired pointed down and from a height. The prosecution said the killing was premeditated because Pistorius took time to put on his prosthetic legs before the shooting. Pistorius' statement, however, said that he was on his stumps and feeling vulnerable when he opened fire.
The detective said all Pistorius would say after the shooting was "he thought it was a burglar."
Botha also said Pistorius had no license for the .38-caliber gun, making it illegal for him to have the ammunition, which was kept in a safe in his bedroom, the Associated Press reported.
Another element introduced was the matter of communication after the shooting. Police said they found two iPhones in the bathroom and two BlackBerrys in the bedroom, but none had been used to get help. Pistorius had said he called the manager of his gated housing complex and a private paramedic service.
Defense attorney Roux countered again, saying Pistorius did make calls, including to the guards of the housing complex, and one of them could hear Pistorius crying.
"Was it part of his premeditated plan, not to switch off the phone and cry?" Roux asked sarcastically.
Earlier, South African prosecutors said a witness heard "non-stop shouting" at the athlete's home before shots were fired, the BBC reported.
In cross examination, Botha said the witness who heard the fight lived in a home 600 meters (.37 miles) away from Pistorius' house.
Later, when called back for additional questioning by prosecutor Gerrie Nel, Botha said the distance in fact was much closer.
The defense said an autopsy showed no other signs of assault on Steenkamp's body. It also stated that her bladder was empty, suggesting she had gone to the toilet.
In his affidavit, Pistorius said he awoke to sounds in the bathroom, leading him to think there was an intruder in the house. He said he fired shots at the toilet door, thinking that Steenkamp was still in his bed.
Two past incidents were described in testimony, as the prosecution tried to show that Pistorius has a history of violent behavior. At a Johannesburg restaurant, Pistorius was involved in an incident in which a gun was fired, Botha said. He said Pistorius asked someone else to take the blame, according to CNN.
In another incident, police said Pistorius threatened to assault someone at a racetrack, CNN reported.
It's still not clear if a decision will be made on bail on Thursday. But Nair may have signaled he is considering it. After arguments that Pistorius is a flight risk, Nair said, "Is it plausible for someone who has won (a Paralympic) gold medal to forsake his career instead of proving his innocence in court?"
On Tuesday, the first time Pistorius appeared in court, Steenkamp's family held a memorial service in the southern coastal town of Port Elizabeth. Mike Steenkamp, the victim's uncle, said his niece's body would be cremated.
Pistorius' family has opposed the premeditated charge. "After consulting with legal representatives, we deeply regret the allegation of premeditated murder," Arnold Pistorius, Oscar's uncle, told reporters. "We have no doubt there is no substance to the allegation and that the state's own case, including its own forensic evidence, strongly refutes any possibility of a premeditated murder or murder as such."
Called the "Blade Runner" for his carbon-fiber running blades, Pistorius is well-known around the world for his success on the track and fight to compete against able-bodied athletes. He competed at his first Paralympic Games in Athens in 2004, winning gold and bronze medals and setting a world record in the 200 meters. He qualified for the London Olympics in the 400 meters and 4x400 relay last summer.
South Africans are following the case closely and locals say they are still undecided on Pistorius' innocence.
"The fact is, he has shot his girlfriend," said Hamza Moosa, 32, a fan of the runner. "But based on what I read so far, it could have been an accident. I don't think he intentionally wanted to kill her."
Others were less sure.
"I'm in two minds," said Bronwyn Russell, 32. "The one is he did it and the other is that the whole thing was an accident. But when you look at the evidence and what you are hearing, you think it's a different story."
Contributing: The Associated Press.


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When it comes to countertops, you have a lot of options. There are several countertop types available in the market and you could also build your own (not recommended) if you want to or if you are really that inventive. There are no laws against that. However, choosing the best one for your kitchen or bathroom could be somewhat tricky. The tricky part is knowing the best option for your kitchen and bathroom.
That is why today, we are going to help you choose by introducing you to Silestone Countertops and get in depth with it by telling you how to clean them. Just in case you actually buy it and have it installed in your house.
First off, let us understand silestone countertops and the different things that make it up. Silestone countertops are built from naturally - occurring materials. These materials are really tough and durable which makes it suitable for countertops. In terms of strength, they really are a force to reckon with. Also, it doesn't stain and can withstand extreme heat. Its elegant to look at and once you install it in your kitchen, you can be sure that it would make the entire kitchen look good. Caring and maintaining silestone countertops is also an easy task to do. It doesn't require resealing nor does it need to be refinished once in a while. You don't even have to re - sand it.
How to keep it clean?
You can regularly wash it with soap and water just like any other countertops but you could also use any type of cleaner. You don't have to worry about damaging it because it can actually be cleaned with any type of chemicals. However, the best option is always a mild cleaner. You can use either a piece of cloth or a regular sponge to wipe it regularly or after every use. Do not use scouring pads, it might chip the surface.
After washing it, rinse it with water and dry it using a paper towel or a dry cloth. Do not allow soap, water or any chemical stand or dry on its surface. silestone countertop in Millmont, PA. silestone countertop in Millmont, PA. It would cause ugly spots, streaks or film.
When dealing with hot things, its best to place these things on a potholder or a trivet and not directly on the surface. Although it could withstand heat, it doesn't mean that it is resistant to heat. Better safe than sorry.
Also, when you spill something on top of it, you should immediately wipe it off to make sure that you could clean it easily. As I have said earlier; never allow anything to dry on its surface.
And that is about it. That is all that you need to know about silestone countertops and how to clean it. remember, maintaining your things and keeping it clean are the best ways of ensuring that your things would last for a long time. This would save you a lot of money, time and effort.
For a professional quotation please call 888-492-4386 today and book your personal consultation with the industry leaders.
Being economical is a vital aspect of every Silestone Countertop work. On the other hand, you are looking for professional quality work, and Fabulous Counters provides you with both equally. We are going to give you expert strategies to deal with any sort of price range, so you can relax knowing your own Silestone Countertop project won't break the bank.
Fabulous Counters isn't obscure with regards to when we're going to get there or when the job can be concluded. We estimate the stretch of time and price, and help you stay informed when corrections happen. Through saving time, you'll save money, and we appreciate the significance of finishing any project fast. In addition, we prevent the general errors of other businesses to help you save both money and time by never wasting it. This conserves money on materials, given that we understand what we're doing, and don't ever squander resources on blunders.We're here for your needs! You'll be able to contact us to start setting up your Fabulous Counters undertaking by contacting 888-492-4386 right now.
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FTIR study of the adsorption of the capping material to different platinum nanoparticle shapes. The Journal of Physical Chemistry A [Internet]. 2003 ;107(40):8371-8375. Available from: http://dx.doi.org/10.1021/jp0300694.
Self-assembly of platinum nanoparticles of various size and shape. Journal of Physical Chemistry A. 2001 ;105:5542-5547..
Activation energy of the reaction between hexacyanoferrate(III) and thiosulfate ions catalyzed by platinum nanoparticles. Journal of Physical Chemistry B. 2000 ;104:10956-10959..
Kinetically controlled growth and shape formation mechanism of platinum nanoparticles. Abstracts of Papers of the American Chemical Society. 1998 ;215:U176-U176..
Shape transformation and surface melting of cubic and tetrahedral platinum nanocrystals. Journal of Physical Chemistry B. 1998 ;102:6145-6151..


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971 Butternut Dr., Holland, MI 49424, (616) 399-3600
Call: (616) 399-3600
It is our goal to keep your mouth healthy, your teeth fully functional, and your smile bright — and we are proud of all the services we offer to do exactly that. At the same time, we want you to understand all that modern dentistry in general has to offer you. To that end, we have assembled a first-rate dental library in which you can find a wealth of information on various dental topics, including:
From a thorough professional cleaning to a full smile makeover, there is an amazing array of services that cosmetic and general dentists offer to make sure your teeth stay healthy, function well and look great. If your smile is not all you want it to be, this is the place to start. Read more about Cosmetic & General Dentistry.
When you have a dental emergency — whether it's caused by a sudden accident or chronic disease — your teeth and/or the tissues of the mouth that surround them need to receive proper care right away. It's also important to be aware, before you're actually in the situation, of what you can do to ensure the best outcome. Read more about Emergency Dental Care.
This is the branch of dentistry that focuses on the inside of the tooth — specifically the root canals and sensitive, inner pulp (nerve) tissue. When this tissue becomes inflamed or infected, a root canal procedure may become necessary. But contrary to the popular myth, a root canal doesn't cause pain, it relives it. Read more about Endodontics.
If you are missing one or more teeth, dental implants offer the comfort and security of a permanent replacement that looks and functions just like your natural teeth. Dental implants also help preserve the tooth-supporting bone in your jaw that naturally deteriorates when even one tooth is lost. Read more about Implant Dentistry.
Oral health is an essential component of general health and well-being. Good oral health means a mouth that's free of disease; a bite that functions well enough for you to eat without pain and get ample nutrition; and a smile that lets you express your happiest emotions with confidence. Read more about Oral Health.
A major goal of modern dentistry is to help you keep your teeth and gums healthy for a lifetime. By following a conscientious program of oral hygiene at home, and coming to the dental office for routine cleanings and exams, you have the best chance of making this goal a reality. Read more about Oral Hygiene.
The word "surgery" often brings to mind a stay in the hospital, general anesthesia, and perhaps a lengthy recovery period. However, the experience of having oral surgery is usually very different from that. Some common oral surgery procedures include: tooth extractions, dental implant placement, and biopsies of suspicious oral lesions. Read more about Oral Surgery.
Adults and kids alike can benefit from the boost in self-confidence that comes from having a great-looking smile with beautifully aligned teeth. Orthodontic treatment can even improve chewing, speaking and oral hygiene in certain cases. And with today's virtually invisible orthodontic appliances, it's possible to keep your treatment a private matter… until your new smile is unveiled, of course! Read more about Orthodontics.
It's never too early to get your child started on the path toward a lifetime of good oral health, and there are many services to do exactly that. Monitoring your child's dental growth and development, and preventing and intercepting dental diseases along the way, is the primary focus of pediatric dentistry. Read more about Pediatric Dentistry.
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Although oral cancer may not get as much attention as some more widely-known types of cancer, that doesn't mean it's any less deadly. In fact, it is estimated that in the United States, oral cancer is responsible for killing one person every hour, every day. While it accounts for a relatively small percentage of all cancers, oral cancer is dangerous because it isn't usually detected until it has reached an advanced stage. At that point, the odds aren't great: only about 6 in 10 people will survive after five years of treatment.
If there was a simple test that could give you an early warning about whether you're likely to have this disease, would you take it? The good news is — there is! Since early detection has been shown to increase the survival rate of oral cancer to 80% or better, this test can truly save lives. And best of all, having an oral cancer screening is part of something you should be doing anyway: getting regular dental checkups.
An oral cancer examination is fast and painless. Its objective is to identify small changes in the lining tissues of the mouth, lips and tongue that may signify the early stages of this type of cancer. The screening is primarily a visual and tactile (touch) examination. If any abnormalities are noted, a small tissue sample can be retrieved for further testing in a laboratory.
The answer might surprise you. Oral cancer used to be thought of as an older person's disease, and it still mostly affects those over 40. But today, younger people form the fastest-growing segment among oral cancer patients. This is primarily due to the spread of the sexually-transmitted Human Papilloma Virus (HPV16).
Of course, the other major risk factors still apply: If you're middle aged or older, a moderate to heavy drinker or a long-time tobacco user, you have a greater chance of developing oral cancer. Chronic exposure to the sun, long known to cause skin cancer, is also associated with cancers of the lips. Genetic factors are thought to have a major impact on who gets the disease as well.
A thorough screening for oral cancer is part of your routine dental checkup — another reason why you should be examined regularly. The screening includes a visual assessment of your lips, tongue, and the inside of your mouth, including a check for red or white patches or unusual sores. You may be palpated (pressed with fingers) to detect the presence of lumps and swellings, and your tongue may be gently pulled aside for an even better view. A special light, dye, or other procedure may also be used to help check any suspect areas. If anything appears to be out of the ordinary, a biopsy can be easily performed.
If you notice abnormal sores or color changes in the tissue of your mouth, lips and tongue, they may be a symptom of oral cancer — most, however, are completely benign. But sores or other unusual changes that haven't gone away by themselves after 2-3 weeks should be examined. Remember, the only way to accurately diagnose oral cancer is through a laboratory report. Early diagnosis, aided by thorough screenings at your regular dental checkups, is one of the best defenses against oral cancer.
Oral Cancer This article may just save your life. Learn how to notice any unusual lesions (sores or ulcers) anywhere in your mouth that do not heal within two-three weeks. Early detection is key... Read Article
Strategies To Stop Smoking Cigarette smoking is the number one preventable cause of illness and death. Quitting smoking could prevent a large number of diseases and deaths each year. Many smokers find it difficult to stop, a fact that is confirmed by the staggering rate of relapse. Given the fact that cigarette smoking is a learned behavior that is reinforced over time, it makes sense that to be successful in quitting, you must "unlearn" this behavior. Here are some suggested ways to learn how... Read Article


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Jimmy Kimmel shares his theory about Anderson's uncontrollable laughing fits, on the Ridiculist.
Post by: Anderson Cooper
Filed under: The RidicuList
Nice to know someone on the television is human! Go Mr. Cooper.
My two very favorite tv personalities; it just doesn't get an better than this...!
Oh my GOD – that expalins it! Huge fan of Anderson and his shows! I thought it was funny too ... fyi.
Anderson Cooper goes beyond the headlines to tell stories from many points of view, so you can make up your own mind about the news. Tune in weeknights at 8 and 10 ET on CNN.
Questions or comments? Send an email
Want to know more? Go behind the scenes with AC361°


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Like many determined San Francisco 49ers faithful, a Hayward couple spent last week scouring the Web looking for Super Bowl tickets.
They found on Craigslist what they thought was a fair price: $5,900 for four seats, about double face value — even if they'd have to send their money cross-country to a dreaded Baltimore Ravens' season ticket holder.
So after emailing, texting and talking with the seller on the phone for a week, they wired the money to his credit union. On Monday, the highly anticipated package arrived — by FedEx.
Instead of Super Bowl tickets, inside was a picture of quarterbacks Colin Kaepernick and Joe Flacco with a message underneath that read: "Enjoy the game!!!! Go Ravens!!! LOL."
"I'm just sick — like, physically sick," said Sharon Osgood, a 49-year-old Hayward resident. "All over the envelope it says 'go Ravens' — even on the FedEx label."
Of course, police and officials warn fans of ticket scams all the time, but typically scammers disappear once they make off with the money. What's different here is that someone took the time to actually mail an overnight package, complete with a return address and phone number, and insert a special, anti-Niners note to rub it in.
It also highlights the desperation Niners fans have gone to in an attempt to score tickets to a game for which the average resale value is about $3,000 a ticket.
Osgood, a season-ticket holder at Candlestick Park for four years, and her boyfriend have bought seats in the new Santa Clara stadium and were planning to go to the Super Bowl in New Orleans with two other family members in their RV. They still plan on going — even if it means watching the game at a bar on Bourbon Street.
The scam artist told the couple he was a corporate tax attorney living in Boca Raton, Fla., and his wife was eight months pregnant, which was why they couldn't go to the game themselves. .
"For a week I was on the phone with this guy," Osgood said. "That's the only reason why we" trusted him.
No one answered the phone at the number listed on the all-CAPS, exclamation point-heavy Craiglist ad, which has since been taken down. Right underneath the ad, a Craigslist warning says: "Do NOT wire funds."
Osgood, who said she reported the crime to the police on Monday night, is still excited for the game.
"Do we want to let this affect our celebration of our team going to the Super Bowl?" she said. "We need to get past that."
Contact Mike Rosenberg at 408-920-5705. Follow him at twitter.com/RosenbergMerc.


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Tyler Perry once again is brilliant.
He is also a bit sensitive about everything.
So either this is a calculated response to people writing petitions and threatening to boycott his movie because Kim Kardashian is end it or he just had an emotional breakdown and decided to vent.
Either way, it is driving tremendous interest in a film that the majority of people had no interesting in seeing.
Here is what Tyler Perry had to say.
I think many of you know that this is a very difficult time of year for me, so what I try to do is make sure that I'm working during this time. All I wanted to do was shoot a great film and try to keep my mind off the holiday grief that I have been experiencing for the past two years. I could not have imagined I'd be getting all these emails about Kim Kardashian. I HAVE SEEN THEM!! YOU HAVE BEEN HEARD!! …LOL. Now, may I say something? Can a brother get a word in?….LOL. Y'all gave me a new movie title, Tyler Perry's "Diary of a Mad Black Woman Cause You Hired Kim Kardashian, Don't Make Me Take Off My Earrings and Boycott Yo A**."…LOL. Some of my ladies are upset. Ok, all jokes aside, can I have my say? Will you at least here me out?
After I finished writing this movie, I sat back and re-read it. Half way through my read, the gravity of what I had written hit me. I knew that this message was not only for my age group, but for all audiences, especially the youth. ESPECIALLY THE YOUTH!! YOUNG FOLKS NEED TO SEE THIS!!! And not just the young people that follow me, but the young people that are following other young people, as well. I wanted a younger cast, that's why I put Jurnee in the lead and invited Lance Gross, Robbie Jones and Brandy. About two months ago, long before I even heard about Kim's marriage or divorce, I was trying to finish up the casting. I said to one of my producers, "who else is out there that young people are looking up to?" One of my producers showed me pictures that his daughter had taken of several hundred kids lined up around the corner to get into a Kardashian store. They wanted to meet Kim. I thought, what better person! She literally has millions of young people following her.
I thought and still do think, that it would be very responsible of her to be a part of this film. To have the young people that look up to her, see her in a film that is about, what happens in life when you make the wrong choices. Whether you're aware of it or not, to be honest with you I wasn't, millions of young people adore her and are following her every move. If one of those young people see this film and find the strength to live a better life and not go through what these characters went through in this movie, then we have all done what I feel I'm being led to do here. I hope you understand. I really do!
And lastly, because I believe that my films speak from the inside out, why wouldn't Kim Kardashian be invited into a film about Faith, Forgiveness and the healing power of God? What is wrong with that??
So I called up Spike Lee to get his reaction.
I am sorry, but I find this whole thing hilarious, you should too. Just because Kimmy made a sextape (Video: Kim Kardashian and Ray J Sex Tape "Superstar" NSFW) no need to get your granny panties in a bunch.
Oh one last thing if you are part of that petition to get the Kardashian's off air I am 100% sure you haven't had sex since George Bush was in office.


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Musical World
Ivo Pogorelich
- Pianist
Ivo Pogorelich press reviews
. . . Pogorelich turns the best performances of all. The Haydn is extraordinary in its motoric, yet natural pulse and wonderful sense for the composer's dramatic genius. Mozart's "Turkish Rondo" Sonata is one of his more decorative piano works, and Pogorelich makes it ring with excitement when called for, and allows the softer, slower music to emerge with natural dignity. Not a note seems out of place here. The production is perfectly adequate. Camerawork is calm and efficient, and the sound is quite good, capturing the ambience of the small hall in Racconigi Castle.
Record Review / Peter Burwasser, Fanfare (Tenafly, NJ) / Mar 2008
. . . pianist Martha Argerich, recognizing a fellow Dionysian in this young Croatian virtuoso, called Mr. Pogorelich a "genius" . . . Sensitive to the music's shifting moods, Mr. Pogorelich is muscular and virile one moment, delicate and pristine the next . . . Mr. Abbado, with the London Symphony Orchestra, seems at one with his soloist . . . this fascinating release tells all.
Miscellaneous / Anthony Tommasini, The New York Times / 01. July 2006


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Scoundrels! Liars! How dare they?! Well, it's just another day in the 2012 campaign.
I tuned in Wednesday to Roger Ailes' latest Fox News creation, The Five, which is every bit as funny, sexy, partisan and confrontational as everything else Ailes does well. The Five co-hosts were outraged over the outrageous ad by the Democratic super PAC Priorities USA that blamed Mitt Romney for the cancer death of a woman whose husband was once laid off by a company in which Romney invested. There was extended discussion of what the Obama campaign knew and when they knew it about the facts that were distorted in the ad. "They don't just have egg on their face, they have a whole omelet," announced co-host Kimberly Guilfoyle, speaking generally about both Priorities and the Obama campaign. "It's so obvious. It's embarrassing. They have no credibility." It went on like this for a while.
On Thursday, I opened the New York Times to find that "Mr. Romney Hits Bottom on Welfare." The newspaper's editorial writers were outraged over an outrageous new spot by the Romney campaign that falsely claimed Obama was pushing waivers to undo the Clinton-era welfare-to-work requirements. Of course, as you probably know, the Obama waiver, far from abandoning work placement, actually requires documentation that the work placement of recipients improve. But Romney is happy to gloss this over. "This is what happens when a flailing campaign searches for a wedge issue to gain popularity among blue collar workers," the editorial concluded.
(PHOTOS: Political Pictures of the Week, Aug. 4-10)
Both rants are similar in their selective use of the most basic commodity of the modern presidential campaign: outrage. The word itself is a bit of a misnomer in this context. It derives from the Latin ultra, meaning to push beyond, which assumes that there are some accepted standards of decency in political combat beyond which a campaign should not go. The elemental move in modern politics always looks like this: The other side is not playing by the rules. An injustice has occurred. Be outraged.
But who draws the lines when strategists for both parties believe there is little cost to peddling deliberate, carefully crafted falsehoods? The vast majority of the American voting public long ago demonstrated their willingness to simultaneously forgive fibs told by their own team and express umbrage at the deception offered by the other team. Something like 90% of the country who will vote have already decided who they like in the coming presidential campaign, and no level of Obama fibbing or Romney deceiving is likely to dislodge most supporters from their guy. As for the remaining 10%, most of them are too busy and exhausted to spend time differentiating between the relative qualitative and quantitative levels of mendacity.
And yet outrage continues to be the basic currency of political discourse, because it is unmatched in its ability to turn a complex intellectual choice about ideology and policy into a simple emotional choice about character and honesty. It turns supporters into deeper, more motivated supporters. The watercooler discussion begins with "Can you believe that guy?," not "Will Romney or Obama give me a lower marginal tax rate in 2014?" So the campaigns and the ideological press keep churning it out for a hungry public. Turn on Fox to find out the latest Democratic outrage. Turn to the New York Times editorial page for the latest Republican outrage. Neither outlet need confuse its audience by cross-pollinating its outrage with context. Both sides reinforce the divide, and, in preaching to the choir and building the team spirit and the sense of victimization, they both clear the way for more deception.
(MORE: Checking Romney's Claim That Obama Wants to 'Gut Welfare Reform')
The Huffington Post's Jon Ward got to the heart of this Wednesday when he retweeted a Washington Post report that gave four Pinocchios to the Romney welfare ad and three Pinocchios to the Obama pushback on the welfare ad. (The Romney ad falsely claimed that Obama supported waiving welfare's work requirement; the pushback falsely claimed that Romney has supported the same sort of waiver as governor of Massachusetts.) "Sums up the race," Ward wrote succinctly.
All of this creates a huge problem for the nonpartisan, less ideological core of the fourth estate. We journalists, after all, are supposed to be champions of facts, accuracy and truth. But audiences have left nonpartisan outlets for the comfort of organizations, like Fox News and the New York Times editorial page, that focus on one side of the outrage story. I can already imagine all the angry readers of this blog who will write in the comments to protest that by claiming "everybody does it" I have given a pass to Romney or Obama, who is really the true villain of the political sphere. For those Obama supporters who think their guy would never stoop as low as Romney did with the welfare ad, I recommend reading this, about Obama's false abortion ad. And for those Romney supporters who believe that Obama is the true liar, I would ask them to consider that Romney claimed Wednesday in his stump that Obama "removed the requirement of work from welfare," a seven-word phrase that is false no matter how much you bend the facts of the waiver Obama approved.
But just saying the world is rotten and full of lies is no solution either. On Wednesday, the news side of the New York Times had a good story on Obama's view of the press, which focused on an oft repeated complaint that is hard to avoid in the West Wing. "Privately and publicly, Mr. Obama has articulated what he sees as two overarching problems," the Times reported, "coverage that focuses on political winners and losers rather than substance; and a 'false balance,' in which two opposing sides are given equal weight regardless of the facts." For Obama, it matters that Republicans have shown far less ideological flexibility than he has in recent deficit negotiations, and he feels wronged by the degree to which the unequal willingness to compromise on policy matters is reported by the press as an equal failure to reach agreement. He has a strong point, even if it is an ironic one coming from a President who has appreciated a need for relativism in other contexts.
(PHOTOS: The Obama Presidency in Pictures)
Is there a similar dynamic when it comes to telling the truth in a political campaign? At times, and in specific categories of deceit, one campaign is more mendacious than the other. But it is difficult to make quantitative generalizations, given the nuance in the twisting of facts that takes place every day. Just look at the mess that is the current fact-checking industry. Is "pants on fire" the same as lie? Are four Pinocchios worse than three? How much? Given that fact checking often requires subjective calls, even the independent fact checkers sometimes disagree.
Perhaps the better approach to this whole problem would be to change the currency — to remove the emotional highs and lows of outrage and refocus our umbrage on the home team, not the other guy. Let us just assume the following: Both politicians in the current race employ political professionals who are paid to use the most effective tactics in their business, often with little regard to ethical abstractions like fairness and honesty. This does not mean that neither candidate has a moral core. It only means that the behavior of his campaign is a poor gauge of his core and that both men, as presidential aspirants, have made peace with the idea that stretching the truth is a basic requirement of the game at this level.
Now, this does not mean that the fibbing is acceptable. But if we remove the outrage, or at least minimize it, then maybe we can focus not just on the deceptions of the guy we don't like but also on the deception of the guy we like. For in the end, there is only one thing that will force these candidates, their campaigns and supporters to hue a straighter line: Their own constituencies must object. Obama supporters must say there is a cost if Obama misrepresents Romney's abortion policy to scare women. Romney supporters must say it is wrong for Romney to misrepresent Obama's welfare policy to scare white men. There must be a cost for these politicians, and the only way there will be a cost is if the emotional level of partisanship decreases and facts gain on outrage as the basic building block of discourse. In a partisan and divided country that has niche information streams, the judgment must come from a campaign's own supporters to be effective.
This is not going to happen anytime soon. But it is good to remember that the misrepresentations of Romney and Obama are a reflection of what the voting public allows. In a competitive democracy, politicians move on a dime. If the voters stopped feeling so wronged and outraged about the other party and its candidate, they would allow fewer transgressions by their own party. If they stopped succumbing to the pleasures of outrage, they might find a way to have less to be outraged about.
(VIDEO: Governor Mitt Romney Talks to TIME)


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Career & Work Counsellor Alumni Bursary
Scholarships and Bursaries
Career & Work Counsellor Alumni Bursary
Awarded to domestic full-time students enrolled in any year at any campus.
Applying is Easy
Registered students with an active timetable are able to apply for all bursaries that are administered by the college though our single on-line bursary application.
By completing this application, you will be considered for all college-administered bursaries and scholarships for which you are eligible. To apply, log into myCampus (the student portal), and go to the Student Centre section. The Apply Now! button will open the on-line application as long as you have a valid SIN on file. If you do not have a valid SIN on file, you are required to provide proof of SIN (any government issued document with your name and SIN) and government issued photo-id at the Registrar's Office so your record may be updated. Please note that bursary applications will not be evaluated until after the application deadline date.
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Unweighted, per 1 million enrollees. Error bars indicate 95% CIs. The blue portions of the y-axes indicate 0 to 20 000 in the first graph and $0 to $2 million in the second graph.
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Liu H, Waxman DA, Main R, Mattke S. Utilization of Anesthesia Services During Outpatient Endoscopies and Colonoscopies and Associated Spending in 2003-2009. JAMA. 2012;307(11):1178–1184. doi:10.1001/jama.2012.270
© 2023
Author Affiliations: RAND Corporation, Boston, Massachusetts (Drs Liu and Mattke); RAND Corporation, Pittsburgh, Pennsylvania (Ms Main); and RAND Corporation, Santa Monica, California (Dr Waxman).
Context The frequency with which anesthesiologists or nurse anesthetists provide sedation for gastrointestinal endoscopies, especially for low-risk patients, is poorly understood and controversial.
Objective To quantify temporal comparisons and regional variation in the use of and payment for gastroenterology anesthesia services.
Design, Setting, and Patients A retrospective analysis of claims data for a 5% representative sample of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients between 2003 and 2009.
Main Outcome Measures Total number of upper gastrointestinal endoscopies and colonoscopies, proportion of gastroenterology procedures with associated anesthesia claims, payments for gastroenterology anesthesia services, and proportion of services and spending for gastroenterology anesthesia delivered to low-risk patients (American Society of Anesthesiologists physical status class 1 or 2).
Results The number of gastroenterology procedures per million enrollees remained largely unchanged in Medicare patients (mean, 136 718 procedures), but increased more than 50% in commercially insured patients (from 33 599 in 2003 to 50 816 in 2009). In both populations, the proportion of procedures using anesthesia services increased from approximately 14% in 2003 to more than 30% in 2009, and more than two-thirds of anesthesia services were delivered to low-risk patients. There was substantial regional variation in the proportion of procedures using anesthesia services in both populations (ranging from 13% in the West to 59% in the Northeast). Payments for gastroenterology anesthesia services doubled in Medicare patients and quadrupled in commercially insured patients.
Conclusions Between 2003 and 2009, utilization of anesthesia services during gastroenterology procedures increased substantially. Anesthesia services are predominantly used in low-risk patients and show considerable regional variation.
The continuous increase in spending on medical care has triggered a debate concerning which services and procedures provide adequate value and which do not, and therefore represent potential areas to reduce cost.1 The use of anesthesiologists, nurse anesthetists, or both during gastrointestinal endoscopies has been identified as one such potential area.2 Under current payment guidelines for gastrointestinal endoscopies, if intravenous sedation is needed, the endoscopist has to administer it with support of a nurse, and the sedation component is included in the professional fee. Involvement of an anesthesiologist or nurse anesthetist, which implies an additional payment, is only justified for procedures performed on high-risk patients.3-5
Recent data from a large insurer in the United States, however, suggest that the proportion of colonoscopy and upper gastroenterology procedures with anesthesia service was 24% in 2007 and is projected to increase to 53% by 2015.6 Given the high volume of gastrointestinal endoscopies, the additional payment for anesthesia services can be substantial. For example, Cohen and Benson7 estimated that total payment would amount to as much as $8 billion per year if anesthesia services were used for all 20 million endoscopic procedures. It is unknown at this point what drives the increase in anesthesia use during endoscopies and to what degree the increase reflects potentially discretionary spending, which may present an opportunity to reduce cost.
We analyzed insurance claims data for Medicare fee-for-service and a large commercially insured sample between 2003 and 2009 to examine temporal comparisons in the use of gastroenterology procedures, the proportion of those procedures assisted by a separate anesthesiologist or nurse anesthetist, and the payments for gastroenterology anesthesia services. In addition, we evaluated regional variation in gastroenterology anesthesia use and estimated the potentially discretionary proportion of gastroenterology anesthesia, defined as services delivered to low-risk patients (American Society of Anesthesiologists [ASA] physical status class 1 or 2).
We conducted a retrospective analysis of insurance claims data for Medicare and commercially insured patients for the years between 2003 and 2009. We used the Medicare Limited Data set, a nationally representative 5% sample, to represent the beneficiaries in the fee-for-service program, and the Thomson Reuters MarketScan data set, which includes claims from approximately 150 commercial health plans serving larger companies, to represent nearly 40 million commercially insured individuals. The MarketScan data contain approximately 20% of the population that is covered by employer-sponsored insurance. MarketScan national weights were constructed based on the Medical Expenditures Panel Survey, and these weights can be used to generate national estimates.8 The study was approved by the RAND institutional review board.
Our study sample consisted of all patients who received outpatient upper gastrointestinal endoscopies and colonoscopies as identified based on Current Procedural Terminology, edition 4 (CPT-4) codes (upper gastrointestinal endoscopy: codes 43234-43259; colonoscopy: codes 45378-45392, G0105, G0120, and G0121). We excluded patients younger than 18 years because of the different decision criteria for anesthesia use, and patients for whom we did not have complete claims data for the 6 months before the respective endoscopy.
Our outcomes of interest were (1) the number of upper endoscopies and colonoscopies, (2) the proportion of gastroenterology procedures that used anesthesia services, (3) the average and aggregate payment for gastroenterology anesthesia services, and (4) the proportion of anesthesia services and payments provided to low-risk patients, defined as ASA physical status class 1 or 2. Because the sample size varied over time, unweighted number of procedures or aggregate payment is presented as rates per million enrollees to describe temporal comparisons. The number of procedures or aggregate payment in any given year was divided by the number of enrollees in the sample for that year, including those without a gastroenterology procedure. Outcomes were evaluated by calendar year and by geographic region. We used the consumer price index to adjust all US dollar figures to 2009 dollars.9
Anesthesia services were identified using 2 anesthesia CPT-4 codes (code 00740 for anesthesia service associated with upper gastrointestinal endoscopies and code 00810 for colonoscopy-associated anesthesia service). Gastroenterology procedures were linked to anesthesia service records, using unique patient identifiers and dates of service.
To mirror current coverage policies, we approximated patient need for anesthesia services during endoscopy based on the ASA physical status classification.3-5 We labeled patients with an ASA physical status level 3 (severe systemic disease) or higher as having a clinical indication for anesthesia coverage during gastroenterology procedures; conversely, in low-risk patients with ASA physical status levels 1 and 2, the anesthesia service use was considered to be potentially discretionary.
In 14.1% of the commercial anesthesia service claims (unweighted n = 277 203), ASA physical status classification was coded explicitly on the insurance claims with a physical status modifier. For the remaining commercially insured and Medicare patients, we developed a statistical model to predict ASA physical status level of 3 or higher, because we could not identify an existing approach to determine anesthesia risk based on claims data.
Using the subset of procedures with coded ASA physical status levels, we constructed a multivariate logistic model to estimate a patient's probability of having an ASA physical status level of 3 or higher at the time of a given procedure as a function of age, sex, comorbid medical conditions, and presence of an inpatient admission during the 3 months before the procedure. We forced cardiopulmonary conditions into the model that are important contributors to anesthesia risk (cardiac arrest, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, asthma, and cystic fibrosis). Then, we used a backward stepwise selection method (with P ≤ .10) to identify additional conditions that were significant predictors of ASA physical status level, based on major disease categories defined by Clinical Classification Software developed by the US Agency for Healthcare Research and Quality.10
The following additional conditions were selected by the stepwise regression—cerebrovascular disease, hypertension, peripheral artery diseases, anemia, gastrointestinal bleeding, inflammatory bowel disease, hepatobiliary disease, pancreatic disease, diabetes, dementia, human immunodeficiency virus, renal failure, cancer, and psychiatric disorder. In addition, we classified all patients with a diagnosis of sleep apnea in the prior 6 months as having an ASA physical status level of 3 or higher, because sleep apnea is an important risk factor for respiratory compromise during sedation and regarded as requiring anesthesia supervision.11 All comorbid conditions were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes on claims within the 6 months before each procedure.
We used the estimated coefficients from the regression model to predict the probability of having an ASA physical status level of 3 or higher for patients without a coded ASA physical status level. The probability predictions of all patients without a coded ASA physical status level were summed to generate the expected number of patients with an ASA physical status level of 3 or higher. We then rank-ordered these patients by their predicted probability and assigned an ASA physical status level of 3 or higher to this expected number of patients with the highest predicted probabilities.
The payment estimates for anesthesia services include both insurer payments to anesthesiologists or nurse anesthetists and co-payments or deductibles from patients, which correspond with the allowed charge variable in the Medicare claims data and the payment variable in the MarketScan data. In patients who underwent more than 1 upper gastrointestinal endoscopy or colonoscopy in the same quarter (Medicare) or on the same date (MarketScan), we could not assign anesthesia use unambiguously to 1 procedure. Thus, calculations of average payment per procedure and the proportion of anesthesia use among low-risk patients were based on patients with only 1 upper gastrointestinal procedure or 1 colonoscopy in a specific quarter (Medicare) or on a specific date (MarketScan), which accounted for 33.4% (2009) to 44.3% (2003) of all procedures in the Medicare sample and 85.1% (2009) to 92.0% (2003) in the commercially insured sample.
A significance level α = .05 was used throughout the analysis. Comparison of means was performed using t tests or regressions. The significance of the relationship between categorical variables (eg, age group) and dichotomous outcomes (presence or absence of anesthesia service) was tested using χ2 tests or logistic regressions. Confidence intervals of potentially discretionary use and payments were estimated using the bootstrap method with 50 replications. The results in the main text are unweighted; estimates weighted to the national level are shown in eTable 1, eTable 2, eTable 3, eFigure 1, and eFigure 2. Unweighted statistics on the commercially insured sample with anesthesia service use and recorded ASA physical status level are shown
in eTable 4 and eTable 5.
In our 2 samples, a total of 6.6 million unique patients (Medicare fee-for-service sample, 1.1 million; and commercially insured sample, 5.5 million) had either an upper gastrointestinal endoscopy or a colonoscopy as outpatients during the period between 2003 and 2009 (Table 1). Overall, 26.6% of Medicare patients and 28.6% of commercially insured patients received anesthesia services. No substantial difference exists in age, sex, and number of chronic conditions between patients with and without anesthesia services.
A total of 2.2 million gastroenterology procedures were performed on Medicare beneficiaries and 7.0 million gastroenterology procedures were performed on commercially insured patients between 2003 and 2009. Although the number of gastroenterology procedures per million enrollees per year remained largely unchanged in Medicare patients, with a mean of 136 718, the number of gastroenterology procedures per million enrollees per year increased more than 50% in commercially insured patients, from 33 599 in 2003 to 50 816 in 2009 (Table 2). The proportion of procedures using anesthesia services increased at a similar rate for commercially insured patients (13.6% to 35.5%) and Medicare patients (13.5% to 30.2%).
The proportion of procedures with anesthesia services varied substantially by geographic region (Table 2). Patterns were similar for Medicare and commercially insured patients, with the lowest use in the West region (Medicare sample, 14.0%; and commercially insured sample, 12.6% in 2009) and the highest use in the Northeast region (47.5% and 59.0% in 2009, respectively).
Overall, the proportion of anesthesia services delivered to low-risk (predicted ASA physical status level of 1 or 2) patients was more than two-thirds in the Medicare population, and more than three-quarters among the commercially insured population (Table 2). This proportion decreased over time from 78.6% (95% CI, 77.9%-79.2%) in 2003 to 64.1% (95% CI, 63.2%-64.6%) in 2009 in the Medicare fee-for-service population, whereas it remained constant in the commercially insured patients (86.5%; 95% CI, 85.8%-86.9% in 2003 and 83.9%; 95% CI, 83.7%-84.0% in 2009).
Annual payments for anesthesia services among Medicare patients almost doubled in real terms, from $2.2 million in 2003 to $4.2 million in 2009 per 1 million enrollees (Table 3). Annual payments per 1 million commercially insured patients increased more than 4-fold from 2003 ($1.9 million) to 2009 ($8.4 million). The cost per procedure payment for anesthesia services remained stable in real terms for Medicare patients ($147.20 in 2003 and $150.20 in 2009) and increased by 13.6% for commercially insured patients ($447.10 in 2003 and $508.70 in 2009).
The number of procedures with anesthesia services for low-risk patients increased substantially in the Medicare population during the study period (Figure 1). For this group, the number of procedures per 1 million enrollees increased from 13 989 (95% CI, 13 867-14 098) in 2003 to 25 069 (95% CI, 24 721-25 265) in 2009. Annual payments per 1 million enrollees for such potentially discretionary anesthesia services increased by approximately 8% per year (from $1.69 [95% CI, $1.67-$1.71] million in 2003 to $2.65 [95% CI, $2.63-$2.68] million in 2009).
The increase in the number of procedures with anesthesia services for low-risk patients was more pronounced in commercially insured patients (Figure 2), from 3938 (95% CI, 3908-3957) to 15 108 (95% CI, 15 077-15 143) per 1 million enrollees. The associated payments per 1 million enrollees increased more than 4-fold during the study period (from $1.69 [95% CI, $1.68-$1.70] million to $7.05 [95% CI, $7.04-$7.06] million).
Weighted to the national level, annual spending on gastroenterology anesthesia services is estimated to have more than tripled during the period between 2003 and 2009, increasing from $0.4 billion in 2003 to $1.3 billion in 2009 (eTable 3). The estimated utilization of gastroenterology anesthesia services provided to low-risk patients reached 3.1 million procedures in 2009 (eFigure 1), with 1.2 million procedures for Medicare patients and 1.9 million procedures for commercially insured patients. The estimated associated spending (eFigure 2) amounted to $1.1 billion in 2009 (Medicare sample, $129.0 million; and commercially insured sample, $944.9 million).
Our study represents the first attempt to our knowledge to quantify spending on outpatient gastroenterology associated anesthesia service use on a national level based on nationally representative samples, including both Medicare fee-for-service and commercially insured patients. We demonstrated that the number of gastroenterology procedures per 1 million enrollees increased by more than 50% in commercially insured patients but remained essentially unchanged in Medicare patients during the study period. The proportion of gastroenterology procedures using anesthesia services doubled in both populations, from approximately 14% in 2003 to more than 30% in 2009. We found substantial regional variation in gastroenterology anesthesia use and most of that use was for low-risk patients. Both findings suggest that a substantial share of the spending for gastroenterology anesthesia may be considered potentially discretionary.
The increase in spending was attributable mainly to increased use; the inflation-adjusted cost per procedure payment for gastroenterology anesthesia service remained largely unchanged for Medicare and showed only a slight increase for commercial insurance. Our estimates are similar in magnitude to those derived by others from smaller samples. Cohen12 reported an increase in the proportion of gastrointestinal endoscopies with anesthesia services from 22% in 2003 to 38% in 2006 based on the Medicare claims data for fee-for-service patients. Inadomi et al6 described trends in anesthesia service use for a single insurance carrier and found that 9% of procedures in 2003 but 25% in 2009 used anesthesiologists or nurse anesthetists.
Our study is the first to our knowledge to stratify anesthesia use during gastrointestinal endoscopies by predicted ASA physical status classification, and to quantify the payments associated with use among low-risk patients. Our results suggest that the majority of gastroenterology-related anesthesia services are provided to low-risk patients and can be considered potentially discretionary based on current payment policies. Supporting the hypothesis of potentially discretionary use, we observed substantial regional variation in anesthesia service use, with a nearly 4-fold difference in use between the lowest-use and highest-use regions. This variation is unlikely to be fully explained by regional differences in patient risk. A similar pattern has previously been reported in smaller studies.6 Similarly, Aisenberg et al13 showed that use of anesthesia services for colonoscopies was more common in areas in which insurer payment policies were favorable, indicating that payment policies rather than clinical need drives decision making about anesthesia use.
This increased use of anesthesia services has been partly attributed to the adoption of propofol, which by virtue of a short half-life and rapid onset of action is thought to be more convenient and to offer a more consistent level of sedation than regimens previously used, but in the United States "should be administered only by persons trained in the administration of general anesthesia."14,15 Insurers' payment policies and marketing by the anesthesiology community have also been cited as drivers of increased use.13
Our data estimate that use of anesthesia services for low-risk patients during gastrointestinal endoscopies may have increased steadily to more than $1.1 billion per year at the national level. Because anesthesia use is projected to increase further, addressing such potentially discretionary use represents a sizeable target for cost savings. This is particularly true because the number of colonoscopies is likely to increase in the coming years. Recent studies have shown that more than 50% of privately insured and more than 60% of publicly insured adults aged 50 to 65 years have never had a screening colonoscopy, despite current guidelines recommending the procedure.16 In addition, the passage of the Patient Protection and Affordable Care Act of 2010 will provide coverage to an estimated 32 million individuals. The Affordable Care Act has specific provisions for coverage of preventive services recommended by the US Preventive Services Task Force, including screening colonoscopies.17
The use of anesthesia service may be valuable to the low-risk patients who prefer deep sedation or general anesthesia during a gastroenterology procedure due to psychological reasons. However, prior literature has demonstrated that in low-risk patients, sedation administered by nonanesthesiologists is safe or offers patient satisfaction comparable with sedation administered by an anesthesiologist or nurse anesthetist.14,18 In fact, the only published randomized clinical trial on the topic shows that endoscopist-administered sedation during colonoscopies results in higher patient satisfaction and fewer adverse effects than anesthetist-administered sedation.19
Our study has several limitations. Most importantly, we base our determination of anesthesia use for low-risk patients on a statistical model, because ASA physical status level coding was present for only a small proportion of the patients in our sample. However, prior estimates of the proportion of low-risk patients among those receiving gastrointestinal endoscopies have been higher than our estimate. For example, according to the Clinical and Outcome Research Initiative data,20 a large national gastroenterology procedure registry, 12% of its population had an ASA physical status level of 3 or higher. Thus, it seems likely that we have overestimated patient risk and thus underestimated the proportion of patients who are at low risk. We also emphasize that we cannot determine actual clinical need for anesthesia service in individual patients, but our goal was to estimate the rate of anesthesia services among low-risk patients in a large sample. In addition, our analysis did not include procedures performed in inpatient settings, or among patients younger than 18 years, enrolled in Medicare managed care, eligible for Medicaid but not Medicare, or who paid out of pocket; therefore, our estimates cannot be readily generalized to these populations. Our calculation, based on 2009 data, showed that approximately 17% of the adult population was not captured in our analysis.21-26
Between 2003 and 2009, the number of gastroenterology procedures and utilization of anesthesia services increased considerably. Substantial regional variation and the fact that most anesthesia was provided for low-risk patients suggest that much of the spending can be considered potentially discretionary. Realizing such opportunities continues to be a pressing requirement, because the nation's health care costs are projected to reach more than 17% of the gross domestic product in 2011.27 As both colonoscopy rates and use of anesthesia during gastrointestinal endoscopies are projected to increase in the coming years, the overall cost of colonoscopy screening programs will be closely scrutinized by payers and policy makers.
Corresponding Author: Soeren Mattke, MD, DSc, RAND Corporation, 20 Park Plaza, Ste 920, Boston, MA 02116 (firstname.lastname@example.com).
Author Contributions: Drs Liu and Mattke had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Liu, Waxman, Mattke.
Acquisition of data: Liu, Waxman, Main.
Analysis and interpretation of data: Liu, Waxman, Main, Mattke.
Drafting of the manuscript: Liu, Waxman, Mattke.
Critical revision of the manuscript for important intellectual content: Liu, Waxman, Main, Mattke.
Statistical analysis: Liu, Waxman, Main.
Obtained funding: Liu, Mattke.
Study supervision: Mattke.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This study was financially supported by Ethicon Endo-Surgery Inc, Cincinnati, Ohio.
Role of the Sponsor: Ethicon Endo-Surgery Inc had no role in the design and conduct of the study or in the collection, analysis, and interpretation of the data. A draft manuscript was reviewed by Ethicon Endo-Surgery Inc, but the study authors made final decisions regarding the content and study conclusions.
Online-Only Material: The Author Video Interview is available here.
Additional Contributions: We thank Ethicon Endo-Surgery Inc (Cincinnati, Ohio) for the financial support of the research. Sydne Newberry, PhD (RAND Corporation), provided help with the preparation of the manuscript. Dr Newberry did not receive any compensation for her contribution apart from her salary as a RAND Corporation employee.


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We will explore the role of religions in politics and social relations in East and South, South East Asia and China in particular, and will analyze the origins, central teachings, divisions and branches, rituals and practices, influences on culture, and responses to modern challenges for each tradition. The emphasis throughout the course is on the hermeneutic difficulties attendant upon the study of religion in general, and Asian religions in particular. We will explore new Asian religions as dynamic, ongoing forces in the lives of individuals and in the collective experience of modern societies.
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