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flurandrenolide (topical tape), Cordran (cont.)
HOW TO USE: Use this medication on the skin only. However, do not use it on the face, groin, or underarms unless directed to do so by your doctor.Wash and dry your hands before using. Clean and dry the affected area before applying the tape. Measure the proper amount of tape to be used. Tape should always be cut, never torn. Apply the tape to the skin and press on the tape to keep it in place. Remove the tape after 12 hours and replace with fresh tape unless directed otherwise by your doctor. Do not use other bandages or cover/wrap the area unless directed to do so by your doctor. If used in the diaper area on an infant, do not use tight-fitting diapers or plastic pants.After applying the medication, wash your hands, unless you are using this medication to treat the hands. Use carefully if applying to the face. Avoid contact with the eyes because this may worsen or cause glaucoma. Also, avoid applying this medication in the nose or mouth. If you get the medication in your eyes, nose, or mouth, remove the tape and rinse with plenty of water.Use this medication only for the condition prescribed. Do not use more tape than prescribed, apply more often, or use for longer than prescribed. Your condition will not clear faster, but your risk of side effects may be increased.Inform your doctor if your condition persists or worsens after 2 weeks.
SIDE EFFECTS: Stinging, burning, itching, irritation, dryness, or redness of the skin may occur when the tape is first applied to the skin. These effects should disappear in a few days as your body adjusts to the medication. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor immediately if any of these unlikely but serious side effects occur: stretch marks, skin thinning/discoloration, acne, too much hair growth, hair bumps (folliculitis).Skin infections can become worse when using this medication. Notify your doctor promptly if redness, swelling, or irritation does not improve.Rarely, it is possible this medication will be absorbed from the skin into the bloodstream. This can lead to side effects of too much corticosteroid. These side effects are more likely in children, and in people who use this medication for a long time or over large areas of the skin. Tell your doctor right away if any of the following side effects occur: unusual/extreme tiredness, weight loss, headache, swelling ankles/feet, increased thirst/urination, vision problems.A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
Report Problems to the Food and Drug Administration
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This message was edited 2 times. Last update was at 05/16/12 09:28 PM
BadnessDefined wrote:There is one in the Base Game, under Décor > Misc
You can use One More Slot Mod to raise it up and look like she's holding it.
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Michel Tire
Michel tires are your reliable expert supplier for brand new tires for almost any kind of car, SUV or truck. Their tire experts offer you the practical experience and knowledge to help you go through the maze of tires to appropriately find the ones that not only suit your vehicle, but also your particular style of driving in any kind of road condition. Take a look at their tire offers, look into getting a tire quote, or schedule a consultation to meet up with their expert specialists at your local Michel tire store.
Michael tires is more than just an ordinary tire expert. They have the expertise in each and every support your car will need. Be it a new battery, braking system, wheel alignment, or some other type of car repair, they've got an auto repair specialist possessing the right skills to do the job correctly. Every Michel tires car care features the most recent auto care engineering and a staff of professional specialists you can rely on each time. Their goal would be to offer you with reliable car assistance that you will appreciate.
Maintaining and taking care of your vehicle the right way could be complicated, but at Michel tire car care, we guarantee that it will be easy. Michel tires specialize in setting up parts that fulfill or surpass standards of the manufacturer while giving the best quality and price anywhere. No hat tricks here. Keeping your vehicle appropriately maintained by having an oil change or tune-up can help you spend less over time. Understand your vehicle's suggested maintenance or gas saving ideas to help make your car run smoothly.
Here is a list of some of the Michel Tire Plus branches:
Michel Tire Plus
(502) 267-4400
9514 Taylorsville Rd
Louisville, KY 40299.
Michel Tire Plus
(513) 737-3600
750 NW Washington Blvd
Hamilton, OH 45013
Michel Tire Plus
11700 Princeton Pike Cincinnati, OH 45246
Michel Tires Plus
Michel Tire Plus
(859) 727-8400
3707 Dixie Hwy
Elsmere, KY 41018
Michel Tire Plus
41056 606-759-5688
416 Market Square Dr,
Maysville, KY


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Frank Cullen Albert
Position: QB-DB
Height: 5-10 Weight: 166 lbs.
Throws: Left
Born: January 27, 1920 in Chicago, IL
Died: September 4, 2002 in Palo Alto, CA
High School: Glendale
College: Stanford (school history) (Albert college stats)
Drafted by the Chicago Bears in the 1st round (10th overall) of the 1942 NFL Draft.
1-time Pro Bowler (fine print)


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Seven food-friendly wine pairing suggestions that will work perfectly with your Thanksgiving dinner.
All about Beaujolais Nouveau; how it's made and why it's such a popular choice to serve with Thanksgiving dinner.
When it comes to food, a dry Riesling pairs nicely with seafood and chicken; semisweet varieties pair with spicy Asian cuisines and sweet varieties work well as dessert wines or aperitifs.
Wine and chocolate can be a divinely delicious pairing provided you follow a few guidelines for choosing the right combinations.
A brief introduction to Chianti, its origin, flavor profile, various styles and a list of pairing suggestions.
Some basic facts about champagne to help you decipher the label on your next bottle of bubbly.
A basic guide to the best known wine producing regions in France.
A brief history of the success and growth of the California wine industry.
Select a different category:
Hello! I'm Lynne Webb, lifelong food lover & chief recipe creator here at MyGourmetConnection where we have more than 1500 original recipes, cooking tips & entertaining ideas for you to enjoy. Learn more »


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Birth, Life and Death: The Philosophy of Your Life
What can philosophy teach us about our experiences, decisions and trials as we live our lives and ultimately face our deaths? In this course, we will follow the course of a life, from birth, through childhood and education, to one's career and ultimately to death. Along the way, we'll examine the difficult and pressing choices we have to make. How do we find meaning in our life? What is the relationship between a good life and a good paycheck? Can one ever make a rational decision about having children? How does our identity develop as children? How should we face our inevitable demise? Careful consideration of philosophical arguments will help us answer these questions, and students will develop their abilities to think clearly and carefully about these crucial moments we all face. By the end of the semester, students will improve their abilities to understand and work through the philosophical underpinnings of everyday decisions and apply those skills to the decisions they actually face.


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Travelzoo Special Offer
Escape to a boutique style upscale hotel in the heart of Coconut Grove.
Indulge in our magnificent views high above Biscayne Bay. Savor Peruvian cuisine and poolside cocktails, and relax in our modern guest rooms and suites, all in a casual Miami neighborhood.
Room Only - Rates from $99
|Offers valid for travel thru December 25, 2013. Full pre-payment required, non-refundable and non-cancelable. Complimentary valet parking for 1 car per room. For new bookings only. Certain restrictions apply.


text: The Jackson JS3V Concert 5 String Electric Bass Guitar provides rock solid features and earth shaking low end growl at a great price! An Indian cedro body, bolt-on maple neck with rosewood fingerboard and 24 jumbo frets provide great tone and a fantastic feel. The JS3V Concert 5 string bass features two Jackson high output humbuckers for massive tone with great versatility thanks to Bass, Mid and Treble controls!


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MICU® Premium
The MICU Premium® provides RTO technology and telematic services for the energy and mining industries. AxURE Technologies® MICU Premium® has been designed to optimize space, installation, response time, and service quality. The MICU Premium® has built-in telematic support for a wide variety of satellite dishes and terrestrial communications systems.
The MICU Premium®, customizable to accommodate up to 4 operators, is insulated and built of flame retardant materials. The unit has emergency doors, guaranteed acoustic enclosure, a fire extinguisher, and an auxiliary power system, autonomous in case of primary power failure.
The MICU Premium® offers simultaneous service to up to 30 on site users and provides wireless technology infrastructure to each one of the users of a project.


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Shakespeare Authorship DebateThis article was published on Monday 6 June 2011
Shakespeare Authorship Debate from The English-Speaking Union on Vimeo.
On Monday 6 June, the ESU hosted the Shakespeare Authorship Debate, with director Roland Emmerich.
The debate also featured Professor Stanley Wells CBE, Professor Michael Dobson, Rev Dr Paul Edmondson, Charles Beauclerk, and Doctor William Leahy. The chairman for the evening was James Probert.
The ESU hosted the event in conjunction with Sony Pictures, the ESU and the Shakespeare Birthplace Trust to coincide with the release of multi-award-winning director Emmerich's latest film, Anonymous.
Inspired by the upcoming release of Emmerich's new film Anonymous, starring Derek Jacobi, Vanessa Redgrave and Rhys Ifans, the two panels debated whether Shakespeare really was the author that most people believe him to have been.
To a packed room, the eminent panellists argued, under the motion 'This House Believes that William Shakespeare of Stratford-Upon-Avon wrote the plays and poems attributed to him', conspiracy, signatures, the role of Hamlet as autobiography, and whether Shakespeare was in fact an uneducated commoner.
At one stage, Dr William Leahy branded Shakespeare "an opportunist", and claimed had stolen the works and passed them off as his own. Paul Edmondson, Head of Learning and Research at the Shakespeare Birthplace Trust, rebutted that " this evening we have been entertained by a post-modern cocktail of historical fact, and historical fiction."
The questions from the floor were no less heated with guests, some of whom had travelled across the Atlantic for the evening, getting stuck in to a discussion that chairman James Probert said "has been going on for long before we arrived here tonight and will continue long after this evening ends."
While a vote indicated a resounding win for the proposition, the conversations being had as the audience left Dartmouth House indicated that there was far more to discuss, and that the question of the authorship of Shakespeare's plays is far from resolved.


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Pitch the wagon mentality
For what its worth, pitch the "on-the-wagon-off-the-wagon" mentality. That mindset will only set you up for failure, because when you "blow it" the brain automatically says, "okay, since I'm *off the wagon* anyway, I might as throw in the towel for the rest of the day and blow it big time." All or nothing has got to go!
To be honest, the wagon mentality is a most welcome excuse for major binge eating. The sad part is the binge can last for a day, two days, two weeks, three months or even years before the mind gets psyched up again to "get back on the wagon."
Don't involve any wagons! They are for ponies and children and hayrides, but not for getting your health back and staying healthy!
At the slightest slip up, recognize it, yet don't make a big deal out of it.
So you blew it. Big deal. It only proves you are a human being. Keep moving forward immediately in your journey to health. Don't give blowing it another thought. Delete it from your cranium. It's no big deal in your overall journey to optimal health.
You are making progressive changes whether you can see them or not. Forget the scales for this week. Forget the mirror. Is your waist a bit smaller? Is it easier to get out of a chair? Is it less tiring to climb a flight of stairs? Is it easier to roll over in bed at night?
Focus on the positive. Minimize the negative.
You'll get there. I know you will!
Cheering for you today! You have many cheering for you today!


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Item: 2046086
| Model: EF-BT310BAEGUJ
(6 reviews)
This slim and lightweight Galaxy Tab 3 8" tablet book cover is made from premium synthetic leather material. It lets you use your tablet in 2 positions: landscape and typing mode. Best of all, it provides easy access to all Tab 3 connectors. It even wakes and sleeps your device for added convenience.Product Features:
(based on 6 reviews)
of respondents would recommend this to a friend.
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Meets my needs
By frmartel
from Kenner, LA, USA
Comments about BJs Wholesale Club Samsung Galaxy Tab 3 8" Tablet Book Cover - Brown:
I really like this cover. It's not as bulky as so many other covers out there. I never use the stand-up feature so I can't comment on that but I would highly recommend this cover for you Galaxy Tab 3.
Bottom Line Yes, I would recommend this to a friend
Was this review helpful? Yes / No
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By Gadglover1
from Undisclosed
Good product overall, was expecting more, especially at this price. The camera lens did not line up with the hole on the case, my lens is at the side and the case hole is in the middle
By Anonymous
Bought this cover for my tab. As in previous reviews, the design of the stand is flimsy. So much, that it caused the tablet to fall, cracking my screen. Tablet is only a little more than a month old. Samsung's warranty does not cover physical damage, even when their own product made to protect the Tab is the cause. Was quoted $200 to repair the screen.
Bottom Line No, I would not recommend this to a friend
Expensive, but excellent!
By Energizer
from Long Island, NY
You can spend a lot less $$, but this is the highest quality and slimmest case available. When you fold the cover back for reading it is very comfortable to hold, while less expensive cases can be uncomfortable. If you want the best, this is it!
Great material, fits well, falls over when used as a support
By almoh
from Tampa
If you are going to use this cover to support the Tab in the horizontal position for hands free use, it will fall over if you tap the screen. The front cover does not have a strong magnet. When the screen is tapped, it will fall flat on its back. Other models have a tab to insert the cover into when the cover is used as a stand to keep it from falling flat on its back.
tab cover
By kingslee
from TN
When you go to use the stand feature, it falls over. Cover is OK but stand does not work
BJs.com uses several different shipping methods to best serve our Members. More than one shipping method is available for certain items. Please be aware that not all shipping methods are available for all items.* By clicking on the "Change" button in the "Shipping Methods" section of the "Final Order Review" page, you will be able to see a list of available shipping options. If a certain shipping method is not displayed, we regret that it is not available for that item.
* Shipping information is always approximate and may be based on information given to us by manufacturers and vendors.
Orders placed via these shipping options are not guaranteed to be delivered within a certain time frame. Standard Ground is generally the least expensive option.
Standard Ground: Standard Ground includes delivery via U.S. Priority Mail®, United States Postal Service®, UPS® Ground and FedEx® Ground.
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Item: 157032124 |
Model: EF-BT310BAEGUJ


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The MidFirst Bank Sun Devil IMG Sports Network and ASU Football reaches most of the State of Arizona via an extensive affiliate network as well as San Diego.
The broadcasts for Sun Devil football are slated for Arizona Sports 620 AM and will move to 92.3 FM, if there is a conflict with the Diamondbacks or Suns schedule.
Tim Healey, in his 16th season, will once again serve as the voice of the Sun Devils on football, basketball and baseball broadcasts. Former ASU quarterback Jeff Van Raaphorst will provide color commentary for football and Doug Franz will serve as the sideline reporter, as well as the host of the pregame show.
Craig Grialou will host an hour-long call-in show, "Sun Devil Sound-Off," live at Macayo's Depot Cantina in Tempe 30 minutes after each home game.
Former guard Kyle Dodd and former infielder Seth Dhaenens will provide color commentary for basketball and baseball, respectively.
MidFirst Bank Sun Devil IMG Sports Network (football)
Phoenix (FLAGSHIP) - KTAR-FM 92.3
Flagstaff - KBXZ-AM 1650
Globe-Miami - KIKO-AM 1340
Sedona - KAZM-AM 780
Prescott - KYCA-AM 1490
Eagar - KNKI-FM 106.7
Show Low - KRVZ-AM 1400
Lake Havasu City - KNTR-AM 980
Safford - KATO-AM 1230
San Diego - KCBQ-AM 1170
Lakeside - KZUA-FM 92.1
Douglas - KDAP-AM 96.5


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William Draper, DVM, better known as "Dr. Will," is a well-known small animal practitioner in the Atlanta, GA area. He grew up in Inglewood,...More
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Those "that obey not the gospel of our Lord Jesus Christ" are to be "punished with everlasting destruction from the presence of the Lord" (2 Thessalonians 1:8-9). Rather than questioning the reality of hell, which is the just destiny of all who reject or ignore the free gift of salvation provided by the infinite love and sacrificial suffering of God Himself in Christ on their behalf, men and women should come to Christ in faith and "be saved from wrath through him" (Romans 5:9).
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Maryland CASH passes suite of asset building/protection policies
Posted by rmckinney on 04/11/2012 @ 12:50 PM
Maryland CASH Campaign advocated for 5 key asset building and asset protection bills this session.
Making Work Pay
Maryland CASH supported a 5% increase in the state Earned Income Credit to offset regressive tax and fee increases. HB 331/SB 943 were both heard in their respective houses. The Senate included a 5% increase in the EITC, spread over 5 years, in their approved budget plan. The House budget did not include the EITC, but did not impact households making less than $100,000. By the last day of the session, the House and Senate could not pass a comprehensive budget and were forced to pass the "doomsday budget." Since the 2 houses could not agree, the Governor will be calling a special session to stave off the impact of the $500 million of cuts, set to begin on July 1, 2012. Maryland CASH will monitor the special session to make sure that low-moderate income taxpayers are not negatively impacted.
Making Savings Fun
Maryland CASH passed a bill in 2010 to allow credit unions to offer savings promotions raffles, also called prize-linked savings. A last-minute amendment from the banking industry delayed implementation until banks could participate under Federal law. Maryland CASH passed HB 786/SB 1053 to broaden the program to banks and credit unions, while balancing the prohibitions on banks to offer raffles at the federal level. Maryland CASH worked closely with the banking industry to craft a bill that works for both banks and credit unions. The law goes into effect on June 1, 2012.
Protecting Credit and Homeownership
Maryland CASH pushed HB 555/SB 295 to allow parents/guardians to freeze a credit report for minors or other protected persons. This is the first law of its kind in the country. Currently, a credit reporting agency cannot freeze a report for a minor, since they do not knowingly create reports for minors under the age of 18. This bill helps to prevent identity theft and allows minors/protected persons to better manage their own credit.
HB 600/SB 580 prevents cancelled debt due to a mortgage foreclosure from being considered as taxable income. Since 2007, the federal government has exempted this debt from income, but this provision is set to expire on December 31, 2012. These bills will protect homeowners from state tax debt if Congress fails to act. Given the recent Attorney General settlement with mortgage lenders, there is great concern that homeowners may not access the benefits/programs available if they think it could be taxable.
Sustaining the Asset Building Field
Maryland CASH pushed HB 515/SB 476, which creates a new Financial Education and Capability Commission. This standing commission will include various state agencies, non-profits, and funders who will monitor financial education and asset building activities and make policy recommendations. This bill builds off of the work of the Financial Literacy Task Force, which ran from 2008-2010. In order to balance out a costly fiscal note, an amendment passed to have Maryland CASH staff the commission. Maryland CASH will be the first non-governmental agency to staff a legislative commission in the state's history.


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By Pocahontas123
24 October 2008 20:16
Is riding bareback on roads and bridleways legal? I love bareback but wasn't sure if it is alrigh to hack or not?
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In the matter of tack, the Highway Code says what you SHOULD do when riding on the road, not what you MUST by law do. It is advisory in this matter.
However, if you are ever unfortunate enough to be in an accident, whether or not you have abided by the advice in the Highway Code is likely to have a bearing on any legal decisions made either in your favour or against you.
In addition, your rider's insurance or your horse insurance may well dictate that you are not covered to ride on the road unless using a saddle and a bridle.
So, although no policeman will arrest you for riding your horse bareback down the road, you might wish that he had done if you are involved in an accident and end up badly injured with no insurance cover, or if you are sued by someone and your insurance was invalid ...
04 November 2008 19:00
hmm i totally know what you mean I'm pretymuch the same my new loan horse (YEYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY) is coming on monday (YEYYYYYYYYYYYYYYYYYY) and im going to lead him over the busy road next to my house a few times before i get on him properly, and about the 5th time out once im onto the bridleways im going to jump on him bareback but then jump off for the roads. I wouldnt ride bareback on busy roads to be honest haha sorry i havent really answered your question im just so excited i cant think straight hahahahahah x
01 November 2008 11:37
Do you know about bridleways? thanks guys! v. annoying though! hehe!
31 October 2008 19:46
No, if you read the Highway Code (or Rules of the Road - Ireland) as quoted above, and also the BHS Riding and Road Safety book, you'll see that you have to ride with horse tacked up (saddle and bridle). Sorry! But looks like you'll have to keep the bareback sessions for the arena!
28 October 2008 10:41
I would say, I will never come closer to you if you riding bearback on a road. I don't want to break my trusty old car which is already half broken.
I would say, I will never come closer to you if you riding bearback on a road. I don't want to break my trusty old car which is already half broken.
27 October 2008 12:47
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UCLA 74, Oregon State 69
March 2, 2014
UCLA head coach Steve Alford
"It was a very interesting halftime. I was not happy with our effort at all in the first half. We haven't had many halves like that in the first half. It was like that in Corvallis. Our effort in the second half was much like what we are. This Oregon State team is a hard matchup. They gave us some problems. I was proud of the team in the second half. They did a lot of good things in the second half."
on the matchups presented by Oregon State
"When you get to this point, matchups are a huge key. We're not blessed with an abundance of big size up front. We are who we are. With Stanford, we beat them soundly here, but we had a tough half there. This team [Oregon State] is an even tougher matchup. They have more size and can play guys at a 3 or 4. When you have a scorer like Roberto Nelson, it just stretches you. We were better in the second half. We had 11 steals, had nine in the transition game, got to the free throw line, and we ran a better offense."
on UCLA's size against Oregon State
"We played Tony [Parker] and one of the Wears together. That's our size. It's worked out pretty good all year. There are not a lot of teams that can put the size on floor that Oregon State can. They're 6-10, 6-10, 6-8. We can match the size, but it's really about who can take care of the mismatches and who can out-execute who. Our effort was much better in the second half, and that's what made the difference. The second half was more like how we play."
on UCLA's post play
"It was a good adjustment by Dave [Wear] and Tony [Parker]. Tony had some tough times against Devon Collier until we reminded him that he was left-handed, then he adjusted well to post play. Early in this game, we were hurt with post play, but our low post play got better as the game went on. [Angus] Brandt went in with 10-straight double-figure games, and he had nine points today. I thought that was good for our post players."
on the team's mindset prior to the Pac-12 Tournament
"It's March. We talked about a month ago about how February sets it up. I thought we were playing good basketball going into March. The month of March is a player's month. It should be the time of their lives. You mentioning it is the first time I thought about clinching a bye. We have two road games left. I'm proud of Dave and Travis and Aubrey. They got to play in Pauley one last time and win. You want to see your seniors win for the last time at home, and you want to play really good basketball going into the tourney.
UCLA guard Jordan Adams
on what he learned from a one-game, team-issued suspension
"It was a learning experience, but I'm glad that our teammates still fought and didn't back down because we weren't playing. That really showed us a lot about their character."
on overcoming a difficult first half
"We had to adjust to what they were doing. In the second half, it eventually broke open with the scoring margin. They [OSU] are just a big team, and they matched up really well."
on serving a one-game team-issued suspension
"We would like to apologize to our fans, our families and our coaching staff and teammates for having not played in that last game due to our issues. And we'd like to thanks our teammates and all of our fans for their support, still, after having missed the Oregon game."
UCLA guard Kyle Anderson
"I just wanted to help my team by playing well tonight. Oregon State is a long, athletic team, and we had a talk at halftime. We got better after that. We talked about ball movement and we talked about taking shots too early in the shot clock."
UCLA forward David Wear
"You look back at the games, and it goes by very fast. I can't be happier than to finish the home season this way, with a win. From starting in the old Pauley, going to the Sports Arena, and then back to the New Pauley, it's been an experience. It hasn't really sunk in yet, that I won't be playing here anymore."
UCLA forward Travis Wear
"I'm not sure why we did not come out with a lot of energy. I thought that our defense was good, but we just couldn't get it going offensively."
UCLA guard Aubrey Williams
"It was great [getting playing time on Senior Night], and it was bittersweet. This is a family like no other, and I'm going to cherish every moment."
Oregon State head coach Craig Robinson
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"Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle–brachial index in adults: 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: U.S. Preventive Services Task Force. Screening for peripheral arterial disease: recommendation statement. Am Fam Physician. 2006 Feb 1;73(3):497-500.
Peripheral artery disease (PAD)
Asymptomatic adults who do not have a known diagnosis of peripheral artery disease (PAD), cardiovascular disease (CVD), severe chronic kidney disease, or diabetes
Resting ankle–brachial index (ABI) as a screening test for peripheral artery disease (PAD) or as a risk predictor for cardiovascular disease (CVD)
Note from the National Guideline Clearinghouse (NGC): An evidence synthesis was prepared by the Kaiser Permanente Research Affiliates Evidence-based Practice Center (EPC) for the U.S. Preventive Services Task Force (USPSTF) (see the "Availability of Companion Documents" field).
Data Sources and Searches
The EPC staff searched MEDLINE and the Cochrane Central Registry of Controlled Trials from 1996 through September 2012 to locate relevant English-language studies for all Key Questions. The staff supplemented searches with suggestions from experts and reference lists from 62 recent relevant existing systematic reviews. The staff also searched ClinicalTrials.gov on September 12, 2012 for relevant ongoing trials.
Study Selection
Two investigators independently reviewed 4,434 abstracts and 418 full-text articles (see Appendix D of the comparative effectiveness review) against the specified inclusion criteria (see Appendix E of the comparative effectiveness review). We resolved discrepancies by consultation with a third investigator. We list the studies we excluded at the full-text phase (i.e., based on exclusion criteria or for poor quality) in Appendix F of the comparative effectiveness review.
The review focuses on the clinical utility of resting ankle-brachial index (ABI) as the primary screening modality because it is the most commonly used and is able to detect asymptomatic persons. Therefore, this review excluded other methods of screening (e.g., questionnaires, exercise ABI, toe pressure measurement, pulse oximetry, duplex ultrasound, magnetic resonance angiography [MRA]). This review also focuses on generally asymptomatic adults, which may include populations with atypical symptoms or minor symptoms not recognized as peripheral arterial disease (PAD). The EPC staff excluded studies whose subjects primarily had known intermittent claudication. The staff also excluded studies conducted exclusively in persons with known cardiovascular disease (CVD), diabetes, or severe chronic kidney disease (stage 4 and 5). The staff excluded studies conducted in hospital or specialty settings (i.e., vascular clinics or laboratories), as these settings typically represented populations selected for known or highly suspected PAD. Because the focus is on largely asymptomatic persons, primary outcomes of interest are CVD events and risk factor reduction, rather than lower-extremity symptoms. If studies that met the inclusion criteria also reported PAD-specific outcomes (e.g., limb function, ambulation, amputation), however, the EPC staff considered these outcomes. Likewise, included treatments focused on pharmacologic or lifestyle interventions primarily aimed at CVD risk reduction (e.g., smoking cessation, cholesterol lowering, blood pressure control, and antiplatelet therapy). Therefore, the staff excluded interventions aimed primarily at management of lower-extremity symptoms or functioning (e.g., cilostazol, supervised exercise training or physical therapy, revascularization).
For Key Question (KQ) 1, the EPC staff considered any trial (randomized, controlled trial [RCT] or controlled clinical trial [CCT]) or systematic review that compared ABI screening to no screening reporting any outcome of interest (i.e., CVD or PAD-specific morbidity or mortality). For KQ 2, the staff considered prospectively conducted diagnostic accuracy studies or well-conducted systematic reviews of diagnostic accuracy. The staff excluded case-control studies in which cases were selected based on having known PAD. Distorted selection of subjects in recruitment or case-control designs has repeatedly been shown to overestimate sensitivity. A distorted selection of subjects directly affects the applicability of the study findings and threatens its validity (i.e., spectrum bias). Spectrum bias refers to the phenomenon that the diagnostic test performance may change between clinical settings due to changes in patient case-mix. For KQ 2, diagnostic accuracy studies had to compare ABI with a reference standard. Because the gold standard, digital subtraction angiography (DSA), is an invasive test that presents known risks, it is not ethical to administer this test in asymptomatic persons. Therefore, the staff considered any diagnostic test that could image the degree of atherosclerosis (e.g., MRA, computed tomography angiography [CTA]) or degree of impaired blood flow (e.g., duplex ultrasound) to be a reasonable diagnostic reference standard. The staff accepted all measures of diagnostic accuracy (e.g., sensitivity, specificity, positive or negative predictive values, positive or negative likelihood ratios). For KQ 4, the staff considered prospective longitudinal cohort studies or systematic reviews of risk prediction. Included risk prediction studies had to assess ABI in addition to existing Framingham Risk Score (FRS) factors, as defined in ATP III (i.e., age, sex, smoking status, systolic blood pressure, total cholesterol, and high-density lipoprotein [HDL] cholesterol). While studies could adjust for additional known risk factors, the staff excluded studies that did not consider all existing FRS factors as a minimum. For KQ 5, the staff included any trial (RCT or CCT) or systematic review with at least 12 weeks of follow-up that compared treatment of PAD with no treatment, with placebo treatment, or with delayed treatment. Again, the EPC staff considered any outcome of interest (i.e., CVD or PAD-specific morbidity or mortality). While the staff included reviews, trials, cohort studies, and case-control studies for KQs 3 and 6, case series or case reports were excluded.
Not applicable
Data Extraction and Quality Assessment
For screening studies, the EPC staff extracted details about each study's location, recruitment, inclusion/exclusion criteria, participant characteristics, reference standard, test performance characteristics, and adverse events. For risk prediction studies, the staff extracted details about each study's location, recruitment, inclusion/exclusion criteria, participant characteristics, technique for measuring ankle-brachial index (ABI), adequacy and length of follow-up, method for ascertaining outcomes, inclusion of prognostic factors other than ABI, analytic approach, and outcomes. Outcomes included relative event outcomes (e.g., hazard ratio [HR], relative risk [RR], or overall risk [OR]) or measures of risk reclassification. Measures of discrimination or risk reclassification included differences in the area under the curve (AUC) or c-statistic, percent reclassified (i.e., from a reclassification table), and net reclassification improvement (NRI).
Risk reclassification refers to the change in risk when a new predictor is added to an existing risk prediction model (i.e., subjects may be placed into a different risk category than the one they were in when the original model was used). This movement between risk categories may be displayed as a reclassification table. This table shows the number (and percent) of subjects in each risk category using the original model versus the number (and percent) of subjects in each risk category using the model with the new predictor. While studies may report the percent of subjects who change risk categories, this does not ensure subjects were correctly recategorized. Subjects who will have an outcome event should move to a higher risk category, while subjects who will not have an event should move to a lower risk category. For subjects who will have an event, movement to a higher risk category is improved classification, while movement to a lower risk category is worse (incorrect) classification; likewise, for subjects who will not have an event, movement to a lower risk category is improved classification, while movement to a higher risk category is worse classification. The NRI quantifies this as (proportion of subjects who will have an event moving higher minus proportion of subjects who will have an event moving lower) + (proportion of subjects who will not have an event moving lower minus proportion of subjects who will not have an event moving higher). Another way to think of the NRI is the sum of the improvement in sensitivity and the improvement in specificity.
In a risk reclassification table, those cells representing no change in risk category between prediction models lie on a diagonal; the other cells represent a change in risk between the original model and the new model. If the original and new prediction models were the same, the numbers in the cells representing change would be symmetric about the cells representing no change. The number of subjects who will have an event moving to a higher risk category would equal the number moving to a lower risk category and the number of subjects who will not have an event moving to a lower risk category would equal the number moving to a higher risk category. If an NRI were calculated for the entire table, it would be zero. However, an NRI might be calculated only for certain risk categories, as defined by the original model. Only those cells lying in certain rows of the risk reclassification table would be used, and some of the symmetric cells from the reclassification table would be excluded. An NRI could be calculated; if it were positive, it would imply improvement, even though the models were identical. Therefore, an NRI for any subset of risk categories will be artificially inflated by this expected NRI simply because some of the symmetrically distributed cells are excluded. A corrected NRI may be calculated by subtracting the expected NRI from the apparent NRI. For risk prediction studies reporting NRI for subgroups (i.e., intermediate-risk groups), the EPC staff calculated a corrected NRI for the intermediate risk category where data were available to do so.
The AUC—specifically, the area under the receiver operating characteristic curve—represents a model's ability to discriminate between subjects who will and will not have an event. The AUC is the probability that a model will assign a higher risk for an event to a randomly selected subject who will have an event than to a randomly selected subject who will not have an event. The range of the AUC is 0.5 (no discriminatory ability) to 1 (perfect discrimination). For prognostic models, the AUC is typically 0.6 to 0.85. When a new predictor is added to a model, the improvement in the model's ability to discriminate may be measured by the difference between the AUC for the model with the new predictor and the AUC for the original model. An increase in the AUC of 0.025 is considered clinically relevant.
For treatment trials, the EPC staff extracted details about each study's location, recruitment, inclusion/exclusion criteria, patient characteristics, experimental and comparison intervention(s), internal validity, retention, method for ascertaining outcomes, analytic approach, outcomes, and adverse effects. A second reviewer verified all extracted data. The staff contacted study authors by email for clarification, when necessary.
At least two reviewers independently critically appraised articles meeting inclusion criteria using the USPSTF's design-specific quality criteria, supplemented with the National Institute for Health and Care Excellence (NICE) methodology checklists, Quality Assessment of Diagnostic Accuracy Studies (for studies of diagnostic accuracy [KQ 2]), and the Newcastle-Ottawa Scale and Hayden criteria (for prediction studies [KQ 4]). Articles were rated as good, fair, or poor quality. In general, a good-quality study met all criteria well. A fair-quality study did not meet (or it was unclear whether it met) at least one criterion but also had no known important limitation that could invalidate its results. A poor-quality study had a single fatal flaw or multiple important limitations. The most common flaws leading to poor-quality ratings among studies about diagnostic accuracy were having an inappropriate reference standard, a biased spectrum of subjects, or verification bias. The most common flaw leading to poor-quality ratings among studies about prognosis was lack of relevant outcomes. However, the majority of prognostic studies were excluded because they did not include all the Adult Treatment Panel (ATP) III FRS factors in multivariable models and therefore did not meet the inclusion criteria. For treatment trials, the staff excluded the majority of studies because they were conducted in persons with intermittent claudication. The staff excluded poor-quality studies from this review.
Synthesis and Analysis
The EPC staff did not conduct any quantitative analyses for any of the KQs due to the low volume, heterogeneity, and nature of our included studies. They found no studies for KQ 1. For KQs 2 and 3, the staff included only one study and therefore describe the results of this single study along with the quality and applicability assessment. For KQ 4, the staff included 14 studies representing eight different cohorts and one large individual patient-level data meta-analysis. The meta-analysis included all but two of the cohorts represented in the 14 other studies. Given the available information, the staff was unable to attempt further quantitative syntheses. Instead, they qualitatively synthesized data from this pooled analysis, comparing and contrasting its results with findings from individual studies by outcomes, focusing primarily on measures of risk reclassification and secondarily on measures of association (HR and RR) adjusted for FRS factors (i.e., age, sex, smoking status, systolic blood pressure, total cholesterol, HDL cholesterol). They use summary tables to display differences between important study characteristics and outcomes across included studies. For KQs 5 and 6, the staff included only two treatment studies that were quite different from one another. Therefore, the staff summarizes the results of these studies in the context of their quality and applicability.
For each KQ, the EPC staff summarizes the overall body of evidence, commenting on several domains, including quality of findings (including risk of bias), applicability of findings, consistency of findings (including possible clinical heterogeneity explaining inconsistencies), magnitude of findings, and precision around the magnitude of findings.
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 statement 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 Task Force 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 Task Force considers indirect evidence. To guide its selection of indirect evidence, the Task Force 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 Task Force 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 Task Force's overall assessment of evidence was described as good, fair, or poor. The Task Force 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 Task Force 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 Task Force'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 Task Force 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 Task Force 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 Task Force 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 Task Force assesses the certainty of net benefit of a preventive service by asking the 6 major questions listed above. The Task Force 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 the Recommendations" field). The Task Force 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 Task Force 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].
I Statements
For I statements, the USPSTF has a new plan to commission its Evidence-based Practice Centers to collect information in 4 domains pertinent to clinical decisions about prevention and to report this information routinely. This plan is described in the paper: Petitti DB et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med. 2009;150:199-205. www.annals.org
The first domain is potential preventable burden of suffering from the condition. When evidence is insufficient, provision of an intervention designed to prevent a serious condition (such as dementia) might be viewed more favorably than provision of a service designed to prevent a condition that does not cause as much suffering (such as rash). The USPSTF recognized that "burden of suffering" is subjective and involves judgment. In clinical settings, it should be informed by patient values and concerns.
The second domain is potential harm of the intervention. When evidence is insufficient, an intervention with a large potential for harm (such as major surgery) might be viewed less favorably than an intervention with a small potential for harm (such as advice to watch less television). The USPSTF again acknowledges the subjective nature and the difficulty of assessing potential harms: for example, how bad is a "mild" stroke?
The third domain is cost—not just monetary cost, but opportunity cost, in particular the amount of time a provider spends to provide the service, the amount of time the patient spends to partake of it, and the benefits that might derive from alternative uses of the time or money for patients, clinicians, or systems. Consideration of clinician time is especially important for preventive services with only insufficient evidence because providing them could "crowd out" provision of preventive services with proven value, services for conditions that require immediate action, or services more desired by the patient. For example, a decision to routinely inspect the skin could take up the time available to discuss smoking cessation, or to address an acute problem or a minor injury that the patient considers important.
The fourth domain is current practice. This domain was chosen because it is important to clinicians for at least 2 reasons. Clinicians justifiably fear that not doing something that is done on a widespread basis in the community may lead to litigation. More important, addressing patient expectations is a crucial part of the clinician–patient relationship in terms of building trust and developing a collaborative therapeutic relationship. The consequences of not providing a service that is neither widely available nor widely used are less serious than not providing a service accepted by the medical profession and thus expected by patients. Furthermore, ingrained care practices are difficult to change, and efforts should preferentially be directed to changing those practices for which the evidence to support change is compelling.
Although the reviewers did not explicitly recognize it when these domains were chosen, the domains all involve consideration of the potential consequences—for patients, clinicians, and systems—of providing or not providing a service. Others writing about medical decision making in the face of uncertainty have suggested that the consequences of action or inaction should play a prominent role in decisions.
What the U.S. Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice
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.
A formal cost analysis was not performed and published cost analyses were not reviewed.
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 Comment. A draft version of this recommendation statement was posted for public comment on the USPSTF Web site from 19 March to 15 April 2013. The USPSTF received few comments, several of which agreed with the recommendation. Some comments provided additional studies and different interpretations of the evidence reviewed by the USPSTF. The USPSTF reviewed all of these studies and determined that they did not provide the necessary evidence to change its conclusions because the recommendation focuses on asymptomatic adults who do not have a known diagnosis of peripheral artery disease (PAD), cardiovascular disease (CVD), severe chronic kidney disease, or diabetes and are treated in a primary care setting.
Comparison with Guidelines from Other Groups. Recommendations for screening from the following groups were discussed: American College of Cardiology Foundation and the American Heart Association (AHA).
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
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for peripheral artery disease (PAD) and cardiovascular disease (CVD) risk assessment with the ankle–brachial index (ABI) in adults. (I statement)
Clinical Considerations
Patient Population Under Consideration
This recommendation applies to asymptomatic adults who do not have a known diagnosis of PAD, CVD, severe chronic kidney disease, or diabetes.
Assessment of Risk
In addition to older age, major risk factors for PAD include diabetes, smoking, hypertension, high cholesterol level, obesity, and physical inactivity, with smoking and diabetes showing the strongest association. PAD is more common in men than in women and occurs at an earlier age in men, possibly in part because of the higher prevalence of smoking in men. Among healthy U.S. men aged 40 to 75 years without a history of CVD, the risk for PAD over 25 years in the absence of 4 conventional cardiovascular risk factors (smoking, hypertension, hypercholesterolemia, or type 2 diabetes) is rare (9 cases per 100,000 person-years). These 4 risk factors account for 75% of all cases of PAD, and at least 1 of them is present at the time of PAD diagnosis in 96% of men. Therefore, if screening is determined to be beneficial, it would probably be most beneficial to persons who are at increased risk for PAD and are not already receiving cardiovascular risk reduction interventions.
PAD is a manifestation of systemic atherosclerosis and is typically considered a predictor for other types of CVD (CAD or cerebrovascular disease) and CVD events, such as myocardial infarction (MI), cerebrovascular accident, and death. Patients with PAD are at increased risk for CVD events because of concomitant coronary and cerebrovascular disease.
Screening Tests
Resting ABI is the most commonly used test in screening for and detection of PAD in clinical settings, although variation in measurement protocols may lead to differences in the ABI values obtained. The ABI is calculated as the systolic blood pressure obtained at the ankle divided by the systolic blood pressure obtained at the brachial artery while the patient is lying down. A ratio of less than 1 (typically defined as <0.9) is considered abnormal and is commonly used to define PAD. Physical examination has low sensitivity for detecting mild PAD in asymptomatic persons.
Although femoral bruit, pulse abnormalities, or ischemic skin changes significantly increase the likelihood ratio for low ABI (≤0.9), these signs indicate moderate to severe obstruction or clinical signs of disease. Although often done, the clinical benefits and harms of screening for PAD with a physical examination have not been well-evaluated and are beyond the scope of this review.
In addition to its ability to detect PAD, an abnormal ABI may be a useful predictor of CVD morbidity and mortality. ABI measurement may increase the discrimination or calibration of existing CVD risk assessments apart from whether it accurately detects PAD. However, the number of patients with an abnormal ABI who also have other diseases or findings that would indicate treatment and whether there is value to these patients knowing they have an abnormal ABI is not clear.
Screening Intervals
No studies provided evidence about the intervals for screening for PAD with the ABI.
Evidence shows that low-dose aspirin treatment in asymptomatic patients with a low ABI does not improve health outcomes and may increase bleeding. No trials provided evidence on other interventions to reduce CVD events or interventions that might delay the onset of lower extremity symptoms.
Suggestions for Practice Regarding the I Statement
In deciding whether to screen for PAD with the ABI in asymptomatic adults, clinicians should consider the following factors.
Potential Preventable Burden
The true prevalence of PAD in the general population is not known. Recent data from the National Health and Nutrition Examination Survey show that 5.9% of the U.S. population aged 40 years or older (7.1 million persons) has a low ABI (≤0.9). More than half of these persons do not have typical symptoms of PAD. The proportion of these patients who will go on to develop symptoms is not known; however, PAD is an indicator of CVD. Studies estimate that in persons with stable claudication but not critical ischemia, approximately 70% to 80% will remain stable over 5 years, whereas 10% to 20% will have worsening claudication and 1% to 2% will develop critical ischemia. Similar data are not available for asymptomatic patients with a low ABI.
Potential Harms
Although minimal harms are associated with the ABI test itself, downstream harms are possible. False-positive results, anxiety, labeling, and exposure to gadolinium or contrast dye if either magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is used to confirm diagnosis may occur. Using the ABI in conjunction with Framingham Risk Score (FRS) results may reclassify a patient's risk. Given the uncertainty of the appropriateness of such reclassifications, patients could either be reclassified to a higher risk category and receive additional treatments with resulting adverse effects or be reclassified to a lower risk category and discontinue treatments that may be beneficial.
The cost of the ABI test is primarily in time and staff resources; performing the test in the office setting takes approximately 15 minutes. In addition, new equipment that performs pulse volume recordings or Doppler wave form tracings may need to be purchased. Providing this test to asymptomatic patients may divert time from other prevention activities that may be more beneficial to the patient.
Current Practice
In a survey of primary care practices across the United States, nearly 70% of providers reported never using the ABI in their practice settings, 6% to 8% reported using it once a year, and only 12% to 13% reported using it once a week or month.
None available
The type of supporting evidence is not specifically stated for each recommendation.
Benefits of Detection and Early Treatment
The U.S. Preventive Services Task Force (USPSTF) found no evidence that screening for and treatment of peripheral arterial disease (PAD) in asymptomatic patients leads to clinically important benefits. It also reviewed the potential benefits of adding the ankle-brachial index (ABI) to the Framingham Risk Score (FRS) and found evidence that this results in some patient risk reclassification; however, how often the reclassification is appropriate or whether it results in improved clinical outcomes is not known.
Determining the overall benefit of ABI testing requires not only evidence on appropriate risk reclassification but also evidence that this reclassification leads to treatments shown to improve clinical outcomes. One randomized trial found that aspirin did not reduce CVD events in patients with a low ABI. No studies assessed the effect of lipid-lowering therapy or other cardiovascular risk reduction interventions in patients with asymptomatic PAD and no known diagnosis of CVD or diabetes. The USPSTF found inadequate evidence that early treatment of screen-detected PAD leads to improvement in clinical outcomes.
Harms of Detection and Early Treatment
The U.S. Preventive Services Task Force (USPSTF) found no studies addressing the magnitude of harms of screening for peripheral arterial disease (PAD) with the ankle-brachial index (ABI); however, the direct harms to the patient of screening itself, beyond the time needed for the test, are probably minimal. Other harms resulting from testing may include false-positive results, exposure to gadolinium or contrast dye if magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is used to confirm diagnosis, anxiety, labeling, and opportunity costs.
The USPSTF found inadequate evidence on the harms of early treatment of screen-detected PAD. One study showed that low-dose aspirin treatment in asymptomatic patients with a low ABI may increase bleeding. Additional harms associated with treatment include use of unnecessary medications (or higher doses) and their resulting adverse effects and discontinuation of medications known to be effective in patients with established coronary artery disease (CAD) if the patient is reclassified to a lower risk category on the basis of a normal ABI.
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.
The U.S. Preventive Services Task Force (USPSTF) is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
U.S. Preventive Services Task Force (USPSTF)
Task Force Members*: Virginia A. Moyer, MD, MPH (Chair) (American Board of Pediatrics, Chapel Hill, North Carolina); 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, and James J. Peters Veterans Affairs Medical Center, Bronx, New York); Linda Ciofu Baumann, PhD, RN (University of Wisconsin, Madison, Wisconsin); 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); Francisco A.R. García, MD, MPH (Pima County Department of Health, Tucson, Arizona); Adelita Gonzales Cantu, RN, PhD (University of Texas Health Science Center, San Antonio, Texas); David C. Grossman, MD, MPH (Group Health Cooperative, Seattle, Washington); Jessica Herzstein, MD, MPH (Air Products, Allentown, Pennsylvania); Wanda K. Nicholson, MD, MPH, MBA (University of North Carolina School of Medicine, Chapel Hill, North Carolina); Douglas K. Owens, MD, MS (Veterans Affairs Palo Alto Health Care System, Palo Alto, and Stanford University, Stanford, California); William R. Phillips, MD, MPH (University of Washington, Seattle, Washington); and Michael P. Pignone, MD, MPH (University of North Carolina, Chapel Hill, North Carolina)
Former USPSTF member who contributed to the development of this recommendation: Timothy Wilt, MD, MPH
*Members of the USPSTF at the time this recommendation was 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.
Potential Conflicts of Interest: Dr. Moyer: Support for travel to meetings for the study and other purposes: Agency for Healthcare Research and Quality. Disclosure forms from USPSTF members can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1670 .
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) is an application designed to provide primary care clinicians and health care teams timely decision support regarding appropriate screening, counseling, and preventive services for their patients. It is based on the current, evidence-based 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 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 NGC summary was completed by ECRI on June 10, 2005. The information was verified by the guideline developer on June 17, 2005. This NGC summary was updated by ECRI Institute on October 25, 2013. The updated information was verified by the guideline developer on November 11, 2013.
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.
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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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CINCINNATI, Ohio (Ivanhoe Newswire) – Strokes kill 130,000 Americans every year, which is 1 out of every 19 deaths. It is also the leading cause of disability. But would you recognize the signs of a stroke if it was happening to you or to a loved one?
The day started liked any other for Brad and Sara Fahrenkamp with breakfast before work with their two little boys.
But suddenly Brad got very sick.
Sara Fahrenkamp told Ivanhoe, "He said I just don't feel well, I feel kind of nauseous and flu-like. I'm just going to stay home today."
Throughout their marriage, Brad had always been healthy. By nighttime they knew something was very wrong.
Stroke patient, Brad Fahrenkamp told Ivanhoe, "My left arm and part of my face were numb and tingling. I went to stand up to dress myself and I fell right to the floor.
Sara Fahrenkamp said, "I was absolutely shocked when the physician in the ER said to us, your husband has had not just one stroke, but three strokes."
A stroke occurs when blood flow is blocked to the brain or blood leaks in the brain and damages cells. Symptoms occur in the parts of the body controlled by those cells.
Neurological Physical Therapist for the University of Cincinnati , Paige Thomas, PT-MSR told Ivanhoe, "The quicker that you can obtain emergency services and emergency care, the quicker you can receive treatment and medication that can hopefully stop the stroke or prevent it from becoming worse."
That's why experts say it's important to know the stroke warning signs. Signs include numbness or weakness in your face, arm, or leg, speech or vision problems, dizziness, severe headache and nausea.
Brad survived and is recovering well thanks to intensive therapy.
Brad Fahrenkamp told Ivanhoe, "Seek help as fast as possible. It's one thing that you won't regret."
Doctors with the American Stroke Association say that your chances of recovery are better if you can get medical treatment within about 3 hours of a stroke. While stroke can happen to anyone, smoking, diabetes, and high blood pressure are significant risk factors.
For additional research on this article, click here.
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here.
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University of Cincinnati Health
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text:
Pattern Detail
Men's Beanie
Design by Bobbi Intveld
Worked in single crochet, this structured hat is a great beginning crochet project.
price: $9.00*
* digital PDF pattern files only
• Blue Sky Alpacas Worsted Cotton (100g/150yds): 1 hank
• Size H (5mm) hook, or size needed to obtain gauge
• Tapestry needle
• Stitch marker
Colors shown: Graphite - #625
SizesCircumference: 22"
Width: 11"
Depth: 8"
GaugeIn Sc st, 16 sts and 20 rows = 4"
Find a Pattern
- Free Patterns
- We sometimes make changes to our patterns after they've been published. Check here to find out if your pattern's been updated and get all the details to complete your project!
- Pattern Updates
Multi Cotton
Worsted Cotton


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I bought the fabric from the clearance bin at the fabric, it's pretty
different than a lot of the fabric in the house but I was thinking of
making it into a rug for our bedroom but ended up stretching around a
large canvas and hung it next to the bed.
Poketo's line at Target is cute and I picked up a luggage tag for Israel's
bag. I may go back and grab a little makeup bag for me too.
I made these shelves a month ago. They didn't turn out like I had originally
intended but I like that I have a place to display a few things in our pseudo
We call this bread quesadilla in Guatemala. I know you are all familiar with
the cheese and tortilla version of the word but to us, this is the name of the
most delicious pound cake/coffee cake you'll ever have. It's made from a cheese
my mom's uncle makes and sends to us. My mom gave us some this afternoon and all
3 of us inhaled it likes pigs.
You can buy some of this deliciousness here-request quesadilla!
The cutest little mushroom from the ever talented Susanna Vento. Israel thought
it was very charming as he laughed when I first gave it to him. Pretty cute huh?
Have a great weekend!
4 comments:
Love your finds and purchases and... OH MY! I love quesadillas! I actually saw that photo on your flickr and I was already drooling...ReplyDelete
Happy weekend!
I LOVE the fabric find! And I'm so curious about this quesadilla. I'm going to go peruse the internet for a recipe.ReplyDelete
I like the shelves, they turned out great.ReplyDelete
ps. At first glance I thought the mushroom was a hammer!
Great fabric,and great pound cake!,son deliciosos!ReplyDelete
thank you for your comments!
if you have any questions please email me via the 'contact' link.


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BOULDER- The University of Colorado volleyball team will start its 25th season in program history on Friday and Saturday, August 27-28 at the Coors Events Center. The Buffs will host Furman on Friday and Duke on Saturday with both matches starting at 6:30 p.m.
The Buffs return two starters to their line-up. Junior Rosie Steinhaus ranked second on the team offensively with 2.67 kills per set while sophomore Kerra Schroeder was third on the team with 2.51 kills per set. Schroeder ranked third on the team with 2.12 digs per set and Steinahaus added 1.71 digs per set. Steinhaus and Schroeder, along with junior transfer Anicia Santos will serve as the 2010 captains.
Furman finished the 2009 season with a 26-4 record and was 16-0 in Southern Conference action. The Paladins top returners are junior right side hitter Kelly Kirby and sophomore middle blocker Caroline Adams. Kirby recorded 2.58 kills per set and 1.66 digs per set while Adams notched 2.49 kills per set and 1.00 blocks per set. Furman won the only previous meeting against the Buffs in a close five-set match on Sept. 3, 2007. CU took the first two sets 30-13, 30-24 and then dropped the next three 30-25, 30-28, 15-12.
The Duke Blue Devils earned a trip to the 2009 NCAA Tournament with a 27-6 record (17-3 in the Atlantic Coast Conference). They return senior middle blocker Becci Burling and junior outside hitter Sophia Dunworth. Burling hammered 2.83 kills per set and posted .99 blocks per set. Dunworth recorded 2.59 kills per set and .49 digs per set. Duke received votes in the 2010 preseason AVCA Division I Coaches Poll.
This is just the second meeting between CU and Duke, but it should be the third contest as the two teams were set to face-off against each other on Sept. 6, 1996. The match was canceled due to Hurricane Fran. Colorado won the first meeting 15-4, 15-8, 15-8 on Oct. 17, 1988.
The first 250 fans to the match on Friday will get free pizza and the first 200 fans on Saturday will get a free t-shirt. Following both matches there will be a meet and greet with the entire team. The weekend is also the reunion weekend for the 2010 summer CU Volleyball campers.
Parking for home matches will once again be free in lot 436, but due to construction of the practice facility there are a few minor changes to entering the building. The main entrance will still be the northwest side of the building. When you get to the top of the ramp leading to the gate, stay to your left to pass the Buffalo statue.
Over the summer, the Coors Events Center also had new video and ribbon boards installed which will add to the exciting environment. Season tickets can be purchased online at CUBuffs.com for $25 or by calling 303-49-BUFFS. Single match tickets are also available.
The matches this weekend will be streamed live on the web with audio and will be free at CUBuffs.com. A subscription required will be required for the rest of the season. Live stats will be free all season long at CUBuffs.com.
And don't forget to check out the latest news and highlights with coach Liz Kritza on the Buffalo Stampede: Volleyball Edition, exclusively on BuffsTV at CUBuffs.com/volleyball. New shows air every Tuesday starting August 31.


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- Filed Under
PRESS RELEASE: Direct from EDTS
AUGUSTA, GA and GREENVILLE, SC – April 23, 2013 – EDTS, a full-service technology consulting firm specializing in network security and managed IT services for Southeastern business, has added Katie Ard and Andrew Mailey to its rapidly growing team.
A native of Columbia, South Carolina, Mrs. Ard has over 30 years of business-to-business sales, management and marketing experience in a variety of industries including media, publishing and telecommunications. Most recently, she served as sales executive with Morris Communications' Main Street Digital business unit. Prior experience included professional sales or management roles with Hearst Media Group, Beasley Broadcasting and Bell Atlantic.
In her role as account executive with EDTS, Mrs. Ard will work in outside sales and client development activities for EDTS across the organization's growing Southeastern footprint, and will be based in EDTS's Augusta, GA headquarters. A graduate of the University of South Carolina with a B.A. in Psychology and History, she is active in the Aiken and North Augusta chambers of commerce. Married with one daughter, she resides in Clarks Hill.
Mr. Mailey joins EDTS as a support engineer from UTC Aerospace Systems, formerly Goodrich, Inc. At the Fortune 500 company serving aftermarket and OEM manufacturers in the aerospace industry, Mr. Mailey supported network and security initiatives for multiple business units across the United States. At EDTS, his role will include providing network and system administration support to EDTS clients across the Southeast from the firm's network operations center.
A native and current resident of Evans, Georgia, Mr. Mailey is CompTIA Network+ certified and experienced with virtual desktop infrastructure implementation and support. He holds a B.B.A. in Information Systems from Georgia Southern University.
"Katie and Andrew are highly skilled and client-focused professionals with outstanding experience in their own areas of focus, and each is a welcome addition to the EDTS team," said Charles Johnson, EDTS CEO. "We constantly seek to grow our team and capabilities by hiring the best talent available, thereby advancing our mission of being the premier technology solutions provider in our markets. These new colleagues will play an important role in that strategy."
EDTS was recently named to the Inc. 5000 Fastest-Growing Private Companies in America for the third consecutive year, and as the seventh fastest-growing small company in South Carolina on the inaugural statewide 2012 Roaring Twenties list, which cited EDTS's growth rate of 198.4 percent in overall revenues since 2010. The firm recently opened its third office in Columbia, SC.
# # #
Founded in 1999, EDTS has grown to a staff of over 50 professionals serving clients 24/7/365 across the Southeast from offices in Augusta, GA and Columbia and Greenville, SC. A full service technology consulting firm, EDTS specializes in networking, security and managed IT services for business. The firm helps customers increase productivity and reduce cost associated with information technology. Visit them at www.edtsolutions.com.


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Non-Stock Subscription Agreements
Original post by Dennis Hartman of Demand Media
A business must balance its financial needs with its owners' vision and strategy in order to be successful. Striking this balance can be a challenge for small businesses that owners set up as partnerships or sole proprietorships. Giving up exclusive control may mean the ability to raise money through a non-stock subscription agreement, but it adds the need for owners to carefully select the concessions they make as leaders.
A non-stock subscription agreement is a contract between an investor and a business that governs the relationship between the two parties regarding finances and leadership of the business. For example, a partnership consisting of two business founders may allow a third individual to invest a set amount of cash in the company in exchange for a role as a limited partner. A non-stock subscription agreement for this arrangement would lay out the new partner's powers within the company, share of future profits and financial responsibility to make an initial investment to help the business grow.
Role of Stock
Stock, which represents partial shares of ownership in a public company, is one way for individuals to invest in a business. If a company is publicly traded, it may offer stock-based subscription agreements that require an investor to purchase a given number of shares in exchange for a certain type and level of involvement in the company. In the case of a non-stock subscription agreement, no stock changes hands. This means that non-stock subscription agreements are open to businesses that are not yet publicly traded, providing an alternative means of raising capital from investors.
Non-stock subscription agreements can take many forms, although most follow the same basic template. The agreement must name both the business and the investor entering into the agreement. It may also include a statement of risk, outlining the fact that an investor may never receive a profit or be able to recover the investment if the business fails. The body of a non-stock subscription agreement outlines the new investor's contribution and role in the company, including any formal title, executive responsibilities or voting privileges. Finally, a non-stock subscription agreement closes with an acceptance in which both parties sign and date the document.
A business is free to generate its own non-stock subscription agreements as long as they are in accordance with contract laws. Basic templates eliminate the need to have an attorney heavily involved unless an investor has specific demands that must be written into the agreement. The investor and business owners can negotiate the terms of the agreement to suit both parties. If another investor is available who will offer the same amount of money but ask for less control of the business, owners may have a strong bargaining position. However, if a business needs money quickly to meet its expenses and few investors are available, the investor holds an advantage and can request a more favorable non-stock subscription agreement.
- Startup Business: Private Placement Subscription Agreement
- Murdock Capital Partners: Murdock Opportunity Fund L.P. - Subscription Agreement and Power of Attorney
- Indiana University Foundation: Investment Policy Statement
About the Author
Dennis Hartman is a freelance writer living in California. His work covers a wide variety of topics and has been published nationally in print as well as online. Hartman holds a Bachelor of Fine Arts from Syracuse University and a Master of Arts from the State University of New York at Buffalo.


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The 1985 Breeders' Cup
Aqueduct Racetrack
November 2, 1985
Attendance: 42,568
Handle: $28,350,245
Races: 7
Weather: 54°
New York played host to the second Breeders' Cup and the Juvenile got the event off to a rousing start when Tasso nipped Storm Cat at the wire. Over the next 20 years, Storm Cat would become one of the world's most influential sires of Thoroughbreds. Remarkable performances were provided by Precisionist, who won the Sprint following a nearly four-month layoff; the English filly Pebbles defeating male rivals in the Turf and the 3-year-old Proud Truth winning the Classic over Gate Dancer. Jockey Jorge Velasquez rode both Precisionist and Proud Truth to victory.
1985 Breeders' Cup Champions
|Winning Horse
|1985 Breeders' Cup Classic
|Proud Truth
|J. Velasquez
|V. Veitch
|Darby Dan Farm
|Mrs. John W. Galbreath
|Sentient Jet Juvenile
|1985 Grey Goose Juvenile
|L. Pincay Jr.
|N. Drysdale
|Gerald Robins
|Gerald Robins and Timothy Sams
|Longines Distaff
|1985 Breeders' Cup Distaff
|Life's Magic
|A. Cordero Jr.
|D. Lukas
|Mel Hatley & Eugene Klein
|Mr. & Mrs. Douglas Parrish & David C. Parrish III
|Longines Turf
|1985 Breeders' Cup Turf
|Pebbles (GB)
|P. Eddery
|C. Brittain
|Sheikh Mohammed bin Rashid al Maktoum
|Warren Hill Stud
|1985 Breeders' Cup Mile
|W. Guerra
|J. Nerud
|Clover Racing Stables
|John A. Nerud
|14 Hands Winery Juvenile Fillies
|1985 Breeders' Cup Juvenile Fillies
|Twilight Ridge
|J. Velazquez
|D. Lukas
|Mr. & Mrs. Eugene V. Klein
|Thomas E. Burrow
|TwinSpires Sprint
|1985 Breeders' Cup Sprint
|C. McCarron
|L. Fenstermaker
|Fred W. Hooper
|Fred W. Hooper