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The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score.
A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children.
Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata.
The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk.
Acute appendicitis is the most common cause of an acute abdomen requiring surgery, with a lifetime risk of about 7% [1]. Symptoms of appendicitis overlap with a number of other conditions making diagnosis a challenge, particularly at an early stage of presentation [2]. Patients may be suitably triaged into alternative management strategies: reassurance, pursuit of an alternative diagnosis or observation/admission to hospital. If admitted to hospital, appropriate imaging may be required prior to proceeding to an appendectomy [3].
Clinical prediction rules (CPRs) quantify the diagnosis of a target disorder based on findings of key symptoms, signs and available diagnostic tests, thus having an independent diagnostic or prognostic value [4]. They can also extend into clinical decision making if probability estimates are linked to management recommendations, and are subsequently referred to as clinical decision rules. CPRs have the potential to reduce diagnostic error, increase quality and enhance appropriate patient care [4]. In 1986, Alvarado constructed a 10-point clinical scoring system, also known by the acronym MANTRELS, for the diagnosis of acute appendicitis as based on symptoms, signs and diagnostic tests in patients presenting with suspected acute appendicitis (Figure 1) [5].
The Alvarado score enables risk stratification in patients presenting with abdominal pain, linking the probability of appendicitis to recommendations regarding discharge, observation or surgical intervention [5]. Further investigations, such as ultrasound and computed tomography (CT) scanning, are recommended when probability of appendicitis is in the intermediate range [6]. However, the time lag, high costs and variable availability of imaging procedures mean that the Alvarado score may be a valuable diagnostic aid when appendicitis is suspected to be the underlying cause of an acute abdomen, particularly in low-resource countries, where imaging is not an option.
A recent clinical policy document from the American College of Emergency Physicians reviews the value of using clinical findings to guide decision making in acute appendicitis [7]. Under the heading of the Alvarado score, they state that 'combining various signs and symptoms into a scoring system may be more useful in predicting the presence or absence of appendicitis'. Although not a strong recommendation, the Alvarado score is the only scoring system presented in the document.
The Alvarado score was originally designed more than two decades ago as a diagnostic score; however, its performance and appropriateness for routine clinical use is still unclear. The aim of this study was to perform a systematic review and meta-analysis of validation studies that assess the Alvarado score in order to determine its performance (diagnostic accuracy or discrimination at two cut-points commonly used for decision making, and calibration of the score). As studies have suggested that the accuracy of the Alvarado is affected by gender and age [8-12], we focused our analysis on three separate groups of patients: men, women and children.
Data sources and search strategy
An electronic search was performed on PubMed (January 1986 to 4 April 2011), EMBASE (January 1986 to 4 April 2011), Cochrane library, MEDION and DARE databases. The search strategy is presented as a flow diagram in Figure 2. A combination of keywords and MeSH terms were used; 'appendicitis' OR 'alvarado' OR, 'Mantrels', was used in combination with 26 specific terms for CPRs, including 'risk score', 'decision rule', 'predictive value', 'diagnostic score', and 'diagnostic rule' [13]. A citation search of included articles was undertaken using Google Scholar. The references of included studies were also hand searched for relevant papers. Authors of recent papers (2001 onwards) were contacted when included studies did not report sufficient data to enable inclusion. No language restrictions were placed on the searches.
Figure 2. Flow diagram for the selection of studies for inclusion in the meta-analysis.
Study selection
To be included in this study, participants had to be recruited from an emergency department or a surgical ward and present with symptoms suggestive of acute appendicitis, including abdominal pain, rebound tenderness, nausea, vomiting or elevated temperature. Each included study assessed the performance of the Alvarado score in comparison with the histological examination of the appendix following surgery (reference standard). For those who did not undergo appendectomy and histological examination, outpatient follow-up or no repeat presentation were used as alternative outcome measures. To be included, studies had to report results in a manner that allowed data to be extracted for either the diagnostic test accuracy analysis of the Alvarado score at specific cut points or the calibration analysis. Studies that focused on pregnant patients were excluded.
Two reviewers (RO and FO'R) completed the review process. The inclusion criteria were defined a priori. They reviewed titles and abstracts independently and after discussion decided which articles should be reviewed in full. Full text articles were reviewed independently by the same reviewers and any disagreements were resolved by discussion.
Quality assessment, data extraction and statistical analysis
Quality assessment of included papers was assessed using QUADAS (quality assessment of studies of diagnostic accuracy included in systematic reviews) and the risk of bias table in Review Manager 5 software from the Cochrane collaboration [14,15]. A summary of the quality of included papers is presented in Figure 3. Quality assessment was performed independently by two investigators (RO an FO'R) and any disagreements were resolved by discussion with a third investigator (KO'B).
Figure 3. Summary of quality assessment of included studies.
Diagnostic accuracy of the Alvarado score
For the diagnostic accuracy (discrimination performance) of the Alvarado score, data were extracted and 2 × 2 tables constructed for use of the score as a criterion for admission (score 1 to 4 versus score 5 to 10, Figure 1) and as a criterion for surgery (score 7 to 10 versus score 1 to 6, Figure 1). Data extraction was carried out independently by two reviewers (RO and FO'R) and the data compared. A bivariate random-effects model was used to compute summary diagnostic sensitivity and specificity which allowed for heterogeneity beyond chance as a result of clinical and methodological differences between the studies to be taken into account. Heterogeneity was assessed using the variance of logit transformed sensitivity and specificity, where smaller values indicate less heterogeneity across studies. HSROC (hierarchical summary receiver operating characteristic) curves were also constructed with 95% confidence regions illustrating the precision with which pooled values are estimated and a 95% prediction region, illustrating the amount of between-study variation. Analyses were carried out using STATA software (StataCorp LP, College Station, TX, 77845, USA), using the "metandi" command [16,17].
Calibration analysis of the Alvarado score
The initial derivation study of the Alvarado score was used as the predictive model against which all validation studies were compared [5]. The number of patients diagnosed with appendicitis as estimated by the Alvarado score (predicted events) was compared to the actual number of patients with appendicitis (observed events) in each of the validation studies. The analysis was performed separately across three risk strata of the Alvarado score (low risk, score 1 to 4; intermediate risk, score 5 to 6; and high risk, score 7 to 10) (Figure 1). Within each risk stratum, each of the three main study populations, men, women and children were analysed separately [8,10-12,18].
The results from the calibration assessment were presented as risk ratios (RRs with 95% confidence intervals) and are illustrated as forest plots. RR < 1.00 indicates an under-prediction of appendicitis by the score (observed number with appendicitis is greater than the predicted number) and RR > 1.00 indicates an over-prediction of appendicitis by the score (observed number with appendicitis is less than the predicted number). RR = 1 indicates a matched calibration between observed and predicted numbers. Review Manager 5 software from the Cochrane collaboration was used to perform the pooled analysis, determine heterogeneity and produce the forest plots. RRs with their 95% CIs were computed by the Mantel-Haenszel (M-H) method. A random-effects model was used and heterogeneity assessed by I2 statistic.
Prevalence was investigated as a source of heterogeneity in a subgroup analysis. Studies were dichotomised, based on their prevalence, as being either higher or lower than the Alvarado's derivation study; the effect on heterogeneity and the calibration of the score were also investigated.
The literature search yielded > 3,000 titles and abstracts for screening. The full text of 91 articles met the eligibility criteria, and these articles were retrieved (Figure 2). Thirty-seven articles were included from the search, and a further five articles were retrieved after citation searching, with a total of 42 articles meeting the inclusion criteria. The included studies came from a variety of settings and countries (Table 1). Nine studies took place in a surgical ward; three studies only specified that patients were hospitalised, all remaining studies were performed in an emergency department setting. Detailed characteristics of all included studies are presented in Table 1.
Table 1. Characteristics of included studies
Results of the quality assessment are shown in Figure 3. The overall quality of the included studies is considered acceptable for most of the quality items. The assessment of the clinical variables composing the Alvarado score and the reference standard for diagnosis (histological results of the appendectomy) were interpreted independently in most studies. The retrospective studies rarely reported if the scorer was aware of the final diagnosis (blind assessment). The quality item, 'time between tests', is the time between administering the Alvarado score and verifying the diagnosis with pathology or follow-up and was very poorly reported. As part of our inclusion criteria, all studies had to confirm the diagnosis of appendicitis on those undergoing appendectomy; however, follow-up of those discharged was poor in the majority of studies (item 'All verified with reference test').
Diagnostic accuracy of the Alvarado score
The Alvarado score discriminated well as an observation/admission criterion (cut point of 5) by achieving high pooled sensitivity of 99% overall (n = 28 studies, [5,8,10,18-42]) and in studies where data were available, it also performed well in the subgroup analysis for men, woman and children (pooled sensitivities: 0.96 for men, n = 5 [23,30,33-35]; 0.99 for women, n = 5 [23,30,34,35,43] and 0.99 for children, n = 9 [10,21,23,27,28,30,40-42]) (Table 2 and Additional file 1 - Figure S1). In patients presenting with higher Alvarado scores (cut point of 7, the criterion for surgery), pooled diagnostic accuracy results had more limited clinical value (pooled specificity for all studies 0.82, n = 29, [5,8,10,11,18-25,27-32,34-38,41,42,44-47]), with pooled specificities ranging from 0.57 for subgroup analysis of men (n = 6, [9,23,30,34,35,45]), 0.73 for subgroup analysis of women (n = 7, [9,23,30,33-35,45]) and 0.76 for subgroup analysis of children (n = 9, [10,21,23,27,28,30,41,42,47]) (Table 2 and Additional file 1 - Figure S1).
Additional file 1. Figure S1. Summary ROC curves (sensitivity and specificity with 95% CIs are presented in Table 2). Figure S2. Predicted versus observed cases with appendicitis per study, sub-grouped by prevalence. The studies were re-grouped into high- or low-prevalence according to the prevalence cut-off point (82%) found in Alvarado's derivation study: A. Low risk, score 1 to 4; B. Intermediate risk, score 5 to 6; C. High risk, score 7 to 10.
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Table 2. Summary estimates of sensitivity and specificity calculated by a bivariate random-effects model
Overall, heterogeneity was high when all studies were included and was particularly high in the children subgroup as indicated by the variance logit transformed sensitivity and specificity (Table 2) and the prediction ellipses on the SROC curves Additional file 1 - Figure S1).
Calibration of the Alvarado score
The Alvarado score performed well in all three risk strata for men: (low risk RR 1.06, 95% CI 0.87 to 1.28; intermediate risk 1.09, 0.86 to 1.37 and high risk 1.02, 0.97 to 1.08). In women, there was a systematic over-prediction across all risk strata: low risk (RR 5.35, 2.17 to 13.19), intermediate risk (RR 1.82, 1.20 to 2.78) and high risk (RR 1.14, 1.04 to 1.25). In children, there was a non-significant trend towards over-prediction in the low risk strata (5.03, 0.52 to 48.82) and a significant over-prediction in the intermediate risk category (1.81, 1.13 to 2.89) and high risk strata (1.13, 1.01 to 1.27) (Figures 4, 5, 6). Heterogeneity in terms of between-study predicted/observed risk ratio estimates is apparent in children across all risk strata and in women at a high risk (I2 > 50%), and, therefore, these pooled estimates should be treated with caution.
Figure 4. Low risk group (1 to 4): predicted versus observed cases with appendicitis in children, women and men.
Figure 5. Intermediate risk group (5 to 6): predicted versus observed cases with appendicitis in children, women and men.
Figure 6. High risk group (7 to 10): predicted versus observed cases with appendicitis in children, women and men.
In a subgroup analysis based on prevalence (Additional file 1 - Figure S2), the high prevalence category consisted of six studies [9,10,23,32,37,39] - the score predicted well in this group and heterogeneity was below 50% in the high and low risk groups (low risk RR 0.65, 95% CI 0.25 to 1.75, I2 = 34%; intermediate risk RR 0.99, 95% CI 0.70 to 1.40, I2 = 72%; high risk RR 0.99, 95% CI 0.96 to 1.02, I2 = 0%). The low prevalence subgroup consisted of 24 studies, there was a significant overprediction across all risk strata; however, heterogeneity was extremely high (I2 = 78% to 85%) suggesting that other factors, perhaps age and gender, contributed to the high levels of heterogeneity in this group. Unfortunately, not enough studies had age and gender information to allow us to do further subgroup analysis.
Principal findings
This systematic review shows that the Alvarado score at the cut point of 5 performs well as a "rule out" CPR in all patient groups with suspected appendicitis. Pooled diagnostic accuracy in terms of "ruling in" appendicitis at a cut-point of seven points is not sufficiently specific in any patient group to proceed directly to surgery. In terms of calibration, the observed, predicted estimates in men suggest the score is well calibrated across all risk strata. Application of the Alvarado score in women over-predicts the probability of appendicitis across all strata of risk and should be used with caution. The validity of the Alvarado score in children was inconclusive; the calibration analysis showed high levels of heterogeneity across all risk strata. Further validation studies are required before clinical implementation of the Alvarado score for this age group could be recommended.
Clinical implications
A recent clinical policy document from the American College of Emergency Physicians reviewed the value of using clinical findings to guide decision making in acute appendicitis [7]. They state that combining various signs and symptoms, as in the Alvarado score, may be more useful in predicting the presence or absence of appendicitis. This systematic review supports the use of the Alvarado score as a triage CPR that can be applied to 'rule out' appendicitis at a score below five points (sensitivity 94% to 99%), but not as a 'rule in' for appendicitis. Patients with a score less than 5 can be considered for discharge with the proviso that watchful waiting and re-assessment may be required if symptoms change or deteriorate. The advantage of applying the Alvarado score in this way is that resources in terms of admitting a patient to hospital or performing diagnostic imaging can be reserved for higher-risk scoring patients. Such an approach may be particularly useful in low-resource settings where diagnostic testing is limited or not available [38].
Based on the results of this review, the Alvarado score at a cut-off of five points compares favourably with other CPRs used in clinical practice. The Ottawa ankle and knee rules represent "rule out" CPRs of similarly high sensitivity that are used in emergency departments to decide if a patient should be referred for radiography to determine if their ankle or knee is fractured. The application of these CPRs is to identify those patients with a very low risk of fracture, where fracture can be confidently ruled out and the patient can be discharged without unnecessary imaging. For this purpose, it is important that such CPRs have high sensitivity. Meta-analysis of validation studies show these rules achieve high sensitivity that is comparable to the Alvarado score at a cut-off of five points (ankle rule - 97.6% [48], knee rule - 98.5% [49] and Alvarado score at cut-off of five points - 99%).
The use of the Alvarado score as a 'rule in' CPR for surgery at a cut point of 7 is not supported by our diagnostic test accuracy results. Our analysis indicates that the Alvarado score has moderate to high sensitivity (all studies 82%, men 88%, women 86% and children 87%) and a moderate specificity (all studies 81%, men 57%, women 73% and children 76%), suggesting it is not sufficiently accurate to rule in or rule out surgery (Table 2). However, several studies report that the application of Alvarado score as a sole decision criterion for surgery (cut point of 7) produces negative appendectomy rates of 13.3%, 15.6%, 16.2% and 14.3%, respectively, without an increase in perforations [11,20,29,35]. This is comparable with a clinician's judgment in other reports (17.1%, 12%, 12.5% and 11%) [5,8,19,27]. An Alvarado score ≥ 7 is useful at identifying those at high risk of acute appendicitis who require a surgical consultation or further diagnostic imaging, it should not be used as the sole criterion for ruling in surgery in any patient group.
During the last 10 years, the diagnostic imaging by CT scan in the diagnosis of appendicitis has become a common practice. In some centres over 90% of the patients presenting with suspected appendicitis undergo CT imaging. CT has a high sensitivity and specificity for the diagnosis of appendicitis and it considerably reduces the level of negative appendectomy. However, some studies have shown that the use of CT does not necessarily change the clinical management of a patient, especially in those at high risk [33,50]. CT imaging may also delay the time of operation and, therefore, may increase the subsequent risk of perforation [51]. Assessing the use of the Alvarado score and CT imaging as a series of diagnostic investigations on all these types of outcomes is warranted.
Lastly, the results of this systematic review have important implications in low-resource countries. First, in low-resource settings where the decision to operate may be based on a clinical judgment, the Alvarado score provides an accurate and consistent triage tool for ruling out appendicitis and identifying those at higher risk who would benefit at most from an admission to a hospital. Second, the Alvarado score could serve as a simplified tool for the emergency physician in order to stratify patients for referral for surgical consultation.
Context of other research
Although the Alvarado score was developed in a mixed gender population, the ratio of men to woman was 1.4:1 and the score has subsequently been shown to perform poorly when applied to women of child-bearing age [8-11]. It is also possible that a certain loss of diagnostic information may have occurred due to dichotomisation when the score was originally constructed in the derivation study. Abdominal pain in women is a diagnostically challenging symptom as there are more diagnostic possibilities aside from appendicitis, such as pelvic inflammatory disease and other gynaecological pathologies. Alternative risk scores or CPRs, such as Lindeberg [52], Eskelinen [53] and Fenyo [54] scores for appendicitis, have different numerical values for symptoms depending on whether the patient is male or female [55]. The Van Way, Teicher and Arnbjornssion scores include gender as one of their components [55]. Of note, Ohman et al. [55] reported that the Alvarado score outperformed each of these other scores.
Distinguishing appendicitis from other causes of abdominal pain in children is also challenging, particularly in young children who cannot articulate how they feel or where the pain is. There is also a wide variation in presenting symptoms and it is often hard to elicit the classical presentation [2]. The use of symptoms and signs to identify children who are at risk of acute appendicitis is particularly appealing as diagnostic imaging using a CT scan exposes children to ionizing radiation and the diagnostic accuracy of ultrasound is still uncertain [7]. A recent review found that "fever" in a child is the single most important sign associated with appendicitis, followed by rebound tenderness and migration of pain, suggesting that the Alvarado score may not be the most appropriate scoring system for children as double points are scored for tenderness in the right lower quadrant and leukocytosis, but only one point for each of all other signs (Figure 1) [2]. This review also reported the accuracy of clinical scoring systems, including the Alvarado score, where the likelihood ratio for cut points of 7 and 5 (based on three studies) was similar to our pooled estimates (cut point of 7, 3.1 and 3.5; cut point of 5, 0.05 and 0.02, respectively). Two of the studies in the review by Bundy et al. were included in this review [11,21].
Strengths and weaknesses of the present study
Our study does have a number of limitations. First, although it is usually related mainly to discrimination, some degree of misclassification may have also occurred when calibration was considered by comparing predicted versus observed patients with appendicitis; however, given the high levels of diagnostic performance, overall (especially, at the cut-off point of 5) this appears unlikely.
Second, a moderate to high level of heterogeneity was shown across the included studies in both the diagnostic test accuracy analysis and the calibration analysis (Table 2, Figures 4, 5, 6 and Additional file 1 - Figure S1). There are a number of possible sources for heterogeneity, including chance; variation in pre-test probability; the case mix of men, woman and children; a threshold effect caused by observer variation in the measurement of signs and symptoms; no active follow-up of patients discharged and other unanticipated factors. We addressed a number of these potential sources of heterogeneity by performing subgroup analysis. The main focus of this paper was an analysis of such subgroups as men, woman and children. The performance of the score has been shown by others [8-12] to be affected by age and gender and, therefore, high heterogeneity in the overall results may be due to the gender and age spectrum of the patients in the included studies (for example, Table 2, all studies, variance logit sensitivity is 3.37). The prevalence of appendicitis among the validation studies was highly variable (range 32% to 91%, Table 1). Although this was investigated in a subgroup analysis a good deal of heterogeneity still existed, suggesting that other factors contributed towards heterogeneity in this analysis (Additional file 1 - Figure S2). Unfortunately it was not possible to do further subgroup analysis based on age, gender and prevalence due to a lack of studies with this information. Finally, a number of the studies used no repeat admission as a negative proxy measure for appendicitis. The lack of active follow-up in these studies may have led to misclassification if patients presented to a different hospital. This may have led to a lower reporting of appendicitis cases, particularly in the low-risk groups, and inflated our estimates of sensitivity and specificity.
Finally, although we used an up-to-date systematic search strategy, we acknowledge that it was not exhaustive and it is possible, as with all systematic reviews, that relevant articles may have been missed. As we did not search the grey literature, there is also the possibility of publication bias, with smaller negative studies being under reported, leading to inflated estimates of sensitivity and specificity in our meta-analysis.
Future research and applications in clinical practice
The criteria for selection of the included articles were broad and reflected the nature of the validation studies themselves, producing a high level of heterogeneity across the studies in some of the risk strata. Further analyses are needed to explore the reasons behind the over-prediction of the Alvarado score in women. Such future analyses may suggest ways to adjust the predicted estimates according to the population prevalence in the various settings and/or a re-calibration or re-modelling of the score itself, mainly in low-prevalence settings and in women. Obtaining individual-level data from the validation studies to perform meta-analysis of the risk ratios can make such approaches possible, particularly for the more detailed exploration of the various sources of heterogeneity.
This study shows that the Alvarado score accurately predicts appendicitis and is well calibrated in men. As a decision rule for observation/admission, the Alvarado score performs well as a 'rule out' criterion (high sensitivity). As a decision rule in relation to surgery the Alvarado score cannot be used to 'rule in' a diagnosis of appendicitis without surgical assessment and further diagnostic testing. Patients presenting in the emergency department and in primary care settings, especially in low-resource countries, could benefit from the implementation of the Alvarado score as a triage decision rule.
CPRs: clinical prediction rules; CT: computed tomography; HSROC: hierarchical summary receiver operating characteristic; MANTRELS, a popular mnemonic used to remember the Alvarado score factors: Migration to the right iliac fossa, Anorexia, Nausea/Vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever), Leukocytosis, and Shift of leukocytes to the left; M-H method: Mantel-Haenszel method; QUADAS: quality assessment of studies of diagnostic accuracy included in systematic reviews; RR: risk ratio.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
RO, FO'R and KO'B were responsible for study protocol, data collection, and data elaboration and analysis. TF and BDD were responsible for the concept and study design and contributed to the data analysis and their interpretation, and drafting the report. All authors contributed to the interpretation of results, critical review of the manuscript and agreed on the final layout for submission. BDD is guarantor of the study.
We thank Dr Alvaro Sanabria, Dr Kailash Singh, Dr Paul Eduardo Lada, Dr Robert Winn and Dr Madasir Wani for providing additional information on their studies. We also thank Dr. C Teljeur for statistical advice. This study was funded by the Health Research Board of Ireland (HRB) under grant reference HRC/2007/1.
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Biomedica 2007, 27:419-428. PubMed Abstract | Publisher Full Text
Singh K, Gupta S, Pargal P: Application of Alvarado scoring system in diagnosis of acute appendicitis.
Soomro AG, Siddiqui FG, Abro AH, Abro S, Shaikh NA, Memon AS: Diagnostic accuracy of Alvarado Scoring System in acute appendicitis.
Stephens PL, Mazzucco JJ: Comparison of ultrasound and the Alvarado score for the diagnosis of acute appendicitis.
Conn Med 1999, 63:137-140. PubMed Abstract
Tade AO: Evaluation of Alvarado score as an admission criterion in patients with suspected diagnosis of acute appendicitis.
West Afr J Med 2007, 26:210-212. PubMed Abstract
Yildirim E, Karagulle E, Kirbas I, Turk E, Hasdogan B, Teksam M, Coskun M: Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis.
Diagn Interv Radiol 2008, 14:14-18. PubMed Abstract | Publisher Full Text
Rezak A, Abbas HM, Ajemian MS, Dudrick SJ, Kwasnik EM: Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis.
Arch Surg 2011, 146:64-67. PubMed Abstract | Publisher Full Text
Shreef KS, Waly AH, Abd-Elrahman S, Abd Elhafez MA: Alvarado score as an admission criterion in children with pain in right iliac fossa.
Afr J Paediatr Surg 2010, 7:163-165. PubMed Abstract | Publisher Full Text
Escriba A, Gamell AM, Fernandez Y, Quintilla JM, Cubells CL: Prospective validation of two systems of classification for the diagnosis of acute appendicitis.
Pediatr Emerg Care 2011, 27:165-169. PubMed Abstract | Publisher Full Text
Saidi RF, Ghasemi M: Role of Alvarado score in diagnosis and treatment of suspected acute appendicitis.
Am J Emerg Med 2000, 18:230-231. PubMed Abstract | Publisher Full Text
Baidya NRG, Rao A, Khan SA: Evaluation of Alvarado score in acute appendicitis: a prospective study.
Denizbasi A, Unluer EE: The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident.
Eur J Emerg Med 2003, 10:296-301. PubMed Abstract | Publisher Full Text
Kang W-M, Lee C-H, Chou Y-H, Lin H-J, Lo H-C, Hu S-C, P'eng F-K: A clinical evaluation of ultrasonography in the diagnosis of acute appendicitis.
Surgery 1989, 105:154-159. PubMed Abstract
Muenzer JT, Jaffe DM, Schwulst SJ, Dixon DJ, Schierding WS, Li Q, MacMillan SK, Oppedal D, Warner BW, Dillon PA, Lin N, Checchia PA, Cobb JP: Evidence for a novel blood RNA diagnostic for pediatric appendicitis: the riboleukogram.
Pediatr Emerg Care 2010, 26:333-338. PubMed Abstract | Publisher Full Text
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G: Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.
BMJ 2003, 326:417. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Bachmann LM, Haberzeth S, Steurer J, ter Riet G: The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review.
Ann Intern Med 2004, 140:121-124. PubMed Abstract
Santos DA, Manunga J Jr, Hohman D, Avik E, Taylor EW: How often does computed tomography change the management of acute appendicitis?
Am Surg 2009, 75:918-921. PubMed Abstract | Publisher Full Text
Karakas SP, Guelfguat M, Leonidas JC, Springer S, Singh SP: Acute appendicitis in children: comparison of clinical diagnosis with ultrasound and CT imaging.
Pediatr Radiol 2000, 30:94-98. PubMed Abstract | Publisher Full Text
Lindeberg G, Feny G: Algorithmic diagnosis of appendicitis using Bayes' theorem and logistic regression. In Bayesian Statistics 3. Edited by Bernardo JM, DeGroot MH, Lindley DV, Smith AF. Oxford, UK: Oxford University Press; 1988:665-669.
Eskelinen M, Ikonen J, Lipponen P: A computer-based diagnostic score to aid in diagnosis of acute appendicitis: a prospective study of 1333 patients with acute abdominal pain.
Fenyo G: Routine use of a scoring system for decision-making in suspected acute appendicitis in adults.
Acta Chir Scand 1987, 153:545-551. PubMed Abstract
Ohmann C, Yang Q, Franke C: Diagnostic scores for acute appendicitis.
Eur J Surg 1995, 161:273-281. PubMed Abstract
Malik KA, Khan A, Waheed I: Evaluation of the Alvarado score in diagnosis of acute appendicitis.
Shrivastava UK, Gupta A, Sharma D: Evaluation of the Alvarado score in the diagnosis of acute appendicitis.
Trop Gastroenterol 2004, 25:184-186. PubMed Abstract
Winn RD, Laura S, Douglas C, Davidson P, Gani JS: Protocol-based approach to suspected appendicitis, incorporating the Alvarado score and outpatient antibiotics.
ANZ J Surg 2004, 74:324-329. PubMed Abstract | Publisher Full Text
Subotic AM, Sijacki AD, Dugalic VD, Antic AA, Vukovic GM, Vukojevic VS, Glisic TM, Galun D: Evaluation of the Alvarado score in the diagnosis of acute appendicitis.
Acta Chir Iugosl 2008, 55:55-61. PubMed Abstract
Andersson M, Andersson RE: The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score.
World J Surg 2008, 32:1843-1849. PubMed Abstract | Publisher Full Text
Prabhudesai SG, Gould S, Rekhraj S, Tekkis PP, Glazer G, Ziprin P: Artificial neural networks: useful aid in diagnosing acute appendicitis.
World J Surg 2008, 32:305-309.
discussion 310-311PubMed Abstract | Publisher Full Text
Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Poll results – Did MVP deserve a world title run?
Dec 6, 2010 - by Steve Gerweck
Did MVP deserve a world title run?
* Yes (61%, 380 Votes)
* No (39%, 241 Votes)
Total Voters: 621
Pro Wrestling Since 1997
Dec 6, 2010 - by Steve Gerweck
Did MVP deserve a world title run?
* Yes (61%, 380 Votes)
* No (39%, 241 Votes)
Total Voters: 621
What did he do to deserve it?
for real? i can name a few others that derserved it before him. i can also name a few others who have been champion that shouldn't have been. MVP was misused but don't think for a minute he was world title ready
For real. Jack Swagger was World Champion. Besides I don't think it matters the World title means very little IMO and should be unified with the WWE title. I only see a handful of superstars on the smackdown roster worthy of being a world champion. Don't worry people he'll be a world champion with TNA. Because giving ex wwe stars the TNA World Championship proves that the WWE has inferior talent.
just because of people like jack swagger? that's your reasoning?? two wrongs don't make a right reyo. if you start handing out world title runs because of what this guy got or what that guy got then it's only a matter of time before every superstar gets a world title run. if the world title has little value is it fair to say that mvp has little value? think about it.. and if you agree then why should this guy be world champion. WORLD champion. i bet mvp wouldn't be recognized on a busy street. can you say the same for hhh, austin, hogan, rock, lesnar, goldberg, hart, cena, savage, michaels, flair, undertaker, orton, kane.. the list of champions goes on and on. MVP ='d a mid carder with potential (who didn't live up to it). maybe he was misused, maybe he was overlooked, but at no point should he have won the strap.
there are a few who have been world champion who deserved it less than mvp, such as:
jack swagger
the great khali
the miz

subset: commoncrawl


text:
This photo is awaiting approval and will be posted soon.
Play our fun game and find out if the one you like likes you back. Confide in us if you think you'd hit it off by clicking: Yes, No, or Maybe. We'll anonymously find out and let you know if the feeling is mutual. You have nothing to lose!
You've already said YES! If the feeling is mutual, we'll let you both know.
You've already said No. If you've changed your mind, let us know. If you say Yes, we'll anonymously find out if the feeling is mutual. You have nothing to lose!
You've already said Maybe. If you've changed your mind, let us know. If you say Yes, we'll anonymously find out if the feeling is mutual. You have nothing to lose!
You both said YES! The feeling is mutual. Now the rest is up to you! Say Hi and get the conversation started.
I am a very positive, open, honest, caring person. I am as comfortable in a room full of strangers as I am with my friends. I enjoy cooking, outdoors, theatre...the list goes on! I have a life I enjoy filled with more love and laughter than I ever imagined possible. I enjoy my kids and my job. Seems the only thing missing, other than possibly hitting the lottery, is to meet someone to share it all with! Maybe you??
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text:
Live Performances From George Jones [VIDEOS]
Today we lost country music legend George Jones who's career was remarkable to say the least.
George Jones was 81. In his lifetime he charted more than any other country music artist.
Classic country is one of my favorite genres of music and George Jones one of my all-time favs. Having said that, when I last saw him at the Heymann Center several months back, he looked in poor health and his voice had left him. As saddened as I was while sitting in the audience, I was still very honored to be in his presence.
Here are a few live performances of George Jones classics:
George Jones "He Stopped Loving Her Today"
George Jones "Bartender's Blues"
George Jones "The Grand Tour"
George Jones and Tammy Wynette "Golden Ring"
George Jones "The Race Is On"
George Jones and Barbra Mandrell "I Was Country When Country Wasn't Cool" (Only Copy I Could Find)


text:
A deficiency of circulating leukocytes is called?
Not medical advice: It is called "Leukopenia", a term used for low, decrease or deficiency of white blood cell (leukocytes) count. When you have a low white blood cell (WBC) count you may be immunosuppressed, which means you are more at risk for potentially serious infections that do not go away or are hard to treat. In most cases it is due to low lymphocytes (lymphocytopenia) and/or neutrophils (neutropenia). Both of these cell types play a big role in the body's defense against infections.
Infections like viral infections, autoimmune disorders such as lupus, certain medications (including chemotherapy and some antibiotics), radiation therapy, and bone marrow illnesses (such as leukemia or myelodysplastic syndromes) can lead to decreases in neutrophils and/or lymphocytes.
Of interest, researchers at the University of British Columbia have developed a new way to detect blood doping using DNA, white blood cells are inspected for different populations of genes using PCR (polymerase chain reaction). Find out more at UBC.
Related Questions
What is the deficiency of lymphocytes called
Where are leukocytes formed?
What are some symptoms of Vitamin-D deficiency?
The most abundant leukocytes in the blood are what
Define deficiency
What are the signs of iodine deficiency?
What's the difference between leukocytes and granulocytes?
Is it possible to have a diet deficiency of chicken?
Is chewing ice a deficiency of iron?


text:
Title: Viability of Listeria monocytogenes on Uncured Turkey Breast Commercially Prepared with and without Buffered Vinegar during Extended Storage at 4 and 10°C
Authors: Porto Fett AC, Campano SG, Shoyer BA, Wadsworth S, Luchansky JB
Journal: J Food Prot
Accepted date: 2014 Feb 12
Interpretive summary: Food safety is still a major concern for consumers, and the manufacturing of natural ready-to-eat meats without antimicrobials may be a challenge for the meat industry, since these products may support the outgrowth of foodborne pathogens, especially Listeria monocytogenes. Therefore, research is warranted to evaluate the effectiveness of selected food grade antimicrobials to lessen the likelihood of pathogen persistence and human illness due to the consumption of ready-to-eat meat products. Thus, we evaluated the behavior of Listeria monocytogenes (about 10 thousand cells per slice) on the surface of on uncured turkey breast formulated with and without buffered vinegar and then surface treated with a solution of sodium chlorite in vinegar during storage at different temperatures. When product was formulated without antimicrobials, pathogen numbers increased to about 1 billion cells per slice after 90 and 48 days of storage at 4 or 10 degree Celsius, respectively. However, at 4 degree Celsius, when lower concentrations of buffered vinegar were added to the formulation, alone or in combination with surface treatment with sodium chlorite in vinegar, a slight growth of the pathogen was observed, whereas when buffered vinegar was used at high concentration, growth of the pathogen was inhibited throughout storage. As expected, the higher the storage temperature, the greater the pathogen levels on the surface of turkey breast. At 10 degree Celsius, lower concentrations of buffered vinegar and sodium chlorite in vinegar resulted in an increase greater or equal to 100 to 100,000 cells per slice, whereas at higher concentrations of both antimicrobials, pathogen numbers remained relatively unchanged. These data substantiate that inclusion of buffered vinegar, alone or in combination with VSC added to the package, appreciably suppressed the outgrowth of Listeria monocytogenes that may be present on the surface of natural deli turkey breast due to post-process contamination.
Publication date: 2014 Jun 1
Volume: 77
Issue: 6
Pages: 987-92


text:
one of the most amazing kids ever
we should take him snowboarding!
check out the vids...this kid lost his eyes when he was 3, but he plays ball, rides a bike, rollerblades & never uses a cane or sight dog...he uses sound! incredible!
part 1...
YouTube - Extraordinary People - The boy who sees without eyes [1/5]
part 2...
YouTube - Extraordinary People - The boy who sees without eyes [2/5]
there's 5 parts to the documentary...check 'em out if you want!
I remember seeing some people with these skills on the news a while back. they each had different tricks. one guy made clicking noises with his mouth and heard the echo's back off objects, there was a girl that used echo from her shoes. Crazyyyy...people developing bat skillZ
leave it to me to think of something perverted in relation....
this kid's gonna make some girl reeeeally happy one day with his skilled tongue :cheeky4: lol
I just saw this on 20/20 last night. Its pretty amazing.
Not to take away from him, but his mother is one of the most remarkable people I've ever heard about, and is (no doubt) the only reason he behaves the way he does....
what an amazing true story...
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Household Durables
Company Overview of Terwilliger Pappas Multi-Family Partners, LLC
Executive Profile
J. Ronald Terwilliger
|Total Calculated Compensation
|This person is connected to 3 Board Members in 3 different organizations across 2 different industries.
See Board Relationships
Mr. J. Ronald Terwilliger, Ron serves as National Managing Partner of Trammell Crow Residential. Mr. Terwilliger is responsible for all residential development and operations conducted by Trammell Crow Residential in 23 offices throughout the United States. He served as Chief Executive Officer of Trammell Crow Residential Company from 1986 to 2008. He serves as Chairman of Enterprise Community Partners, Inc. and Terwilliger Pappas Multi-Family Partners, LLC. He served ...
Corporate Headquarters
1111 Metropolitan AvenuePhone: --
Charlotte, North Carolina 28204
United States
Fax: --
Board Members Memberships
Harvard Business School
Unknown/Other Education
United States Naval Academy
Other Affiliations
Annual CompensationThere is no Annual Compensation data available.
Stocks OptionsThere is no Stock Options data available.
Total CompensationThere is no Total Compensation data available.
|There is no Competitor Compensation data available.
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text:
Everything tagged
Latest from The Spokesman-Review
Yahoo to spin off its stake in Alibaba
Jan. 28, 2015 in Business on Page A10 SAN FRANCISCO – Yahoo CEO Marissa Mayer is spinning off the company's $39 billion stake in China's Alibaba Group Holding in a move that wards off a potential shareholder rebellion. …
Yahoo apologizes
Nov. 13, 2012 in Sports on Page B2 Yahoo Sports is apologizing for a site outage that left thousands of fantasy football players complaining of last-minute lineup problems and possible lost money on an NFL Sunday. Ken Fuchs, …
Tax incentives spur Yahoo expansion
Dec. 5, 2010 in City on Page B3 QUINCY, Wash. – State tax incentives to get more data centers plugged into Grant County's cheap power seem to be working. Yahoo, the Internet mega-company, began construction last week on … 1
Paul Allen sues Google, Apple, other tech companies
Aug. 27, 2010 in Business Microsoft Corp. co-founder and billionaire Paul Allen is suing nearly a dozen major technology companies, including Google Inc. and Apple Inc., alleging that they infringed on four Web technology patents …
Microsoft now fueling Yahoo's search engine
Aug. 24, 2010 in Business A 34-year-old Lapwai man has been arraigned on charges stemming from a collision between two boats on the Snake River that killed a 15-year-old Lewiston boy earlier this month.
Microsoft applies to expand at Quincy
May 22, 2010 in Business on Page A6 One month after Washington state lawmakers gave a sales tax break to data centers, Microsoft has begun seeking an expansion of its giant data storage center in rural Grant County. …
Microsoft, Yahoo agree to combine online efforts
July 30, 2009 in Business on Page A10 SAN FRANCISCO – Microsoft finally persuaded Yahoo to surrender control of the Internet's second most popular search engine and join it in a daunting battle – taking on the overwhelming …
Microsoft, Yahoo agree on long-sought search deal
July 29, 2009 in Business SAN FRANCISCO — Microsoft finally persuaded Yahoo to surrender control of the Internet's second most popular search engine and join it in a daunting battle — taking on the overwhelming …


text:
Annual event features The Great Cardboard Boat Regatta and Picnic in the Park at Lake Ellyn Park, parade, family fest and fireworks. Visit website for...
Over seven miles of trails for hikers, bikers and
equestrians. Amenities include group picnic shelters, an off-leash
dog area, a youth-group...
Start in a huge park with lots of playground equipment, a picnic
area, tennis courts and soccer fields. From the northwest corner of
the park, hop...
with nature at one of our 5 fun-filled sites! Make your child's
birthday a journey of discovery. Choose from a wide variety of age
3.2-acre park with boardwalks and a wildflower garden.
1.75 mile paved walkway along the DuPage River.
On the east edge of the Fox River, this park has an 18-hole miniature golf course, 9-hole golf course, community center, swimming pools, softball field,...


text:
The sound of boots clicked on the tile floor and echoed in the hallway. A man dressed completely in white and gold. Gloves even covered his hands. The only skin that was seen was between his white hair line and a metal mask that hid his nose, down to his chin. His eyes were an icy blue and his long white hair fell to the back of his knees. His aura radiated nothing but cold. Even the man next to him didn't seem to want to be there.
He passed many doors in the long hallway to pause at one in particular. The man he had brought along opened the door for him to enter into. The room inside was nothing like the white hallway out side of it. It was dark. The stones upon the ground were rough and uneven. There was a man within the room, a thick, black collar around his neck and hands. The man looked a little thin, as if he hadn't been fed in a while. Fiery red hair was just long enough to fall into his electric green eyes. He smirked at his visitor. "Sevy." He cooed at the man.
The older man narrowed his eyes at him, "Your nick name for me Michael, is disgusting."
Michael laughed openly, "I knew that you couldn't stay away Sevy, but really? That's all you came to tell me?"
Sevotarthe tipped his head slightly to stretch his neck. A slight tick of irritation. Michael was the angel of war. He needed this piece of s**t to do his bidding, and Michael knew it. "Are you ready to behave?"
Michael's eyes lit up, his roughed up face changing from the indignant smirk, to an almost child like hope. "Is she?" Sevotarthe gave a single nod. Michael let out another loud laugh and got to his feet. He opened his arms to Sevotarthe, "Then I'm off." He held out his hands, the look of fire returning to his eyes. "One thing though. It's hard to be an angel with these...." Sevotarthe pulled out a key and unlocked the collars around his neck and hands.
The two standing together was a huge expression of how tall Sevotarthe was. Michael stood at 5'9" and was easily dwarfed by the man in white. Before he could move away from Michael, he grabbed a gloved hand and gave a big kiss on the back of it. "Thanks Sevy." He hissed before slipping around him.
Sevotarthe pulled off the glove and tossed to the officer behind him, "Burn it." he ordered before following Michael down the hallway.
Jack had just gotten off work. He was a waiter and he worked a lot to make sure he could pay for his apartment where he and the love of his life lived. His light brown hair was slightly mussed from him running his hands through it too many times out of frustration. His hazel eyes showed how exhausted he was. He straddled his bike and pushed off, headed home for the night. He was starving and hoped that dinner was waiting for him at home. He had worked all day and had an extra two hundred dollars in his pocket. He wished he could have stopped and bought her something like a flower.... No, they needed the money else where.
He stopped at a light and glanced around. He damn near did a double take. There had been something down that alleyway. Had there been? He wasn't sure. Whatever it was, he felt a prickle run up his back. The dumb side of him wanted to check it out. Thankfully, the light changed and he was back going again.
It didn't take long to reach the apartment and he pushed his bike into the elevator and hit the button. It was strange, he couldn't shake off the feeling he had gotten earlier. The doors opened on the third floor and he made his way to his door. Unlocking it, he called out, "I'm home sweetie."


text:
LONDON (MarketWatch) -- BP BP, +0.70% BP., +1.26% said it is expected to take some three months to finish work on the first relief well as it attempts to contain a leak in the Gulf of Mexico. To date the oil spill response team has recovered about 30,000 barrels of oil-water mix, BP said. The total length of deployed boom is now over 700,000 feet as part of the efforts to stop oil reaching the coast. Some one million feet is available and more than 300,000 feet is on order. Suitable weather conditions allowed controlled burning of surface oil to be carried out.
Market Pulse
BP: Three months to finish relief well
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Top Stories


text:
Stock Report: Broadcom Corporation Class A (BRCM) Report Updated: Oct 05, 2015 | Print This Page
Report Features:
Stock Analysis
|Fundamental Grade:
|Sales Growth:
|Operating Margin Growth:
|Earnings Growth:
|Earnings Momentum:
|Earnings Surprises:
|Analyst Earnings Revisions:
|Cash Flow:
|Return on Equity:
|Quantitative Grade:
|Total Grade:
Rating: Monthly View
Rating: Weekly View
|This Week:
|B no change
|Last Week:
|B no change
|Two Weeks Ago:
|B no change
Broadcom Corporation Class A© quotemedia
Company Profile
Broadcom Corporation designs and develops semiconductor solutions for wired and wireless communications. It provides a portfolio of system-on-a-chip (SoC) and software solutions. The companys products deliver voice, video, data, and multimedia connectivity in the home, office, and mobile environment. Its Broadband Communications segment offers cable modem SoCs; femtocell SoCs; MPEG/AVC/VC-1 encoders and transcoders; xDSL, xPON, and cable modem customer premises equipment and central office solutions; powerline networking SoCs; and digital cable, direct broadcast satellite, terrestrial, and Internet protocol (IP) set-top box SoCs. The companys Mobile and Wireless segment provides Wi-Fi and Bluetooth SoCs, wireless connectivity combo chips, global positioning system/ global navigation satellite system SoCs, EDGE/3G and 4G baseband solutions, multimedia processors, applications processors, power management units, voice over IP SoCs, mobile TV SoCs, near field communications tags, and cellular radio frequency (RF) chips. Its Infrastructure and Networking segment offers Ethernet copper transceivers, Ethernet controllers and switches, backplane and optical front-end physical layer devices, security processors and adapters, broadband processors, and microwave modems and RF. The company markets and sells its products through direct sales force, distributors, and manufacturers representatives in the United States; and through regional offices, and a network of independent distributors and representatives in Asia, Australia, Europe, and North America. Broadcom Corporation was founded in 1991 and is headquartered in Irvine, California.
Recent News: Broadcom Corporation Class A
|2015-10-05 10:40:29
|M&A Daily: Paving Way For Apple Car?
|2015-10-05 08:00:00
|Broadcom Enables New Open Source Networking Innovations with Release of OpenNSL 2.0
|2015-09-29 18:52:59
|Bloomberg: Ethernet chipmaker Aquantia planning IPO
|2015-09-29 12:10:00
|Meet 30 National Finalists of the Broadcom MASTERS® Middle School STEM Competition in Silicon Valley
|2015-09-29 00:00:00
|Filing of certain prospectuses and communications in connection with business combination transactions - Form 425
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CSU Channel Islands Choir Announces Spring Concert, "Sounds of Love and Nature"
Camarillo, Calif., April 29, 2013 – The CSU Channel Islands Choir invites the public to "Sounds of Love and Nature," the group's spring concert. The performance will be held Saturday, May 11, at 2 p.m., at St. Columba's Episcopal Church, 1251 Las Posas Road, Camarillo.
The choir will be joined by children of the Pleasant Valley School District Chorus. Artistic Director Dr. KuanFen Liu will conduct. The accompanist will be Fern Fay. Admission is by free-will donation; $20 is suggested. Parking is free.
The CSU Channel Islands Choir is a diverse campus/community group that meets as a weekly class in the University's Performing Arts Program. Led by Professor KuanFen Liu, the choir offers participants exposure to a wide range of musical genres and periods, as well as the opportunity to perform publicly on campus and throughout Ventura County.
Channel Islands Choral Association (CICA) is the choir's sponsor. CICA is a 501(c)(3) organization that serves Ventura County, bringing music education and performance to the local schools and community. For more information, call 805-484-6601 or visit the CICA website at www.cicachoir.org. To learn more about the CI class, as well as upcoming events and auditions, visit the choir's website at http://choir.csuci.edu.
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Animal abusers in Colorado may soon find themselves on a list they probably would rather not belong to – an animal offender registry that acts similar to a sex offender registry and would require offenders to be listed for up to five years in a public database.
The bill, House Bill 1087, went before the Colorado House Committee yesterday, and would cost about $160,000 to implement if passed. Supporters of the bill say it would help keep people safe as well, pointing out that many serial killers begin by abusing animals.
Whatever the motivation behind this bill, I think it is a great start toward helping to save the lives of animals. Suffolk County in New York was the first place to adopt such a bill, but states such as Arizona, California, Maryland, Rhode Island and Tennessee are considering similar bills.
Though this does nothing to prevent new offenders from abusing animals, it may help to ensure they do not have such easy access to their victims in the future.
According to the Quick Poll found beneath the reference article, 80 percent of voters believe animal abuse should be tracked better, while a mere 20 percent say it would cost the state too much and should not be treated as seriously as sex offenses.
I don't think anyone intends to compare animal abuse to an offense on humans, but the idea of a registry is a solid one and can potentially help to save the lives of not only animals, but also humans.


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All Rights Reserved
The Pasco County School Board is taking another look at its athletic transfer policy, a policy that was upheld in a court case this past school year. Board member Steve Luikart asked for a workshop on the policy next week after a mother and father complained that their sons aren't being allowed to play sports after transferring to Ridgewood High School from Fivay High. The policy says a students must sit out a year from sports after transferring from one high school to another. There is an appeal process, though, where the student can go before a committee and make the case that the transfer was for legitimate reasons that had nothing to do with sports.
The Pasco County School Board is taking another look at its athletic transfer policy, just one year after the policy was put into place in an effort to prevent students and coaches from circumventing recruiting rules.
Board Vice Chairman Steve Luikart asked for a workshop to discuss the rules next week after a mother and father complained Tuesday that their sons aren't being allowed to play sports after transferring to Ridgewood High School from Fivay High.
The policy is definitely not clear enough as it should be, Luikart said.
The policy says student athletes must sit out a year after transferring from one high school to another. There is an appeal process where the student can go before an Athletic Transfer Participation Committee and make the case that the transfer was for legitimate reasons that had nothing to do with sports.
If the committee rules against the student, the student can appeal to the superintendent's office.
Although Superintendent Kurt Browning agreed to schedule a board workshop for Aug. 19, he expressed reluctance to tinker with a policy that withstood a court challenge last school year after the parents of a soccer player filed a lawsuit against the school district. A circuit judge ruled that the school board has the authority to place limits on who is eligible to play sports.
As a district, as a board, either we have a policy that regulates or governs students transferring from one school to the next to play sports, or we don't have a policy at all, Browning said.
The parents of the two boys who transferred to Ridgewood High told school board members that sports provide an outlet for students, helping to keep them focused and out of trouble. They said there is no clarity for parents about why the district makes the decisions it does regarding eligibility.
"I have always put my children in sports to keep them on that straight path," the mother, Charlotte Jones of Port Richey, said.
Tom Wellington, the athletic director at Ridgewood High, told the board the policy was put into place for good reasons, but has led to some bad results, including the decision in this case. He said the process has too much subjectivity, and that when the boys went before the committee July 29, a committee member accused a Ridgewood coach of recruiting them with no evidence, just a hunch.
"I know there haven't been a lot of kids who have been denied (athletic participation)," he said. "If a few kids are getting denied, it's a few too many for something they can't control."
Phil Bell, the district's supervisor of athletic programs, said even with the policy, it's rare for a student to be denied eligibility. Last school year, 183 transfer students went before the committee seeking to gain eligibility, and the committee ruled in favor of 173, allowing them to play sports, he said.
Of the 10 who were denied, eight appealed to the superintendent's office where their cases were heard by Ray Bonti, the district's executive director of support services. Bonti overruled the committee in two cases, clearing the way for those students to play sports, but upheld the committee's decision for the other six.
For those six to be denied, there were probably significant reasons, Bell said.
Without the policy, Bell said, when questions are raised about eligibility and recruiting, he would have to go to the school and investigate why the student had transferred. At that point, if it was determined there was a violation, the school could face the possibility of forfeiting games and incurring fines from the Florida High School Athletic Association.
In other action Tuesday, the school board approved the district's Student Progression Plan after Browning dropped from it a proposal to eliminate high school valedictorians and salutatorians beginning with the class of 2018.
The issue had drawn numerous complaints. Browning told the board the district will revisit the idea next year, though.
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I dont''t own the rights to that image. I''ve been trying to locate the eps formate but can not find it. Only JPEG format.
ok. thanks for that information. this is my first time soing anything like this and would not want to get anyone in trouble. thanks for enlightening me.
no problem. thank you for letting me know. I appreciate it.
It does now..lol..it didn''t originally as I am new to all this and have never created a logo before. but you are right, the best solution is for everyone to submit their own design.


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As a result, school officials say, rather than receiving a diploma from their high school, these students will get "certificates of completion," which is hardly enough recognition, considering their years of difficult classroom work.
The on-again, off-again exit exam requirement came about after the recent settlement of a lawsuit filed against the state by a rights group for the disabled. For the last two years, the group was able to get an exemption for students with learning disabilities, but failed to do so this year.
Without the exemption, a good number of the disabled students in the Mountain View-Los Altos High School District may not be eligible to graduate with their peers this school year. Students get the chance to take the math and English portion of the exit exam up to six times between their sophomore and senior years, and must achieve a passing grade on both to be eligible to receive a diploma.
Last year, school officials say, 63 local students did not pass the exit exam test, including 33 from special education and 21 who qualified for the exemption. The district does not yet have a firm count of how many students may miss or fail the test this year, but expects to know in a few weeks.
All of this angst surrounding the test could vanish with a stroke of a pen from state Superintendent of Schools Jack O'Connell, who wrote the legislation requiring that all students take the exit exam when he was a state senator more than 10 years ago. The measure has proven highly controversial, and rightfully so, due to its absolute requirement that all students must pass to receive a diploma.
Mr. O'Connell is way off base on this one. It should be up to local teachers and administrators, not a rigid state law, to decide if some special needs students should receive a diploma. We are not calling for the state to abandon the exit exam, but it should provide a way for local educators to award a diploma if a student has completed all the requirements.
Most students with a learning disability work very hard just to attain the minimum requirements for graduation. To take away the credential showing they have reached that goal is hardly fair, which is why we urge Mr. O'Connell to exempt these learning-disabled students from the exit exam. It's the least the state can do to honor those who work so hard to achieve what other students can accomplish with very little effort.


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In February, following the loss of most of the Netherlands East Indies, the ABDA Command was done away with. From that point forward, the Pacific became an American responsibility, with the British assuming authority from Singapore to Suez. Jiang continued to control the China Theater, and Wavell, headquartered in India, had authority over India and Burma. At the same time, Stilwell formed a new headquarters, the American Armed Forces: China, Burma, and India. The command included the small prewar U.S. military advisory group and Major General Claire Chennault's American Volunteer Group (AVG, known as the Flying Tigers), later a part of Tenth Army Air Force.
This command structure continued until the August 1943 Quebec Conference, when Churchill and Roosevelt agreed on the establishment of the more integrated South-East Asia Command (SEAC), with British Admiral Lord Louis Mountbatten as commander and Stilwell as his deputy. Operations in Burma were separated from those in India, now under command of General Claude Auchinleck, commander in chief there since June 1943.
Designed to improve Allied military operations in the region, the new command structure did not achieve that end. Conflicts and different goals remained, with Jiang being the chief problem in Allied cooperation. But the British and Americans also had different priorities. The British were mainly concerned with the defense of India and preventing the Japanese military from exerting an influence on growing Indian nationalism. London saw defeating the Japanese in Burma as the chief means to bring about that end, rather than as a means to channel supplies to China. British military efforts in Burma would thus ebb and flow. The United States was primarily interested in building up China's military strength, and Burma would be a chief route for these supplies to reach China; indeed, President Roosevelt saw China taking its rightful place as a major world power at war's end. U.S. military planners also saw China as a potential location for heavy bombers to be used in the strategic bombing of Japan. These conflicting views were exacerbated by the personalities involved. Stilwell continued to feud with Jiang, and he also held that the British were more interested in defending their Asian empire than in fighting Japan. Stilwell wanted to recover Burma, and he worked hard to improve the fighting ability of those Chinese army units he could influence. The only way to get substantial military heavy equipment to China—which was essential if its fighting ability was to improve dramatically—was by way of Burma, and so construction of the so-called Ledo Road there became imperative. In the meantime, the United States undertook a massive logistical air supply operation to China from bases in India over "the Hump" of the Himalaya Mountains, the highest in the world. The ubiquitous C-47 (DC-3) aircraft was the workhorse for much of this campaign.
Construction of the 478-mile-long Ledo Road to connect the old Burma Road from Ledo, India, to Bhama, Burma, took 25 months. The new road ran through jungles, over mountains, and across 10 rivers. U.S. Army Brigadier General Lewis A. Pick had charge of this vast project, one of the major engineering accomplishments of the war.
Meanwhile, Jiang refused to yield operational command of the growing Chinese military establishment to General Stilwell. Jiang saw the Chinese forces as much as a means to defeat the Communists in China after the war as to destroy the Japanese forces in the current conflict. Stilwell fervently believed that, properly trained and equipped, Chinese soldiers could be the equal of any in the world, but all of his efforts to eradicate corruption, weed out ineffective leaders, and end political interference in the Chinese military were rebuffed by Jiang. The Chinese Nationalist leader repeatedly promised reforms but delivered only sufficient compliance to keep up the flow of U.S. military aid.
General Chennault and airpower advocates believed that Japan might be bombed into submission from bases in eastern China. Stilwell dismissed such views and pointed out that the Japanese could simply carry out an offensive to wipe out the bases. Nonetheless, the first production B-29 Superfortresses were sent to China from India, and an ambitious base-construction program was undertaken. Although a few air bombing missions were carried out, the Japanese responded by mounting a great ground offensive, the ichi-go Campaign, in mid-1944, during which all the bases were captured without significant Chinese ground resistance. The B-29s were shifted from CBI to the Marianas in the Central Pacific. Roosevelt now applied heavy pressure on Jiang to carry out the reforms advocated by Stilwell and place an American general, preferably Stilwell, in command of the Chinese army. Frustrated by its inability to turn China into a major theater of war, the United States increasingly used its massive naval strength to invest in the highly productive "leap-frogging" strategy of securing important islands as stepping stones toward Japan across the Central Pacific. As a result, China was more and more marginalized and downgraded to a minor theater of war, chiefly important for its role in tying down a million Japanese troops.
Stilwell, now at wit's end, reached an impasse with Jiang and was recalled to Washington in October 1944. He was replaced by U.S. Army Major General Albert Wedemeyer, a far more tractable individual bent on getting along with Jiang. The demands for reforms in the Chinese military came to an end. In effect, CBI ended in October 1944 when it was divided into two spheres of command, India-Burma and China. Stilwell's deputy, General Daniel L. Sultan, became the commander of U.S. forces in India-Burma and directed the Allied military effort in northern Burma.
The CBI featured unique air, guerrilla, and logistical operations. Among innovative military and air tactics originating in the CBI was the establishment of Long-Range Penetration Groups, more popularly known as Wingate's Chindits and Merrill's Maurauders. Utilizing air assets, British and U.S. commanders projected ground troops far behind Japanese lines, their communication and supply provided by air. Here and elsewhere, guerrilla operations were developed and intelligence and insurgency operations carried out. William Donovan and the Office of Strategic Services were active in the theater.
Finally, the CBI was a major scene of postwar confrontation. Early in the war, Japan had conquered and overrun much of China and most of the European and U.S. colonies in the Pacific. The arrival of Japanese forces in Indochina was a great blow to French influence, and the defeat of the British at Singapore had an even more powerful impact on British prestige. President Roosevelt envisioned the end of colonization after the war, but with the arrival of the Soviet threat, new U.S. President Harry S Truman was less sympathetic. Although the Philippines, India, Burma, and some other states gained independence just after the war, the process of decolonization was actually delayed in some areas, resulting in costly wars in the Netherlands East Indies and French Indochina. As for China, American efforts by Roosevelt's inept ambassador to China, Patrick J. Hurley, to mediate between the Chinese Nationalists and Communists came to naught; that vast country soon disintegrated into civil war. The United States, which had already committed to Jiang, found itself unable to adopt a neutral stance and paid the price in influence when the civil war ended in a Communist victory in 1949. Eugene L. Rasor and Spencer C. Tucker
Further Reading
Ienaga, Saburo. The Pacific War: World War II and the Japanese, 1931–1945. Oxford: Blackwell, 1968.; Levine, Alan J. The Pacific War: Japan versus the Allies. Westport, CT: Praeger, 1995.; Rasor, Eugene L. The China-Burma-India Campaign, 1931–1949: Historiography and Annotated Bibliography. Westport, CT: Greenwood Press, 1998.; Romanus, Charles P., and Riley Sunderland. United States Army in World War II: China-Burma-India Theater. 3 vols. Washington, DC: U.S. Government Printing Office, 1952–1958.; Schaller, Michael. The U.S. Crusade in China, 1938–1945. New York: Columbia University Press, 1979.; Spector, Ronald H. Eagle against the Sun: The American War with Japan. New York: Vintage Books, 1985.; Thorne, Christopher G. The Approach of War, 1938–1939. New York: St. Martin's Press, 1967.; Thorne, Christopher G. Allies of a Kind: The United States, Britain, and the War against Japan, 1941–1945. New York: Oxford University Press, 1978.; Thorne, Christopher G. The Issue of War: States, Societies, and the Far Eastern Conflict of 1941–1945. New York: Oxford University Press, 1985.; Tuchman, Barbara. Stilwell and the American Experience in China, 1911–1945. New York: Macmillan, 1970.
Eugene L. Rasor and Spencer C. Tucker


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May 2, 2014
• Live Scoring | Current Event Notes | Season Statistics
FRENCH LICK, Ind. – The Wisconsin men's golf team began play at the 2014 Big Ten Men's Golf Championships on Friday in French Lick, Ind., closing out the first two rounds of the 72-hole tournament in 10th place.
The Badgers recorded a 23-over par 311 after the first 18 holes of the conference meet held on the 7,152-yard, par-72 Pete Dye Course at the French Lick Resort. UW then improved nine strokes with a 14-over par 302 in round two to end day at 37-over par 311-302--613.
"What a day at the Dye Course it was," UW head coach Michael Burcin said. "Conditions were brutal and it's just a long demanding 36 hole walk. We are in decent shape despite not playing great overall."
Purdue stands atop the leaderboard of the 12-team field with 18-over par 298-296--594. Illinois (297-298) and Minnesota (295-399) are tied for second place after tallying a 19-over par 595. Ohio State is fourth with 20-over par 302-294--596 and Northwestern rounds out the top-five teams with 26-over par 301-301--602.
The Gophers' Jose Mendez leads the 60-player field with his 1-under par 69-74--143, while Purdue's Philippe Schweizer sits in second place with even-par 72-72--144. Illinois' Brian Campbell caps off the top-three individuals with 1-over par 72-73--145.
Wisconsin's redshirt senior Jack Watson leads the way for the Badgers after day one of competition tied for 12th with a 5-over par 78-71--149. After shooting 6-over par 78 in round one, Watson was one of only six players to shoot under par in round two, tallying 1-under par 71.
"Jack did a superb job shooting minus one in the afternoon," Burcin said. "We are excited about tomorrow and moving up the board."
Thomas O'Bryan led UW after the first 18 holes with 4-over par 76 and wrapped up round two tied for 22nd place with his 36-hole score of 8-over par 76-76--152. Redshirt senior Zach Balit tallied an 11-over par 78-77--155 to end the day tied for 43rd, while redshirt senior Robert Jacobsen is tied for 55th after shooting 16-over par 79-81--160.
Competing for the first time in the conference tournament, freshman Ben Skogen completes the Badgers' roster in 58th place with 20-over par 86-78--164.
Play resumes with round three at 8 a.m. CT on Saturday, and the tournament will conclude with the final 18 holes on Sunday starting at 7 a.m. CT.
Live scoring from the Big Ten championships can be found on Golfstat.com, and results are available at the end of the day at UWBadgers.com.
Wisconsin Results
Team Results
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Things are as bad at City Hall.
We've had a stacked Redistricting Commission from the get go. Domingo
Garcia (one of the worst 2001 State Representatives in Austin per
Texas Monthly
gets appointed to the Redistricting Commission, and immediately teams up with
Billy Ratcliff (not JWP's attorney Billy Ravkind) and Brooks Love (Chief of
Staff for Domingo's wife, County Commissioner Elba Garcia) to bring us another
ugly map of districts that make no sense.
I wanted you to see what a
year's worth of meetings have got us. I wanted you to see what one
honest man could create vs. the product of an unethical alliance between Domingo
Garcia and his wife's Chief of Staff. Don't just take my word for it
or The Dallas Morning News,
there's an incredible blog, Dallas South News
by Shawn Williams, who writes
What's wrong with Bill Betzens 2011 redistricting map -
well not a lot.
So, regardless of the skullduggery and disregard
for procedures and ethics, the end justifies the means?
Look who's running the County. The
same crowd that runs City Hall. The same crowd that runs the DISD.
The same crowd that is running all of our local government into the ground.


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There is a tournament coming up Saturday morning, Sept 24 as part of the "Grapevine Games 2011" at the Bear Creek Park course (map it). Registration opens at 10:45 am prior to trash clean-up. More information, including the full tournament schedule.
Proceeds will go to replace the locks on the baskets at the Bear Creek course so we will be able to use alternate pin placements again.


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A Love Note to the "Hypersensitive," "Too Nice," & "Takers-of-It-Too-Personally." ~ Randi Buckley
We need you.
They say: You're too sensitive. You take it too personally. You're thin-skinned. You need to toughen up.
I hear: I have no idea how in touch with the world you are, nor can I grasp the depths of your empathy, from which I benefit. It's like you can see colors that are naked to my eye.
You carry the awareness of others—of those far away, those unseen—in your heart on behalf of us all. You are the torchbearer of the forgotten. You bear the weight of others' pain so they have a lifeline to the rest of humanity. You take on my share of pain when my words sting you. I can't imagine the space you hold so that others can feel cared for and acknowledged, even when no one else can see that you're doing this.
You bear witness so that we know, so we cannot forget. Your mere presence is equanimity. Your light is omnipresent. Your energy is generously given in service of your ability to intuit and sense even the most subtle change in weather, perspective, mind or heart.
You are a barometer for how we are doing as a species. You are a canary in the coal mine of our culture, and are wrecked by violent movies and the news of pain and mistreatment of fellow humans, animals and the earth.
I'm not aware that your sensitivity can cause you physical pain. If I knew the depths of your consideration, I'd be humbled and inspired. I don't see or consider that you are a gift and should be treasured. I don't know to pay attention. I don't understand, even though I am the beneficiary of your grace.
I say: Thank you, friend. Rest and take care. We need you.
Relephant: A Survival Guide for Sensitive Types at Work.
Described as "equal parts Pema Chodron, Sofia Loren and Clint Eastwood (with a splash of George Carlin)," Randi Buckley takes women from tricky to truth, from icky to ease. She is a coach and guide for wisdom and truth when life gets sticky.
Visit her website at randibuckley.com or email her at firstname.lastname@example.com.
Editor: Thandiwe Ogbonna
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21 Responses to "A Love Note to the "Hypersensitive," "Too Nice," & "Takers-of-It-Too-Personally." ~ Randi Buckley"
Thank you! This is a gift.
Love this. As someone who has been told 'You are too sensitive' all her life and knows that this is exactly what makes me good at what I do, I salute you Randi.
I thank you with all my heart.
"I say: Thank you, friend. Rest and take care. We need you."
Now, if only these words of reassurance could help me with my chronic light sleeping and insomnia, living in conditions adverse to getting a good night's sleep (no, I don't live in a cheaply constructed college dorm–it could only play one on TV) …
Namaste, thank you!
That was absolutely lovely <3
Such a gift… to realize, our sensitivity as human beings is one of THE most precious gifts we have. And… what I have discovered, is that truly, all humans are sensitive. Even the big giants who may not look it at first glance. Some of us expose it more through our tears. Our exposed emotions. We are the lucky ones. Thank you for this Jewel, Randi Buckley! I know many I am going to pass this on to
Beautiful, Randi!
[…] Did you know the people who are the strongest are usually the most sensitive? […]
[…] I have a thin skin, but I still don't care what you think of […]
As someone who is not only hypersensitive, but is in recovery from Borderline Personality Disorder, I wish that others could see this in us, instead of stigmatizing us.
thank you for this it's something those that "care too much" need to hear!
you're welcome and thanks for noticing lovely – great when that happens…..you are a sensitive person too to have written this beautiful piece & we are all sensitive people, some have just disconnected because the modern world teaches you that but it's not true
Yep, this is gorgeous!!!
You made me cry.
Hugs, Sean.
I am a sensitive Cancer, and my love is a fierce Leo. I try not to take his joking comments personally, but sometimes, ouch. What can I do to make him understand that just because he didn't MEAN to hurt my feelings, doesn't mean my feelings aren't valid and he should still apologize? I mean, if you accidentally step on someone's foot, even though it was not intentional, you still say you're sorry to show you care, right? Apology is not necessarily admission of fault or guilt. Sometimes it's just compassion. :-/
I disagree.
I am touched by this where there are no words. Experiencing the gift of this with gratitude… thank you.
If this post strikes a chord with you may I recommend a book? I was told about it by a very perceptive person and it has really helped me. I re read it often just to remind myself that it is okay to feel the way I do. The Highly Sensitive Person (How to thrive when the world overwhelms you) by Elaine N Aron
I think some of us are just made to feel the pain of others,
as are own………….I have been a pain carrier all of my life…and it huts bad and I am getting tired of the baggage….but, my soul doesn't know how to let go…………..
whenever I'm talking to someone about an emotional response I've had to something… When they're maybe looking at me funny or making fun… I simply state, " I feel things deeply.. And I'm ok with showing it. It's my strength."
I love the ability to be empathetic. Do I wish I were less emotional in certain settings? Sometimes, but I also recognize I'm passionate … And I'm ok with showing that too. Thanks for the article.


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BackgroundBased on the popular children's book series, Wizardology allow players to immersed themself in a visually stunning adventure taking place across the globe. They'll collect objects, search for clues, interact with the environment and use the Wii remote as a wand. As a Wizard's apprentice, players will learn a variety of magical skills needed to free the great Wizards of the world from the evil sorceress Vivienne and recover the great book of Wizardology.
- Genre: Fantasy Adventure (PC)
- Developer: NiK NaK Games
- Publisher: Codemasters
Released North America Jun 1, 2010