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Monday 4th March 2013 1 Comment
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Former Lombard Finance directors Sir Doug Graham, Bill Jeffries, Lawrie Bryant and Michael Reeves began their attempt to reclaim their reputations in the Court of Appeal, saying they couldn't have foreseen the 'perfect storm' that engulfed finance companies starting in early 2008.
All four were in the Court of Appeal in Wellington, accompanied by family members, to hear their lawyer Jim Farmer QC begin his case. The hearing is set down for four days though that includes one day for the Crown to appeal against the sentences handed down.
The four avoided the jail term the Crown had sought and were sentenced to community service in March last year after being found guilty of making untrue statements in investment documents and advertisements in late 2007 and early 2008. At sentencing, Justice Robert Dobson said the damage to the men's reputation of a criminal conviction couldn't be underestimated.
Farmer argued today that projections the Lombard board had in signing off on the prospectus in late 2007 gave them some confidence the finance sector climate could improve and that in any case the prospectus did broadly outline the key risks for investors. Those included being a lender on terms outside the parameters of retail banks.
That included the risk Lombard would not be able to repay its borrowing obligations in the event of an extreme loss of confidence in the sector.
"The unforeseen and dramatic change in February 2008 reflects the risk," Farmer said. "The extreme event, the perfect storm arrived."
The 4,400 Lombard Finance investors were owed $127 million at the time of the receivership in April 2008. The failed company's major asset was a property loan book of 27 loans with a book value of $136.8 million, mostly for bare land subdivisions or development properties. Of the 27, only nine were first ranking security.
Finance company failures began in 2006 and the following year big names including Bridgecorp, Nathans Finance, Geneva Finance and Capital + Merchant had joined the list.
Still, 2008 was to yield even greater carnage, with 22 finance companies failing or going into moratorium.
Justice Anthony Randerson asked Farmer to provide a full time-line of industry failures and asked whether he viewed the failures of Bridgecorp and Nathans in 2007 as being well known in the market place.
"If anything, the reinvestment rate remained very strong up until the time of the prospectus even though there was concern about finance company collapses," Farmer said.
At the sentencing last year Justice Dobson said the offending of the Lombard investors was serious but not of the same magnitude of those involved in Bridgecorp or Nathans Finance.
Sir Doug told BusinessDesk at the break that there has been something of a baying for blood with finance company directors, with few if any escaping censure. He said the media hadn't helped with its salacious portrayal of the Lombard directors.
Graham and Bryant each received 300 hours community service and were required to pay $100,000 each in reparation, while Jeffries and Reeves were sentenced to 400 hours community service.
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MARKET CLOSE: NZ shares plunge after Brexit vote; Xero, A2, banks hit hard
NZ dollar, swaps tumble as Brexit confounds pollsters; central banks likely to act
Fronde chairman Jon Mayson ousted, two other directors also exit
NZ interest rates plunge as Brexit gets closer to reality
Smiths City annual profit drops 30%, sales rise as retailer ditches low-margin business
Cavalier raises 2016 earnings guidance on better performance from broadloom carpets
NZ stocks turn as UK referendum result keeps investors guessing
Update: APN and NZME pay $36.3 million to settle disputed tax avoidance and other cases
Ryman board seeks 9% pay rise to cope with bigger business
NZ dollar spikes then drops in illiquid market as UK results dribble in


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Bumpy and rough! ► Open205-229 W Burleigh St Milwaukee, WI 53212, USANeeds replacing!· Reported by An anonymous SeeClickFix user · Share · Flag Flagged
Rough road ► Open2635 N 8th St Milwaukee, WI 53206, USAExtremely rough and over patched street.· Reported by An anonymous SeeClickFix user · Share · Flag Flagged
Pot hole ► Open612 E Burleigh St Milwaukee, WI 53212, USACorner of Holton and burleigh
North bound
terrible hole ► Open3299-3337 West Good Hope Road Glendale, WisconsinRight at the tracks in the eastbound lanes of Good Hope at the rail crossing east of Teutonia is a deep, sharp, tire-damaging hole.· Reported by Mark · Share · Flag Flagged
Accident with huge backup ► OpenI-94 Milwaukee, WI 53214, USA94 east by Miller park
Deer splattered on rd ► OpenWi-145 Milwaukee, WI 53224, USA
Terribly rough bumpy road ► Open5526 W Fond Du Lac Ave Milwaukee, WI 53216, USAThe other side of the street is under construction but this west bound side needed it worse! I've already popped a tire on the potholes and have came close to bottoming out with my car. Unfortunately there is no other route to my work or I would have taken that long ago
Huge pothole ► Open2700-2704 N 4th St Milwaukee, WI 53212, USAOn the corner just before the stop lights in the "straight" lane
Bad road under heavy trucks shakes houses ► Open1720 S 1st St Milwaukee, WisconsinIt's starts around 5:30 am. When a heavy truck or bus drives down 1st Street at a decent clip because the light is green it bounces over the buckled road shaking the whole house. The noise sounds like someone in the middle of the house with a bass drum and the shaking is so bad it wakes you up. This just started after these last two super cold winter causing damage. The situation is stressful and constant. The road should either be fixed or trucks need to be stopped from driving down here. I am talking about the road in between Maple and Mitchell on 1st St.· Reported by a better MKE · Share · Flag Flagged
constant shaking house (Guest)I have been suffering from chronic insomnia due to this issue. I have found since writing this I am actually starting to be woken at 3:30 am and am fully awake by 5:30am. It is a living @#$%. I can not get more than a few hours of sleep before I am woken by the shaking and banging of the semi trucks bouncing over the buckled road. Can anyone suggest what I can do to maybe get this looked at by the city or something for sound proofing or I don't know what, but if something isn't done, it is uninhabitable.
bad roads HELP! (Guest)
I want to add that I discovered this effect is due to the actual method of repair that was done to this section of road. Instead of paving it, huge block slabs were set in place. This creates seams at regular intervals on the road. The huge overweight trucks that are obviously too heavy for this street, Bouce over these seams, slamming into the road every couple of yards. Making a huge bass sound and shaking the houses.
Why can't we have a sign that says no trucks? Why can't we at least stop them from coming this way? They can go down KK instead which is not residential and they won't be bothering anyone.
It just sucks to live like this.
a better MKE (Registered User)still loud
4 VotesFix it! Voted!
Buckled road! ► Open4111 S 51st St Milwaukee, WI 53220, USA51st Street northbound at utility easement. Bone jarring as well as suspension wrecking buckled area. No way around it as it spans the width of 51st Street. Basically the whole stretch between Coldspring road and Howard Avenue on 51st street is buckled up!· Reported by Jim · Share · Flag Flagged

subset: commoncrawl


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The Donna Reed Show TV Show Watchlist
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SAFETY ALERT – Inflatable lifejackets equipped with Hammar Hydrostatic Inflator manufactured before 2006.
This Safety Alert was recently distributed to shipping authorities and advertised in the trade press, boating magazines and digital media worldwide. The Hammar Hydrostatic Inflator is attached to the lifejacket with a sealing ring. In 2006, CM Hammar upgraded the sealing ring with new state of the art raw materials, to eliminate potential defects and increase long term durability. A small number of sealing rings manufactured before 2006 have suffered premature material degradation, most likely after being exposed to extreme environmental conditions. When exposed to high temperature and high humidity for a long period of time, the sealing ring might become stiffer, change colour and in severe cases cracking of the plastic may occur. The change does not occur overnight and can be detected at the recommended service or inspections.
CM Hammar are concerned that a damaged sealing ring might put the user at risk. We recommend owners of lifejackets manufactured before 2006 that have not been serviced recently to contact the nearest authorized service station for an annual service. The date of manufacture can be identified on the inside of the lifejacket cover. Owners who still want to do the check of the sealing ring themselves are advised to visit www.cmhammar.com/inflator for further information. Lifejackets manufactured after 2006 are not affected by this Safety Alert.
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Earlier this week, Mazda announced that it is once again profitable, having its first annual net profit in five years.
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The proposed fight between Daniel Cormier and Dan Henderson is near being finalized, and the winner of the bout will likely earn a shot at the UFC light heavyweight title, according to a report on Wednesday.
UFC Tonight reported that the fighters have both agreed to the UFC 175 match-up, and have been told that the winner will be next in line for a shot at the belt after Alexander Gustafsson.
As of now, current title holder Jon Jones is preparing for a fight with Glover Teixeira later this month at UFC 172 in Baltimore. When that match-up concludes, the winner will be paired with Gustafsson on a fight card to be announced thereafter.
MMAWeekly.com confirmed with sources over the weekend and earlier this week that the Cormier-Henderson fight was in the works for the UFC 175 pay-per-view. The fight is expected to be made official soon.
The July 5 card, which takes place in Las Vegas at the MGM Grand Garden Arena, will be headlined by a middleweight title fight between champion Chris Weidman and Lyoto Machida.
At 45 years of age, Dan Henderson has been fielding questions about possibly retiring for several years. He now appears ready to entertain the idea. read news >>
From Yahoo Sports: Hendo's contract is expiring and he's got plenty of options on the table. In his own words: 'This could actually be the last fight.' read news >>
Watch Beneil Dariush earn a knockout (punches) victory over James Vick at UFC 199 in Inglewood, California. read news >>
Dan Henderson picked up an emphatic win at UFC 199, knocking out Hector Lombard in their main-card fight on Saturday night's pay-per-view in Inglewood, California. read news >>
Dan Henderson (32-14) is known for his "H-Bomb" of a right hand, but at UFC 199 he brought out the "H-Bow" against Hector Lombard (34-6-1, 2 NC). The two veteran middleweights went toe-to-toe in one read news >>
Middleweight legend Dan Henderson took on the explosive Hector Lombard on Saturday on the UFC 199: Rockhold vs. Bisping 2 main card. Check out the video highlights. read news >>
MMA legend Dan Henderson discusses the possibility of retirement following his UFC 199 knockout win over Hector Lombard. read news >>
Michael Bisping realized his dream on Saturday night, winning the middleweight championship at UFC 199, but Dan Henderson stood atop the payroll. read news >>
The most anticipated event in a good long while, UFC 200 is packed with names in a way never seen before in UFC history. The full card is as follows: Main Card (Pay-Per-View) Daniel Cormier vs. Jon J read news >>


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Desert Sunrise At Horseshoe Bend is a photograph by Matt Tilghman which was uploaded on July 19th, 2011.
Seen here at sunrise, the Colorado River takes a hairpin turn at Horseshoe Bend, near Page, Arizona. The deep sandstone canyons are part of the same... more
Desert Sunrise At Horseshoe Bend
Matt Tilghman
Seen here at sunrise, the Colorado River takes a hairpin turn at Horseshoe Bend, near Page, Arizona. The deep sandstone canyons are part of the same geological formation as the Grand Canyon, though this site is just outside the National Park's borders.
July 19th, 2011
Viewed 1,466 Times - Last Visitor from Seattle, WA on 06/28/2016 at 8:46 PM
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Comments (78)
Oh, Matt, this is an absolutely amazing view of the Grand Canyon at its best. The rich color of the rock and the reflection of the stormy sky in the River are really spectacular. A like and a favorite by Charles Robinson, Administrator of the Grand Canyon National Park Group.
Wow!!! An amazing view and capture!
Incredible! May I ask what lens did you use?
Fantastic f/v
Awesome shot!V/F
Awesome !!!!! V
Wonderful Matt! v
Very nice!
Gorgeous image! v
nice. v55
Very nice! V
wow - epic landscape!
Awesome view!
Wonderful image!
Amazing! v
wow.. makes me dizzy looking down to that water. V
Excellent, love the threatening storm clouds overhead.
wow v
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An Obama administration plan to allow energy companies to search for oil off the Atlantic coast is drawing sharp criticism from advocates for marine life. At a rally in downtown Savannah Tuesday a coalition of environmental groups said, the proposal known as seismic air gun testing could destroy endangered right whales and sea turtles.
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A massive federal report on the half-billion-dollar harbor deepening project in Savannah doesn't examine the project's long-term impact on employment. Critics doubt the project will bring more jobs. Proponents say the link between the port and jobs is obvious.


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Big-league green in a small box
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LEED Platinum is an impressive standard and I applaud the architects for achieving it. Also, although I wouldn't be comfortable living in one, I have no objection to modernist styling per se, when well done. This is a beautiful example. The thing I find sadly ironic is how often "green" design standards are married to this kind of modernism. Unlike Wright, who wanted his houses to be "of the earth" and not to sit "on the earth," this house is almost defiantly inorganic. Why can't green design look harmonious with nature? More important from an environmental point of view, why couldn't the landscape be as green as the house? That flat lawn, nearly astroturf in aesthetic value, is just about the worst landscape for the kind of sustainability LEED promotes.
I like the aesthetics of this house, and if it doesn't fit in with the adjoining houses, that it largely because it is a lot more serious piece of architecture.
However, the assertion that it is green is pretty questionable: In a market economy the cost of anything reflects the resources which went into producing it and bringing it to market. At $615 per square foot, I suspect this house used triple the resources per square foot as conventional new houses.
Aesthetic issues aside, a house which is "short on space for things like furniture, shoes and television sets" is likely in the long run to be radically remodeled or just torn down and replaced: either uses even more resources.
It may be (as was explicitly stated in the article) a wonderful prototype for a green house, but it isn't itself green: it's a black hole for resources.
That's OK in a prototype: they are fearsomely expensive. It does seem a shame though that the owners apparently refused to consider the needs of the next owners. Even in a prototype, a house which won't survive the first owners is a mighty waste of resources. And that is a very powerful eco-statement indeed.
For those of you who continue to comment on the sustainability aspects of this house (and other buildings) and LEED without knowing what the points are or how buildings are judged please read --> http://www.usgbc.org/DisplayPage.aspx?CategoryID=19
Amazing! Love the design. All the posters who poo-poo'ed the house need to think outside their own little brain of a box for once. Live a little!
Hi again, everyone, thanks for the wonderful comments. Juli, I think a lot of people have the reaction you did to the price. One thing that I think we must commend this couple for is working with local contractors exclusively, many of whom now have skills in sustainable building who did not previously. This could have a wonderful impact on building in Racine. Eddee, I'd have to disagree with you about Frank Lloyd Wright. One of his homes sits similarly perched on a bluff just a short distance north of the home I wrote about here. In comparison it feels like a hulking mass, a very bulky and impenetrable architecture. It's hard to explain and perhaps not easy to get a sense of from the photographs, but this house feels very transparent. It doesn't mimic the natural world conceptually (and badly) -- it creates a visual and direct access to it. Sitting inside of it on the first level is like being outdoors.
Nice house! It's location and lake views compliment the lightness of
the overall design. Well done. Landscaping is perfect/minimal--nothing
more needs to added or taken away. Did you have a chance to go
down the stairs to lake level?
All the contractors "learned" on this one. Hence, the higher price tag.
For all those in their piece of various shades of tan generica ugdivisions..... you can keep that garbage. They do stuff like that in China where everyone dresses the same. What does it matter someone does something a little different with some modern styling?
Some people like better wine while others think sweet insipid wine is best. It comes from a limited palate and lack of understanding of what "good" actually is. Maybe a little education is in order to appreciate some modern construction. I live in a Craftsman style home next to a Victorian, one with Spanish influence and a Tudor. Variety is a good thing. Wouldn't mind a modern home in the neighborhood for something different to look at. I'm just glad it's not some shade of brown.
Eddee - Sep 27, 2010 2:37 PM...LEED Platinum is an impressive standard and I applaud the architects for achieving it.
I disagree. Not enough credit is given for efficient lighting, heating, shading and exterior (word chosen carefully) sun blinds. How about underground earth tube for fresh air intake, etc....
Now if you could take this concept of new construction to the pre-fab
level...THAT, would be better yet!
For those curious about LEED and energy performance, 27% of the LEED for Homes rating system points are in the Energy and Atmosphere area. The rating system is based off performance testing of the home as constructed - not just designed - using the successful Energy Star for Homes protocol, which results in a HERS score. The Racine home's performance testing resulted in a very respectable HERS score of 33 - representing that it will use 33% of the energy as a typical new home constructed to code. For more information on the home's R-value and other construction attributes, you can view the LEED for Homes Project Profile at the provider's web site: http://www.leedforhomesillinois.org/il-project-list/
One final note - keep in mind the cost per square foot folks are calculating based on the 1.2 mill figure includes the cost of the land, so it is not the true construction cost.
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South africa vs gabon score 2012 6/15
Friendly 2012 - World - Worldwide Soccer
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South Africa vs Gabon score
information, played on Friday June 15 ,2012 on a Friendly 2012 soccer match:
Current match Status Gabon vs South Africa:
has finished
South Africa vs Gabon Final Result:
Winner is South Africa with final score of 3-0
South Africa vs Gabon Goals:
62' South Africa (Tshabalala), 72' South Africa (Modise), 90' South Africa (Mashaba),
15 june - Friendly 2012
Has finished
South Africa
Goals: 62' South Africa (Tshabalala), 72' South Africa (Modise), 90' South Africa (Mashaba),
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Barcelona vs Bayern Munich score 2013 july 24 - Bayern Munich v Barcelona Results
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The Little Graphic that Could: Overcoming Facebook's 20% Rule
A new rule on Facebook is changing the design game for custom images in marketing and advertising. Graphics–particularly custom graphics–account for a significant amount of internet traffic. The design of these graphics is now being governed by the 20% text rule, turning an art into a science and forcing designers to steer dangerously close to stifling their own creativity....Read more
3 Ways You Can Use Visuals to Impact Social Media Customer Engagement
This is a special guest post by Erica Bell, a small business writer who focuses on topics such as customer service and social media trends. She is a web content writer for Business.com. Designers and marketers are becoming more closely aligned as social media moves toward more visually driven platforms. Pinterest, Vine and Instagram are just some of the major players...Read more
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Serie A
Serie B
Champs Lge
Euro 2016
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'Good chance to win Champions League'
Max Allegri believes his Juventus side have a 'good chance' of winning the Champions League against Barcelona.
Allegri: 'Focus on Inter, Coppa'
Juventus Coach Massimiliano Allegri warns his players not to be distracted by the upcoming Champions League final.
Morata: 'Not thinking about Madrid'
Juventus striker Alvaro Morata insists he's not thinking about a return to Real Madrid, but says scoring against them was 'painful'.
Sacchi offers Juve advice
Arrigo Sacchi congratulates Juventus for reaching the Champions League final, and offers advice on how to beat Barcelona.
Benitez in Madrid frame?
Juventus' Champions League semi-final victory could affect Napoli, with Rafa Benitez reportedly a candidate for the Real Madrid job.
Tavecchio: 'Juve good for calcio'
FIGC President Carlo Tavecchio lauds an 'amazing achievement' by Juventus after the club reached the Champions League final.
Toulalan has Juve regrets
Monaco midfielder Jeremy Toulalan admits seeing Juventus in the Champions League final causes him regret.
Allegri: 'Historic year for Juventus'
Massimiliano Allegri describes Juventus' season as 'historic', and predicts people will tell their children about it.
Lippi: 'Juve like my Italy'
Marcello Lippi sees similarities between Juventus and his World Cup winning Italy side - 'I hope the outcome is the same'.
Birindelli: 'Allegri fantastic'
Former Juventus defender Alessandro Birindelli praises 'fantastic' Max Allegri, and believes the club's success is good for Italian football.
Chiellini: 'Juve can beat Barcelona'
Giorgio Chiellini said Juventus are "convinced we can beat" Barcelona in the Champions League Final after eliminating Real Madrid.
Evra: 'Allegri changes the menu'
Patrice Evra reveals his half-time advice to Juventus and why Max Allegri's "menu" was crucial in the Champions League.
Vidal: 'Game of our lives'
Arturo Vidal said Juventus will play "the game of our lives" against Barcelona in the Champions League Final.
Tevez: 'Now for Messi'
Carlos Tevez is looking forward to facing Leo Messi in the Champions League Final between Juventus and Barcelona.
Coppa Italia Final on May 20
As Juventus have reached the Champions League Final, the Coppa Italia Final against Lazio is moved to May 20.
Ramos: 'Juve deserved it'
Real Madrid defender Sergio Ramos congratulated Juventus on a "deserved" Champions League Final.
Marotta: 'Juve try to keep Morata'
Beppe Marotta hails Max Allegri's "intelligence" and said Juventus will try to keep Alvaro Morata from Real Madrid.
Ancelotti: 'Madrid did all we could'
Carlo Ancelotti said Real Madrid "did everything we could" against Juventus and admits the club will "evaluate my work."
Morata hurt by Bernabeu jeers
Alvaro Morata admits he was hurt at Real Madrid fans jeering him in the Bernabeu, but Juventus "can continue dreaming."
Allegri: 'Courageous Juve'
Max Allegri reveals he told Juventus to "have courage" against Real Madrid to earn their spot in the Champions League Final.
Buffon: 'Destiny in Berlin'
Gigi Buffon said it was "destiny" that Juventus reached the Champions League Final in Berlin, where he won the 2006 World Cup.
CL: Juve conquer Madrid!
Juventus will face Barcelona in the Champions League Final after eliminating Real Madrid 3-2 on aggregate.
'No Juve cameo in Madrid'
Director Beppe Marotta insists Juventus "are not here for a cameo appearance" against Real Madrid.
Marotta: 'Juve will attack Madrid'
Juventus director Beppe Marotta said they "cannot sit on the laurels" of their first leg win over Real Madrid.
Line-ups: Real Madrid-Juventus
Paul Pogba and Karim Benzema make their comebacks from the start as Juventus visit Real Madrid in the Champions League semi-final.
LIVEBLOG: Real Madrid v Juventus
Join us for all the build-up and action from the Champions League semi-final between Real Madrid and Juventus.
Juventus request water breaks
It's claimed Juventus have asked UEFA for water breaks during tonight's Champions League clash with Real Madrid.
Juve rely on 'Fantastic Four' in Madrid
Juventus look set to deploy the 'Fantastic Four' in midfield for tonight's Champions League semi-final second leg.
Buffon: 'Larsson like Ronaldo, Ibra'
Juventus goalkeeper Gianluigi Buffon brackets Henrik Larsson with Cristiano Ronaldo, and believes in the Champions League.
Vidal: 'Semi-final a dream'
Juventus midfielder Arturo Vidal describes tonight's Champions League semi-final with Real Madrid as 'a dream'.
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Juve's Alves pursuit makes sense
Roma CL return bad for Italy
Juventus pay the price
Wasted chances Real problem for Roma
Milan on the march
The good and bad of Juventus
Roma had to attack Madrid
Re-evaluation needed for Fiorentina
Juve spurn chances in Sevilla
Mature Juventus march on
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Best airfares from Moscow to NovosibirskJetradar compares airfares from Moscow to Novosibirsk with hundreds of airlines (including Lufthansa, Turkish Airlines, Aeroflot) and dozens of online travel agencies in one single place. We provide you with all the options to find the cheapest flights to Novosibirsk, you choose where to book. Also there you can find airlines special offers from Moscow to Novosibirsk. The cheapest round-trip price found within the last week was £121. The cheapest oneway price found within the last week was £68.
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Travelling from Moscow to Novosibirsk advices and facts
- The distance between Moscow and Novosibirsk is 1743 miles (or 2805 kilometers).
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Native Plants
Q. Who is Mr. Smarty Plants?
A: There are those who suspect Wildflower Center volunteers are the culpable and capable culprits. Yet, others think staff members play some, albeit small, role. You can torture us with your plant questions, but we will never reveal the Green Guru's secret identity.
Did you know you can access the Native Plant Information Network with your web-enabled smartphone?
Ask Mr. Smarty Plants is a free service provided by the staff and volunteers at the Lady Bird Johnson Wildflower Center.
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Monday - June 25, 2007
From: Richardson, TX
Region: Southwest
Topic: Grasses or Grass-like
Title: Ornamental bunch grasses to grow under live oak
Answered by: Nan Hampton
QUESTION:I love live oak trees and have one in the back yard that is growing nicely. I don't know if it's the shade or the leaf and acorn droppings that won't allow the grass to grow underneath it. Around the base of the tree liriope is growing, but I want some ground cover, preferably a grass to grow to extend to the corner of the fence under the tree. Any suggestions?
ANSWER:There are no turf grasses native to Central Texas that will grow in full shade. There are, however, two grasses that are ornamental bunch grasses that will do well in the shade (less than 2 hours of sun per day). These are Chasmanthium latifolium (Indian woodoats) and Elymus canadensis (Canada wildrye). If the area does get 2 or more hours of sun, there are a couple of sedges that will work well, Carex texensis (Texas sedge) and Carex planostachys (cedar sedge). For a non-grass plant, you could try Calyptocarpus vialis (straggler daisy) which will form a low mat in full shade and can take a moderate amount of traffic. Phyla nodiflora (Texas frogfruit will also form a mat in part shade (>2 hours of sun/day).
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August 24, 2015 - Hello, Are there a handful of species you would recommend for inclusion in bioswales throughout the US? I realize plants need to be selected based on climate, but I'm wondering if there are two or...
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Native Hill Country grasses, flowers for April garden show
March 17, 2005 - I will be a first ever (!) exhibitor in my garden club's garden show this April 7. Our theme is The Passion of Texas - my specific category is The Hill Country. Help!!! All materials I use must be al...
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August 26, 2011 - My lawn suffered a great loss of grass over the winter and the soil at the edge of the driveway is washing away with watering and the occasional rains that we have. I am trying to get the grass to gr...
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Replacing St. Augustine with native grasses in San Antonio
November 04, 2009 - I am hoping to replace St. Augustine on a sloped yard with native grass. I was wondering where I might get information on the prairie grass seed mats used by the TXDOT highway dept to stop erosion. ...
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Seep Muhly in limited sunlight.
July 01, 2015 - Can Seep Muhly withstand just 3 or 4 hours of direct sunlight in an urban setting?
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November 25, 2009
Our little girl's name is Lily. She is now a little over 5 years old and loves to snuggle and snort.
Because bulldogs are awesome. period
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Harry Potter and the Goblet of Fire - Wand Poster Print (36 X 24)
HARRY POTTER WAND is a licensed reproduction that was printed on Premium Heavy Stock Paper which captures all of the vivid colors and details of the original. The overall paper size is 36 x 24 inches and the image size is 36 x 24 inches. This print is... more
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Male wild turkey
Credit: Alice Cahill
Creative #: 147187445
License type: Royalty-freeRoyalty-free pricing is based solely on the size of the product you need, not the specific use. You don't have to pay any additional royalties on a use-by-use basis. Once you license a royalty-free product, you may use it multiple times for multiple projects without paying additional fees. (Pornographic, defamatory, libelous or otherwise unlawful use of any image is, of course, prohibited.)
Collection: Moment Open
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Male Wild Turkey Stock PhotoAnimal Themes,Animal Wildlife,Bird,California,Close-up,Color Image,Day,Focus On Foreground,Full Length,Grass,Horizontal,Male Animal,No People,One Animal,Outdoors,Photography,Side View,USA,Wild TurkeyPhotographer Alice CahillCollection: Moment Open © 2012 Alice CahillMale wild turkey in grass.


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"Diagnosis of breast disease." has been saved, and will be accessible from the My NGC page.
Go to My NGC
Alert me when this guideline summary is updated.
This is the current release of the guideline.
This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Jan. 47 p. [65 references]
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.
Breast disease, including breast cancer
All average risk patients who have a breast concern or abnormality
A literature search of clinical trials, meta-analyses, and systematic reviews is performed.
A consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) guidelines. Literature search terms for the current revision of this document include diagnosis of breast disease, MRI, mammography, breast pain and breast discharge from August 2009 through August 2011.
In the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, evidence is gathered related to a specific question. Systematic reviews are utilized first. Further literature is incorporated with randomized control trials, observational studies, etc. The evidence addresses the same population, intervention, comparisons and outcomes.
Not stated
Quality of Evidence and Strength of Recommendations
Supporting Literature
In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to direct the reader to other topics of interest. This literature is not given an evidence grade and is instead used as a reference for the associated topic and is found in the references section of the original guideline document.
Guideline Development Process
A workgroup consisting of 6 to 12 members that includes physicians, nurses, pharmacists, and other healthcare professionals relevant to the topic, along with an Institute for Clinical Systems Improvement (ICSI) staff facilitator develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, one or two members may be recruited from medical groups or hospitals outside of ICSI.
The work group will meet for 7 to 8 three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and footnotes and literature citations.
Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.
See the "Rating Scheme for the Strength of the Evidence" field.
The guideline developers reviewed published cost analyses.
Critical Review Process
Every newly developed guideline or a guideline with significant change is sent to Institute for Clinical Systems Improvement (ICSI) members for Critical Review. The purpose of critical review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes necessary across systems in their organization to implement the guideline.
All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within the ICSI.
After the critical review period, the guideline work group reconvenes to review the comments and make changes as appropriate. The work group prepares a written response to all comments.
Each guideline, order set, and protocol is approved by the appropriate steering committee. There is one steering committee each for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The steering committees review and approve each guideline based on the following:
Once the guideline, order set, or protocol has been approved, it is posted on the ICSI Web site and released to members for use. Guidelines, order sets, and protocols are reviewed regularly and revised, if warranted.
Revision Process of Existing Guidelines
ICSI scientific documents are revised every 12 to 36 months as indicated by changes in clinical practice and literature. Every 6 months, ICSI checks with the work group to determine if there have been changes in the literature significant enough to cause the document to be revised earlier than scheduled.
Prior to the work group convening to revise the document, ICSI members are asked to review the document and submit comments. During revision, a literature search of clinical trials, meta-analyses, and systematic reviews is performed and reviewed by the work group. The work group will meet for 1 to 2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate.
If there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations, it is sent to members to review prior to going to the appropriate steering committee for approval.
Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report – January 2012 . In addition, in 2011 ICSI began its transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as a method of assessing the quality of evidence and writing recommendations.
The recommendations for the diagnosis of breast disease are presented in the form of a table with a list of evidence-based recommendations and six algorithms with a total of 69 components, accompanied by detailed annotations. Algorithms and the table are provided in the original guideline document . Algorithms are provided for Evaluation by Primary Care of Patient with Symptoms of Potential Breast Disease (Main Algorithm), Evaluation of Breast Mass, Evaluation of the Breast for Nipple Discharge, Evaluation of Breast Pain, Radiologic Evaluation of the Breast, and Image-Directed Core Needle Biopsy. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.
Quality of evidence (Low Quality, Moderate Quality, and High Quality) and strength of recommendation (Weak or Strong) definitions are provided at the end of the "Major Recommendations" field.
Clinical Highlights
Evaluation by Primary Care of Patient with Symptoms of Potential Breast Disease Algorithm Annotations
See also Annotations #31, "Patient Presents with Nipple Discharge," and #40, "Patient Presents with Breast Pain," (below) for specific symptom-related history and physical.
Guidelines for primary care evaluation are initiated with a history aimed at uncovering and characterizing any breast-related symptoms. Likewise, a risk assessment should also be undertaken for identified risk factors: personal history of any breast cancer, personal history of ductal hyperplasia with atypia on previous breast biopsies, or family history of breast cancer in first-degree relatives. A high-risk patient would be one with a mother, sister, or daughter who had breast or ovarian cancer before age 50, or a history of prior radiation before age 30, or is a carrier of mutated breast cancer genes. She should be referred for genetic counseling and consider testing.
A physical examination should include inspection of the breast for any evidence of ulceration or contour changes. This includes examining the nipple for Paget's disease, and the presence of breast nodule(s), nipple disease, evidence of infection, and/or spontaneous discharge. Palpation should be performed both in the upright and supine position to determine the presence of a palpable mass. Abnormalities detected during a clinical breast examination – such as masses or nodules, nipple discharge, or inflammatory changes – require thorough evaluation and prompt treatment.
Following completion of a physical examination in which no palpable mass is identified, a routine screening mammogram should be obtained if one has not been done within the recommended interval.
Regular mammographic screening has been shown to reduce mortality in breast cancer. The results of the mammogram are provided to the primary care physician for reporting to the patient. Screening mammogram must be recommended every one-two years for women ages 50 to 75 years. Screening mammograms could be recommended to women ages 40 to 49 and over the age of 75. All women over age 40 should routinely be given the opportunity to receive information about breast cancer screening and informed decision-making.
See Appendix A, "Breast MRI," in the original guideline for information on screening high-risk patients.
Should any abnormality be uncovered, it will be the responsibility of the radiologist to complete any additional imaging studies required for the complete radiographic characterization of the lesion. The radiologist should make certain that all recommendations including additional views, follow-up films, ultrasounds, etc., have been completed prior to referral to surgery. However, it is important that the provider ordering the mammogram review the results of these studies to fully understand the impression of the radiologist and to assure that all recommendations by the radiologist have been completed within the department of radiology. Should the recommendation be made by radiology that a surgical consultation is warranted, it will be the responsibility of the primary care provider to establish this referral.
See Algorithm IV, "Radiologic Evaluation of the Breast," in the original guideline document.
Refer to Annotation #9, "Is Screening Mammogram Due?," for recommended mammography screening intervals.
I. Evaluation of Breast Mass Algorithm Annotations
A dominant mass is a palpable finding that is discrete, solid, and clearly different than the surrounding parenchyma. Should a palpable mass be identified, it should be characterized as to whether it represents a dominant (i.e., discrete) mass that requires immediate evaluation. Should physical examination demonstrate a palpable mass that is not clearly discrete and dominant (indeterminate), its size, location, and character should be documented in anticipation of follow-up examination.
Prior to the referral, a mammogram should be obtained. Patients under the age of 30 should receive an ultrasound. For women under age 50, digital mammography is preferable for dense breast tissue. Also see Annotation #50, "Abnormal Screening or Diagnostic Mammogram."
Patients referred to the department of surgery for evaluation of breast disease will have undergone previous mammography that has demonstrated an abnormality that has been worked up and requires further surgical intervention, or the patient may be referred on the basis of a physical finding uncovered in the primary care clinician's office. It is the role of the surgeon to evaluate each and every abnormality uncovered in each patient. It is important for the surgeon to recognize that mammographically depicted lesions and palpable abnormalities may coexist as separate entities within the breast. It is therefore important that each lesion be evaluated for its own merit, using this algorithm.
The importance of communication between the surgical consultant and the primary care clinician cannot be overstated. Patients undergoing biopsy should have results reported both to the surgeon and the primary care clinician. More importantly, patients who do not require biopsy following surgical consultation should be returned to the routine screening process only after the surgeon has completed full evaluation, including any interval follow-up exams, and is satisfied that the symptom does not represent malignancy. For example, if the surgeon feels that the symptom should be followed up in six months to document stability, this follow-up visit should take place with the surgeon. Once the surgeon is satisfied that no further follow-up is needed, the patient may return to routine screening. This process is under the supervision of the primary care clinician. Therefore, it is absolutely necessary for the primary care clinician to know when the patient reenters the routine screening population. In the event that new symptoms arise or occur during the screening interval, the patient should be evaluated by the primary care physician using the primary care evaluation process stated in Algorithm I, "Evaluation of Breast Mass."
A simple cyst is one that resolves with aspiration of non-bloody fluid. If fluid is clear and non-spontaneous (e.g., as in compression mammogram), a workup is not always necessary, as this is benign. Surgical excision should be performed for those cysts with bloody aspirates and those that do not completely resolve with aspiration. A cyst that recurs may be re-aspirated, but the number of times this procedure can be repeated without surgical excision will depend upon the surgeon and patient's level of confidence that the lesion is benign.
Non-bloody fluids should be discarded, based on a study where no cancers were detected among 6,747 non-bloody specimens.
Among 401 patients with cystic masses, only four had cancer and all had either bloody fluid or a residual mass. This would be demonstrated by palpation or imaging.
Should the mass remain following the attempt at aspiration or should a bloody aspirate be obtained during the process, the presence of a malignancy cannot be ruled out. Patients with a residual mass or a bloody aspirate should proceed to image-directed core biopsy or surgical consult.
Bloody aspirate should be considered for cytology.
If no residual mass or blood aspirate remains, a repeat examination should be performed in 4 to 6 weeks at the discretion of clinician. The optimum time for this exam is after one menstrual cycle.
Refer to Annotation #15 for further information.
If no mass is apparent at the time of this examination, the patient should be informed of the appropriate date of her next routine screening evaluation.
II. Evaluation of the Breast for Nipple Discharge Algorithm Annotations
Guidelines for primary care evaluation of patient presenting with complaint of spontaneous nipple discharge are initiated with a history aimed at uncovering and characterizing any breast-related symptoms, including whether discharge has been spontaneous, pathologic, persistent, unilateral versus bilateral, single or multiple ducts, its relation to menses, pregnancy, exercise, trauma, medications, and/or thyroid disorders.
The site around the nipple should be examined for discharge upon pressure and for a mass. Hemoccult test for blood may also be administered.
Pathologic discharges are spontaneous, may be associated with a mass, and are usually bloody, blood-containing or sometimes watery (clear). They are usually unilateral, involve a single duct, and are more worrisome in patients greater than 50 years old.
Physiologic discharges usually are bilateral, involve multiple ducts, are multicolored or milky, sticky and those that are stimulated rather than spontaneous [R].
Bloody or, less commonly, clear watery discharge raises the possibility of cancer, although the most common causes of hemoccult-positive discharges are benign.
Secretory production of fluids other than milk may be due to a pathological process in the breast. The discharge is usually unilateral and localized to a single duct, persistent and spontaneous. It can be serous, sanguineous, or serosanguineous. The most common cause of pathologic nipple discharge is a papilloma (52% to 57%). A papilloma is a papillary tumor growing from the lining of the breast duct. The discharge associated with a papilloma can be clear or grossly bloody. Solitary papillomas can harbor areas of atypia or ductal carcinoma in situ (DCIS). Although there is some debate in the literature, the standard recommendation for management of papillomas is that they be excised whenever they are diagnosed (by core needle biopsy). The remainder of cases are caused by ductal ectasia or fibrocystic changes (14% to 32%). Malignancy is found in 5% to 15% of cases of pathologic nipple discharge. The most common malignancy associated with nipple discharge in the absence of other findings is DCIS. Age is predictive of the risk of cancer in women with nipple discharge. In one series of women with isolated nipple discharge, malignancy was present in 3% of those <40 years of age, 10% of those 40 to 60 years of age, and 32% of those over 60.
Bloody or clear discharge needs further evaluation to determine the etiology.
A mammogram and ultrasound should be obtained with presence of bloody or clear discharge to rule out malignancy. An ultrasound may be helpful to locate an intraductal nodule or duct ectasia to best characterize the lesion, and then be referred to surgery if appropriate. Make certain that all recommendations for additional views, ultrasound examinations, and follow-up studies have been obtained prior to referral to surgery.
Malignancy is found in 5% to 15% of cases of pathologic nipple discharge. The most common malignancy associated with nipple discharge in the absence of other findings is DCIS. Age is predictive of the risk of cancer in women with nipple discharge.
Most pathologic nipple discharges should be treated with duct excision. The use of ductography and/or MRI ductography is dependent on the decision of the surgeon and radiologist.
The appearance of the fluid generally correlates with the cause. Yellow, brown, green, or gray fluid is associated with fibrocystic change in most patients. Purulent discharge can result from duct ectasia or partial duct obstruction.
Obtain prolactin and thyroid stimulating hormone (TSH) levels to determine an endocrinologic basis for the nipple discharge. A prolactinoma typically causes a milky or clear discharge bilaterally.
Assay should be performed for prolactin and TSH as both of these pituitary hormones may induce galactorrhea, may have a reversible cause, and may likewise reflect further underlying pathology (e.g., pituitary adenoma, hypothyroidism, etc.)
If the mammogram and the endocrinology screening studies are normal, the patient should schedule a follow-up visit at the discretion of the responsible clinician. If the hormonal evaluation shows abnormal findings, the patient should be referred to an endocrinologist for further evaluation.
III. Evaluation of Breast Pain Algorithm Annotations
The information gathered should include location and severity of pain, relationship to menstrual cycle or physical activities and hormonal influences.
As appropriate, an exam directed at the cervical and thoracic spine, chest wall and upper extremities may be helpful in assessing other causes of pain.
Breast pain is one of the most common symptoms evaluated in primary care, surgery, or specialty breast clinics. Approximately 41% to 69% of women report having experienced breast pain. Breast pain may interfere with daily activities, relationships, and quality of life.
History and Physical Exam
The symptom of breast pain prompts many patients to make an appointment for a medical examination out of concern for the possible presence of breast cancer. A patient history is directed toward identifying and characterizing breast-related symptoms. The information gathered should include location and severity of pain, relationship to physical activities or the menstrual cycle, association with redness or warmth of overlying skin, and interference with routine activities. Hormonal influences, such as pregnancy, use of contraceptives, and hormone therapy, should also be noted. Obtaining a history may also provide information identifying non-breast sources of pain. The patient should also be asked about any new medications, and those that can be associated with breast pain should be noted. Risk assessment for breast cancer should include the appropriate reproductive, medical, and family history.
A clinical examination of the breast should be performed with careful inspection and palpation of each breast, nipple-areolar complex, and regional lymph nodes. Localized, generalized, or bilateral breast tenderness should be noted. In addition to palpating the breasts while the patient is supine, examining the breasts while the patient is sitting or lying on her side may allow breast and chest wall tenderness to be distinguished.
Laboratory studies are generally not useful. A pregnancy test, however, should be considered in women of reproductive age if the history or examination suggests pregnancy. Other hormone levels (e.g., estrogen, progesterone, and prolactin) are typically normal in patients with breast pain.
Breast pain may occur as a result of pregnancy, mastitis, trauma, thrombophlebitis, macrocysts, benign tumors, or cancer; however, only a minority of breast pain is explained by these conditions. Most breast pain is of unknown cause. A variety of conditions can result in pain perceived in the breast. A variety of conditions can be revealed as a result of a directed history and physical. As appropriate, an exam directed at the cervical and thoracic spine, chest wall, shoulders and upper extremities, sternum, heart, lungs, and abdomen may be helpful in assessing other potential causes of the pain.
Breast pain is commonly categorized into three classifications:
Imaging studies are frequently utilized in the evaluation of the breast. A mammogram should be considered especially in women with a family history of early breast cancer. The risk of malignancy after normal findings on mammographic evaluation for breast pain is about only 0.5%. It is unclear whether the pain is related to the cancer or whether this symptom initiates a breast evaluation in which an asymptomatic cancer is identified. Breast pain secondary to malignancy is typically unilateral and persistent. In these cases, imaging with directed ultrasound may be a more valuable assessment tool. Also see Annotation #9, "Is Screening Mammogram Due?," for further information.
Breast pain may be difficult to assess as the symptoms may appear and subside without provocation, with certain activities, or with the menstrual cycle. An attempt must be made to measure the amount and severity of the patient's breast pain over time, which is difficult as there is no standard unit of pain. Prospective assessment of breast pain may be a valuable tool when considering an intervention. Possible tools to document an individual's pain include pain rating instruments, a daily breast pain chart or a diary to document the occurrence and severity of pain, use of medications, and interferences with lifestyle. These tools are particularly important in making an initial diagnosis of cyclic mastalgia and response to therapy. For more information on pain assessment see the NGC summary of the ICSI guideline Assessment and Management of Chronic Pain.
The first line of treatment for breast pain is to reassure the patient that she does not have breast cancer. The risk of malignancy following a negative examination has been estimated to be only 0.5%, so reassurance following a negative evaluation is appropriate. Approximately 15% of women choose a treatment intervention to reduce the symptom of pain. During encounters for breast pain, the patient's description of the pain, quantitative assessment of the pain, and decisions regarding reassurance, follow-up, or therapeutic intervention should be documented.
Few women will require treatment with more than reassurance and well-tolerated medications such as evening primrose oil. For those with severe, refractory breast pain, the significant side effects of some of these medications must be balanced against the potential benefit in ameliorating breast discomfort and pain.
Non-pharmacologic interventions for breast pain are appropriate for women with breast pain. Although there has been little scientific investigation into the effectiveness of these non-pharmacologic approaches, they are frequently found to improve breast pain symptoms in clinical practice and are of low risk and expense to the patient.
Potential Non-Pharmacologic Therapies
Mechanical Support
A professionally fitted support bra, irrespective of age, cup size, or underlying breast disease, has been shown to relieve breast pain even in patients who have not responded to hormonal treatments. Support bras are recommended for exercise. A soft supportive bra during sleep may also improve symptoms.
Lifestyle Changes
Lifestyle changes such as smoking cessation, stress reduction, and improving coping skills may be possible low-risk interventions. Hot packs, cold packs and massage may also relieve symptoms.
The effectiveness of dietary measures is unclear. Studies have demonstrated improvement in breast pain symptoms following dietary reduction of saturated fat. Caffeine reduction or elimination has been found to be helpful by some patients, particularly those who consume large quantities of caffeine. Clinical studies have not shown this to be a consistent outcome.
Complementary and Alternative Medicine
Evening Primrose Oil
Evening primrose oil is often used as an initial treatment for breast pain because of its low incidence of side effects and positive response rates for cyclic and non-cyclic pain. It is rich in gamma-linolenic acid and is believed to alter the saturated/polyunsaturated fat balance and decrease sensitivity to hormonal influences.
Pharmacologic Interventions
The decision whether to treat breast pain along with the selection of a particular agent to utilize requires balancing the need for symptom relief against the likelihood of medication side effects. If considering a pharmacologic therapy, consult with a specialist should be considered.
Pharmacologic interventions may include the adjustment of medications that may be contributing to breast pain, such as oral contraceptives, hormone therapy, spironolactone, and others. Eliminating or decreasing the dose of estrogen in an oral contraceptive or hormone regimen is often effective.
Analgesics, such as ibuprofen, may reduce breast pain.
Danazol is approved by the United States Food and Drug Administration for fibrocystic conditions, which often cause breast pain.
Danazol relieves breast pain in 75% to 92% of women. Reported side effects are common and include hair loss, acne, decrease in voice pitch, weight gain, irregular menses, and depression. There may also be a possible increase in venous thromboembolic events. Barrier contraception must be utilized. Danazol administered in the luteal phase only has been found to relieve premenstrual breast pain in women with premenstrual syndrome with minimal side effect. It was not effective for other premenstrual syndrome symptoms. According to the package labeling, thromboembolism, thrombotic and thrombophlebitic events have been reported including life-threatening or fatal strokes. Peliosis hepatitis and benign hepatic adenoma have also been reported with long-term use. Danazol may cause benign intracranial hypertension. Pregnancy must be ruled out prior to treatment.
One of the few hormonal abnormalities detected in breast pain has been an increase in thyrotropin induced prolactin secretion. Bromocriptine has been shown to decrease serum prolactin levels in normal and hyperprolactinemic women and may decrease dynamic secretion of prolactin in cyclic mastalgia patients. In several European studies, bromocriptine has shown significant decreases in breast pain (approximately 54%), as well as heaviness and tenderness in the breasts. Prolactin levels decline during therapy while estrogen, progesterone, testosterone, and gonadotropin releasing hormones do not significantly change. Side effects are common and dose related, including nausea, vomiting, headache, dizziness, and fatigue. The beneficial effects lasted three to six months after bromocriptine was discontinued.
Tamoxifen is a selective estrogen receptor modulator (SERM) utilized for the prevention and treatment of breast cancer. Response rates have demonstrated tamoxifen to be effective in reducing pain in 75% to 90% women with cyclic and 56% of women with non-cyclic mastalgia in controlled trials. Tamoxifen has significant side effects, with the principle concerns being from thromboembolic disease and endometrial cancer. Additional side effects include hot flashes, nausea, menstrual irregularity, and vaginal dryness or discharge. Tamoxifen, like other hormonal interventions, should be reserved for women with severe mastalgia. Contraception must be utilized. In 2002, the Food and Drug Administration added a boxed warning stating that serious and life-threatening events (including stroke, pulmonary emboli and uterine malignancy) have occurred at an incidence greater than placebo during use for cancer risk reduction.
FDA Web site
Other Medications
Other medications that have been found to be effective for the treatment of breast pain include goserelin, gestrinone, buserelin, leuprolide, quinagolide, cabergoline, thyroxine, and topical nonsteroidal anti-inflammatory agents. Gestrinone, buserelin and quinagolide are not readily available within the United States. Medroxyprogesterone has shown variable results in the treatment of breast pain. In general, antibiotics, diuretics, and most vitamins have not been effective in the treatment of breast pain.
IV. Radiologic Evaluation of the Breast Algorithm Annotations
It is recommended that an abnormal finding on routine mammography be evaluated under the direction of a radiologist.
Patients referred to the department of radiology most commonly enter for screening mammography. However, patients will occasionally be referred for diagnostic mammography based on the presence of symptoms or findings on examination. In the event of an abnormal finding on mammography, it is recommended that a complete evaluation be undertaken within the department of radiology under the direction of a radiologist in order that a full characterization of the lesion will be provided back to the primary care physician ordering the original study. It will be the responsibility of the radiologist to complete the radiologic assessment of the patient within the department of radiology so that the best possible characterization of the abnormality may be provided to the primary care physician in an expeditious fashion. Any recommendations for referral to the department of surgery for possible biopsy should be made directly to the primary care physician. However, the ultimate responsibility to make the referral will rest with the primary care clinician.
Upon obtaining an abnormal finding on a mammogram, the radiologist will determine whether further mammographic images or ultrasound are required for completion of the evaluation process. Additional projections, spot compression, magnification and/or ultrasound may be necessary to obtain further characterization of indeterminate lesions of the breast. In the event that a soft tissue mass is identified on the mammogram, further studies with ultrasound are required to determine its relative risk for malignancy. These additional studies should be done with the radiologist present, to reduce the risk of patient recall for further studies necessary to evaluate the same lesion and to allow for ultrasound directed intervention such as cyst aspiration if indicated.
Upon completion of these views, each and every abnormality uncovered for each independent lesion of the breast studied should be sorted according to the nature of the abnormality. The radiologist should classify the lesion as representing either suspicious microcalcifications, architectural distortion, or a soft tissue mass. In the event that a soft tissue mass is identified in the mammogram, further studies are required to determine its relative risk for malignancy. Should the mass not be immediately suspicious for cancer, an ultrasound should be performed (if not already done) to determine whether or not the lesion is solid.
In certain circumstances where diagnosis is difficult, a functional exam, either breast MRI or nuclear (molecular) imaging may be suggested by the radiologist or surgeon to sort out inconclusive cases. These cases may include:
If further mammographic studies or sonography demonstrate findings that are felt to be Probably Benign, a repeat image of the breast at 6 months is warranted to document stability of low-risk, probably benign lesions. The term Probably Benign is an assessment category from the Breast Imaging and Reporting Data System (BI-RADS). If the six-month mammogram is felt to be benign, return in 6 months for yearly screening mammography.
BI-RADS Descriptors
If BI-RADS descriptors are used appropriately, lesions placed in the BI-RADS 3 - Probably Benign category have a rate of malignancy lower than 2% (0.5% to 1.7%). Short-term imaging follow-up (6-month intervals for 2 years) will identify by interval progression almost all of the few lesions that actually are malignant. These cancers still have a very favorable prognosis at the time of diagnosis being early-stage cancers. The recommendation for surveillance should be given to the patient in person, immediately after completion of the full imaging workup, while the patient is still in the radiology department and should be done by the radiologist or radiology technologist who is sufficiently knowledgeable to provide a competent explanation of the rationale behind surveillance. Direct discussion with the patient should help to alleviate anxiety and also further ensure compliance.
If the lesion is of benign findings, the patient should be referred back to the screening process and completion of this evaluation should be reported to the ordering clinician. Refer to Annotation #9, "Is Screening Mammogram Due?," for mammography screening intervals.
V. Image-Directed Core Needle Biopsy Algorithm Annotations
Patients referred for biopsy based on the presence of a mammographic and/or sonographic MRI nuclear molecular imaging finding that is suspicious for or highly suggestive of malignancy will undergo either conventional open excisional biopsy or large core needle biopsy.
Large core imaging-guided breast biopsy is now the technique of choice in most institutions in the United States for biopsy of non-palpable breast masses and abnormal calcifications based on decreased cost and less invasiveness. Either stereotactic or ultrasound-guided breast biopsy may be used for reliable diagnosis of breast cancer. Stereotactic guidance is preferable for biopsy of calcifications. Most solid breast masses are amenable to large core needle biopsy with either stereotactic or ultrasound guidance. The location of the lesion, its visibility at ultrasound, equipment availability and the radiologist's expertise will determine the approach selected.
Large core image-guided needle breast biopsy is recommended for tissue diagnosis in cases of obvious cancer, as it is less invasive and saves the patient an additional surgical procedure, is more cost effective and expedites the diagnostic process.
Current Changes in Breast Disease Diagnosis
Over the past 20 years, advances in mammographic and sonographic technology have established a new subspecialty in radiology. Image-guided, vacuum-assisted breast biopsy, and core needle biopsy under image guidance have changed diagnostic breast biopsy from a surgical open biopsy to image-guided needle biopsy.
The following percutaneous techniques have been developed over the past 15 years:
A 22- to 24-gauge needle is used for cytology. This is best used with a cytopathology department. It is also used in abnormal cyst aspiration (where fluid is obviously benign). FNA has limited use in most community hospitals because of inadequate specimens (in 30% to 40% of FNA biopsies). Therefore, large core image-directed breast biopsy has replaced most FNA biopsies.
Spring-loaded devices are used for image-guided biopsies more than any other percutaneous needle. They may be used with solid lesions of any size, under ultrasound guidance.
Vacuum-assisted needles, 8-, 9-, 11- or 12-gauge are used for microcalcifications, small masses or architectural distortion. Larger, vacuum-assisted electro-cautery devices may be used. These larger needles may help with avoiding undersampling and atypia diagnostic problems.
If cancer is diagnosed, definitive therapy may be performed on the basis of stereotactic or image-guided needle biopsy alone.
Any questionable pathologic findings or pathologic findings that do not correlate with the imaging are indications for repeat biopsy by excision to rule out the presence of occult malignancy in the region of the mammographic abnormality.
The original specimen (pathology block) can be reexamined and recut for pathology exam if calcifications were noted. If calcifications cannot be demonstrated mammographically in the specimen, repeat biopsy, excisional or stereotactic, is necessary to assure that the abnormal mammographic lesion has been sampled. Biopsy must be repeated until the calcifications can be confirmed in the specimen.
If the mass is a fibroadenoma, then follow up with mammogram or ultrasound in 6 to 12 months. However, if the patient is experiencing extreme pain and/or extreme tenderness, the fibroadenoma may be surgically removed or undergo cryotherapy.
Patients who have benign results from stereotactic or image-guided biopsy may have a repeat mammogram and/or ultrasound. The radiologist should correlate the pathology results with the mammographic/sonographic abnormalities for all patients. If they do not correlate, rebiopsy with image-directed core needle or excisional biopsy is necessary.
Any lesion which has grown or has become more dense on mammography, despite a previous benign core biopsy, must be rebiopsied or excised to rule out cancer.
Refer to Annotation #9, "Is Screening Mammogram Due?," for mammography screening intervals.
The following detailed and annotated clinical algorithms are provided in the original guideline document :
The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).
Side Effects of Medications
Disadvantages of Diagnostic Procedures
Because of the high rate of false positives, MRI screening should be recommended only to women at high risk of breast cancer.
Once a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group.
In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.
Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.
Detailed measurement strategies are presented in the original guideline document to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).
Implementation Recommendations
Prior to implementation, it is important to consider current organizational infrastructure that address the following:
The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.
Establish a communication plan to include all clinicians involved in the patient's treatment plan:
Establish a system for education of all female patients regarding age-appropriate mammographic screening intervals.
Develop a system for timely assessment of breast symptoms including necessary imaging studies, follow-up, and referral to radiology or surgery for biopsy.
Establish a process that ensures that abnormalities of the breast are accurately identified and sorted, and that all appropriate radiologic imaging studies necessary to the evaluation process are efficiently completed.
Establish a process for timely completion of evaluation of breast lesions and provide additional surgical breast consultation as needed.
Develop a system to document time frame from receipt of pathology to patient information.
Not applicable: The guideline was not adapted from another source.
Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers; Allina Medical Clinic; Aspen Medical Group; Baldwin Area Medical Center; Brown Clinic; Center for Diagnostic Imaging/Medical Scanning Consultants; CentraCare; Central Lakes Medical Clinic; Chippewa County – Montevideo Hospital & Clinic; Cuyuna Regional Medical Center; Essentia Health; Fairview Health Services; Family HealthServices Minnesota; Family Practice Medical Center; Fergus Falls Medical Clinic; Gillette Children's Specialty Healthcare; Grand Itasca Clinic and Hospital; Hamm Clinic; HealthEast Care System; HealthPartners Central Minnesota Clinics; HealthPartners Medical Group & Regions Hospital; Hennepin County Medical Center; Hennepin Faculty Associates; Howard Young Medical Center; Hudson Physicians; Hutchinson Area Health Care; Hutchinson Medical Center; Integrity Health Network; Lake Region Healthcare Corporation; Lakeview Clinic; Mankato Clinic; MAPS Medical Pain Clinics; Marshfield Clinic; Mayo Clinic; Mercy Hospital and Health Care Center; Midwest Spine Institute; Minnesota Association of Community Health Centers; Minnesota Gastroenterology; Multicare Associates; New Richmond Clinic; North Central Heart Institute; North Clinic; North Memorial Health Care; Northwest Family Physicians; Obstetrics and Gynecology Specialists; Olmsted Medical Center; Park Nicollet Health Services; Planned Parenthood Minnesota, North Dakota, South Dakota; Quello Clinic; Raiter Clinic; Rice Memorial Hospital; Ridgeview Medical Center; River Falls Medical Clinic; Riverwood Healthcare Center; South Lake Pediatrics; Southside Community Health Services; Stillwater Medical Group; University of Minnesota Physicians; Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: email@example.com; Web site: www.icsi.org .
The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Security Health Plan of Wisconsin, and UCare. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.
Committee on Women's Health
Work Group Members: Audrey Park-Skinner, MD (Work Group Leader) (Essentia Health) (Surgery); Deepti Pandita, MD (Park Nicollet Health Services) (Internal Medicine); Mary Lechner, MD (Center for Diagnostic Imaging) (Radiology); Sarah Nielsen, DO (Marshfield Clinic) (Radiology); Judy Boughey, MD (Mayo Clinic) (Surgery); Todd Morris, MD (HealthPartners Medical Group and Regions Hospital) (Surgery); Kari Retzer, RN (Institute for Clinical Systems Improvement) (Facilitator); Cindy Harper (Institute for Clinical Systems Improvement) (Systems Improvement Coordinator)
In the interest of full disclosure, Institute for Clinical Systems Improvement (ICSI) has adopted a policy of revealing relationships work group members have with companies that sell products or services that are relevant to this guideline topic. It is not assumed that these financial interests will have an adverse impact on content. They are simply noted here to fully inform users of the guideline.
Mary Lechner, MD, had received speaker's fees from Dilon Technologies in 2009.
No other work group members have potential conflicts of interest to disclose.
Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site .
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org ; e-mail: email@example.com.
The following is available:
None available
This summary was completed by ECRI on July 10, 2000. The information was verified by the guideline developer on April 25, 2001. This summary updated on March 15, 2002. The updated information was reviewed by the guideline developer as of April 25, 2002. This summary was updated again on September 3, 2003. The information was verified by the guideline developer on November 26, 2003. This summary was updated by ECRI on May 26, 2004, and most recently on January 11, 2006. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This summary was updated by ECRI Institute on March 19, 2008. This summary was most recently updated by ECRI Institute on June 23, 2010. This summary was updated by ECRI Institute on January 13, 2011 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This NGC summary was updated by ECRI Institute on May 25, 2012. This summary was updated by ECRI Institute on September 18, 2015 following the U.S. Food and Drug Administration advisory on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs).
This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.
If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.
All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
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text:
Tyne Tees Travel
A look at what's happening across the region
A look at what's happening across the region
Delays of up to 40 minutes on First Transpennine Express between Leeds and Newcastle due to signalling problem at Thirsk.
Northbound lines have reopened and trains can run through the area with delays.
There is no estimate for a normal service.
Also affecting Grand Central, East Coast and CrossCountry.
Police have released CCTV footage in an attempt to trace two men they want to speak to after a serious fire at Fisher Court in Ripon.
Hundreds of images have been unearthed of soldiers who posed for photos before they went into battle at the Somme.
Newcastle United have bolstered their medical department with two new appointments in the hope of improving the club's injury problems