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Media Relations
Press Release:
Lisa Metcalf
561-297-3022, email@example.com
FAU to Test Emergency Alert System
BOCA RATON, Fla. (September 24, 2013) – Florida Atlantic University is scheduled to test all components of the FAU Alert system the afternoon of Thursday, Sept. 26. The FAU Alert system is designed to play a key role in keeping FAU's students, faculty, staff and campus visitors safe during emergency situations.
At approximately 1:50 p.m., the emergency siren and PA system will be activated on FAU's Boca Raton campus, 777 Glades Road, as well as at FAU's John D. MacArthur campus, 5353 Parkside Drive in Jupiter, and at FAU's Harbor Branch Oceanographic Institute in Fort Pierce. During this test, a loud siren sound and a spoken message will be heard across campus, as well as in neighborhoods and business areas located near the campuses. The indoor notification system for Glades Park and Heritage Park towers at FAU's Boca Raton campus will also be tested.
Additionally, FAU's university-wide email, telephone alert, web alert and text messaging will be tested that afternoon. FAU will also test its toll-free emergency hotline phone number – 1-888-8FAU-OWL (8328-695).
-FAU-Florida Atlantic University, established in 1961, officially opened its doors in 1964 as the fifth public university in Florida. Today, the University, with an annual economic impact of $6.3 billion, serves more than 30,000 undergraduate and graduate students at sites throughout its six-county service region in southeast Florida. FAU's world-class teaching and research faculty serves students through 10 colleges: the Dorothy F. Schmidt College of Arts and Letters, the College of Business, the College for Design and Social Inquiry, the College of Education, the College of Engineering and Computer Science, the Graduate College, the Harriet L. Wilkes Honors College, the Charles E. Schmidt College of Medicine, the Christine E. Lynn College of Nursing and the Charles E. Schmidt College of Science. FAU is ranked as a High Research Activity institution by the Carnegie Foundation for the Advancement of Teaching. The University is placing special focus on the rapid development of three signature themes – marine and coastal issues, biotechnology and contemporary societal challenges – which provide opportunities for faculty and students to build upon FAU's existing strengths in research and scholarship. For more information, visit www.fau.edu.


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Bobbi Brown Hydrating Gel Cream
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Bobbi Brown
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This refreshing and lightweight water-based emulsion provides a burst of moisture, leaving skin refreshed, healthy and rejuvenated - and perfectly prepared for a seamless makeup application.
1.7 oz. / 50 ml
A champion of the natural look, makeup artist Bobbi Brown has earned a devoted worldwide following by inspiring women to look and feel their best. Founded in 1991, Bobbi Brown Cosmetics skincare line creates a moisturized canvas for the application of its universally flattering face, eye, and cheek makeup collections. Formulated in timeless hues and skin tone-flattering shades, the brand's best-selling foundation sticks, shimmer bricks, long-wear eye shadows, and blushes are designed to enhance a woman's natural beauty.
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Serves 3 |
Prep Time 15 minutes |
Cook Time 15 minutes
Sandwich Ingredients
2 tsp Eden Extra Virgin Olive Oil
8 ounces organic five grain tempehor any variety of tempeh
1/2 cup water
2 to 3 tsp Eden Shoyu Soy Sauce
1 tsp Eden Brown Mustardor Eden Yellow Mustard
3 slices whole grain bread
3 whole romaine lettuce leavesor any leaf lettuce
3 slices organic tomatoes, sliced about 1/2" thick
Homemade Mayonnaise
1/4 cup Edensoy Unsweetened
1/4 cup Eden Extra Virgin Olive Oil
1/4 cup Eden Safflower Oil
1 Tbsp Eden Apple Cider Vinegar
1/4 tsp Eden Yellow Mustard
2 1/4 tsp organic apple juice concentrate
1/2 tsp Eden Sea Salt
2 to 3 drops prepared hot sauce, optional
1/8 tsp freshly ground black pepper
Heat the oil in a cast iron or heavy medium skillet. Place the tempeh in the skillet and fry until golden. Flip over and fry the other side until golden. Add the water and shoyu. Cover and bring to a boil. Reduce the flame to medium-low, and simmer for 10 to 15 minutes or until all water has evaporated, flipping the tempeh from time to time. Turn the flame to high the last few seconds, cook off any remaining liquid and brown each side of the tempeh. Remove and allow to cool.
While the tempeh is cooling, prepare the mayonnaise. Place the Edensoy in a blender, set on high speed, and press blend. Combine the oils and slowly (several drops at a time) add the oil to the Edensoy until all oil is blended and the mixture becomes very thick and creamy. This will take several minutes. When thick add all remaining ingredients, and blend several seconds until well blended. Remove and place in a serving container.
When the tempeh is cool enough to handle, cut into 1/4 inch thick slices or strips. Place 1 lettuce leaf on top of each piece of bread. Place the tempeh on top. Spread mayonnaise over the tempeh. Place a tomato slice on top. Serve whole or cut the sandwich in half before serving.
American, Condiments, Edensoy, Fruit, Good/High Fiber, Good/High Protein, Japanese Food, Macrobiotic, Main Course, Oils, Vegan, Vinegars, Whole Grain


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Trevor A. Macpherson, MD
Dr. Macpherson is a member of the Division of Gynecologic Pathology, the Vice Chair of Pathology Education,
the Director of the Residency and Fellowship Program, and the Chief Medical Officer of the Quest Joint Venture.
Professor of Pathology
Office Location:
Scaife Hall, Suite A711
3550 Terrace Street
Pittsburgh, PA 15261
Contact Information:
Office Telephone: 412-802-6013
Fax: 412-802-6079
E-Mail: email@example.com
- MB, ChB - University of Cape Town, 1970
- MS Adm. Med. - University of Wisconsin, 1997
Clinical ExpertisePerinatal pathology including placental, fetal, newborn and embryo pathology
Research InterestsPerinatal pathology and placental pathology
- Diplomat, American Board of Pathology - Anatomic Pathology
- Fellow, Royal College of Obstetricians and Gynecologists - London
Selected PublicationsView Dr. Macpherson's publications on PubMed
- Abdulkadir AA, Tobita K, Bell MJ, Macpherson TA, Keller BB, Yanowitz TB: Placental Inflammation and fetal Hemodynamics in a Rat Model of Chorioamnionitis. Pediatric Research 68 (6):513-518, 2010.
- Picarsic J, Raval JS, Macpherson T: United States Medical Licensing Examination Step 1 Two Digit Score - A Correlation With the American board of Pathology First-Time Test taker Pass/Fail rate at the University of Pittsburgh Medical Center. Arch Pathol Lab Med 135:1349-1352, 2011
- Cajaiba M, Witchel S, Madan-Khetarpal S, Hoover L, Macpherson T, Surti U: Prenatal Diagnosis of trisomy 6 rescue Resulting in Paternal UPD6 with Novel Placental Findings. American Journal Medical Genetics (In Press)


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HOME Philadelphia Eagles Gear Philadelphia Eagles Mens Philadelphia Eagles Mens Mens Philadelphia Eagles Mens Mens Shorts & Pants (48 items) Product ID: 1638420
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Celebrate your Philadelphia Eagles fandom with these Speed Vent performance shorts! These shorts come in team colors and feature a printed Philadelphia Eagles graphic on the front of the left leg. Two ventilated panels on the back legs along with ON Field technology make these Nike shorts the perfect way to stay cool and comfortable while boasting your Philadelphia Eagles pride.
- Material: 100% Polyester
- Hydra Void fabric is water-resistant to help block out the elements by shedding water to keep you dry and comfortable
- Size XL inseam measures approximately 10"
- Two front pockets
- Vent holes at lower back legs and inseam
- Machine wash
- Officially licensed
- Imported
- Brand: Nike
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French Fragrance
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Fragrance Oils in the Floral Scents of Fine French Perfumes
- Floral scented oils are ideal for a variety of uses
- Expertly blended from the finest ingredients
- Choice of Gardenia, Jasmine, Vanilla, Tea Rose, Freesia or Lilac
These wonderful scented oils are ideal to use in diffusers or to refresh potpourri and sachets. Add a few drops to homemade soaps and moisturizers — anywhere you want to enjoy their intoxicating and evocative floral scents. To use on the skin, make a 5% solution of these oils with an unscented carrier oil or moisturizer.
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- Fragrance oils and essential oils
- 1/3 fluid ounce
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Welcome to The University of Texas at Brownsville Counselor and Advisor Web site. It is an important part of our mission to prepare our students as much as possible before they begin their post-secondary educational endeavors. This website is designed to assist you with answering any questions or concerns our future students at UTB might have for you. We hope this will be as seamless a transition for you as well as our future Scorpions. You may contact any of our Admissions staff at (956) 882-8860 at anytime.
Update: All first-year students are required to take First Year Seminar. Transfer students with less than 30 credit hours will be required to take the course. Dual enrollment students who are now UTB students are required to take the course.
We are committed to supporting the important work you do as guidance counsleors, career and technology counselors, transfer counselors and outreach program staff. As our partners, your efforts play a critical role in helping prepare students with admissions, financial aid, scholarships and much more. We hope you find the information on this site valuable and useful.
Applications are accepted on a continuous basis, but all applications, including re-admission, submitted after the priority deadline will be assessed a non-refundable late fee of $15. All documents submitted become property of UTB.
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Fax: (956) 882-7810
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Katz's Deli
Complimentary Pickles
Dr. Brown's Black Cherry
Now for the main event!
Since i'm eating cheap in NYC I may as well add this to the list :)
Katz is classic and undeniably deli greatness.
Can't believe you've never been to Langer's! I recommend a visit pronto!
Great post and pix! I did the Katz's/Langer's challenge last year, and found Langer's comes out on top, both for pastrami and bread (which is pretty much a throw-away at Katz's). Pickles are far better at Katz's though.
Yaaaaay Katz's!
Yep, I DEFINITELY need to plan a trip to Langer's soon since a trip to NYC is not in my immediate future. Thanks for the craving, KFP!
My ONLY question was going to be how does it compare to Langer's?!
never been to katz's, but langer's is deeeeeelectable.
I haven't eaten at Katz yet but just looking on the photo one big difference between Langers and Katz seems to be the quality of bread. Langers is excellent for the pastrami sandwich but Katz looks pretty mediocre.
I've had Langer's pastrami before and it is fantastic! So I can't wait until next month when I can finally try Katz's.
Catty: You definitely should. I'm going again myself in Feb!
Gil: I agree with you 100%!
Darin: I know, I'm slacking. I need a good comparison between the two pastrami giants.
sku: That's good to know, so I wouldn't have to drag back pastrami from Katz's on my next trip.
Misty: :-)
Diana: I think I need to join you on your trip to Langer's...
Weezermonkey: I wish I could answer that question for you as well :P
Amy: Good to know we have a good one here locally. It's too bad they close so damn early!
Two Foodies - One Journey: The bread I agree was pretty meh at Katz's so I'm looking forward to Langer's version.
Remil: So you can compare it for me then!
Me + U + DTAB = Trip to Langer's ASAP. When you free, panda?
Based on my one experience at both places, I like Langer's better. More tender, fattier!
katz's has the better pastrami. langer's has the better sandwich. both are ridiculously overpriced.
Cathy: Let's do it! In March.....
Fiona: Good to know, maybe I don't need to drag a few pounds of pastrami back from NYC this time.
Dustin: Haha, it's definitely not cheap! LOL
The pastrami looks delicious, but then, how can you go wrong?


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A new study says wild blueberries have the potential to improve heart health.
In their study, researchers from Germany's University of Dusseldorf, the United Kingdom's University of Reading and University of Northumbria concluded that wild blueberries may help blood vessels function better and remain healthier, thus relieving pressure on the heart.
Wild blueberries are native to North America and grow naturally in Maine and eastern Canada, the only places that grow them for commercial sale. Maine's annual harvest averages around 86 million pounds a year.
The research study was published last month in the American Journal of Clinical Nutrition.
New research shows wild blueberries help heart
A new study says wild blueberries have the potential to improve heart health.
Copyright 2013 by WCVB.com All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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I have been wondering if, or when, the Wemstroms would respond to the criticism they would of received concerning the article that was published Jan. 6 where they made fun of (in an off-handed way,) those who have served, and died,to protect our values, and way of life. They can quote poets or poetry, indicate that they have written articles in favor of more government funds for veterans till they are blue in the face, but it is still what it is, a cynical disrespect for those who (for better or worse) felt the need, or felt they had no choice, but to go to war. One notices that they(the Wemstroms') haven't shown any contrition, nor are they making any excuses, for they think none is warranted. They have, however, blessed us with their reasoning; their smug attitude is that they are the smart ones, and the rest of us just don't understand. "God Bless All of Our Vets" May We Never Forget! — Richard Rowland, Polo
Location, ST | website.com


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One of the most heartbreaking stories of this year's college-football season – the September death from leukemia of Notre Dame star Manti Te'o's girlfriend – has turned out to be a hoax.
The woman, whom Te'o says he met only online, never in real life, did not exist, the website Deadspin reports.
She was invented by unknown perpetrators, and fooled Te'o along with everyone else, the 21-year-old linebacker claims.
"This is incredibly embarrassing to talk about, but over an extended period of time, I developed an emotional relationship with a woman I met online," Te'o said in a statement Wednesday. "We maintained what I thought to be an authentic relationship by communicating frequently online and on the phone, and I grew to care deeply about her."
He added: "To realize that I was the victim of what was apparently someone's sick joke and constant lies was, and is, painful and humiliating."
The woman, whom Te'o knew as Lennay Kekua, was widely reported last year to have whispered "I love you" to Te'o over the phone just before she died. Compounding the heartbreak for Te'o, his grandmother died the same week.
Notre Dame says Te'o approached the school later in the year after realizing he'd been fooled.
"On Dec. 26, Notre Dame coaches were informed by Manti Te'o and his parents that Manti had been the victim of what appears to be a hoax," the university said in a statement Wednesday. "Someone using the fictitious name Lennay Kekua apparently ingratiated herself with Manti and then conspired with others to lead him to believe she had tragically died of leukemia."
The university said it launched an investigation, which is ongoing.
Deadspin and others have questioned how Te'o could have been deceived for so long, and speculated that he might have been involved in the hoax, perhaps to boost his chances of winning the Heisman Trophy. (That prize went to Texas A&M's Johnny Manziel in December.)
But Notre Dame is backing the player.
"While we still don't know all of the dimensions of this … there are certain things that I feel confident we do know," Notre Dame athletic director Jack Swarbrick said at a press conference. "The first is that this was a very elaborate, very sophisticated hoax, perpetrated for reasons we don't understand."
Wiping away tears, Swarbrick said of Te'o: "The thing I am most sad of is, the single most trusting human being I have ever met will never be able to trust in the same way ever again."
Notre Dame Football Star Manti Te'o's Girlfriend Was a Hoax
Michael Conroy/AP


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Quadruple Helices Appear To Have Role...
Wall Street Decline Takes Its Toll...
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LC-MS Gains Favor Due To the...
Scientists have uncovered a molecular interaction between two cell types that plays a key role in wound healing and could lead to new therapeutic approaches to speeding the repair of chronic wounds. γδ T cells are dendritic epidermal T cells (DETCs) that provide a first line of defense against tissue damage.
The cells normally extend multiple dendritic projections that contact neighboring keratinocytes and monitor for signs of damage or disease, and express a specific T cell receptor that recognizes antigens expressed by keratinocytes as a result of trauma.
Once damage has been detected, the DETCs retract their dendrites, become more rounded in shape, and both DETCs and keratinocytes proliferate and migrate to the site of damage as part of the wound-healing cascade. What hasn't been determined with any clarity, however, is the pathway of molecular interactions beyond T-cell receptor signaling that regulates the DETC response to keratinocyte damage.
Using antibodies that block the ability of keratinocytes to activate γδ T cells in vitro, investigators at the Scripps Research Institute working with colleagues at Osaka University in Japan have now found that a keratinocyte surface receptor, plexin B2, binds to the CD100 receptor on T cells.
"Plexin B2 is very similar to other plexin B family members, including plexin B1, which previously has been shown to bind the CD100 receptor on T cells," explains Scripps researcher Deborah A. Witherden, Ph.D., who is lead author on the team's paper published in Immunity. "So we thought that perhaps plexin B2 and CD100 can interact as well."
The team then went on to demonstrate that B2-CD100 interaction does indeed appear to play a key role in wound healing. Injured keratinocytes in mice with small skin wounds upregulate expression of plexin B2 soon after the wound occurs, while wounds in mice lacking CD100 on their γδ T cells take longer than normal to heal. "This is very similar to what we see in mice that lack γδ T cells altogether," Dr. Witherden continues. Notably, deleting CD100 from other types of T cells didn't affect wound-healing time, suggesting that it is lack of the molecule specifically on γδ T cells that impacts on healing.
In another set of experiments, the team showed that stimulating CD100 with plexin B2 or with a CD100-binding antibody triggered the dendrite-retracting and shape-changing phenomenon observed in γδ T cells in response to a wound. Subsequent work by the Scripps researchers has also shown that plexin B2-CD100 interaction is needed to activate γδ T cells in the mouse intestinal epithelium, indicating that the same signaling mechanism may be involved in repairing epithelial damage generally, and not just in the skin.
"This is a major activation pathway for γδ T cells, and it may be a key to treating slow-wound-healing conditions, such as we see in diabetes," states Scripps Research professor Wendy L. Havran, senior author of the paper. "If deficiencies in this γδ T cell activation pathway are even partly responsible, then we may be able to develop drugs to boost this pathway and treat conditions involving chronic, nonhealing wounds."
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Closed Captioned
A seasoned instructor of linear perspective, Connors shares a brief overview of the significance and history of perspective in art, then leads you through a series of drawing exercises designed to strengthen your perceptual skills and explore compositional strategies. You'll see how these strategies have been employed by other artists and learn how to make your own compositional tools. Using a model landscape, you'll refine your ability to visualize a scene then explore atmospheric perspective by building up a sketch with tonal masses.
Patrick introduces himself, discusses pictorial depth and introduces you to masterpiece works of art that use perspective.
Get the most out of your drawing tools -- sketchbooks, pencils, erasers and more -- and how to store your artwork.
Learn the perceptions and misperceptions of achieving space and depth using line, tone and detail.
Learn to make and use a tool for analyzing space -- the Albertian veil.
Draw a landscape while using a cone of vision, a plumb line, a measure stick and other helpful tools.
Consider the relative space and orientation between objects in your landscape.
Learn how light, midtone and shadow can be used to achieve atmospheric perspective.
"One of my biggest problems in drawing has been perspective. This is one of the best classes on perspective I have taken. Patrick is a wonderful teacher, his explanations and tools have given me a new understanding of perspective and space and I cant wait to try some new drawings with this information. Thanks for such an informative class! And in helping me look at things in a new way!"
- michelle214
snellville, ga


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Filed under:8
Anyone else notice that after
Anyone else notice that after they finished playing what they did of American Idiot, the Bassist started to play Welcome to Paradise. Good on Metallica for doing that.
Haha Metallica makes Green
Haha Metallica makes Green Day sound super poppy. Is this some inkling that Billie is suffering from alcoholism? I couldn't help but think of Alcoholica when he was talking about him. Then again addiction is pretty standard so it doesn't matter exactly what the addiction is.
East Bay Thrashers...I used
East Bay Thrashers...I used to watch Green Day and Neurosis play gigs together--obviously Metallica are connecting the two in tradition.
My Dream! Cry for you, cry
My Dream! Cry for you, cry for you song, cry too much...!! :')
It's great to see Metallica
It's great to see Metallica supporting Green Day!
I wouldn't call it exactly a
I wouldn't call it exactly a cover, more a tribute. I don't have a problem at all with how Metallica handled this - they should be given much credit for being so supportive. I just don't think it should be labeled as a cover, that's all.
I think that every Green Day
I think that every Green Day fan will be grateful for this. And also Green Day members, obviously.
Grandes Metallica, muy
Grandes Metallica, muy grandes...!


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Fall is a time of transition, and with those transitions come a variety of options for outdoor enthusiasts. Hunting becomes foremost for many folks as the early seasons for doves and Canada geese are already underway, and the popular archery deer season is now less than a week away.
As tempting as all those hunting prospects can be, however, many of us aren't ready to put away our fishing tackle just yet either because the cooler days of autumn bring with them some great fishing opportunities as well.
Bass tend to go on feeding sprees during the early weeks of fall, probably to put on some extra weight before winter sets in, and that situation applies to both river smallmouths as well as lake-dwelling largemouths. But trout fishing generally gets the biggest boost with the approach of autumn. Trout, of course, are cold-water fish and therefore respond favorably to the cooler water temperatures that occur during the fall.
In the fall, the best trout fishing will be found on streams that harbor ample populations of wild trout or stocked streams that maintain good numbers of holdover fish. Here in our region, we are blessed with many such trout waters. In addition to those resources, the Pennsylvania Fish and Boat Commission will also stock selected streams and lakes to provide additional fall fishing opportunities.
In our area, the Delayed Harvest sections of the Little Juniata River near Bellwood, Chest Creek near Patton and Black Moshannon Creek in Centre County along with Canoe Creek Lake are scheduled to be stocked on Oct. 1. Duman Lake and Lake Rowena in Cambria County will be stocked on Oct. 3, and Poe Lake in Centre County will be stocked on Oct. 5. Check the Pennsylvania Fish and Boat Commission website, www.fishandboat.com, for a complete listing of fall stockings scheduled throughout the state.
As good as fall trout fishing can be, it also presents a special set of challenges. Right now, most of the streams in our area are low and clear, and unless we receive a major rain event in the next couple of weeks, those conditions are likely to persist, making the trout extra spooky in general.
Also keep in mind that all those fish have spent the spring and summer becoming educated at evading anglers and their offerings, so treat them with an extra measure of respect and stealth.
On smaller streams, stay out of the water as much as possible. On larger streams, wade carefully and slowly to create minimal disturbance. Scaring away your quarry before you have the chance to make your first cast will guarantee failure.
Fly-fishermen enjoy a variety of insect hatches that can produce excellent dry-fly fishing during the fall. Many streams will see several species of caddisflies emerging over the next couple of months.
Look for this activity primarily in mid-morning or late afternoon, but unlike during the spring, hatching times can vary widely during the fall.
To be prepared for fall caddis, I like to carry a range of caddis patterns in cream, tan and brown in sizes 12 through 16. And even when no bugs are hatching, a high-floating caddis imitation will often work well just by fishing the water.
Slate drakes are another great fall hatch on streams that harbor these large gray mayflies, such as the Little Juniata River.
Unlike many species of mayflies that emerge on the water's surface in midstream, slate drake nymphs migrate to shallow water and crawl out onto rocks, logs or other stream side objects to hatch.
Therefore, a hatch of slate drakes often doesn't produce great numbers of rising fish compared to other mayflies. Trout will key on the large dark-colored slate drake nymphs, however, as they swim to the shallows to hatch.
When faced with this situation, fishing a slate drake nymph imitation downstream and allowing it to swing toward shore can draw some vicious strikes.
Remember that the extended trout season in now in effect, so the daily limit of trout is reduced from five to three.
The extended season applies only to Approved Trout Waters and some special regulation areas, so no trout may be killed on wild trout streams. For complete information about specific regulations on various waterways, consult the Pennsylvania Fishing Summary booklet.


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Top Definition
(n) 1. A person having vast knowledge in Fine Arts, Cooking, and Pimpology; (n) 2. Someone being completely opposite of a chauncey; 3. A badass motha(SHUT YO MOUF!)
Brockman can pull any girl you dream of, Dave.
автор: xllx_NeO_xllx 17 октября 2006
Trending Now
Can you define these popular missing words?
A person who has sex with their mother. Will also have sex with their Dad in a pinch.
John is pulling a brockman tonight, don't worry about bringing an extra chic.
автор: Rusty Shackleforde 28 сентября 2006


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The Stetson men's basketball team (5-10, 2-2) defeated Jacksonville (7-10, 2-2) by a score of 81-72 on Monday night to even its Atlantic Sun Conference record to 2-2. Junior Chris Perez and senior Adam Pegg combined for 45 points to lead the Hatters in the victory.
"It's nice to play well enough in the first 30 minutes that you give yourself a cushion, and you can be not your best for the last 10 and still win a game by nine points," Stetson head coach Casey Alexander said after the win. "[I'm] pleased with the win, obviously. [It's] great to bounce back after a tough one Saturday."
Stetson opened the game with a pair of layups from junior Hunter Miller and Perez, eventually taking an early 11-5 lead over the Dolphins just over five minutes into the contest. Jacksonville scored the next four points to get within two, at 11-9, but six straight points that included a pair of jump hooks from Pegg extended the Hatters' lead to eight, at 19-11, with 10:54 to play in the period.
Seven straight from the Dolphins, which concluded with five points from Javon Dawson, gave Jacksonville its first tie of the game since the opening tip, evening the score at 23-23 with 7:40 to play in the half.
After a conventional three-point play by Miller stopped the bleeding, JU used a 6-2 run to take its first and only lead of the game, at 29-28. The Hatters countered with a 10-2 stretch to end the frame to take a 42-34 advantage into the break. Perez scored five points and freshman Leke Solanke came up with two blocks during the run.
"I'm so proud of Chris, not necessarily because he continues to give us great production, but because he's doing it within the framework of what we want to do," Alexander said. "He's finding his way to do what he does best within the framework of how we want to play, and that's what good players do. And that's how good teams are built."
The Hatters scored six out of the first eight points of the second half to extend their lead to 13 points, as senior Liam McInerney's fall away jumper put Stetson up 49-36 less than three and a half minutes into the period.
Less than five minutes later Stetson used an 8-2 run, bookended by three-pointers from juniors Willie Green and Aaron Graham, to take its largest lead of the game at 61-45 with 10:49 to play.
The advantage wasn't as comfortable as the Hatters would have liked, as Jacksonville used its pressure defense to force a few Stetson turnovers, and come within six points. Free throws by Pegg and Perez put the game away though, as Stetson came away with the 81-72 victory.
"It gave us a ton of problems at the end," Alexander said of Jacksonville's pressure. "There was nothing different about what they were doing. We just lost our edge a little bit. Once you let your guard down at all against a team like that, or become a little more casual, or a little more timid, or a little bit more unsure, then the result is some real scary play."
Stetson finished with 12 turnovers, eight of which came in the second half, but a season high of 24 assists gave the Hatters a healthy 2-to-1 assist-to-turnover ratio. It marked the fourth time this season of recording 20 or more helpers in a game for the team that leads the conference in the category.
Perez totaled a season-high 23 points, one off of his career best, to lead the Hatters in the victory. Pegg added 22 points, reaching double figures for the 10th straight contest, on 10-of-19 shooting from the floor. He added seven rebounds in the win.
"Nineteen shots for Adam is the best part of the night," Alexander said of his center's performance. "That means he wants the ball, and that means we're getting it to him, and that's the first part of our offense every time we line up to play a game. Adam demanded the ball, and delivered."
Green gave Stetson three players in double figures, scoring 11 points. The junior forward made his mark on the boards though, grabbing a career best of 11 to record the second double-double of his career. More importantly, six of them came on the offensive side of the ball, which was also a career high.
"[Willie] gave us a huge lift," Alexander said of Green's rebounding. "Our offense is a hard one to really be a great offensive rebounder, because if you're playing the one-through-four spot then you're outside the three-point line most of the time when the shot goes up, so it takes a real effort. Everyone who watched the game saw a guy who wanted to be involved."
Stetson, now 5-10 on the season and even at 2-2 in conference play, will next head back on the road to play at ETSU on Thursday, Jan. 10. The Hatters will then take on USC Upstate in Spartanburg, S.C. on Saturday, Jan. 12 before returning home the next weekend.


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A New Taste for Old World Sauvignon Blanc
SAUVIGNON BLANC—that razor-sharp, refreshing white wine with its lively aromatics and uplifting acidity—is one of the most popular grape varieties in the world. Ask any wine retailer which white they sell the most of and it is odds on the reply will be Sauvignon. I know of one major U.K. merchant that sells more than 10 million bottles a year; another retailer told me that if he could construct a pipe from New Zealand to Europe that carried only Sauvignon Blanc, he would save a fortune in shipping.
From the cooler spots in South Africa, to the northern tip of New Zealand's South Island, to the slopes of Bordeaux and the Loire Valley, this scintillating wine has been cultivated to much success. But what do we really know about its true character?
Where it is produced in the New World—by which I mean New Zealand, South Africa, California and South America—it has a pugnacious kick. One sniff reveals a jumble of flighty aromas jostling for the attention of our olfactory receptors. Gooseberry, sweet herbs, fennel and freshly sliced green pepper bounce off a base of mouth-puckering, thirst-quenching acidity.
In the Old World—in France's Loire Valley and Bordeaux, where it is often blended with Sémillon—it has a more delicate character. Crisp and racy, the wine retains that appealing acidity, but the aromas are more restrained, with notes of grapefruit and white flowers. I like to think of these wines as diametrically opposed to their New World counterparts, with all the power coming on the palate after the first sip has been swallowed.
In France, they seldom label their wines Sauvignon Blanc. Instead, they expect the consumer to know the handful of villages where it is grown. I suspect that, rather like the Chardonnay lover who doesn't drink Chablis (even though it is made of Chardonnay), the majority of those 10 million consumers who buy well-known international brands of Sauvignon like Oyster Bay and Blossom Hill have no idea that wine labeled with the villages of Sancerre, Pouilly-Fumé and Quincy is also made from Sauvignon Blanc.
But while many are happy drinking the New World expression (and why not? it is often exquisite), those wanting to explore wines with a little more delicacy and complexity should look no further than the vineyards of Sancerre and Pouilly-Fumé.
It has been four years since the region lost one of its most respected winemakers. Didier Dagueneau was just 52 when, in 2008, his microlight plane crashed in the Dordogne. Dagueneau, whose aim was to make the best Sauvignon Blanc in the world, did more for showcasing the potential quality of the Loire's Sauvignon than perhaps any other. A disciple of Burgundy's Henri Jayer, his wines displayed a pinpointed purity and taut freshness.
'Ask any wine retailer which white they sell the most of and it's odds on the reply will be Sauvignon.'
"He learned alone and was very meticulous and precise," Charlotte Dagueneau says of her father. "He could have made quantity but he chose quality. He traveled to Burgundy to see what they were doing and when he came back, he said we have the same thing as Burgundy." Ms. Dagueneau now runs the estate with her brother Louis-Benjamin.
All of their wines have their own distinct charm: an attractive purity and minerality. "We are just respecting nature and soils," says Ms. Dagueneau. "We don't use any chemicals. We harvest by hand, take care of the grapes, work slowly and age the wine in oak barrels. It is just common sense. "
Silex is their standout wine, with layers of complexity and flavor simply not found elsewhere. As well as a dry, gunflint taste on the palate, the marriage of a creamy texture with a ferocious attack is sensational. On a first sip, I wrote: clean, purity, energy and zing. The greatest Sauvignon Blanc in the world? Perhaps. I have seldom tasted better.
—Email Will at email@example.com or follow him on Twitter: @Will_Lyons


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Store more items and always find what you're looking for with the Frigidaire FFHT1513PS top-freezer refrigerator . This 14.8 cu. ft. refrigerator features the Store-More™ organizational system to keep food and beverages within easy reach, from gallon door storage to adjustable door bins and a stacked drawer. Adjustable wire shelves can be moved up and down to accommodate tall containers. The full-width freezer rack helps keep frozen items neat and organized. The stainless-steel Frigidaire FFHT1513P top-freezer refrigerator makes refrigerator control simple. Ready-Select controls let you set and adjust the temperature with the touch of a button. A humidity-controlled crisper keeps produce fresh and tasty. And no matter how your kitchen is configured, the reversible door can be installed to open left or right for easier access.
- The Store-More organizational system includes gallon door, stacked drawer and adjustable door bins to keep food organized and easy to find when you need it
- Door storage gives you room for larger items—like a gallon of milk
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- Store-More humidity-controlled crisper drawers keep your fruits and vegetables fresh
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"Do I need to use kosher salt?"
More and more I see recipes specifying kosher(ing) salt or sea salt in recipes. I'm all for using gourmet ingredients but Serious Eats even proposes using sea salt to preserve Meyer lemons! Does there remain any use for which the much more affordable regular American-style iodized salt is preferred, or should I just use what I have left and only stock the higher-end stuff?
—Sent by Anonymous
First of all, let's get one thing straight: chemically there is virtually no difference between table salt, kosher salt, and fancy sea salt. All of them are close to 100 percent pure NaCl (sodium chloride), with a few trace elements thrown in. In the case of table salt, those additives are there to prevent it from caking (hence the old, "When it rains, it pours," Morton's slogan), while for sea salt, they come along for the ride when the salt is harvested from the ocean.
Dissolve those salts in water side by side, and the differences between them become nearly indistinguishable, just as they are when you use them to season your food.
There are, however a few key differences that will affect how you use them.
Relative Bulk Density of Salts
First off is bulk density, or the amount of mass within a given volume of a granular solid. Regular table salt is comprised of many minute, regularly-shaped cubes. This allows them to pack together tightly in a given space. Kosher salt, on the other hand, forms large, craggy flakes that don't fit together very well. Put them into a container, and you also end up with plenty of air space. What does this mean for cooking? It means that if you are measuring by volume, different types of salt are not interchangeable. A cup of table salt will have twice the salting power of a cup of Diamond Crystal Kosher salt.
Here are the relative densities of a few common types of salt you'll find:
- Table Salt: small-grained cubes. 10 ounces/280 grams per cup.
- Morton's Kosher Salt: small flakes. 8 ounces/225 grams per cup.
- Diamond Crystal Kosher Salt: wide flakes. 5 ounces/140 grams per cup.
- Maldon Sea Salt: Large, flaky pyramids. 4 ounces/115 grams per cup.
- Fleur de Sel: Large crystals. 8 ounces/225 grams per cup
Thus if a recipe calls for Diamond Crystal Kosher (as most of our recipes do) and all you've got is table salt on hand, you'll have to halve the amount by volume to get similar end results.
All salt is technically kosher. "Kosher salt" is really a misnomer for "koshering salt," as its large grains make it more effective at drawing out liquid from meat during the koshering process. But that's not why chefs like to use it.
The biggest reason why chefs love to use kosher salt is that it is much easier to pick up between your fingers and thus gives you tighter control over your seasoning. Think about this: how many times have you gone to a restaurant, reached for the salt shaker, shook it over your food and realized that almost no salt was coming out? And how about the opposite? How many times have you accidentally over-salted your food trying to use table salt in a shaker?
Even trying to apply table salt by hand is a tricky feat. Its small grains stick to your fingers and clump together, making it hard to get a feel for exactly how much you've deposited on your food. Kosher salt, on the other hand, has larger, coarser grains that are easy to feel and easy to sprinkle, making it much easier to gauge the proper level of seasoning.
Distributing seasoning evenly is also easier with kosher salt. Try this quick experiment: grab a sheet of black paper and a bowl of kosher salt and table salt. Spread a thin layer of glue on the paper (either a glue stick or spray-glue will work) to get the salt to stick as soon as it hits the surface (as it would on, say, a piece of meat). Now lift up some table salt between your fingers and sprinkle it on the paper, doing your best to cover a 2- by 2-inch square area evenly. Repeat with the kosher salt. Which one distributed more evenly?
Yep, I thought so.
When is Table Salt Ok?
All that said, there are occasions when it's totally fine to use table salt. So long as your salt is going to be dissolved and distributed evenly into the final dish—as with a soup, stew, or braise—there's no reason to use kosher salt other than the convenience of not having to buy two separate types of salt. Just remember, check your recipes and make sure to compensate for table salt's density when adding it.
There is one occasion when table salt actually has a small leg up over kosher salt: when you need to dissolve it quickly in a liquid. When making a high salinity solution (such as a brine), table salt will dissolve a little faster than kosher salt due to the smaller size of its crystals. Incidentally, did you know that maximum solubility of salt in water is pretty much the same no matter how hot or cold your liquid? Wowza!
When Should I Use Fancy-Pants Sea Salt?
In all honesty, you don't have to ever use the stuff. Then again, you don't have to, say, watch Ghostbusters. Neither are essential to survival, but both make life more worth living.
Fancy salts are harvested from oceans and salty rivers and lakes around the world. Depending on exactly how they are formed and the trace minerals the contain, their shape can range from moist, clumpy chunks to pyramid-like, lacy flakes with colors ranging from bright pink to pitch black.
While the color is largely cosmetic, shape can have an effect on their eating qualities. Chefs like using them because they add crunchy texture and a burst of salinity that adds interest to plated foods. It should be used exclusively for finishing dishes. Scattering on the tops of glazed loaves of bread before baking. Sprinkling over sliced perfectly cooked steak just before serving. Adding a touch of crunch to slivers of raw scallops. You get the picture. Fancy-pants food.
If you're using your fancy sea salt to cook with, on the other hand, you may as well replace your toilet paper with dollar bills, because you are flushing all of its good features down the toilet.
As for the question of relative cost, I did a quick online search and found that kosher salt prices are on average about 20 percent greater than table salt prices when you buy both in bulk. Hardly a bank breaker, especially when you consider first that whether you buy regular salt or kosher salt, in any given dish you are likely to be using mere fractions of a penny's worth. For me, the convenience and familiarity of having one type of cooking salt is worth that slight extra cost.
Many table salts have had trace amounts of iodine added to them. This practice was started in the 1920's in order to help battle goiter, a problem that was rampant in the American North from the Great Lakes to the Pacific Northwest. These days, goiter has been all but eliminated in our population due to iodized salt, though it still appears in parts of the world where iodine deficiencies are common.
Do you need to use iodized salt to stay healthy? Chances are, probably not. Fish and seaweed are the best sources of iodine, but most vegetables contain iodine, as does dairy.
As long as you are eating a varied diet that includes plenty of vegetables and/or fish, you'll get the iodine you need even if you use only kosher salt.
As for the flavor, it's mostly undetectable in table salt, though some folks who are particularly sensitive to it might notice it in more mildly-flavored dishes.
What Do I Recommend?
At home I have a salt cellar that is filled with Diamond Crystal kosher salt. I keep it by the stove when cooking and transfer it to the dining room table during dinner. I also keep a small supply of various coarse sea salts of different textures and sizes which I use to finish dishes. The two I most commonly use are Maldon sea salt from England (I love its lacy pyramids), and Fleur de Sel from Guerande (nice large crunchy crystals that will stay undissolved on sliced meat until you bite into it). I don't keep table salt at home.
Got a Question for The Food Lab?
Email your questions to firstname.lastname@example.com, and please include your Serious Eats user name in your email. All questions will be read, though unfortunately not all can be answered.
About the author: J. Kenji Lopez-Alt is the Chief Creative Officer of Serious Eats where he likes to explore the science of home cooking in his weekly column The Food Lab. You can follow him at @thefoodlab on Twitter, or at The Food Lab on Facebook.


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Buttermilk, Pecans, Biscuits, Okra, Peaches. Those are just a few of the titles in, or coming up in, the University of North Carolina Press Savor the South cookbook collection.
Its a great time to be a food lover in the American South, says Elaine Maisner, the UNC Press senior executive editor who commissioned the series. Drawing on the regions triple treasure of farming, cooking and writing, I came up with the idea.
The books in the Savor the South collection are single-subject, 50-recipe cookbooks. At present, a dozen have been commissioned from well-known cooks and food lovers, says Maisner, and they intend to include about 24 volumes.
UNC Press also recently released a 20th-anniversary edition of John Martin Taylors Hoppin Johns Lowcountry Cooking, and Fred Thompsons Southern Sides in addition to Buttermilk and Pecans.
Buttermilk, written by Raleigh author Debbie Moose, hits the market just as fresh, whole creamery buttermilk is making a resurgence. Moose advises on grocery store substitutes and offers recipes both sweet and savory.
In Pecans, Charlotte Observer Food Editor Kathleen Purvis delivers the history of the nut we Southerners claim as native, laced with stories, and sweet and savory recipes laced with tips.
These books offer resources for ingredients. Future books such as Biscuits include techniques. The Savor the South collection is going to provide a Southern pantry library for cooks. (UNC Press, $18 each.)
UNC Press has a long history of publishing books about Southern food and foodways; however, Southern cookbooks are coming from all the major publishing houses in 2012 or 2013. From Charleston authors alone, Mastering the Art of Southern Cooking by Nathalie Dupree (November 2012) will be followed by Charleston cookbooks by the Lee Brothers (spring 2013), chef Sean Brock (fall 2013) and Callies Biscuits (fall 2013).
Rebecca Lang, author of Around the Southern Table, explains it this way:
The food of the South is so hot because we have a relationship with our food like no other part of the country. The trend was really starting to grow about two years ago, as witnessed by the explosion of chefs, restaurants, magazine and newspaper coverage. Authors realized this and responded to it with cookbooks, but it takes about two years from conception to get a book published, so thats why you see them coming in such large numbers now.
Three notables
The essence of Langs book, Around the Southern Table, is its message of Southern hospitality: Come on in and pull up a chair.
The South, writes Lang, stands apart, where there is always room for another plate, another chair, another friend at the table. Subtitled Coming Home to Comfortable Meals and Treasured Memories, the books charming photography beckons the reader to join Lang and her family at her grandmothers antique oak table to enjoy dishes sometimes generations in the making. There are Southern stand-bys such as biscuits, grits and pound cake, and Langs updates. Biscuit dough is layered with country ham and cheddar cheese in a loaf pan to be Biscuit Bread. Egg whites and real Parmesan cheese turn creamy grits into a souffle. Pound Cake From Heaven is used to make French toast. Hungry? Grab a plate. Oxmoor House. $29.95.
While Rebecca Lang has four cookbooks under her belt, Fred Thompson has 10, including the subjects of iced tea, barbecue, bourbon and crab. His latest, Fred Thompsons Southern Sides is encyclopedic.
What really defines Southern cooking, writes Thompson, is the fabulous juxtaposition of tastes from down-home to urban, is the mouthwatering sides balanced against the fried chicken, barbecue, and ribs. Thompson offers 250 recipes ranging from starters to sauces, Scuppernong-Glazed Carrots to Special Dirty Rice. With the longest growing season other than California, Southern states provide a plethora of choices for a table laden with fruits and vegetables. Dig in. UNC Press. $35.
Although New Orleans has its own and very definite accent in the language that is Southern cuisine, Allison Vines-Rushing and Slade Rushing have a unique riff.
In Southern Comfort Food, they lay out a new take on the recipes that they grew up with in Mississippi and Louisiana. Hushpuppies with caviar, pimiento cheese croquettes, cabbage and dried fig salad with garlic vinaigrette, sweet tea-roasted duck in date sauce. Worth talking about. Ten Speed Press. $35.
Recipes Country Ham-and-Cheese Biscuit Bread
Imagine a biscuit already loaded with gooey cheese and salty country ham, and you get this all-in-one bread. Layering the dough in a loaf pan lets you get all that Southern goodness in every bite. Rebecca Lang, Around the Southern Table
6 ounces country ham
1 tablespoon unsalted butter
4 ounces cheddar cheese
31/2 cups self-rising soft-wheat flour (such as White Lily), divided
1/2 cup unsalted butter, cut into 1/2-inch cubes
1 cup buttermilk
1 tablespoon unsalted butter, melted
Preheat oven to 400 degrees. Cut ham into 1/2-inch pieces. Melt 1 tablespoon butter in a large skillet over medium heat. Add ham; saute 4 minutes or until lightly browned. Transfer ham to a small bowl; chill. Grate cheese on the large holes of a box grater, and chill.
Pulse 3 cups flour and 1/2 cup cubed butter in a food processor 8 times, using the metal blade. Add buttermilk; process until a dough forms.
Transfer dough to a well-floured surface. Use floured hands to knead in remaining 1/2 cup flour; knead until dough is smooth and elastic (about 2 minutes). Divide dough in half. Roll each half into a (16x4-inch) rectangle. Cut each rectangle in half crosswise. (You should have 4 rectangles about the size of your loaf pan.)
Place 1 dough rectangle in an ungreased 81/2x41/2-inch loaf pan, patting dough to edges of pan. Top with one-third of ham, pressing very lightly to adhere. Sprinkle with one-third of cheese. Repeat layers two more times, patting each dough layer to edges of pan. Top with remaining portion of dough. Brush with 1 tablespoon melted butter.
Bake at 400 degrees for 35 to 40 minutes or until golden brown. Cool in pan on a wire rack 25 minutes. Serve warm or at room temperature.
Good Luck Black-Eyes
Serves 4-6
If I didnt eat black-eyed peas on New Years Day, my mother would have a pure hissy fit. Its been a tradition for as long as I can remember. Hers were a little plainer than this recipe, but I think youll find the additions welcome. Fred Thompson
From Fred Thompsons Southern Sides: 250 Dishes That Really Make the Plate. Used by permission of the University of North Carolina Press.
3 strips bacon
1 small red bell pepper, cut into small dice
1/2 fennel head, small dice
4 carrots, peeled and cut into small dice
2 celery stalks, small dice
1/2 cup diced onions
4 garlic cloves, minced
2 teaspoons red wine vinegar
3 sprigs thyme, tied
2 sage leaves
2 bay leaves
1 pound dried black-eyed peas
6 cups water
Kosher salt and freshly ground black pepper
Heat the bacon in a large saute pan over medium heat. Cook until the bacon is crisp, 5-8 minutes. Remove the bacon, leaving the fat, drain on paper towels, and crumble. Add the peppers, fennel, carrots, celery, onions, and garlic to the pan. Saute until tender, 6-7 minutes. Pour everything from the pan into a slow cooker. Add the vinegar, herbs, peas and water. Cook on low 10-12 hours or until the peas are tender but still retain their shape. Remove the thyme and bay leaves and discard. Season with salt and pepper, garnish with the bacon, and serve hot or at room temperature.


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Author Affiliations: Departments of Surgery (Drs Turrentine, Hanks, and Schirmer) and Public Health Sciences (Dr Stukenborg), University of Virginia, Charlottesville.
Objective To examine the relationship between body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and 30-day mortality risk among patients in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. Obesity is a prevalent chronic disease in the United States, and general and vascular surgeons are caring for an increasing population of obese patients.
Design Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald χ2 test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure.
Setting A total of 183 sites.
Patients Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program.
Results The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to <29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure.
Conclusions Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death.
Quiz Ref IDObesity is the most prevalent chronic disease in the United States.1 Recent reports suggest that the prevalence of obesity among US adults has increased more than 100% since 1990.2 Current estimates indicate that 63.6 million adults (31.4%) in the United States are obese3 and that the prevalence of obesity among Americans is continuing to increase.4 Increases in obesity-related diseases and obesity-related mortality have accompanied this trend.5- 7 Some studies indicate that obesity is associated with a 20-year decrease in average life expectancy.8 This analysis examines the relationship between obesity (as measured by body mass index [BMI; calculated as weight in kilograms divided by height in meters squared]) and surgical mortality.
Quiz Ref IDThe effect of BMI on perioperative mortality risk has been examined in several prior studies. Many studies indicate that there is no statistically significant association between obesity and perioperative mortality. No difference in mortality was reported for obese patients undergoing general surgery9 or a urologic, gynecologic, or thoracic surgical procedure.10 No difference in mortality was reported for obese patients among elective, non–cardiac surgery patients.11 Obesity also was not associated with increased mortality in patients undergoing coronary artery bypass graft surgery,12 elective laparoscopic colorectal surgery,13,14 pancreatic resection,15 pancreaticoduodenectomy,16 or exploratory laparotomy for adenocarcinoma of the endometrium.17 A few selected studies18,19 have also found no difference in mortality between obese and extremely obese patients undergoing a laparoscopic Roux-en-Y gastric bypass procedure, although that has not been the overall experience in the bariatric surgery literature.
Prior studies, however, have found that obese patients undergoing a renal transplant were at significantly higher risk of death at 1 year20 and at 5 years postoperatively.21,22 Significantly higher mortality rates were also demonstrated for obese patients after rectal resection.23
Patients at the extremes of BMI undergoing a coronary artery bypass graft were found to have a higher risk of death than normal-weight patients.24- 26 Underweight patients have also been reported to have an increased risk of perioperative death following major intra-abdominal cancer surgery27 and following percutaneous transluminal coronary angioplasty.28
Although most studies do not show a difference in mortality between obese and nonobese adult surgical patients, these studies have important limitations, including small numbers of patients, predetermined grouping criteria of levels of BMI, and limited length of follow-up. Few studies have made adjustments for the interaction between BMI and mortality or between BMI and type of surgery.
General and vascular surgeons are treating an increasing population of obese patients for non–weight loss procedures. A better understanding of the relationship between perioperative mortality risk and BMI is needed. Our study takes advantage of the information available about BMI and mortality risk in the large population of patients in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data set with broad coverage of standard general surgical procedures.
Quiz Ref IDOur study examines the relationship between BMI and 30-day mortality among patients who underwent a major surgical procedure that was reported in the ACS NSQIP participant use data file for procedures performed in either 2005 or 2006 for patients from 183 sites.29,30 The ACS NSQIP data are abstracted from the medical records at each site according to a protocol implemented using Web-based software. Participating sites submit cases under varying sampling procedures and case inclusion and exclusion criteria. Hospitals with a high volume of procedures reported the first 40 consecutive cases meeting the inclusion and exclusion criteria for 42, 8-day cycles each year. Hospitals with a low volume of surgical patients submit data for all cases, with a minimum of 900 cases annually. Reported patient data are audited and assessed for accuracy and interrater reliability. The ACS NSQIP data do not include identifying information for individual patients or for participating sites. This research was reviewed and approved as exempt human subject research by the University of Virginia institutional review board.
Baseline differences in mortality risk were measured for each patient in the study population using the ACS NSQIP probability of 30-day mortality risk score. The score is calculated using values for more than 30 demographic characteristics, comorbidities, and preoperative laboratory values measured for each patient. Example characteristics include serum albumin level, blood urea nitrogen level, white blood cell count, American Society of Anesthesia class, presence of disseminated cancer, and patient age in years. The mortality prediction models developed in the ACS NSQIP data have been demonstrated to obtain excellent statistical performance.31- 34
A patient's BMI was measured using the following nonmetric conversion formula: BMI = [(weight in pounds/(height in inches)2)] × 703. Patient BMI values are often grouped into categories for convenient interpretation. Standard thresholds of BMI, obtained from analysis of data collected from large populations of generally healthy adults, classify individuals into the following groups: underweight (<18.5), normal (18.5 to <25), overweight (25 to <30), and obese (≥30).35 However, these threshold values are not directly relevant to our population of patients who underwent major surgery because the overall distribution of values is different from that of the general population. Instead of these standard thresholds, our study identified the actual quintiles of the distribution of BMI values in the study population.
The principal operative procedure is identified in the ACS NSQIP by Current Procedural Terminology codes. The principal operative procedure is defined as the most complex procedure performed by the primary operating team. Categories of principal operating procedures were defined by grouping Current Procedural Terminology codes using the Clinical Classifications Software for Services and Procedures, which arranges the codes into 244 clinically coherent, mutually exclusive categories.36
Multivariable logistic regression analysis was used to measure the independent effect of BMI quintile on mortality risk, adjusted for the concurrent effects of differences in procedures performed and for differences in baseline mortality risk associated with the ACS NSQIP mortality risk adjustment score. The statistical significance and magnitude of the relative difference in the adjusted odds of mortality were assessed for each BMI quintile, with the middle quintile serving as the reference point for these comparisons. Odds ratios (ORs) with 95% CIs were calculated for each BMI quintile, with reference to the middle quintile of BMI values. Statistically significant effects (at the P > .05 level) are represented by CIs that exclude 1.0, which is the ratio obtained when the effects of one group are equal to the effects of the reference group. The overall significance of BMI grouped by quintiles and of the other covariates in the model was measured using the Wald χ2 test statistic, which is used to test the null hypothesis that there is no significant difference between groups in the mean estimated probability of death.
The independent effect on mortality risk of the type of procedure was similarly assessed, with adjustments for the concurrent effects of differences in BMI quintile and for differences in baseline mortality risk measured using the ACS NSQIP. The statistical significance and magnitude of the relative difference in the adjusted odds of mortality were assessed for each type of procedure performed, referent to the average mortality risk in the study population. Odds ratios with 95% CIs were calculated for each procedure using the Wald χ2 test statistic.
Multivariable logistic regression analysis was also used to assess the statistical significance of differences in the effect of BMI on mortality by category of principal operating procedure. The original multivariable model was reformulated to include an additional covariate representing the interaction between BMI and each type of principal operating procedure. Assessment of the statistical significance of this interaction covariate provides an empirical test of whether or not there are meaningful differences in the effect of BMI on mortality across different types of principal operating procedures.
The statistical significance of the effect of principal operating procedure was also assessed separately for patients in each quintile of BMI, adjusted for baseline mortality risk using the ACS NSQIP score. Relative differences in the contribution to model explanatory power made by principal operating procedure, compared with that made by baseline mortality risk, were made by comparing the relative magnitudes of the Wald χ2 test statistic obtained across groups of patients in different BMI quintiles.
The ACS NSQIP data file included data for 211 407 cases submitted by 183 sites. Probabilities of mortality were reported for 189 533 cases with general and vascular surgical procedures (reported in 2005 and 2006). There were 3245 patients who died within 30 days of their surgery (1.7%).
Our Figure presents a plot of the exact distribution of BMI values measured for the study population, with percentages represented for patients grouped within 2 BMI units. Quiz Ref IDQuintiles of the distribution of BMI values are plotted at the following thresholds: 23.1, 26.3, 29.7, and 35.3. Thus, one-fifth of the study population had a BMI of less than 23.1. The percentage of patients in the study population included at standard BMI thresholds were as follows: 2.6% underweight (BMI ≤ 18.5), 30.4% overweight (25 ≤ BMI < 30), 38.3% obese (BMI ≥ 30), 17.6% grade 1 obesity (30 ≤ BMI < 35), 9.1% grade 2 obesity (35 ≤ BMI < 40), and 11.6% grade 3 obesity (BMI ≥ 40).
Figure. Distribution of the percentage of the total study population grouped by body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) values within increments of 2 units of BMI. The horizontal axis displays BMI values at the midpoint of each plotted group. The vertical axis plots the percentage of the total study population included by each group. Quintiles of the distribution of BMI values are identified by portions of the distribution separated by dotted lines located at the following thresholds: 23.1, 26.3, 29.7, and 35.3. For example, patients in the first quintile (Q1) of the study population had a BMI of less than 23.1.
Table 1 presents a summary of the frequencies, number of deaths, and the adjusted odds of mortality associated with each BMI quintile, referent to the middle quintile (BMI range, 26.3 to <29.7). The percentages of deaths among patients in the first BMI quintile (2.8%) was over twice that of the percentage of deaths among patients in the fifth BMI quintile (1.0%), which included patients with a BMI of 35.3 or greater. Patients in the first BMI quintile had statistically significant higher odds of death (OR, 1.40 [95% CI, 1.25-1.58]) than did patients in the middle BMI quintile, after adjusting for the concurrent influence of differences in mortality risk and type of surgery. Patients in the BMI quintiles 4 and 5 who were in the obese range had lower odds of death than did patients in the middle BMI quintile, although these differences in mortality were not statistically significant at the P < .05 level. Each of the reported ORs are adjusted for the concurrent effects of differences in baseline mortality risk (ACS NSQIP probability of death) and for differences in the type of principal operating procedure.
Table 2 presents a summary of frequencies, number of deaths, and adjusted odds of mortality associated with type of procedure. Patients who underwent a laparoscopy were selected as the reference population for comparing the relative effect of each of the other procedure types on mortality. These patients had an overall mortality of 2.0%, which was near the average for the total study population. Patients who underwent an exploratory laparotomy had the highest percentage of deaths (13.9%), in comparison with patients in all other categories of principal surgery. The adjusted odds of death for patients who underwent an exploratory laparotomy (OR, 2.17 [95% CI, 1.47-3.21]) were more than twice that of the reference population (patients who underwent an laparoscopy as their principal procedure). Patients who underwent a breast lumpectomy had one of the lowest overall mortality percentages (0.1%). Their odds of death were 97% lower than those of the reference population (OR, 0.03 [95% CI 0.01-0.07]). Each of the reported ORs are adjusted for the concurrent effects of differences in baseline mortality risk (ACS NSQIP probability of death) and for differences in BMI quintile.
Quiz Ref IDA separate multivariable logistic regression model was developed to assess the interaction between BMI and category of principal operative procedure. A statistically significant interaction was identified for several procedures (P < .05), indicating that the effect of BMI on mortality was significantly different for patients who underwent these procedures compared with patients who underwent the reference procedure (laparoscopy). Procedures for which the effect of BMI on mortality risk was significantly different included colostomy, wound debridement, ileostomy, colorectal resection, musculoskeletal system procedures, endarterectomy of head and neck vasculature, upper gastrointestinal procedures, cholecystectomy, hernia repair, and mastectomy. The P values for the statistical significance of each interaction effect are listed in Table 2.
Table 3 presents results from tests of the overall statistical significance of each parameter's association with mortality risk. Results for 2 multivariable logistic regression model formulations are presented. Both models include BMI quintile, type of principal operative procedure, and the ACS NSQIP estimated probability of death as predictors of death occurring within 30 days of surgery. One model includes an additional predictor for the interaction between BMI and category of primary surgery. Each covariate's overall effect was highly statistically significant (P < .001) in both model formulations. The ACS NSQIP estimated probability of death contributed the most to the explanatory power of each model. Both model formulations explained 34% of the total likelihood explainable by a perfect model. Both model formulations also obtained a C statistic of 0.91, which indicates that the models obtained excellent discrimination between survivors and decedents.
Table 4 presents separate tests of the statistical significance of differences in mortality risk by type of procedure, adjusted for baseline mortality risk using the ACS NSQIP score, for subpopulations of patients in each quintile of BMI. Type of principal operating procedure is a statistically significant predictor of mortality risk for patients in each BMI quintile (P < .001), even after adjusting for differences in baseline mortality risk. Interestingly, the relative magnitude of the contribution made by principal operating procedure to the estimated probability of death increases with increases in BMI, compared with the effect of baseline mortality risk. The overall statistical performance of the model is uniform across quintiles of BMI, accounting for between 32% and 35% of the total likelihood explainable by a perfect model. A C statistic of 0.91 was obtained by the model in each quintile of BMI.
Mortality risk stratification by BMI for specific procedures can be helpful in preoperative decision making and patient education. For general surgery, the question remains whether or not obese patients are at significantly higher mortality risk for specific procedures. General surgeons are having increased experience with the obese and severely obese not only in the area of weight reduction procedures and surgery on postbariatric surgery patients, but also in the increasingly obese population. Intuitively, one might consider that head and neck procedures such as thyroidectomy might be associated with less of a risk than laparotomy. Hawn et al37 evaluated the effect of obesity on general surgical procedures. Their study37 was a retrospective analysis of patients undergoing a cholecystectomy, a unilateral mastectomy, or an abdominal colectomy at a university hospital. They divided their groups into normal-weight, overweight, and obese patients, with the obese patients defined as having a BMI of greater than 30. They evaluated more than 1300 patients and demonstrated that obese patients had a significantly longer operating time than did the other 2 groups of patients. The obese patients did not have a longer length of hospital stay or more complications related to surgery compared with the other 2 groups of patients. The overall complication rate was not affected by any of the 3 different case types. This intriguing study37 begs the question of why a more detailed evaluation of the broad scope of cases was not performed by general surgeons. In our study, a higher percentage of surgical patients compared with the general population were obese. However, our surgical population does include obese patients undergoing gastric restrictive procedures.
Our findings are similar to the findings in Reeves et al.25 They studied obesity in patients who underwent coronary artery bypass graft surgery. Their group of patients included 4372 patients and looked at 4 groups of BMI and multiple outcomes, including early death, perioperative myocardial infarctions, renal and neurologic complications, transfusion requirements, duration of ventilation, and duration of intensive care unit and hospital stay. Reeves et al25 found that underweight patients were more likely to die in the hospital than were patients with normal weight. Overweight patients (with a BMI between 25 and 30), obese patients (BMI between 30 and 35), and severely obese patients (BMI > 35) were not at higher risk for adverse outcomes than normal-weight patients. These 3 groups of patients were less likely than normal-weight patients to require transfusions. Reeves et al25 concluded that obesity did not affect the risks of perioperative death or other adverse outcomes compared with normal-weight patients.
Our data are unique in that the analysis of such a large number of patients allowed us to analyze individual procedures done by general surgeons to a level of specificity not previously available. Interestingly, but in agreement with other studies, the combined group of patients with the highest BMI values do not show an increased mortality compared with the reference group. Our data agree with the data in Mullen et al.27 However, analysis of individual types of procedures demonstrates the unique finding that obesity is related to increased mortality. These individual types of procedures include procedures with which the general surgeon should have definite experience: colorectal resection, colostomy formation, cholecystectomy, hernia repair, mastectomy, and wound debridement. With regard to colorectal procedures, our data are not in agreement with the data in the study by Benoist et al23 in that we do find an effect of obesity on mortality. Benoist et al23 found no difference in overall mortality but a difference in complication rates. Finally, our data are not in agreement with the findings of Hawn et al37 in that we did find increased mortality in the ACS NSQIP data for colorectal resections, mastectomy, or cholecystectomy, whereas they did not.
There is increasing evidence and supportive literature that obesity effects the practice of surgery in the United States and worldwide. Reports to date have shown that, at the very least, complication rates and hospital resources have been affected by procedures on obese patients. The ACS NSQIP database allows for the evaluation of a larger number of patients and for the examination of more specific types of procedures, and it shows the previously unreported finding that mortality risk for several standard general surgical procedures is indeed effected by obesity.
These results indicate that BMI is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death. Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds than the risk of death among patients in the middle range for BMI (26.3 to <29.7). Interestingly, almost 40% of the patients in the study population would be classified as obese using standard thresholds for grouping BMI values. Patients with a BMI of 29.7 or greater had lower odds of death compared with patients in the middle range, but these differences were not statistically significant.
Correspondence: George J. Stukenborg, PhD, MA, Division of Patient Outcomes, Policy, and Epidemiologic Research, Department of Public Health Sciences, University of Virginia School of Medicine, Multistory Bldg (West Complex), 3rd Fl, Rm 3181, PO Box 800821, Charlottesville, VA 22908-0821 (firstname.lastname@example.com).
Accepted for Publication: August 16, 2011.
Published Online: November 21, 2011. doi:10.1001/archsurg.2011.310
Author Contributions:Study concept and design: Turrentine, Hanks, Schirmer, and Stukenborg. Acquisition of data: Hanks and Stukenborg. Analysis and interpretation of data: Stukenborg. Drafting of the manuscript: Turrentine and Stukenborg. Critical revision of the manuscript for important intellectual content: Hanks, Schirmer, and Stukenborg. Statistical analysis: Stukenborg. Obtained funding: Hanks. Administrative, technical, and material support: Turrentine and Hanks.
Financial Disclosure: None reported.
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