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Explore the Entrepreneurship.org Resource Center to find resources. Designed with entrepreneurs in mind, our resource center allows you to find materials to grow great ideas.
This tool will take you through the step-by-step process of developing a business plan that includes all the basic elements needed.
By using the steps in this tool, you will be able to better identify opportunities for change, determine if you are ready for change, recognize what your customers want and create the proper environment for change in your company.
This tool provides a detailed look into the various sections of a cash flow statement. It also describes two methods used to calculate cash flow from operating activities, indirect and direct with examples that will give you an edge when it comes time to preparing a cash flow statement of your own.
The focus of this tool is to provide a general discussion concerning bringing in partners or outside investors to a company. The methods a business can use toward achieving this goal and the problems a business is likely to face in the process will also be addressed.
With recent changes in consumer shopping habits, many companies are adopting sales and marketing strategies that reflect a more personalized approach to servicing their customers. This tool focuses on personalization and on ways you can gear your business to provide products and services individualized to your customersand#39; tastes and needs.
This tool takes a look at different types of promotional media and discuss the pros and cons of effectively reaching a target audience through each.
This tool will help you recognize the significance of your business's intellectual property -- the patents, trademarks, copyrights and trade secrets -- and understand what steps are necessary to ensure that those rights provide value for the company.
This tool will help you choose a customer base that is appropriate for your business by identifying customer characteristics, conducting market research, choosing a target market, and compiling a customer profile.
This news note cites an article, and#34;The Power of Dumb Ideas,and#34; in which Randall Rothenberg argues that, when it comes to success in business, emphasis on strategy imitation outperforms emphasis on innovation. Source for the article is a Booz Allen Hamilton study of successful business strategies over 30 years.
Have venture capitalists overlooked innovation in industries such as nanotech, biotech, medical devices, and semiconductors? A new generation of entrepreneur-innovators is succeeding in such arenas-with promises of more to come. VCs are beginning to take notice. The article offers an overview of industries and products with explanations by entrepreneurs.
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Three third-grade students from the northwest suburban Patton Elementary School in Arlington Heights convinced Illinois Governor Pat Quinn to increase penalties for the inhumane treatment of animals; specifically addressing the egregious mistreatment of dogs and cats in puppy mills reported abcchicago.com.
The three students, Maddie O'Dell, Brooke Martin, and Claire Hackmann were inspired to take action after reading a book about two children who rescued a dog from a puppy mill.
The new legislation, which takes effect immediately was signed on Saturday and now doubles the fines for animal cruelty offenses as defined by the Animal Welfare Act. It was sponsored by Arlington Heights Republican Rep. David Harris and Sen. Pamela Although, a McHenry Republican.
A first violation is more than doubled from $200 to $500. A second violation is doubled from $500 to $1000. The third violation will result in a $2500 fine, and adds a probationary status for the violator.
The students gathered signatures from classmates and the community with the students even testifying before the House Agriculture and Conservation Committee according to a press release from the Governor's office.
"More than half the households of Illinois have a pet in the household. And it is a situation where your dog or your cat or your pet, that's part of your family, and we take care of the family of Illinois," stated the Governor at PAWS Chicago.
In addition, Gov. Quinn created the Illinois Pet Advocacy Task Force which studies animal neglect, cruelty and abuse and makes recommendations to find effective methods to help control the epidemic cruelty to those who cannot speak.
Congratulations students; you are an inspiration to everyone.
If you would like to continue receiving the latest news on pet issues and how we can help those who cannot speak, please click the "Subscribe" icon.
Follow the National Pet Rescue Examiner on Facebook by clicking here. Please visit and "like" my page. You are welcome to submit story ideas by contacting me at email@example.com.
Suggested Links
- Two German shepherds out of sight for public: Life is so unfair for shelter dogs
- Adam: Little chance to get adopted when shelter dog is kept in 'isolation'
- Shepherd mix named Preston: Adorable 'wiggly butt' ready for adoption
- Senior Labrador retriever walks 30 miles to return home: Owners say no
- Updated story: Lab rejected by owner after walking 30 miles to return home

subset: commoncrawl


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Today on the Ellen DeGeneres Show, Alison Sweeney will announce that she will be exiting the role of Sami Brady.
Allison Sweeney has been a member of the DAYS cast since January 1993. After 21 years of loving many men, lying to all of them and blackmailing and killing some of them she will be leaving them all behind. "I decided that it's going to be my last year with the show," Sweeney said to a shocked he studio audience.
As the star of Days and The Biggest Loser she has not had enough time with her family and wants more time with them now.
"I've been on Days of our Lives since I was 16 years old and I have never had more than a two-week vacation in that whole time. I mean, it's so awesome. I love Sami, I love Salem, I love my job, I love daytime, I love the fans, I love everything about it," Sweeney added. "I've worked so much and my daughter just turned five and my son is nine and I just want to be with them and enjoy my last year"
A departure date has not been set
"I'm going to be on DAYS all this year. We don't have a specific time yet, but I'm going to be on all this year and we'll see what happens," Sweeney explained.
How would she like it to end?
"It would be awesome to have some kind of happy ending," Sweeney offered, before noting that her character has also caused a lot of problems for other Salem residents. "She probably deserves some sort of very twisted, like Breaking Bad ending."


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Adventureland Red Band Trailer
by nathanbloch March 02, 2009 at 7:32PM | Views: 131
A red band trailer for Adventureland, the new film by Greg Mottola (the guy who did Supberbad), gives us all the things we didn't get in the green band trailer. Namely sex, drugs and foul-mouthed language. Adventureland looks like it's going to give us lots more of the good stuff we loved about Superbad with a slightly more earnest take on teen angst. The new trailer is much better evidence for this being a really funny movie than the first. Take a look after the jump.


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Fallout From Caribbean Med School's $100 Million NYC Hospital Deal
A board member of New York City's public hospital system has resigned after a lucrative deal the system cut with a Caribbean Medical School landed on the front page of the New York Times.
Under the 10-year pact, reported earlier this week in the Times, Grenada's for-profit St. George's University School of Medicine agreed to pay the city's Health and Hospitals Corporation about $400 per week for each student who does a clerkship in an HHC hospital, plus an annual fee of $50,000 per year for hospitals that take at least 24 students. The total value of the deal was put at $100 million.
Med schools typically pay little or nothing to have their students rotate through the hospitals. Some New York City med schools told the NYT they wouldn't be able to compete dollar for dollar with St. George's. While some local institutions have started paying a flat fee of $250,000 per year, an NYU official said that if the university's med school paid as much as St. George's it would be on the hook for $2.8 million per year.
Daniel D. Ricciardi, a Brooklyn rheumatologist who works as dean of clinical studies at St. George's, resigned yesterday from his position on the HHC board, the NYT reports today. Ricciardi had suggested the arrangement, but recused himself from deliberations over whether the deal should go through. It was awarded after a competitive bidding process.
Ricciardi had earlier told the NYT that "a report was written on the school, and the judgment was made based on merit, not on political push."
Foreign med schools are big business, drawing U.S. students who are willing to pay some $50,000 a year in tuition and who often can't get into U.S. medical schools. The deal, which bars the HHC from awarding clerkship spots to other Caribbean med schools, may help St. George's compete for students against Ross, a Caribbean medical school owned by publicly traded DeVry.
Photo of Elmhurst Hospital Center via nyc.gov


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Ingo Money is giving a free $5 bonus to the first 10,000 new Ingo Money App users who register a prepaid card by March 15, 2014.
Ingo Money is a mobile app that lets you load funds from checks, including payroll, government, and personal checks, to a participating Prepaid Card in minutes.
If you have not yet registered a prepaid card with Ingo Money, you can participate in this Ingo Money Promotion to get a free $5 bonus.
How To Earn $5 Ingo Money Bonus
1. Download the Ingo Money App, enroll, and register any participating Prepaid Card.
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4. Select your participating Prepaid Card to load your $5 onto it.
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There is a limit of 1 load per enrolled user and 1 load per newly registered card.
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Simply enroll and register a participating Prepaid Card in the Ingo Money app to earn this $5 bonus.
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Nest DC rents stylish, lovingly maintained apartments and houses in every quadrant of the District. Think boutique hotel but you call it home. We're picky about the homes that we rent and we think you should be too!
We started our company with a simple philosophy. Great homes attract great tenants. We think everyone should look forward to going home at the end of the day. Happy residents make for better communities. It's a win win.
Our tenants get same day replies when they have a problem and we are fully committed when it comes to regular maintenance and improvements to your space.
We do hope you choose to live in a Nest!
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Similar products
Saunders Pak-Tab™$13.50
Customer Reviews
Customer Reviews
Read 3 Customer ReviewsWrite Your Own Review
- Not bad if you have small fingers. Review by Gary Stargazer
Quality Price Value
I ordered two mediums of this for me and my wife. The thing fit alright, but putting my middle finger through the gripping hole was tight and uncomfortable because the back near the metal bracket is NOT flat. Don't be fooled by the picture above. Near the bracket is actually rounded forward and will dig into the top of your finger as you shoot.
I ordered a larger size for myself and I encountered the same problem. It's not bad for kids or ladies and gents with smaller fingers, but if you've got long fingers, be ready to get some scissors and trim it up.
(Posted on 6/24/14)
- Great Tool/Improves Target Accuracy Review by Recreational Archer
Quality Price Value
My 9 year old daughter got a Little Fox recurve bow and our Lancaster Rep recommended this finger tab. We will wait to shoot to be able to use it, because it improves our accuracy. We are getting one for everyone in our family.
(Posted on 3/15/14)
- Excellent Product Review by Archery Coach
Quality Price Value
Spacer is an excellent addition and calf hair really helps the release.
(Posted on 9/16/12)


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Cafe Parisian Flavored Decaf Coffee (1lb Bag)
Are you ready to indulge in this divine European vanilla, sweet orange, and Mexican liqueur cream flavored coffee without the side effects of caffeine? Here is where the flavor is! This is going to be a feast for your senses, starting with the intoxicating aroma, then the smooth taste and the long finish. Cafe Parisian decaffeinated flavored coffee is perfect for serving guests, as a gift, or as a treat for you to enjoy.
A single 1lb heat-sealed valve bag will ensure our customers the freshest flavored gourmet coffee. Your decaffeinated Café Parisian coffee will be fresh roasted the day it ships. Warm vanilla, sweet orange and liqueur flavoring make this coffee one of life's greatest pleasures.
Cafe Parisian Flavored Decaf Coffee (1lb Bag)
Cafe Parisian Flavored Decaf Coffee (5lb Bag)
New Cadtle, DE
4 Stars
I would recommend this item to a friend.
Cafe Parisian
September 26, 2014
I really like this flavored coffee. I prefer light and smooth coffees instead of the stronger flavors. This has a hint of orange which makes this coffee very mellow. I will definitely order this one again!
carolyn opitz
St Cloud, MN
5 Stars
I would recommend this item to a friend.
January 29, 2014
This was delicious. I liked the orange flavor, and I've tried lots of orange coffees - it is one of my favorites.
Palm Bay, Florida
1 Stars
Strange taste
September 18, 2013
I bought this flavor based on ratings just to try something new. Perhaps I received a bad batch, but it proved to be the worst tasting coffee I have ever experienced. I threw it away. On the other hand, the other new flavor I tried, blueberry, is great.
5 Stars
I would recommend this item to a friend.
Cafe Parisian Decaf
July 12, 2013
Simply Devine! Tastes just like an orange dreamsicle. A new favorite.
Boston, Mass
3 Stars
Not enough flavor
April 25, 2013
Thought I would stray from my many favorites but did not care for this one, hardly no flavor so I will stick with what I know is good which happens to be quite a few of them. Best coffees in the world even if there are a few that don't make my list.
5 Stars
I would recommend this item to a friend.
Delightfully different!
December 7, 2012
Really flavorful, and different from your usual flavored coffee. Wasn't sure if we would enjoy the hint of orange, but it really is good!


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December's coming up, the month during which lots of you are gonna be "requested" to attend holiday "parties" while wearing too many sleeve-to-hem sequins, crushed velvet and bowties, and met with some nice guy who'll slough wax or cement over your face until it looks like an unnatural smile/grimace. Right?
Seriously, though: whenever Madame Tussaud's unveils new wax figures–these two are from New York–the reaction's either "so real!" or "so really horrifying!" These are the latter. MTV called them "terrifying," which makes sense; there's an undeniable touch of the Addams. (It's probably Justin's outfit or his stare, or maybe Selena's crossed arms, or the curtains.) At any rate, if they were going for "we're attending this get-together because we're obligated to, but nevertheless, please socialize with us as little as possible"–fantastic work.
Eeeagh. Here, here's a video montage one of the fine folks of YouTube fandom did, to remind you what these people really look like.


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Security Advisory
ZF2010-02: Potential XSS vector in Zend_Dojo_View_Helper_Editor
Executive Summary
Zend_Dojo_View_Helper_Editor was incorrectly decorating a TEXTAREA
instead of a DIV. The Dojo team has reported that this has security
implications as the rich text editor they use is unable to escape
content for a TEXTAREA.
Action Taken
If you use
Zend_Dojo_View_Helper_Editor, it is strongly
recommended that you upgrade to either the latest available
Zend Framework release, or one of the following releases, immediately:
- 1.9.7
- 1.8.5
- 1.7.9
Other Information
The Zend Framework team thanks the following for working with us to help protect its users:
- Pádraic Brady, who made the initial report and who worked with our team to ensure that the appropriate actions were taken
- Peter Petrison and Mark Corti, for raising related issues in the ZF issue tracker
Reporting Potential Security Issues
If you have encountered a potential security vulnerability in Zend Framework, please report it to us at email@example.com. We will work with you to verify the vulnerability and patch it.
When reporting issues, please provide the following information:
- Component(s) affected
- A description indicating how to reproduce the issue
- A summary of the security vulnerability and impact
We request that you contact us via the email address above and give the project contributors a chance to resolve the vulnerability and issue a new release prior to any public exposure; this helps protect Zend Framework users and provides them with a chance to upgrade and/or update in order to protect their applications.
For sensitive email communications, please use our PGP key.
Zend Framework takes security seriously. If we verify a reported security vulnerability, our policy is:
- We will patch the current release branch, as well as the immediate prior minor release branch.
- After patching the release branches, we will immediately issue new security fix releases for each patched release branch.
- A security advisory will be released on the Zend Framework site detailing the vulnerability, as well as recommendations for end-users to protect themselves. Security advisories will be listed at http://framework.zend.com/security/advisories, as well as via a feed (which is also present in the website head for easy feed discovery)
Released Mon, 11 Jan 2010 16:00:00 -0500.


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George DiCarlo
Two-time NCAA Champion and four-year All American. Twice broke the American record in the 500-yard freestyle. At the 1984 U.S. Olympic Trails, won the 400-meter and 1500-meter freestyle events, setting American records in both. At the 1984 Olympic Games in Los Angeles was the gold medalist in the 400-meter freestyle, setting a new Olympic record; also won the Silver Medal in the 1500-meter freestyle.


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Read an Excerpt
Sleep was always elusive, the first night in a strange bed.
Juliet Browne plumped the pillow, trying to put more volume into it. It was too soft, the mattress too firm and ambient light emanated through a picture window to her right when she was used to cocooning darkness.
She could close the curtain .
Except what she did like about this room was the gnarled pohutukawa branches, spindly as ballerina legs and tufted with leaves dancing in the wind outside the window. Moonlight filtered through them, dappling the stark walls and Spartan-white duvet cover with monochromic graffiti. There was something anarchic about the bony branches that channeled her growing emotion.
Don't be sad.
Rolling on her back, she stared up at the ceiling, shaped like an inverted triangle. This house was pale, stylized and angular, reflecting its architect owner. She liked Mark, liked his steadiness, his creativity, his easy conviction that, gee, life was pretty good, wasn't it?
Tears prickled behind her eyelids and she blinked them away, sidling closer to the edge of the bed, as far away as possible from the man sleeping on the other side. It was normal to feel bewildered, even bereft, under the circumstances. Sex represented the last goodbye in a two-year journey of moving onit was bound to raise Lee's ghost.
Go to sleep, she sternly ordered herself and his ghost.
But if their short, intense relationship had taught her anything, it was that Lee Davis had never been one to lie down quietly. Tucking the sheet around her, Jules thought about the trust agreement she'd been amending that day. The intricacies of subclauses would soothe her faster than watching branches dance.
A sound startled her awake. Opening blurry eyes, she saw her evening clutch bag vibrating on the nightstand. The realization of where she was returned slowly. Glancing over her bare shoulder at Mark, curled away from her, sound asleep, she turned back in time to see her quivering bag topple onto the floor, spilling its contents.
Mark muttered but didn't wake. Just as wellshe'd told him she'd switched off her cell. He'd wanted an intimate dinner with no outside interruptions. Instead, she'd put it on vibrate, unwilling to entirely disconnect from the world.
The low hum stopped as the call went to message. Rolling to the edge of the mattress, Jules shoved her things back into her handbag. A lipstick, comb, a couple of business cardsJuliet Browne, Solicitor, West Harbor Lawa credit card and keys hooked to a miniature tennis ball. Just out of reach, her cell pinged a message, its screen casting a green glow across the white carpet.
She frowned, catching sight of the time. Who would be trying to contact her at six o'clock on a Sunday morning? Pushing aside the covers, she crept out of bed, grabbing her cell en route to the bathroom, where she slid the partition door shut before flicking on the light switch. Ignoring the naked brunette illuminated in the mirror, she checked her messages. Texts from Dan, Ross and Nate . Surely Lee's surviving army buddies weren't already after a progress report? And two missed calls from Nate. She scanned the text messages first.
From Ross at midnight: Have you talked to Nate yet?
From Dan at 1:00 a.m.: Phone me soon as you've talked to Nate.
Anxiously she listened to Nate's voice messages, the first sent at eleven-thirty the night before. "Jules, I need to talk to you urgently. Good news, incredible news but" he gulped "call me, okay?"
His second was the call a few minutes ago. "Where are you if you're not at home?"
Then she read a text from him: CALL ME!
In growing alarm, she punched in his number.
He picked up after the first ring. "Jules," he said. "Thank God. Claire and I are bouncing off walls here."
"What's happened?"
"It's good newsthe bestbut you need someone with you."
"Someone is with me. I'm at Mark's." There was a moment's silence. "Oh shit, you've slept with him."
"What did you think we'd do when you guys set us up, play tiddlywinks? What's going on?"
"Hang on." A few seconds later, Claire, her best friend and Nate's fiancée, came on.
"This needs to be done in person," Claire said by way of greeting. "Go home and we'll meet you there." She and Nate lived forty minutes east of Whangarei, the small city that acted as a gateway to northern New Zealand.
Jules clutched the cell. "Ifyou're up this early on a Sunday it must be bad." Claire was notoriously grumpy in the mornings.
"I swear it's brilliant news astonishing" Her voice broke.
Nate came back on the line. "Look, we can't do this over the phone, Jules," he said impatiently. "Just get home."
"Is Claire cry" The bathroom door opened and Mark came in, rubbing his face. His hair was ruffled. And he was naked. Resisting the urge to cover her own nudity, Jules cut the conversation short. "Fine. The spare key is under a fake rock to the left of the potted geraniums."
"You can't be serious," Nate said, incredulous. She broke the connection before the former celebrity bodyguard could lecture her about security.
"What's going on?" Mark asked.
"That was Nate and Claire." In the mirror, two people stood naked in a confined space under a bank of spotlights. Jules edged past him and into the bedroom. "Good news, apparently, but they want to tell me in person."
"Why would they withhold good news? That doesn't make sense."
"It doesn't, does it?" Anxiously, she started dressing, putting a run in her nylons in her haste. Jules wiggled into her cocktail dress, a fitted sheath in flamingo-pink, and stepped into the matching stilettos. "Zip me up?"
He did, and then dropped her shawl, a fine paisley silk, across her shoulders. "Want me to come with you?"
"No." Mark raised an eyebrow and Jules patted his arm. "Thanks, but I'm sure it's fine." A romance was one thing, letting him into her relationship with Lee's friends something else. Even if the guys had set them up. Mark's brother Richard served with Ross in the SAS and Mark had designed the renovations for Claire and Nate's home.
Her new lover pulled on jeans and walked her to the front door, which he unlocked. "Phone me when you know."
"I will." She waited for him to open it.
"Wait a sec. You forgot something."
Jules tamped down her impatience as he disappeared in the direction of the kitchen. A few minutes later he returned with the enormous bunch of pink peonies he'd given her the night before, still in their cellophane. He'd wrapped the ends in damp newspaper. And as much as Jules wanted to race home and find out what the hell was going on, she took a minute to kiss this thoughtful man.
"I had a great time," she said, then added more truthfully, "I'm glad it was you." Last night had been about more than a physical connectionshe'd needed the tenderness. And if the sex hadn't been earth-shattering, it would get better as she practiced letting go.
He grinned, suddenly boyish as he turned the burnished doorknob. "I'm glad it was me, too. Call me."
"I will." When he closed the door, she ran.
Thirty minutes later, Jules spun into the quiet cul-de-sac where she lived, the loud rumble of her recent purchasea 1959 Cadillac de Villevying with the dawn chorus of the sparrows nesting in the old oak in her front yard.
Nate's glossy black four-wheel drive was already parked in her driveway and she screeched to a halt behind it. Opening her clutch bag, she pulled out her diamond ring and slid it on, then grabbed her house keys and the flowers. In last night's clothes, with tousled hair, slutty stilettos and kiss-swollen lips, she felt like Cinderella minus the midnight intervention. Which was crazyher friends wouldn't judge her.
No, she was doing that herself.
The door opened before she could insert the key in the lock and she found herself dragged into a convulsive hug by her best friend.
Jules froze. "Oh God, I knew it was bad news."
"No, it's great." Claire loosed her hold. "I'm sorry, I've crushed your flowers." Tugging them from Jules's hands, she nervously smoothed out the cellophane. "Go sit down."
But Jules was looking beyond her to Nate, who was standing by the tiny tiled hearth, his fists jammed in the pockets of his jeans. Her stomach dropped. His dark eyes were red-rimmed. Her attention shot to Claire. Her friend's long blond hair was tied back, revealing her pale face; she'd clearly been crying, too. And her piercing blue gaze reminded Jules of a nurse assessing a patient.
"You're scaring me," she croaked.
"If you'd just sit"
"Tell me now!"
"It's Lee." Nate sucked in a breath, then his face split in a wide, shaky grin. "Jules, he's alive."
The words made so little sense she couldn't process them. Lee was dead, his body detonated by insurgents after an ambush in Afghanistan nineteen months and three days ago. They'd held a memorial service and his SAS comrades had played the Last Post. She shivered, recalling the echo of that mournful bugle. "I misheard you," she said politely.
"What did you say?"
"Lee has been discovered alive." Claire gave a half laugh, half sob and reached out a hand, but Jules fended her off.
"No!" It was fatal to let in a whisper of doubt or hope after so many months of fighting to accept the grim reality. But the word alive had already found a resonance inside her and was sucking all the oxygen out of her lungs. In front of her, Claire kaleidoscoped to a tiny smiling dot.
Jules returned to consciousness to hear Nate say, "We should have made her sit down."
Something pressed against her left cheek. "Ow!" She fumbled at what felt like a wet plastic bag of marbles and opened her eyes. She was lying on the floral couch, her legs raised on cushions.
"It's okay." Nate replaced a package of frozen peas on her left cheekbone. "Only a bruise."
"What happened?" she said in bewilderment.
Tenderly, Claire pushed strands of hair away from her face. "You fainted and hit your head falling. It was the shock."
Lee's alive. Shoving away the peas, Jules jerked upright, and then swayed under a wave of dizziness.
"Easy." Nate steadied her by grasping her shoulders. "Give yourself time to grasp that Lee's a"
Jules wrenched free. "Stop saying that. It's cruel!" Her teeth began to chatter and she hugged herself, blaming the frozen peas for the shivers.
Sitting on the couch, Nate tugged her into his arms. "I swear to God," he rasped, holding her resistant body tight against his chest. "Lee's alive. He's safe."
The sob burst out of Jules, as graceless as a retch. Then another and another. Alive. She was barely aware of Nate rocking her, of Claire wrapping her arms around both of them, laughing and crying. A rush of elation percolated through her bloodstream and she started laughing, too.
"Tell me how why?"
Nate launched into an explanation of some setup and a body switch. Clinging to Claire's fingers, Jules nodded but all she could hear was the beating of her heart. Alive. Alive. Alive!
".and when the Americans raided a remote mountain outpost, they discovered the dugout where they'd been holding him."
Some dark thread in his tone caught her attention.
"He's been a prisoner of the Taliban."
Nate read her fallen expression and added soothingly, "He's in a military hospital in Bagram. His condition can't be too critical or he'd have been evacuated to better facilities in Germany."
"We have to go to him."
Nate exchanged a glance with Claire, who put her arm around Jules. "The SAS has arranged for the guys to fly out tonight."
For a moment she stared at her friend blankly. "Oh, my God." Jules massaged her temples. "He doesn't know about his dad."
Nate gestured to the rock on Jules's finger. The diamond was big and brash, a powerhouse that seemed to seize all ambient light. "Or that he's engaged."
Knowing Lee had intended to propose, his buddies had given her the engagement ring. They'd found it when they'd packed up his personal effects.
Reality hit her like an oncoming locomotive. Instinctively Jules covered the ring with her other hand.
"Now he can propose in person," Claire said cheerfully, as though a six-week whirlwind romance easily withstood a year-and-a-half's separation. A separation where one of the parties had been presumed dead and the other was boinking someone else.
And that was the least of her problems.
Lee woke at first light, habituated by many months of the rhythmic chanting of dawn prayers that his captors began their day with. And found himself in a private room in a military hospital at Bagram.
His prayers had been answered.
He stretched his fever-weakened muscles, relishing the clean, scratchy cotton against his torso and any damn mattress, even this serviceable hospital one, cushioning his body. Frankly, he needed the sensory reminder that he wasn't lying on a dirt floor, scratching fleabites while his belly squirmed with dysentery.
The comfortable bed allowed him to close his eyes, confident he wouldn't be kicked into consciousness, and helped him bypass those terrible waking seconds when he thought, I have to survive another day. And later, when he'd given up all hope of rescueWhat am I surviving for?
Opening his eyes, he scanned the simple prefab hospital room, luxuriating in the peacefulness. Closed his eyes and reveled in the lack of pain.
The Americans who'd found him had been kind, treating him with brisk efficiency. A Special Forces soldiera Kiwifound alive. Except none were missing. That information had been enough for Lee to begin to doubt his sanity. Again.
Too hyped to sleep he switched on the lighta light!and poured himself a glass of water from the jug beside the bed. Because he could drink his fill, he had another. Grateful for the small things. A glass. Being hydrated. Hair clean, if uncut. Lips moistened with lip balm, wounds cared for, fever broken. Particularly thankful that his thigh ached from the drugs they'd pumped into it to treat his viral leish-maniasis.
The condition he'd lived with, untreated, for weeks. Along with his name and his unit, it was the only thing he kept repeating between delirium dreams.
Still taking inventory, Lee ran his fingers across his chin, enjoying the smoothness. Last night a nurse had shaved off his beard in preparation for the big meet with the brass this morning, the first he was capable of since his rescue a few days ago. He traced the ridge of scar tissue on his cheek. Maybe designer stubble would be a better idea.
He paused to examine his hand, ignoring the tube taped to the back that connected to an IV feeding him salts, glucose, amino acids and vitamins. His knuckles were swollen. Above the fresh white bandages on his wrist, the skin was weathered and scarred, ingrained dirt in the calluses. His ragged nails were at various stages of regrowth. Not so pretty.
He wiggled his feet, lifted them off the bed, enjoying the light-as-air sensation after months of wearing leg irons. Under the bandages the raw flesh prickled and burned with the effort so he lowered them again.
All that water had made him need to pee. Grabbing the IV stand, he used it as a support and hobbled painfully into the bathroom. He marveled at the clear stream produced by his hydrated kidneys.
At the sink, Lee turned the tap on and off a few times before lathering up his hands. On impulse he cupped them under his nose and inhaled the sudsy fragrance deeply, though God knows there was nothing special about military-grade soap.
Before returning to bed he dropped to the floor and began laboring through five sit-ups and five push-ups. That was all he could manage in his current state. But it was second nature to force himself through this ritual, to try to retain what muscle he could in the forlorn hope he'd find an opportunity to escape.
It hadn't come.
And yet here he was. Free.


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By LUELLA DOWContributor
July 3, 2014 | Vol. 118 -- No. 11
June Labish
June and Joe Labish moved around a lot, but still managed to build a strong family. They have four children, nine grandchildren and nine great-grandchildren.
I was the "new kid on the block" in a group of rural women who called themselves Merry Makers when I first met June Labish. Some of the women stared at me. Others ignored me. June smiled and made me feel welcome.
June and her husband Joe had tackled the 24-hour chore of milking 20 cows on the Boone Mill place. Residents of the Amber area could tell you exactly where that was. The Labish's milk was shipped to Darigold for processing. Tired of the dairy business, June and Joe moved to the wheat hills on Bud Reynolds' place. There they stayed for 12 years.
It was time to move again. Turnbull W...
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In today's environment of emerging security threats, the U.S. Department of Defense has recognized the critical need for highly-qualified, experienced information assurance personnel. To ensure a knowledgeable and skilled workforce the DoD has taken the necessary steps to develop a directive that involves the credentialing and continuing education of all DoD employees with privileged access to DoD information systems.
Specifically, the U.S. Department of Defense Directive 8570.1, signed in August of 2004, requires every full- and part-time military service member, defense contractor, civilian and foreign employee with privileged access to a DoD system, regardless of job series or occupational specialty, to obtain a commercial certification credential that has been accredited by the American National Standards Institute (ANSI).
Directive 8570.1 in Brief
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Requires continuous learning to maintain certification status (typically, 40 hours annually, 120 hours over three years)
Establishes DoD IA Certification Oversight Advisory Board under the DoD CIO/NII
Requires privileged user agreement outlining responsibilities, plus legal and policy limitations of their authority
The draft manual, 8570.1M, specifies that the Department of Defense requires approximately 110,000 identified Information Assurance professionals to be certified within a five year time period. The Defense Information Assurance Program office has divided its Information Assurance workforce into six defined categories (see chart below). The manual also specifies the types of commercial information assurance credentials that qualify for each of the defined categories.
The above chart was provided by the Defense Information Assurance Program (DIAP) Office. As of June 2005, the certifications shown above are the only commercial certifications DoD will accept as fulfillment for the 8570.1M requirement.
CISSP is the first certification to earn the stringent requirements of the ANSI accreditation to ISO/IEC Standard 17024. The SSCP, CAP, CSSLP, CISSP-ISSAP, CISSP-ISSEP and CISSP-ISSMP certifications have also met these requirements and has been approved by ANSI to the ISO/IEC Standard 17024.
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"Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement." has been saved, and will be accessible from the My NGC page.
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This guideline updates a previous version: Screening for cervical cancer: recommendations and rationale. Am Fam Physician 2003 Apr 15;67(8):1759-66. [32 references]
Cervical cancer
Women who have a cervix, regardless of sexual history
Note: This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are human immunodeficiency virus [HIV] positive).
Key Question 1: When should cervical cancer screening begin, and does this vary by screening technology or by age, sexual history, or other patient characteristics?
Key Question 2: To what extent does liquid-based cytology improve sensitivity, specificity, and diagnostic yield and reduce indeterminate results and inadequate samples compared to conventional cervical cytology?
Key Question 3: What are the benefits of using human papillomavirus (HPV) testing as a screening test, either alone or in combination with cytology, compared with not testing for HPV?
Key Question 4: What are the harms of liquid-based cytology?
Key Question 5: What are the harms of using HPV testing as a screening test, either alone or in combination with cytology?
Note from the National Guideline Clearinghouse (NGC): A systematic evidence review was prepared by the Oregon Evidence-based Practice Center (EPC) for the Agency for Healthcare Research and Quality (AHRQ) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Companion Documents" field).
Data Sources
EPC staff initially searched for systematic reviews, meta-analyses, and evidence-based guidelines on cervical cancer screening listed in the Database of Abstracts of Reviews of Effects, the Cochrane Database of Systematic Reviews, PubMed, and the Health Technology Assessment Database from 2000 through 2007. Two systematic reviews addressing liquid-based cytology (LBC) screening were used to identify primary studies before 2003. No systematic reviews on human papillomavirus (HPV) testing that met the inclusion criteria were identified. The EPC staff considered all studies in the previous USPSTF review and conducted literature searches from 2003 through September 2010 by using MEDLINE, the Cochrane Central Register of Controlled Trials, and PsycINFO.
EPC staff conducted a targeted search for any studies related to the trials included in their review (published from September 2010 to 3 August 2011 in PubMed) to ensure that all relevant studies were captured in their previous literature searches. In addition, selected experts in the field were queried on 8 August 2011 to identify relevant publications. EPC staff found 9 additional studies, none of which provided additional data on trials included in the review: 4 contextually relevant or unrelated reports from previously identified cohorts, 1 performance study of a new HPV test, 2 unrelated reports from trial authors, and 2 public health reports. None added primary results to the key questions, but most added to the discussion.
Study Selection
EPC staff evaluated 4262 abstracts and 641 full-text articles (see Figure in the systematic review [see the "Availability of Companion Documents" field]). Two reviewers evaluated abstracts and articles against prespecified inclusion criteria. Discrepancies were resolved by consensus. Fair- to good-quality studies that provided evidence regarding test performance for detection of cervical intraepithelial neoplasia 2+ (CIN2, CIN3, or cancer) or CIN3+ (CIN3 or cancer), as well as harms, were included. Included studies met design-specific quality standards that minimized the effect of verification bias and were conducted in routine screening populations in countries with developed population-based screening for cervical cancer. For question 3, EPC staff evaluated the evidence regarding the use of HPV testing in screening scenarios: primary screening with HPV testing alone, primary HPV testing with cytology triage of positive HPV (reflex cytology), primary HPV plus cytology screening (co-testing), and cytology testing with HPV triage of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion on cytology (reflex HPV). Cytology with reflex HPV is covered in the full report (see the systematic evidence review [see the "Availability of Companion Documents" field]).
The Evidence-based Practice Center (EPC) evaluated 4262 abstracts and reviewed 641 full-text articles.
Key Question 1: 95 articles were reviewed; 6 articles, encompassing 5 studies, were included.
Key Question 2: 149 articles were reviewed; 7 articles, encompassing 4 studies, were included.
Key Question 3: 337 articles were reviewed; 48 articles, encompassing 28 studies, were included.
Key Question 4: 11 articles were reviewed; no studies were included.
Key Question 5: 49 articles were reviewed; 5 articles, encompassing 4 studies, were included.
Not applicable
Data Extraction and Quality Assessment
At least 2 investigators critically appraised and independently rated the quality of all eligible studies by using criteria based on the USPSTF methods, supplemented by the National Institute for Health and Clinical Excellence criteria for quality of systematic reviews and the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool. Good-quality studies generally met all design-specific criteria, whereas fair-quality studies did not meet all the criteria but had no fatal flaws in study design. Poor-quality studies had substantial flaws or lack of reporting that implied bias affecting interpretation of study results and were therefore excluded after agreement among reviewers. One investigator abstracted data from included studies into evidence tables, and a second reviewer verified these data.
Data Synthesis and Analysis
EPC staff members performed qualitative data synthesis because heterogeneity in the samples, study designs, screening protocols, and instruments did not allow for quantitative synthesis. Results from diagnostic accuracy studies (to evaluate 1-time test performance) were synthesized separately from randomized, controlled trials (RCTs). For RCTs of human papillomavirus (HPV) screening, EPC staff report results for each round of screening, as well as cumulative results. In these RCTs, results were generally reported for women screened (rather than an intention-to-screen analysis). For consistency, the results for women screened (denominator) were reported unless otherwise noted. EPC staff also synthesize results for both cervical intraepithelial neoplasia (CIN) 2+ (CIN2, CIN3, or cancer) and CIN3+ (CIN 3 or cancer), even though many CIN2 lesions will regress.
The U.S. Preventive Services Task Force (USPSTF) systematically reviews the evidence concerning both the benefits and harms of widespread implementation of a preventive service. It then assesses the certainty of the evidence and the magnitude of the benefits and harms. On the basis of this assessment, the USPSTF assigns a letter grade to each preventive service signifying its recommendation about provision of the service (see Table below). An important, but often challenging, step is determining the balance between benefits and harms to estimate "net benefit" (that is, benefits minus harms).
Table 1. U.S. Preventive Services Task Force Recommendation Grid*
*A, B, C, D, and I (Insufficient) represent the letter grades of recommendation or of insufficient evidence assigned by the U.S. Preventive Services Task Force after assessing certainty and magnitude of net benefit of the service (see the "Rating Scheme for the Strength of the Recommendations" field).
The overarching question that the USPSTF seeks to answer for every preventive service is whether evidence suggests that provision of the service would improve health outcomes if implemented in a general primary care population. For screening topics, this standard could be met by a large randomized, controlled trial (RCT) in a representative asymptomatic population with follow-up of all members of both the group "invited for screening" and the group "not invited for screening."
Direct RCT evidence about screening is often unavailable, so the USPSTF considers indirect evidence. To guide its selection of indirect evidence, the USPSTF constructs a "chain of evidence" within an analytic framework. For each key question, the body of pertinent literature is critically appraised, focusing on the following 6 questions:
The next step in the process is to use the evidence from the key questions to assess whether there would be net benefit if the service were implemented. In 2001, the USPSTF published an article that documented its systematic processes of evidence evaluation and recommendation development. At that time, the USPSTF's overall assessment of evidence was described as good, fair, or poor. The USPSTF realized that this rating seemed to apply only to how well studies were conducted and did not fully capture all of the issues that go into an overall assessment of the evidence about net benefit. To avoid confusion, the USPSTF has changed its terminology. Whereas individual study quality will continue to be characterized as good, fair, or poor, the term certainty will now be used to describe the USPSTF's assessment of the overall body of evidence about net benefit of a preventive service and the likelihood that the assessment is correct. Certainty will be determined by considering all 6 questions listed above; the judgment about certainty will be described as high, moderate, or low.
In making its assessment of certainty about net benefit, the evaluation of the evidence from each key question plays a primary role. It is important to note that the USPSTF makes recommendations for real-world medical practice in the United States and must determine to what extent the evidence for each key question—even evidence from screening RCTs or treatment RCTs—can be applied to the general primary care population. Frequently, studies are conducted in highly selected populations under special conditions. The USPSTF must consider differences between the general primary care population and the populations studied in RCTs and make judgments about the likelihood of observing the same effect in actual practice.
It is also important to note that one of the key questions in the analytic framework refers to the potential harms of the preventive service. The USPSTF considers the evidence about the benefits and harms of preventive services separately and equally. Data about harms are often obtained from observational studies because harms observed in RCTs may not be representative of those found in usual practice and because some harms are not completely measured and reported in RCTs.
Putting the body of evidence for all key questions together as a chain, the USPSTF assesses the certainty of net benefit of a preventive service by asking the 6 major questions listed above. The USPSTF would rate a body of convincing evidence about the benefits of a service that, for example, derives from several RCTs of screening in which the estimate of benefits can be generalized to the general primary care population as "high" certainty (see the "Rating Scheme for the Strength of Recommendations" field). The USPSTF would rate a body of evidence that was not clearly applicable to general practice or has other defects in quality, research design, or consistency of studies as "moderate" certainty. Certainty is "low" when, for example, there are gaps in the evidence linking parts of the analytic framework, when evidence to determine the harms of treatment is unavailable, or when evidence about the benefits of treatment is insufficient. Table 4 in the methodology document listed below (see the "Availability of Companion Documents" field) summarizes the current terminology used by the USPSTF to describe the critical assessment of evidence at all 3 levels: individual studies, key questions, and overall certainty of net benefit of the preventive service.
Sawaya GF et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med. 2007;147:871-875. [5 references].
What the U.S. Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice
Note: The following statement is undergoing revision.
Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.
USPSTF Levels of Certainty Regarding Net Benefit
Definition: The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.
The developer reviewed published cost analyses.
Peer Review. Before the U.S. Preventive Services Task Force (USPSTF) makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft evidence review to 4 to 6 external experts and to Federal agencies and professional and disease-based health organizations with interests in the topic. The experts are asked to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the USPSTF in memo form. In this way, the USPSTF can consider these external comments before it votes on its recommendations about the service. Draft recommendation statements are then circulated for comment among reviewers representing professional societies, voluntary organizations, and Federal agencies, as well as posted on the Task Force Web site for public comment. These comments are discussed before the final recommendations are confirmed.
Response to Public Comments. A draft version of this recommendation statement was posted for public comment on the USPSTF Web site from October 19, 2011, through November 30, 2011. Many comments pointed out a lack of clarity about the harms of false-positive results and the harms of screening with cytology more frequently than every 3 years or screening women younger than age 21 years. Several comments requested clarification on how information about sexual history may affect screening. Some comments highlighted the importance of reaching women who are not being screened at all. Many comments urged the USPSTF to reconsider its draft recommendation on human papillomavirus (HPV) co-testing and review new evidence that had been published since its deliberation. In response to these comments, the USPSTF clarified throughout the statement the harms that would occur from screening too frequently and in women younger than age 21 years. The USPSTF also clarified that this recommendation statement applies to women regardless of sexual history. The USPSTF agrees that the greatest effect on cervical cancer incidence and mortality would result from efforts to screen women who have not been adequately screened, and this is stated in the Rationale and elsewhere.
After the public comment period, the USPSTF considered new evidence that was published since its initial deliberation—specifically the update of the POBASCAM results and the study by Katki and colleagues. With this new evidence, in addition to the previously considered evidence, the USPSTF decided to recommend HPV testing combined with cytology (co-testing) as a reasonable alternative for women age 30 to 65 years who wish to extend the screening interval beyond 3 years.
Recommendations of Others. Recommendations for screening for cervical cancer from the following groups were discussed: the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP); the American College of Obstetricians and Gynecologists (ACOG); and the American Academy of Family Physicians (AAFP).
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the levels of certainty regarding net benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.
Summary of Recommendations and Evidence
This recommendation statement applies to women who have a cervix, regardless of sexual history. This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are human immunodeficiency virus [HIV] positive).
The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval (A recommendation).
The USPSTF recommends against screening for cervical cancer in women younger than age 21 years (D recommendation).
The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors (D recommendation).
The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer (D recommendation).
The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years (D recommendation).
Clinical Considerations
Patient Population Under Consideration
This recommendation statement applies to all women who have a cervix, regardless of sexual history. This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
Screening Tests
The effectiveness of cervical cancer screening observed in the United States over the past several decades is attributed to the use of conventional cytology. Current evidence indicates that there are no clinically important differences between liquid-based cytology and conventional cytology. The USPSTF realizes that the choice of cytology method may not be under the direct control of the clinician and considers cytology screening in appropriate age groups at appropriate intervals to be of substantial net benefit, regardless of method. HPV testing with Digene Hybrid Capture 2 (HC2) (Qiagen, Germantown, Maryland) is commonly used in the United States, and both HC2 and polymerase chain reaction–based methods have been evaluated in effectiveness trials. Although alternative HPV detection methods are emerging, the clinical comparability and implications of these methods are not completely understood.
Screening Interval
Screening women age 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms. Among women age 30 to 65 years, HPV testing combined with cytology (co-testing) every 5 years offers a comparable balance of benefits and harms and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval. Screening with cytology more often than every 3 years confers little additional benefit, with large increases in harms, including additional procedures and assessment and treatment of transient lesions. Treatment of lesions that would otherwise resolve on their own is harmful because it can lead to procedures with unwanted side effects, including the potential for cervical incompetence and preterm labor. Similarly, the frequency of HPV testing with cytology should not be more often than every 5 years in order to maintain a reasonable balance of benefits and harms similar to that seen with cytology alone every 3 years. Maintaining the comparability of the benefits and harms of co-testing and cytology alone demands that patients, clinicians, and health care organizations adhere to currently recommended screening intervals, protocols for repeat testing, cytologic thresholds for further diagnostic testing (that is, colposcopy) and treatments, and extended surveillance as recommended by current American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology (ACS/ASCCP/ASCP) guidelines.
Women choosing co-testing to increase their screening interval (and potentially decrease testing) should be aware that positive screening results are more likely with HPV-based strategies than with cytology alone and that some women may require prolonged surveillance with additional frequent testing if they have persistently positive HPV results. Because HPV test results may be positive among women who would otherwise be advised to end screening at age 65 years on the basis of previously normal cytology results alone, the likelihood of continued testing may increase with HPV testing. The percentage of U.S. women undergoing co-testing who will have a normal cytology test result and a positive HPV test result (and who will therefore require additional testing) ranges from 11% among women age 30 to 34 years to 2.6% among women age 60 to 65 years.
Timing of Screening
Women Younger Than Age 21 Years
Cervical cancer is rare before age 21 years. The USPSTF found little evidence to determine whether and how sexual history should affect the age at which to begin screening. Although exposure of cervical cells to sexually transmitted HPV during vaginal intercourse may lead to cervical carcinogenesis, the process has multiple steps, involves regression, and is generally not rapid. There is evidence that screening earlier than age 21 years, regardless of sexual history, would lead to more harm than benefit. The harms are greater in this younger age group because abnormal test results are likely to be transient and to resolve on their own; in addition, resulting treatment may have an adverse effect on future child-bearing.
Women Older Than Age 65 Years
Clinicians and patients should base the decision to end screening on whether the patient meets the criteria for adequate prior testing and appropriate follow-up per established guidelines. The ACS/ASCCP/ASCP guidelines define adequate prior screening as 3 consecutive negative cytology results or 2 consecutive negative HPV results within 10 years before cessation of screening, with the most recent test occurring within 5 years. They further state that routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a high-grade precancerous lesion, even if this extends screening past age 65 years. The ACS further states that screening should not resume after cessation in women older than age 65 years, even if a woman reports having a new sexual partner.
Women Older Than Age 65 Years Who Have Never Been Screened
Screening may be clinically indicated in older women for whom the adequacy of prior screening cannot be accurately accessed or documented. Women with limited access to care, minority women, and women from countries where screening is not available may be less likely to meet the criteria for adequate prior screening. The USPSTF realizes that certain considerations may support screening in women older than age 65 years who are otherwise considered high risk (such as women with a high-grade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised).
Assessment of Risk
It is well established that HPV infection is associated with nearly all cases of cervical cancer. Other factors that put a woman at increased risk for cervical cancer include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer.
Women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer are not at risk for cervical cancer and should not be screened. Women who had their cervix removed during surgery for ovarian or endometrial cancer are not at high risk for cervical cancer and would not benefit from screening. Clinicians should confirm through review of surgical records or direct examination that the cervix was removed.
Screening aims to identify high-grade precancerous cervical lesions to prevent development of cervical cancer and early-stage asymptomatic invasive cervical cancer. High-grade lesions may be treated with ablative and excisional therapies, including cryotherapy, laser ablation, loop excision, and cold-knife conization. Early-stage cervical cancer may be treated with surgery (hysterectomy) or chemoradiation. The treatment of precancerous rather than early-stage cancerous lesions is unique to cervical cancer and is the foundation of the success of cervical cancer screening. Treatment of precancerous lesions is less invasive than treatment of cancer and results in fewer adverse effects.
Other Approaches to Prevention
Many individuals and clinicians have used the annual Papanicolaou (Pap) smear screening visit as an opportunity to discuss other health problems and preventive measures. Individuals, clinicians, and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient. Efforts should also be made to ensure that individuals are able to seek care for additional health concerns as they present.
The overall effect of HPV vaccination on high-grade precancerous cervical lesions and cervical cancer is not yet known. Current trials do not provide data on long-term efficacy; therefore, the possibility that vaccination might reduce the need for screening with cytology alone or in combination with HPV testing is not established. Given these uncertainties, women who have been vaccinated should continue to be screened.
None provided
The type of supporting evidence is not specifically stated for each recommendation.
Benefits of Detection and Early Intervention/Treatment
Women Age 21 to 65 Years
There is convincing evidence that screening women age 21 to 65 years with cytology every 3 years substantially reduces cervical cancer incidence and mortality. Among women age 30 to 65 years, there is adequate evidence that screening with a combination of cytology and human papillomavirus (HPV) testing (co-testing) every 5 years provides benefits similar to those seen with cytology screening alone every 3 years.
Among women younger than age 30 years, there is adequate evidence that screening with HPV testing (alone or in combination with cytology) confers little to no benefit.
There is adequate evidence that screening women younger than age 21 years (regardless of sexual history) does not reduce cervical cancer incidence and mortality compared with beginning screening at age 21 years.
There is adequate evidence that screening women older than age 65 years who have had adequate prior screening and are not otherwise at high risk provides little to no benefits.
Women After Hysterectomy
There is convincing evidence that continued screening after hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefits.
Harms of Detection and Early Intervention/Treatment
Screening with cervical cytology or human papillomavirus (HPV) testing can lead to harms, and the harms of screening can take many forms. Abnormal test results can lead to more frequent testing and invasive diagnostic procedures, such as colposcopy and cervical biopsy. Evidence from randomized, controlled trials and observational studies indicates that harms from these diagnostic procedures include vaginal bleeding, pain, infection, and failure to diagnose (due to inadequate sampling). Abnormal screening test results are also associated with mild psychological harms; short-term increases in anxiety, distress, and concern about health have been reported with cytology and HPV testing.
Harms of Treatment of Screening-Detected Disease
The harms of treatment include risks from the treatment procedure itself and the potential downstream consequences of treatment. Summary evidence from observational studies indicates that some treatments for precancerous lesions (such as cold-knife conization and loop excision) are associated with adverse pregnancy outcomes, such as preterm delivery, that can lead to low birthweight in infants and perinatal death. Evidence is convincing that many precancerous cervical lesions will regress and that other lesions are so indolent and slow-growing that they will not become clinically important over a woman's lifetime; identification and treatment of these lesions constitute overdiagnosis. It is difficult to estimate the precise magnitude of overdiagnosis associated with any screening or treatment strategy, but it is of concern because it confers no benefit and leads to unnecessary surveillance, diagnostic tests, and treatments with the associated harms.
There is adequate evidence that the harms of screening for cervical cancer with cytology alone or in combination with HPV testing in women age 30 to 65 years are moderate. Positive screening results are more common with strategies that include HPV testing than with strategies that use cytology alone. Therefore, the likelihood of prolonged surveillance and overtreatment may increase with strategies that incorporate HPV testing. Cervical treatments may increase the risk for adverse pregnancy outcomes (for example, cervical insufficiency and preterm delivery) in women who have not yet completed childbearing.
Women Younger Than Age 30 Years
There is adequate evidence that the harms of HPV testing (alone or in combination with cytology) in women younger than age 30 years are moderate.
There is adequate evidence that the harms of screening in women younger than age 21 years are moderate.
There is adequate evidence that the harms of screening in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk are at least small.
There is adequate evidence that screening after hysterectomy among women who do not have a history of a high-grade precancerous lesion or cervical cancer is associated with harms.
The experiences of the first and second U.S. Preventive Services Task Force (USPSTF), as well as that of other evidence-based guideline efforts, have highlighted the importance of identifying effective ways to implement clinical recommendations. Practice guidelines are relatively weak tools for changing clinical practice when used in isolation. To effect change, guidelines must be coupled with strategies to improve their acceptance and feasibility. Such strategies include enlisting the support of local opinion leaders, using reminder systems for clinicians and patients, adopting standing orders, and audit and feedback of information to clinicians about their compliance with recommended practice.
In the case of preventive services guidelines, implementation needs to go beyond traditional dissemination and promotion efforts to recognize the added patient and clinician barriers that affect preventive care. These include clinicians' ambivalence about whether preventive medicine is part of their job, the psychological and practical challenges that patients face in changing behaviors, lack of access to health care or of insurance coverage for preventive services for some patients, competing pressures within the context of shorter office visits, and the lack of organized systems in most practices to ensure the delivery of recommended preventive care.
Dissemination strategies have changed dramatically in this age of electronic information. While recognizing the continuing value of journals and other print formats for dissemination, the USPSTF Task Force will make all its products available through its Web site . The combination of electronic access and extensive material in the public domain should make it easier for a broad audience of users to access USPSTF materials and adapt them for their local needs. Online access to USPSTF products also opens up new possibilities for the appearance of the annual, pocket-size Guide to Clinical Preventive Services.
To be successful, approaches for implementing prevention have to be tailored to the local level and deal with the specific barriers at a given site, typically requiring the redesign of systems of care. Such a systems approach to prevention has had notable success in established staff-model health maintenance organizations, by addressing organization of care, emphasizing a philosophy of prevention, and altering the training and incentives for clinicians. Staff-model plans also benefit from integrated information systems that can track the use of needed services and generate automatic reminders aimed at patients and clinicians, some of the most consistently successful interventions. Information systems remain a major challenge for individual clinicians' offices, however, as well as for looser affiliations of practices in network-model managed care and independent practice associations, where data on patient visits, referrals, and test results are not always centralized.
Not applicable: The guideline was not adapted from another source.
The U.S. Preventive Services Task Force (USPSTF) is a federally-appointed panel of independent experts. Conclusions of the USPSTF do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or its agencies.
United States Government
U.S. Preventive Services Task Force (USPSTF)
Task Force Members*: Virginia A. Moyer, MD, MPH, (Chair) (Baylor College of Medicine, Houston, Texas); Michael L. LeFevre, MD, MSPH, (Co-Vice Chair) (University of Missouri School of Medicine, Columbia, Missouri); Albert L. Siu, MD, MSPH, (Co-Vice Chair) (Mount Sinai School of Medicine, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York); Kirsten Bibbins-Domingo, PhD, MD (University of California, San Francisco, San Francisco, California); Susan J. Curry, PhD (University of Iowa College of Public Health, Iowa City, Iowa); Mark Ebell, MD, MS (University of Georgia, Athens, Georgia); Glenn Flores, MD (University of Texas Southwestern, Dallas, Texas); Adelita Gonzales Cantu, RN, PhD (University of Texas Health Science Center, San Antonio, Texas); David C. Grossman, MD, MPH (Group Health Cooperative, Seattle, Washington); Joy Melnikow, MD, MPH (University of California Davis, Sacramento, California); Wanda K. Nicholson, MD, MPH, MBA (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Carolina Reyes, MD, MPH (Virginia Hospital Center, Arlington, Virginia); and Timothy J. Wilt, MD, MPH (University of Minnesota Department of Medicine and Minneapolis Veteran Affairs Medical Center, Minneapolis, Minnesota). Former USPSTF members who contributed to the development of this recommendation include George J. Isham, MD, MS (HealthPartners, Minneapolis, Minnesota); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York); Bernadette Melnyk, PhD, RN (Ohio State University College of Nursing, Columbus, Ohio); George F. Sawaya, MD (University of California, San Francisco, San Francisco, California); and J. Sanford Schwartz, MD, MBA (University of Pennsylvania Medical School and the Wharton School, Philadelphia, Pennsylvania).
*Member of the U.S. Preventive Services Task Force (USPSTF) at the time these recommendations were finalized. For a list of current Task Force members, go to http://www.uspreventiveservicestaskforce.org/Page/Name/our-members .
The U.S. Preventive Services Task Force (USPSTF) has an explicit policy concerning conflict of interest. All members disclose at each meeting if they have a significant financial, professional/business, or intellectual conflict for each topic being discussed. USPSTF members with conflicts may be recused from discussing or voting on recommendations about the topic in question.
Electronic copies: Available from the Annals of Internal Medicine Web site .
The following are available:
Evidence Reviews:
Electronic copies: Available from the U.S. Preventive Services Task Force (USPSTF) Web site .
Background Articles:
Electronic copies: Available from the USPSTF Web site .
The following are also available:
The Electronic Preventive Services Selector (ePSS) , available as a PDA application and a web-based tool, is a quick hands-on tool designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. It is based on current recommendations of the USPSTF and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors.
Print copies: Available in English and Spanish from the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse. For more information, go to http://www.ahrq.gov/research/publications/index.html or call 1-800-358-9295 (U.S. only).
Myhealthfinder is a new tool that provides personalized recommendations for clinical preventive services specific to the user's age, gender, and pregnancy status. It features evidence-based recommendations from the USPSTF and is available at www.healthfinder.gov .
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on January 17, 2003. The updated information was verified by the guideline developer on January 20, 2003. This NGC summary was updated by ECRI Institute on June 11, 2012. The updated information was verified by the guideline developer on June 21, 2012.
Requests regarding copyright should be sent to: Lisa S. Nicolella, Senior Editor, Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850; E-mail: email@example.com.
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.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
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Jul 8, 2010
Weekend Planner: Dollar Days & Free Festivals
Go easy on the wallet this weekend at these family events that only cost a few dollars -- some are even free!
Admission to Hagley Museum in Wilmington, DE is only $1 today (and every Thursday in July & August).
Enjoy $1 ice cream, yoga classes, doggie treats & more along the Baltimore Ave. Dollar Stroll this evening in Phila.
Also tonight in Phila., you can take advantage of the 5 After 5 promotion at the National Constitution Center, where admission is only $5 after 5pm.
FREE family festivals on Saturday include the Bastille Day re-enactment at Eastern State (it's more silly than scary!), a Christmas in July celebration out in Lancaster County, PA, and the weekend-long Haddonfield (NJ) Crafts & Fine Arts Festival.
Stephanie Halinski is calendar editor of MetroKids. For more weekend events, search hundreds of activities on our calendar. Receive weekend event highlights directly in your inbox each week! Sign up for MetroKids' e-newsletter today.


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April 20, 2000
1999-2000 UCLA Women's Golf Averages
Leilani Bagby, Jr., Santa Monica (76.6)
Bridget Dwyer, Fr., Kailua, HI (79.5)
Jamie Kim, Fr., Beverly Hills (79.5)
Amanda Moltke-Leth, Sr., Copenhagen, Denmark (73.5)
Laura Moffat, Jr., West Kilbride, Scotland (75.3)
Julie Oh, Jr., Torrance (83.1)
Vivan Phosomran, Fr., Long Beach (79.8)
Alicia Um, So., Newbury Park (78.5)
UCLA Website: www.uclabruins.com
Upcoming Events : The UCLA women's golf team, ranked 14th in the CGF MasterCard rankings and 20th in the Sagarin poll, will participate in the 14th Annual Pacific-10 Women's Golf Championships hosted by Oregon, Apr. 24-26 at the Eugene Country Club.
Team Update : The Bruins won their first tournament in more than three years when they placed first in the Rainbow Wahine Fall Classic, Nov. 8-10 at the Kapolei Golf Resort on Oahu. After their third place finish at Peg Barnard Invitational at Stanford, the Bruins extended their streak to six straight top 10 finishes. The Bruins captured third at the Pioneer Bruin Classic, Mar. 12-14, fifth at the Fall Preview in September and finished ninth at the TRW Regional Challenge, Feb. 7-9. On Feb. 23, UCLA finished 10th in the Arizona Invitational. They placed 13th at the Stanford Intercollegiates in October.
Senior Amanda Molte-Leth: Leads the team with a 73.5 stroke average in 26 rounds. She was ranked eighth in the Apr. 19 MasterCard poll and 14th in the Sagarin rankings for Apr. 19. In her best outing, she won the Peg Barnard Invitational by two shots over USC's Candie Kung and Washington's Kellie Kamimura. The victory was her fifth as a collegian, but first at UCLA. Earlier in the year, tied for first with teammate Laura Moffat at the Rainbow Wahine event, but lost in a playoff. She also tied for second at the Fall Preview and tied for fifth at the McGuire Invitational with a one-under par score of 218. At the PING/ASU event, she tied for sixth place after posting a final round, one-under par 71. She has a streak of six straight tournaments in which she has placed among the top 10 individually. At the Arizona Invitational, she fired a second round, four-under par 68 en route to a tie for ninth place at 214, two-under par. The 68 tied her collegiate best, which she shot as a freshman at Memphis. She recorded a fifth top 10 finish by tying for 10th place at the Regional Challenge. At UCLA's Pioneer Classic, she finished 14th and fired a one-under par 71 in the first round. She tied for 24th at the Stanford event in the fall. All 27 of her rounds this season have counted toward the team's score. She leads the team with four top five finishes, seven top 10 finishes and six rounds under par, including one round under 70.
The Juniors
Leilani Bagby : Has averaged 76.6 in 23 rounds. In her best collegiate finish at the Pioneer, she tied for second place with a two-over par score of 75-72-71:218. Her final round score of 71 was her first collegiate round under par. At the Peg Barnard Invitational, she tied for 13th place at 154. She also tied for 14th at the Rainbow Wahine, tied for 24th at the Stanford tournament and tied for 31st at the Fall Preview. This week, she was ranked 87th in the MasterCard poll and 95th in the Sagarin rankings. All of her rounds have counted in team competition this season.
Laura Moffat : Won her first collegiate tournament by winning a two-hole sudden-death playoff with teammate Amanda Moltke-Leth and Hawaii's Melanie Matsumura at the Rainbow Wahine Classic. She captured 15th place at the Pioneer Classic with scores of 76-75-75:226. She also tied for 16th place at the PING/ASU tournament, tied for 19th at the Peg Barnard Invitational, tied for 18th at the Fall Preview and tied for 20th at the Arizona Invitational. At the Arizona event, she recorded a one-under par 71 in the second round, a collegiate best. She also finished 29th at the Regional Challenge, where she posted a 73 in the final round. She improved her overall season stroke average to 75.3 in 23 rounds with 100% of her scores counting toward the team score. She improved to 51st in the Sagarin rankings on Apr. 19th and was ranked 61st in the CGF MasterCard poll on Apr. 20.
Julie Oh : Has averaged 83.1 in 12 rounds this season and tied for 70th at the McGuire Invitational. Her best round of the season was a 77 in the second round at that event.
Sophomore Alicia Um : Has averaged 78.5 in 20 rounds this season. Best score of 74 was posted in the first round of the Arizona Invitational. She recorded her best finish of the season, tied for 23rd, at the Pioneer Classic. In her last five starts she has averaged 76.5 strokes per round with 13 of the 14 scores counting toward the team total. Her percentage of rounds used has increased to 75% in her last 12 rounds.
The Freshmen
Bridget Dwyer : Earned a spot on the travel roster by qualifying for the Arizona Invitational. Fired a collegiate best score of 76 in the first round of the Arizona event. Also travelled to the PING/ASU Tournament and matched her collegiate best in the first round before tying for 79th place. Played as an individual in the Pioneer Classic and tied for 58th. She is averaging 79.5 in nine rounds.
Jamie Kim : Has averaged 79.5 in 15 rounds this season. Tied for 38th at the Peg Barnard Invitational to record her best collegiate finish. Played as an individual at the Regional Challenge and fired a final round 73, her collegiate best. Played as an individual in the Pioneer Classic and tied for 49th. Tied for 65th at the Fall Preview
Vivan Phosomran : Has averaged 80.1 in 15 rounds this season. Best finish was a tie for 33rd at the Rainbow Wahine event. She also tied for 40th playing as an individual in the Stanford Intercollegiates. Tied for 46th at the Pioneer Classic, playing as an individual. Best score of 74 was posted in the first round at the Rainbow event.
Head Coach Carrie Leary : The first-year coach guided the Bruins to their first team title in three years at the Rainbow Wahine Fall Classic. She opened her UCLA coaching career by leading the Bruins to a surprising fifth place finish at the 1999 Fall Preview hosted by Oregon State. This week the Bruins are ranked 14th nationally by the CGF in the MasterCard poll, their highest ranking under Leary. Already this season the Bruins have improved their team stroke average by five strokes from last season. The 28-year old coach served three seasons at Cal State Northridge where she earned 1998-99 Big Sky Coach of the Year honors and improved the Matadors' scores 31 strokes during her tenure. Leary joined the Bruins as a walk-on player in 1989, earned a scholarship and played in 11 of 12 tournaments as a freshman, including UCLA's 1990 Pac-10 championship team. She was also a member of UCLA's 1991 NCAA Championship team.


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I have software that generates PDFs and sends them to print via the
lp program. The same PDF prints slightly different to 2 different printers. The font and margins are different.
How can I standardize the margins and font between the two printers? Is this just a difference in the drivers for each printer?
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page-top etc options do not have any effect.


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About Us
Info for Patients
Referring Physicians
Our Faculty & Staff
Current Nephrology Fellows
Office Staff
Nursing Staff
Job Opportunities
Fellowship Training Program
Nephrology Faculty
Abe, Akira, Ph.D.
Adjunct Research Investigator
Afshinnia, Farsad, M.D., M.S.
Clinical Lecturer
Atkins, Kevin, M.S., Ph.D.
Assistant Research Scientist
Berthier, Celine, Ph.D., M.S.
Assistant Research Scientist
Bitzer, Markus, M.D., M.S.
Associate Professor
Boyer Jr., Charles J., P.A.C.
Physician Assistant
Bragg-Gresham, Jennifer
Research Area Specialist Lead
Brosius III, Frank C., M.D.
Division Chief, Nephrology
Chief, Nephrology Clinical Services
Byun, Jaeman, Ph.D.
Assistant Research Scientist
Cibrik, Diane M., M.D., M.S.
Fan, Shuling, Ph.D., M.D.
Assistant Research Scientist
Garg, Puneet, M.D.
Assistant Professor
Gipson, Patrick E., M.D.
Assistant Professor
Director, Glomerular and Inherited Diseases Clinics
Harder, Jennifer L., M.D.
Hatamizadeh, Parta, M.D.
Clinical Lecturer
Heung, Michael, M.D.
Associate Professor
Director, Inpatient Dialysis Programs
Hicken, Margaret, Ph.D.
Research Investigator
Hinkovska-Galcheva, Vania, M.S., Ph.D.
Research Assistant Professor
Hsu, Chen Hsing, M.D.
Professor Emeritus
Huang, Yihung (Eric), M.D.
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Humes, H. David, M.D.
Inoki, Ken, M.D., Ph.D.
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Messana, Joseph M., M.D.
Director, Peritoneal and Home Hemodialysis Program
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Associate Professor
Ojo, Akinlolu O., M.D., MPH, Ph.D.
Florence E. Bingham Research Professor of Nephrology
Patel, Sanjeevkumar R., M.D., M.S.
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Wiggins, Roger C., M.B., B.Chir.
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New Chase Bank in Menifee Opens Today
Customers of Chase Bank will soon find banking to be a little more convenient now that the nation...
Currently, Chase customers in Menifee have been using the Sun City branch where parking has often been a challenge, or driving to branches in Murrieta and Lake Elsinore.
The much anticipated opening led to a rush of bank customers that made the new bank branch look crowded like a lunch hour on pay day. Bank managers greeted everyone with smiles, but could not provide comments to us without clearance from the corporate office.
However, Laura Riesenberg, branch manager of the new Chase location, said there will be a more formal Grand Opening event on December 3.
But folks who stop by today can pick up some freebies, such as piggy-bank key chains, letter-openers, frisbees and pens among other goodies.
JPMorgan Chase & Co. originally started in 1799 in New York City according to the company's website. In 2008, they acquired the assets of Washington Mutual which turned many Menifee residents into Chase Bank customers overnight.


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Video Industry News Video Company News Technology Industry News Technology Company News Novelty Industry News Novelty Company News Gay Industry News Gay Company News Legal Industry News All Company News
Released: Mar 01st, 2008
Running Time: 52 Min.
Director: Uncredited
Company: California Star Productions
DVD Extras: Still Gallery(ies), Trailer(s)
Cast: Mina Meow, Loren Chance, Master Liam
Critical Rating: AAAA
Genre: BDSM
Master Liam has a real thing for tying up his subjects and hanging them upside-down, which is an art unto itself. This is the basis of Liam's Suspension Knots.
The ladies Liam practices this knot-tying with, Loren Chance and Mina Meow, are lovely, especially Chance: a pin-up style girl with red hair and killer curves who ends up tied spread-eagle and trying to escape, her lovely ass on full display.
Then, Mina, a petite, dark girl, hangs from the ceiling while her tiny body stretches every which way.
Straight bondage isn't for everyone, but this is well done, and fans will love it.