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Meghan King Edmonds Is "Bewildered and Awestruck" By Her Growing Baby Bump
July 27, 2016 • 11:34 AM ET
Time flies when you're pregnant. That at least seems to be the case for Meghan King Edmonds, who celebrated being five months pregnant with another gorgeous bikini pic showing off her growing baby bump. This time, however, The Real...Read more
Lisa Vanderpump Reveals How American and British Manners Differ
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Wondering just how different Americans are in the manners department in comparison to our British counterparts? Well, Lisa Vanderpump is spilling all the etiquette tea to Harper's Bazaar. The Real Housewives of Beverly Hills restaurateur shares...Read more
Zachary Quinto Responds to George Takei's Criticism of an Openly Gay Sulu
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George Takei's reaction to the news that it would be revealed that Sulu is gay in the upcoming Star Trek Beyond surprised many ahead of the film's release last Friday. "I'm delighted that there's a gay character," the actor who played Sulu in the...Read more
Drew Barrymore Reveals Her Best and *Worst* Red Carpet Moments
July 27, 2016 • 10:52 AM ET
Yes, even style icons make mistakes sometimes. Read Blog
Porsha Williams and Phaedra Parks Go Glam at the Democratic National Convention
July 27, 2016 • 10:23 AM ET
It only comes but every four years, so when Porsha Williams and Phaedra Parks landed in Philly for the Democratic National Convention this week, they let their fashion do the talking. The Real Housewives of Atlanta besties were in attendance at...Read more
Which Celeb Hottie Has the Greatest Mustache... Ever? Reza Farahan Knows All
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When it comes to mustaches, there are very few men who understand the right and wrong ways to rock facial hair better than Reza Farahan. The Shahs of Sunset star is basically a facial hair guru, and his mustache is always perfectly groomed....Read more
Did Romance Bloom for Ben Robinson and Tiffany Copeland After Below Deck Med?
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As this season of Below Deck Mediterranean started to wind down, things started heating up for Ben Robinson and Tiffany Copeland. The chef and stewardess, respectively, locked lips and hooked up during the crew's very last night on the boat in...Read more


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Let me get this out of the way, I do not THINK you will like this movie if you do not like gore in your movie. Cause there is a lot of it in the end. It's not all gore though cause the movie does start off pretty scary also. There was one scene that seriously made me get an uneasy scared feeling. I don't want to ruin it though so I won't mention it here. There were also scenes that made me feel uneasy in a different way... as in a `turn your head and don't look at that gore' way.
Ok now that that is out there, the movie starts out with a car wreck that's already happened. We see a woman, Sarah, bloodied and barely alive. Her dead husband or boyfriend (I can't remember) is next to her in the passenger seat. Sarah is also pregnant.
We see Sarah later at the doc's office. She's getting her baby looked at and is told they'll be inducing labor the next day. She looks miserable, and it's because of her lost love, not her new kid, who I don't think she even cares about anymore.
That night she is visited by a stranger at the door. And we, the viewer, are visited by a really good scary/gory movie. I thought the mood of the movie turned over from a little boring to unnerving to suspenseful to shocking to crazy in exactly the right moments and it was done so well. The atmosphere of the house is so claustrophobic that I constantly found myself having a hard time breathing. You want her to run, but you know she cant just make a break for it for two reason. No room and a big prego belly.
Now there are some things that didn't make sense that might turn some people into haters. For instance...Read more ›
À l'intérieur (2007/8)
'À l'intérieur' is the much-talked-about release from first-time writer/director Alexandre Bustillo (the man behind the upcoming 2009 'Hellraiser' reboot). The film, a brutal one to say the least, focuses on a pregnant woman who becomes the subject of a mysterious and violent stalker. Moving from a startling open scene with a violently damaged foetus to a rather bloody mess of a fatal car accident which seriously injures our star, Sarah (played by Alysson Paradis, sister of Johnny Depp's partner, Vanessa) and kills the father, Matthieu (Jean-Baptiste Tabourin).
The actual plot starts four months later (which seems a bit surprising as Sarah's baby bump was already looking like a baby hill at the time of the wreck, and she's just now arriving near her due date). The disturbed Sarah, an action photographer for the local journal, suffers from some seriously odd dreams involving vomiting up copious amounts of some milky substance, CGI black cats and birthing her child, err, incorrectly . It's after one of these nightmares that Sarah meets the terrifying Femme (Béatrice Dalle) at her, Sarah's, front door. Sarah, perturbed by the oddities of the meeting and La Femme's resistance to leave, phones the police. Here, we learn one important thing: French police ACTUALLY care! In most American films (and real-life situations), a late-night distress call about a nuisance at your door would usually result in one officer driving by the house hours too late. In France, however, three cops arrive quickly, do a full check of the premises, AND a follow up. Now THAT is civil service!Read more ›
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I have not been so sucked in by a movie in a LONG time. This movie is gory, has a great story line and is full of suspense. Read morePublished 3 days ago by M. Quantrell
Well we all love Beatrice Dalle, right? We all love tons of gore, yeah? Well roll the two up and you have Inside! Read morePublished 23 days ago by Richard S. Wilson
Terrible. This movie was pretty bad and definitely unrealistic. The main character makes incredibly stupid decisions for no reason. Read morePublished 1 month ago by Scarebear
This movie isn't as much of a masterpiece as many people consider it to be. Implausible situation after another. Read morePublished 2 months ago by AlPal
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February 12, 2014
This groups sounds perfect to meet new people, I'm always trying to find things to do during the day.
I am single and I work as a casual.
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Book your room at Point West Apartments
This apartment is situated in the city center.
Property Features
Along with self parking, this smoke-free apartment has laundry facilities and a convenience store. WiFi in public areas is free.
Room Amenities
All 40 individually furnished apartments provide free WiFi, free wired Internet, and DVD players. Guests will find kitchens with refrigerators, stovetops, microwaves, and dishwashers. Weekly housekeeping is available.Would you like to give us feedback? Share it! Opens in a new window
Point West ApartmentsLondon England SW7 4XE
Hotel Amenities
Hotel Amenities
Point West Apartments features laundry facilities, a grocery/convenience store, and an elevator (lift). Public areas are equipped with complimentary high-speed wired and wireless Internet access. Onsite parking is available (surcharge).
Point West Apartments is a smoke-free property.
- Elevator/lift
- Free WiFi
- Free wired high-speed Internet
- Front desk (limited hours)
- Grocery/convenience store
- Laundry facilities
- Number of buildings/towers - 1
- Number of floors - 9
- Self parking (surcharge)
- Smoke-free property
- Total number of rooms - 40
- Year Built 1989
Family Friendly Amenities
- DVD player
- Free Wi-Fi
- Grocery/convenience store
- Kitchen
- Laundry facilities
- Microwave
- Refrigerator
- Rollaway/extra beds available
- Washer/dryer
Available in all rooms: Free WiFi , Free wired high-speed Internet
Available in some public areas: Free WiFi , Free wired high-speed Internet
Self parking (surcharge)
Room Amenities
- Air conditioning
- Balcony or patio
- Blackout drapes/curtains
- Free toiletries
- Cookware, dishware, and utensils
- Cribs/infant beds (surcharge)
- Digital TV service
- Dishwasher
- DVD player
- Free WiFi
- Free wired high-speed Internet
- Hair dryer
- In-room safe
- Individually furnished
- Iron/ironing board
- Kitchen
- Microwave
- Phone
- Private bathroom
- Refrigerator
- Rollaway/extra beds available
- Shower/tub combination
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Check-in time ends at 6 PM
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Extra-person charges may apply and vary depending on hotel policy.
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- Deposit: GBP 150 per stay
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- Self parking fee: GBP 15 per night
- Early check-in fee: GBP 257
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- Air conditioning fee: GBP 45 per week
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- Onsite credit card charges are subject to a surcharge
Hotel Name
- Point West Apartments London
- Point West London
- Point West Apartments Apartment London
- Point West Apartments By Crown Lawn Hotel London
- Point West Apartments By Crown Lawn London, England


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Electrical problem
2004 Chrysler Crossfire 6 cyl Two Wheel Drive Automatic
Engine stalls while driving then will not crank back up for about 30 minutes or so. This started happening all at once. The car showed no signs of trouble. It ran fine up till now. The engine will turn over, but will not crank. What do you think it is?
Wednesday, July 16th, 2008 AT 3:41 AM


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First printing/First DELUXE edition of 12 copies with gelatin silver print. SIGNED, housed together in an elegant stamped portfolio box. (Also available Deutschland, Sverige, God Jul & Gott Nytt Ar, Oglunda, Kvidinge, Ulan Bator, Amerika DELUXE editions w/prints.) « Show less
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I had been hosting my podcast through Squarespace, but I am leaving that service soon so I can have all of my sites running on my own WordPress sites. So I am trying to move my podcast without affecting any listeners. Here's what I've done so far:
-- added the iTunes new feed tag to the old podcast feed at Squarespace
-- used Squarespace's URL mapping feature to do a 301 redirect
I've had some success: the iTunes feed has indeed updated, and I checked one podcast client on iOS (Castro app) and saw that it works. There are two issues I'd like to correct:
1. In changing the feed, the data of the podcast changed. The title is not formatted correctly, and the byline says "By Unknown," which I'd like to correct. I have no idea how to go about fixing either.
2. The feed is not updating everywhere. I use Downcast, a fairly popular podcast app, and it's still pulling from the old feed. Is there something I've yet to do that can fix this? I considered simply asking people to update the feed by releasing a short audio note on old podcast feed, but I can't even search for the new feed in Downcast. It still pulls up the old feed.
Thanks for your help on this. I am not using any plugins for the podcast -- just a category feed that only gets the podcast episodes. Here's the link to the iTunes page if that helps: https://itunes.apple.com/us/podcast/critics-agree-podcast-carroll/id671331919?mt=2
Appreciate your reading! Willing to try any ideas you may have...


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The most epic lawsuit of all time, perhaps. A Peoria Illinois man is about to bring legal action against the former MVP for missing the entire 2013 season. HipHop365 reported that Matthew Thompson, a self-described long time Bulls fan, and electrician by trade filed a lawsuit on Thursday against Derrick Rose. Thompson claims Rose's absence caused him to have mental breakdowns, emotional distress and ultimately to gain tons of weight. According to reports Thompson also claims that Rose displayed negligent behavior by refusing to play despite being cleared by doctors. No reports yet if Peoria county officials will entertain the man's complaints or not. The silliness of the claims speak for itself, but you have to admit attributing weight gain to depression stemming from your favorite athlete being hurt is one A+ excuse. *slow clap*
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•January 1, 1970
Tourism Photos
Tourism Photos
st44: What a laugh now the left is calling the ' Russians ' a threat, Don't these idiot leftists remember that at the 2012 debates we had Romney telling dumbo about Russia capable of being a threat. But nothing for a corrupt politician to fear cause she claims all her 30,000 e-mails deleted and was also investigated by FBI, State Dept. and even the news media, And all e-mails were on a ' private server ' besides no one wants to look at chelseas wedding photos.


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Fax: (585) 276-1885
Review Article
Impact of a 21-gene RT-PCR assay on treatment decisions in early-stage breast cancer
An economic analysis based on prognostic and predictive validation studies†
Version of Record online: 20 FEB 2007
DOI: 10.1002/cncr.22506
Copyright © 2007 American Cancer Society
Volume 109, Issue 6, pages 1011–1018, 15 March 2007
Additional Information
How to Cite
Lyman, G. H., Cosler, L. E., Kuderer, N. M. and Hornberger, J. (2007), Impact of a 21-gene RT-PCR assay on treatment decisions in early-stage breast cancer. Cancer, 109: 1011–1018. doi: 10.1002/cncr.22506
- †
Presented, in part, at the 42nd Annual Meeting of the American Society of Clinical Oncology, June 2–5, 2006, Atlanta, GA.
Publication History
- Issue online: 7 MAR 2007
- Version of Record online: 20 FEB 2007
- Manuscript Accepted: 14 NOV 2006
- Manuscript Revised: 13 NOV 2006
- Manuscript Received: 29 SEP 2006
- Abstract
- Article
- References
- Cited By
- breast cancer;
- 21-gene RT-PCR;
- lymph node-negative;
- estrogen receptor-positive;
- tamoxifen;
- microarray;
- adjuvant chemotherapy;
- economic analysis;
- costs
The prognostic accuracy for distant recurrence-free survival using a 21-gene reverse-transcriptase polymerase chain reaction (RT-PCR) assay underwent validation in 668 lymph node-negative, estrogen receptor-positive women with early-stage breast cancer receiving tamoxifen on National Surgical Adjuvant Breast Program (NSABP) B-14. The predictive accuracy for treatment efficacy also underwent validation in 651 patients randomized on NSABP B-20 and 645 patients on NSABP B-14.
Patients were classified as high (recurrence score [RS] ≥ 31), intermediate (RS 18–30), or low (RS < 18) risk for distant recurrence at 10 years. Cost-effectiveness ratios were estimated for RS-guided treatment compared with either tamoxifen alone or the combined chemotherapy and tamoxifen.
Distant recurrence was reported in RS low-risk, intermediate-risk, and high-risk patients at 10 years in 3.7%, 17.8%, and 38.3% receiving tamoxifen alone and 5.0%, 10.1%, and 11.1% receiving the chemotherapy and tamoxifen. RS-guided therapy is associated with a gain in individual life expectancy of 2.2 years compared with tamoxifen alone, whereas it is associated with similar life expectancy to that seen with the chemotherapy and tamoxifen strategy. RS-guided therapy is estimated to provide a net cost savings of $2256 compared with chemotherapy and tamoxifen with an incremental cost-effectiveness ratio of $1944 per life year saved compared with tamoxifen alone.
Treatment decisions based on RS-guided therapy compared with tamoxifen alone are associated with greater efficacy with acceptable cost-effectiveness ratios, and associated with similar efficacy and lower cost compared with chemotherapy and tamoxifen for patients with lymph node-negative, estrogen receptor-positive early-stage breast cancer. Cancer 2007 © 2007 American Cancer Society.
More than 200,000 women are diagnosed with invasive breast cancer in the US annually, with approximately 40,000 dying from the disease, with nearly half of these women presenting with lymph node-negative, hormone receptor-positive disease.1 The decision to treat early-stage breast cancer (ESBC) with adjuvant hormonal therapy and/or chemotherapy is based on several clinical and pathological criteria. Current guidelines for the management of patients with ESBC recommend adjuvant chemotherapy and endocrine therapy for the majority of women with lymph node-negative, hormone receptor-positive ESBC.2, 3 Unfortunately, systemic chemotherapy is associated with considerable immediate morbidity and cost along with increasing evidence for significant delayed toxicities such as neurocognitive dysfunction and secondary malignancies.
Many patients with lymph node-negative, hormone receptor-positive ESBC do not experience distant recurrences or death from breast cancer even in the absence of adjuvant chemotherapy. At the same time, randomized controlled trials have demonstrated that some patients develop distant recurrence despite receiving adjuvant chemotherapy.4 Due in large part to the limited ability of clinical criteria to accurately assess an individual's risk, many patients continue to be overtreated or undertreated. Interest has recently developed in the possible role of gene expression profiles and other molecular techniques in more accurately assessing the risk of recurrence and the impact of treatment to guide clinical decisions on adjuvant therapy.5
A gene expression profile assay has been developed based on reverse-transcriptase polymerase chain reaction (RT-PCR) methods that permit quantification of gene expression in fixed paraffin-embedded tissue.6 Candidate genes consisted of 250 cancer-related genes gathered from the cancer literature, genomic databases, and microarray data.7–10 A 21-gene expression signature including 16 functional and 5 references genes was found to provide excellent RT-PCR performance. Prognostic information was obtained on 447 women with ESBC including 233 from the National Surgical Adjuvant Breast Program (NSABP) Study B-20 in whom archived tissue was available.11 A recurrence score (RS; Oncotype DX) ranging from 0–100 was derived from each patient's gene expression results using a proprietary formula. This 21-gene signature has been independently validated as a prognostic indicator of distant recurrence-free survival in 668 evaluable patients in node-negative, receptor-positive ESBC receiving tamoxifen on the NSABP B-14 study.12–15 Multivariate analysis demonstrated this assay to be a significant independent prognostic factor for distant recurrence after adjustment for age and tumor size with an adjusted hazard ratio of 3.21 (95% confidence interval [CI]: 2.23, 4.61; P < .00001).11
A previous economic analysis based on the initial validation of the prognostic capability of the assay has been reported.16 A cost-utility analysis was conducted using the RS in patients classified as having a low or high risk of distant recurrence based on National Comprehensive Cancer Network (NCCN) clinical guidelines. The analysis considered survival, quality of life, and costs from a societal perspective. At baseline values, the RS applied to 100 potential patients predicted an increase quality-adjusted survival by 8.6 years while reducing overall costs by $202,828. The RS was more accurate than NCCN guidelines as an indicator of prognosis for lymph node-negative, estrogen receptor-positive ESBC and was cost effective.16 The predictive accuracy of the 21-gene signature has recently been validated based on the observed impact of chemotherapy and tamoxifen on distant recurrence-free survival (DRFS) among 651 patients on NSABP B-20 and 645 patients on NSABP B-14.17 The study reported here incorporates the extended validation results into an economic model of the 21-gene expression signature to guide the use of adjuvant chemotherapy and hormonal therapy in patients with lymph node-negative, estrogen receptor-positive ESBC.
Risk Assessment
As noted above, the original validation study of prognostic accuracy for the 21-gene expression signature was based on women with lymph node-negative, estrogen receptor-positive ESBC treated with tamoxifen on NSABP B-14. Of the 2617 eligible women, 688 were evaluable based on availability of the original tumor block and adequate tumor to provide RNA for RT-PCR analysis.11 The predictive accuracy for DRFS based on response to chemotherapy and tamoxifen has also undergone validation in 651 patients randomized on NSABP B-20 and 645 patients on NSABP B-14.17 An RS was generated as a continuous measure by fitting a time-varying piece-wise log-hazard ratio model to the data, whereas the 10-year distant recurrence rate was estimated by a Breslow-type estimator as previously described.18 Women with node-negative, receptor-positive ESBC were classified as high (RS ≥ 31), intermediate (RS 18–30), or low (RS < 18) risk of distant recurrence at 10 years (Fig. 1).11
Outcome Measures
The clinical impact of different treatment strategies was assessed by estimating the gain in life expectancy or life years saved derived from NSABP B-20 and B-14. The impact of treatment strategies on health-related quality of life was based on a time trade-off method where patients are asked to state the maximum number of years of their actual life expectancy in the diseased state that they would be willing to give up for time in full health. This method is based on the premise that many patients would be willing to give up some length of survival for a higher quality of survival if that was a viable option. Clinical outcomes were expressed in the form of quality-adjusted life years (QALYs) by taking the product of the actual life expectancy and the patient utility.
Data on costs of cancer care were obtained from the Centers for Medicare and Medicaid Services as well as published literature and are described elsewhere.16, 19 Chemotherapy costs were based on reported Average Wholesale Price and include only drug costs. Other treatment-related direct and indirect costs were not considered, eg, costs of administration, testing, transportation, etc. Utility estimates for the quality of life impact of adjuvant beast cancer chemotherapy were derived from the literature as described above.20, 21 Costs not considered in this analysis include both additional direct costs associated with drug administration, professional fees, and laboratory testing along with indirect costs such as transportation and loss of productivity costs and patient out-of-pocket expenses.
Cost Effectiveness and Cost Utility
A clinical decision model was developed comparing clinical, economic, and quality of life outcomes for 3 adjuvant treatment strategies: 1) tamoxifen alone, 2) chemotherapy followed by tamoxifen, or 3) RS-guided therapy based on the results of the 21-gene RT-PCR assay. The RS-guided strategy employs tamoxifen for low-risk patients and chemotherapy and tamoxifen for intermediate- and high-risk patients. Table 1 presents baseline probability and cost assumptions. Treatment strategies were compared in the framework of cost-effectiveness and cost-utility analyses providing summary outcome measures reflecting additional cost of 1 strategy over another (marginal cost) and the additional clinical benefit (marginal efficacy) or quality-adjusted clinical benefit (marginal utility). The balance between cost and benefit was expressed in terms of cost-effectiveness (C/E) and cost-utility (C/U) ratios of the marginal cost and the marginal effectiveness representing the added cost per life year or QALY saved.22–24 Incremental costs ($), life years, QALYs, as well as C/E and C/U ratios were estimated for each treatment strategy.
|Baseline value
|Distribution type
|10-Year distant recurrence-free survival
|Low risk
|RS-guided therapy
|Intermediate risk
|Paik et al.11
|RS-guided therapy
|High risk
|RS-guided therapy
|Low risk patients
|Intermediate risk patients
|Paik et al.11
|High risk patients
|Direct costs ($)
|Adjuvant chemotherapy
|Normal, SD 2500
|Oestreicher et al.19
|Surveillance without recurrence
|Normal, SD 1000
|Oestreicher et al.19
|OncotypeDx assay
|Genomic health
|Treatment of recurrence
|Normal, SD 20,000
|Oestreicher et al.19
|Healthy life expectancy, y
|Annual mortality rate following recurrence
|Paik et al.11
|Quality of life
|Utility with chemotherapy
|Earle et al.20
Monte Carlo Simulation
Monte Carlo simulation was conducted for DRFS and estimated costs based on available distributions. Sampling distributions and summary estimates of cost, efficacy, and variance were based on 1000 replicates.
Risk Stratification
Of the 651 patients on NSABP B20 with corresponding gene expression assays, 64 (9.83%) developed distant recurrence including 31 (13.66%) randomized to tamoxifen and 33 (7.78%) receiving chemotherapy and tamoxifen. Distant recurrence was observed within 10 years in 3.2%, 9.1%, and 39.5% of RS low-risk, intermediate-risk, and high-risk patients, respectively, receiving tamoxifen alone and in 4.4%, 10.9%, and 11.9% in those receiving chemotherapy and tamoxifen. No significant difference in life expectancy at 10 years was seen between the RS-guided therapy and the combined chemotherapy and tamoxifen strategies, whereas RS-guided therapy is associated with a gain in individual life expectancy of 2.2 years compared with tamoxifen alone.
Expected Costs
Under baseline cost assumptions, the lowest expected overall cost is associated with treatment with tamoxifen alone, whereas the greatest expected cost is that associated with the chemotherapy and tamoxifen strategy (Table 2). The expected costs of each strategy increase as the cost of treating distant recurrence increases. Above a cost of treating recurrence of $100,759, RS-guided therapy provides a net cost savings compared with other strategies and is always cost-saving compared with the chemotherapy and tamoxifen strategy. Tamoxifen is associated with lowest costs for all reasonable follow-up cost assumptions among those not recurring, whereas RS-guided therapy is always associated with lower costs than a chemotherapy and tamoxifen strategy.
|Cost ($) per life year saved (LYS)
|Treatment strategy
|Chemotherapy and Tamoxifen
The expected costs associated with both the chemotherapy and tamoxifen and the RS-guided therapy strategies increase as the direct cost of chemotherapy increases, but they do so at different rates. As shown in Figure 2, the expected costs favor the RS-guided therapy strategy over the chemotherapy and tamoxifen strategies, for total chemotherapy costs exceed $5822. The estimated costs associated with 5 commonly used adjuvant chemotherapy regimens are indicated including: 1) doxorubicin and cyclophosphamide (AC) every 3 weeks × 4 cycles; 2) AC every 2 weeks × 4 cycles with colony-stimulating factor (CSF) support; 3) AC followed by paclitaxel (AC-T) every 3 weeks × 8 cycles; 4) AC-T every 2 weeks × 8 cycles with CSF support; and 5) docetaxel, doxorubicin, and cyclophosphamide (TAC) every 3 weeks × 6 with CSF support. Whereas every 3-week doxorubicin and cyclophosphamide without myeloid growth factor support is associated with a lower cost, most of the commonly used adjuvant breast cancer regimens are associated with costs that favor their targeted use based on the 21-gene expression signature. A net cost savings is estimated for RS-guided therapy for: AC-T Q3 weeks ($458); AC Q2 weeks ($946); AC-T Q2 weeks ($5159), and TAC Q3 weeks ($9810).
Incremental Cost-Effectiveness
The expected incremental costs associated with the RS-guided therapy and chemotherapy and tamoxifen strategies are $4272 and $6527, respectively, compared with tamoxifen alone (Table 2). The incremental cost-effectiveness ratio compared with tamoxifen alone favors the RS-guided therapy strategy ($1944/life year saved) over the chemotherapy and tamoxifen approach ($3385/life year saved). Incremental life years saved for the RS-guided therapy compared with tamoxifen alone increases as healthy life expectancy increases, whereas the cost effectiveness decreases from $41,433/life year saved at a healthy life expectancy of 5 years to $1101/life year saved with a life expectancy of 40 years to chemotherapy and tamoxifen with varying healthy life expectancy.
Cost Utility
The baseline assumptions indicated in Table 1 reflect no adjustment for the impact of chemotherapy on quality-of-life. Such adjustments have the anticipated effect on the estimated QALYs and, therefore, the cost utility or cost per QALY gained. Expected QALYs were found to favor the RS-guided therapy strategy over chemotherapy and tamoxifen for all values of health utility, with increasing incremental QALY as the impact of chemotherapy on measured utility increased. The utility associated with chemotherapy has no impact on the expected QALYs associated with the tamoxifen-alone strategy. Greater expected QALYs compared with tamoxifen alone are seen for RS-guided therapy until the utility associated with chemotherapy falls below 0.80. At a utility of 0.90 associated with adjuvant chemotherapy, RS-guided therapy is associated with a gain of 0.97 QALYs and a cost utility of $4432/QALY compared with tamoxifen alone and a gain in 1.71 QALYs compared with the chemotherapy and tamoxifen combination despite a net cost savings.
Monte Carlo Simulation
Monte Carlo simulation was conducted as described above. Mean and median incremental cost-effectiveness ratios were $2769/life year saved and $1784/life year saved, respectively, for RS-guided therapy compared with tamoxifen alone. As shown in the cost-effectiveness scatterplot (Fig. 3), the RS-guided therapy and the chemotherapy strategies are associated with quite separate distributions of costs and effectiveness compared with that associated with tamoxifen alone. Assessment of the incremental cost-effectiveness ratios demonstrate that the relation between RS-guided therapy and tamoxifen alone is primarily that of an increase in life years saved, albeit with a small increase in cost resulting in cost-effectiveness ratios with a very high probability of falling below $50,000/life year saved (Fig. 4). An assessment of the incremental cost-effectiveness ratios for the relation between RS-guided therapy and the chemotherapy and tamoxifen strategy demonstrates that the RS-guided therapy reduces the estimated cost with an actual reduction in cost in 70% of replicates in Monte Carlo analysis and an overall benefit in terms of life expectancy. In a willingness-to-pay (WTP) analysis (data not shown), under baseline conditions and a WTP value = 0, the tamoxifen-alone arm is favored by virtue of being the least costly option. The RS-guided therapy option becomes equally favored at a WTP of $7500/life year saved. The chemotherapy and tamoxifen strategy is equally favored compared with tamoxifen at a WTP of $13,000, whereas the RS-guided therapy remains the favored option approximately 70% of the time when the WTP exceeds $15,000/life year saved.
Treatment decisions based on the RS-guided therapy compared with tamoxifen alone are associated with greater efficacy, with cost-effectiveness ratios well within accepted ranges for technology adoption, whereas they are associated with similar efficacy and substantially lower toxicity and cost compared with chemotherapy and tamoxifen for all patients. Decisions on the adjuvant treatment of women with ESBC are often based on patient age or menopausal status as well as clinical and pathological factors associated with limited prognostic accuracy.25, 26 Multiple large, randomized, controlled trials and meta-analyses of those trials have demonstrated the efficacy of adjuvant systemic therapy in ESBC. Nevertheless, systemic chemotherapy is associated with short-term as well as long-term toxicities of considerable concern. As a result, many patients receive potentially toxic adjuvant chemotherapy who are already disease-free, whereas some do not receive potentially curative adjuvant therapy who might have benefited. Current clinical guidelines encourage the use of adjuvant chemotherapy in addition to hormonal therapy in all but the lowest risk categories of lymph node-negative, estrogen receptor-positive women with ESBC.2, 3 The 21-gene expression signature RS for distant disease recurrence was initially validated in 668 evaluable lymph node-negative, estrogen receptor-positive ESBC patients receiving tamoxifen on NSABP B-14.11 More recently, the predictive accuracy of the assay has also been validation-based on the response to chemotherapy and tamoxifen in 651 patients on NSABP B-20 and 645 patients on NSABP B-14.17 The study reported here was undertaken to further evaluate the economic impact of the 21-gene signature when used to guide common clinical decisions concerning the use of adjuvant chemotherapy and hormonal therapy in patients with lymph node-negative, estrogen receptor-positive ESBC. The economic impact of the gene expression profile signature to guide the type of adjuvant systemic therapy was compared with the strategy of tamoxifen alone or chemotherapy and tamoxifen.
Under baseline assumptions, the lowest expected cost was found to be associated with tamoxifen alone, whereas the RS-guided therapy strategy was associated with lower expected costs than the chemotherapy strategy. The estimated incremental cost with RS-guided therapy and chemotherapy compared with tamoxifen alone was $4272 and $6527, respectively. An estimated average cost savings of more than $2000 was estimated for RS-guided treatment. The estimated incremental cost per life year saved compared with tamoxifen alone favored RS-guided therapy over the chemotherapy strategy, with a cost saving of over $1000 per life year saved with RS-guided therapy. The RS-guided therapy strategy was found to be more costly for low-cost chemotherapy regimens not requiring additional supportive care, whereas a net cost savings between $500 and $10,000 is estimated with RS-guided therapy for other commonly used adjuvant chemotherapy regimens. The estimated cost savings provided here for RS-guided therapy are probably underestimates, as they do not consider other direct costs associated with adjuvant chemotherapy including drug administration, professional fees, laboratory testing and the costs of complications. In addition, the model does not consider indirect costs such as those associated with transportation and loss of productivity costs as well as out-of-pocket expenses. Therefore, it is likely that additional savings from a societal perspective would be associated with the RS-guided therapy strategy.
Several studies have addressed the potential impact of cancer chemotherapy on patient quality of life.27–31 Whereas no quality of life adjustment was considered under baseline conditions, the greater the impact of chemotherapy on quality of life, the greater the incremental cost utility favoring RS-guided therapy compared with systemic chemotherapy. Likewise, RS-guided therapy was associated with superior cost utility compared with tamoxifen alone for chemotherapy utility exceeding 80%.
Despite the favorable clinical and economic results for the 21-gene assay presented here, it is clear that more work is needed to develop assays with both greater accuracy as well as broader clinical application. As with this assay, careful and comprehensive validation of assays with potential use in estimating disease prognosis and treatment response in women with ESBC is needed.32–35 A recent review of 17 studies of gene expression assays with validation based on recurrence-free survival in women with ESBC in a broad range of potential clinical settings demonstrates wide variation in test accuracy.36 Assay performance measures including sensitivity and specificity varied widely across studies. Of potential interest for investigators in future studies is the observed significant correlation between the number of genes in the assay and test performance as reflected in the diagnostic odds ratio. As gene expression assays and other biomarkers improve in prognostic and predictive accuracy, further increases in the clinical benefit and cost effectiveness of these tools should be achieved.
In summary, RS-guided therapy applied to lymph node-negative, estrogen receptor-positive ESBC is associated with lower expected cost per life year or QALY gained compared with empiric chemotherapy across all reasonable model assumptions. The use of the gene expression assay in targeting systemic chemotherapy and hormonal therapy toward ESBC patients at greatest risk and most likely to benefit appears to have the potential to provide a net cost savings or to prolong survival along with acceptable cost-effectiveness ratios compared with other commonly used adjuvant treatment strategies. Nevertheless, further evaluation of the clinical utility of gene expression profile signatures in women with ESBC is needed. A large Phase III trial (TAILORx) sponsored by the National Cancer Institute is currently being conducted assigning lymph node-negative, estrogen receptor-positive women with breast cancer hormonal therapy if RS < 11, combination of adjuvant chemotherapy and hormonal therapy if RS > 25, and randomizing patients with RS 11–15 to either hormonal therapy or combination chemotherapy and hormonal therapy. This study will hopefully further define the potential role of the 21-gene expression assay in women with intermediate RS results.
- 1Cancer statistics 2006. Ca-A J Clin. 2006; 56: 106–130., , , et al.
- 2Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer. J Clin Oncol. 2003; 21: 3357–3365., , , et al.
- 3NCCN Guidelines for Breast Cancer. NCCN Task Force Report: adjuvant therapy for breast cancer. J Natl Compr Canc Netw. 2006; 4( Suppl 1): S1–26.
- 4
- 5Molecular profiling of breast cancer: clinical implications. Br J Cancer. 2004; 90: 1120–1124., .
- 6Measurement of gene expression in archival paraffin-embedded tissues. Development and performance of a 92-gene reverse transcriptase-polymerase chain reaction assay. Am J Pathol. 2004; 164: 35–42., , , et al.
- 7Gene expression profiling predicts clinical outcome of breast cancer. Nature. 415; 2002: 530–535., , , et al.
- 8Gene expression patterns of breast carcinomas distinguish dtumor subclasses with clinical implications. Proc Natl Acad Sci USA 98; 2001: 10869–10874., , , et al.
- 9A molecular signature of metastseis in primary solid tumors. Nat Genet. 2003; 33: 49–54., , , .
- 10Estrogen receptor status in breast cancer is associated with remarkably distinct gene expression patterns. Cancer Res. 2001; 61: 5979–5984., , , et al.
- 11A multi-gene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004; 351: 2817–2826., , , et al.
- 12Treatment of lymph-node-negative, oestrogen-receptor-positive breast cancer: long-term findings from National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. Lancet. 2004; 364: 858–868., , , et al.
- 13Five versus more than five years of tamoxifen therapy for breast cancer patients with-negative lymph nodes and estrogen receptor-positive tumors. J Natl Cancer Inst. 1996; 88: 1529–1542., , , et al.
- 14Five versus more than five years of tamoxifen for lymph node-negative breast cancer: updated findings from the National Surgical Adjuvant Breast and Bowel Project B-14 randomized trial. J Natl Cancer Inst. 2001; 93: 684–690., , , .
- 15Tamoxifen and chemotherapy for lymph node-negative, estrogen receptor-positive breast cancer. J Natl Cancer Inst. 1997; 89: 1673–1682., , , et al.
- 16Economic analysis of targeting chemotherapy using a 21-gene RT-PCR assay in lymph-node-negative, estrogen-receptor-positive, early-stage breast cancer. Am J Manag Care. 2005; 11: 313–324., , .
- 17Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006; 24: 3726–3734., , , et al.
- 18Estimation of the survival function for Gray's piecewise-constant time-varying coefficients model. Stat Med. 2002; 21: 717–727., .
- 19The cost of adjuvant chemotherapy in patients with early-stage breast carcinoma. Cancer. 2005; 104: 2054–2062., , , , .
- 20Systematic overview of cost-utility assessment in oncology. J Clin Oncol. 2000; 18: 3302–3317., , , et al.
- 21Treatment decisions for breast carcinoma: patient preferences and physician perceptions. Cancer. 2002; 94: 2076–2080., , , .
- 22A clinician's guide to cost-effectiveness analysis. Ann Intern Med. 1990; 113: 147–154., .
- 23The role of the cost-effectiveness analysis in health and medicine. JAMA. 1996; 276: 1172–1177., , , , .
- 24Understanding economic analyses. Evid Based Oncol. 2001; 2: 2–5., .
- 25Methodological challenges in the evaluation of prognostic factors in breast cancer. Breast Cancer Res Treat. 1998; 52: 289–303., .
- 26Age and the risk of recurrence in women with breast cancer. Cancer Control. 1996; 3: 421–427., , , et al.
- 27Quality of Life after adjuvant chemotherapy for breast cancer. Breast Cancer Res Treat. 2000; 62: 142–150., , , , .
- 28Polychemotherapy for early breast cancer: an overview of the randomised clinical trials with quality-adjusted survival analysis. Lancet. 2001; 358: 277–286., , , , .
- 29Health-related quality of life in axillary node-negative, estrogen receptor-negative breast cancer patients undergoing AC versus CMF chemotherapy: findings from the National Surgical Adjuvant Breast and Bowel Project B-23. Breast Cancer Res Treat. 2004; 86: 153–164., , , et al.
- 30Quantifying trade-offs: quality of life and quality-adjusted survival in a randomized trial of chemotherapy in postmenopausal patients with lymph node-negative breast cancer. Br J Cancer. 2004; 91: 1893–1901., , , et al.
- 31Health-related quality of life parameters as prognostic factors in a nonmetastatic breast cancer population: an international multicenter study. J Clin Oncol. 2004; 22: 3381–3388., , , et al.
- 32Diagnostic and prognostic prediction using gene expression profiles in high-dimensional microarray dta. Br J Cancer. 2003; 89: 1599–1604..
- 33Gene expression profiling for the prediction of therapeutic response to docetaxel in patients with breast cancer. Lancet. 2003; 362: 362–369., , , et al.
- 34Prediction of docetaxel response in human breast cancer by gene expression profiling. J Clin Oncol. 2005; 23: 422–431., , , et al.
- 35Molecular classification of tamoxifen-resistant breast carcinomas by gene expression profiling. J Clin Oncol. 2005; 23: 732–740., , , et al.
- 36Gene expression profile assays as predictors of recurrence-free survival in early stage breast cancer; a meta-analysis. Clin Breast Cancer. 2006; 7: 372–379., .


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Dr. Kerlin is a Penn Medicine employed physician.
Dr. Kerlin's clinical interests are primarily in critical care, including the management of respiratory failure and sepsis. She serves as attending physician in the Medical Intensive Care Unit and on the Critical Care Outreach and Procedure Service of the Hospital of the University of Pennsylvania.
A facility of the Hospital of the University of Pennsylvania
Medical School: Vanderbilt University
Residency: Yale-New Haven Hospital
Fellowship: Hospital of the University of Pennsylvania
Dr. Kerlin completed a Master of Science program in the Center for Clinical Epidemiology and Biostatistics. Her primary research interests have been in the intersection between medical education, organizational structure, and patient outcomes in intensive care units. Her current active projects include (1) several studies devoted to the evaluation of physician staffing models in critical care medicine, with respect to patient-centered outcomes, processes of care, physician staff outcomes, and educational outcomes, and (2) defining the role of physician factors in patient outcomes among patients with acute respiratory failure.
Meeta Prasad Kerlin, Dylan S. Small, Elizabeth Cooney, Barry D. Fuchs, Lisa M. Bellini, Mark E. Mikkelsen, William D. Schweickert, Rita N. Bakhru, Nicole B. Gabler, Michael O. Harhay, John H. Hansen-Flaschen, Scott D. Halpern: A randomized trial of nighttime physician staffing in an intensive care unit. The New England Journal of Medicine 368 (23): 2201-9,2013.
Meeta Prasad, Eric S. Holmboe, Rebecca S. Lipner, Brian J. Hess, Jason D. Christie, Scarlett L. Bellamy, Gordon D. Rubenfeld, Jeremy M. Kahn: Clinical protocols and trainee knowledge about mechanical ventilation. The Journal of the American Medical Association 306 (9): 935-41,2011.
Helen C. Koenig, Barbara B. Finkel, Satjeet S. Khalsa, Paul N. Lanken, Meeta Prasad, Richard Urbani, Barry D. Fuchs: Performance of an automated electronic acute lung injury screening system in intensive care unit patients. Crit Care Med 39 (1): 98-104,2011.
Congratulations to the 184 Penn physicians listed below who were included in Philadelphia Magazine's Top Doctors 2016.
Penn Medicine is one of the world's leading academic medical centers.
A clinical trial is a research study involving patient volunteers that are conducted to find safe and effective treatments for a variety of health conditions.


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Skip to comments.Iowa Grandmother, Donna Holman, Jailed for Discouraging Abortion (judge ordered a Psych. Test)
Posted on 01/18/2008 4:59:17 PM PST by Coleus
In March, 2007, Donna Holman was convicted of a charge of "harassment" as she engaged in "sidewalk counseling" to discourage women from entering a Planned Parenthood abortion clinic in Iowa City, Iowa. Judge Karen Egerton found Mrs.Holman guilty on the hearsay testimony of Planned Parenthood employees. The woman Mrs. Holman allegedly harassed did not even show up for the hearing. Despite being unable to confront her accuser and offer exculpatory evidence, the Iowa Supreme Court declined to review the case.
"While murderers and rapists run free, a harmless 72-year-old Christian grandmother, Donna Holman, must languish in jail for having the temerity of speaking out on behalf of the unborn," said Dr. Gary Cass, Chairman and CEO of the Christian Anti-Defamation Commission. "The double standards of justice used against pro-life Christians are staggering. If Donna Holman had been a union or homosexual activist she would have been released and the trumped up charges dropped. Donna is only guilty of caring for the weakest and most vulnerable among us. The courts are guilty of aiding and abetting the abortion industry as it plies its bloody trade on bodies of innocent babies while harming unsuspecting women. It is especially troubling that she is beginning this ordeal on the eve of the 35th anniversary of the Roe v. Wade decision.
(Excerpt) Read more at christiannewswire.com ...
The rub on courts everywhere at every level is that if they rule in favor of any anti-abortion case brought before their court, they will be admitting they were wrong. Wrong to the tune of 50,000,000 deaths. To admit they got Roe wrong is never-ever going to happen. Leaving judges both sitting and retired a legacy of being murderers is not something they will allow to happen.
what is evil is good and what is good is evil,
Where have I read that?
Donna Holman has my prayers. Her sacrifice will bring graces to a world in desperate need of grace.
I pity the eternity of such judges.
DONNA HOLMAN, Defendant.
NOW COMES THE DEFENDANT, DONNA JEAN HOLMAN, pro se; being of sound mind, and of a sound body, pursuant to Iowa Code section 902.4, to move this court to reconsider its sentence in the above titled case.
I find it strange and disingenuous for a woman, especially for a mother, not to recognize the humanity and worth of a child in the womb. I find it especially strange and abhorrent that a female judge would somehow think it is normal for Planned Parenthood to systematically kill babies in the womb, but abnormal for me to oppose these serial killers.
Is it not hypocritical for this court to acknowledge a woman's purported right in seeking medical help for destroying her child, while denying me the basic right to refuse "medical help?" I believe psychiatry to be a
psuedoscience on par with astrology, fortune telling, and palm reading.
Must I be punished for my refusal to recognize psychiatry as a legitimate medical science? What gives this court the right to order medical help for which I have no need or desire? Is it not "my body, my choice?" Must I also ingest mind altering psychotropic drugs prescribed by a psychiatrist to satisfy this court order? Does this court routinely order psychiatric evaluations for misdemeanor convictions?
If I were physically or mentally impaired I should indeed be pitied. This court is apparently questioning my morality! This court is acting as if it were lawful and morally righteous to slaughter the unborn. Yet
35 years ago it was unlawful, and unrighteous. Does changing the law change morality? Does changing the law change right or wrong? Does changing the law change the reality of aborticide?
In 1856, the U.S. Supreme Court ruled that a Negro is "chattel." By denying Dred Scott his freedom, slavery was made "safe and legal." Had I stood before this court for opposing slavery or the "Jim Crow laws" instead of aborticide, would this court suspect me of being mentally
deficient or ill?
Prior to the 1973 Roe v. Wade decision, the humanity of the unborn child was understood; his status as a "legal person" was unquestioned. It is the same perversion of law which refused to recognize the humanity and worth of "the Negro" that denies equal protection under the law to the
child in the womb.
Outside this courthouse, on numerous occasions, I have demonstrated the humanity and worth of the pre-born child. I have displayed pictures of aborted babies which should have excited compassion on their behalf. I have also distributed literature on these very court house steps with statistics of abortions in Iowa.
One out of every 3 children In Iowa is killed by aborticide. The Iowa Department of Public Health reports that 7,564 Iowa children were "terminated" in 2006. It is a great evil which permits this holocaust under color of law.
It is unjust for this court to find me guilty of harassment, to forbid me from performing my ministry to the pre-born at Planned Parenthood, to sentence me to a year's probation, ordering me to get a psychiatric examination, and obey psychiatric advice.
Since I have been enjoined from being at Planned Parenthood there is nobody there to advise desperate women against aborticide! In consideration of the 4 days I have been incarcerated for this unjust conviction, I respectively request that this court prayerfully reconsider my sentence. Donna Jean Holman, pro se
Reminiscent of Soviet and Chinese re-education camps.
Any time someone is facing jail time, they have the right to an attorney. Donna may have qualified for a public defender. I want to know if she waived her right to a lawyer and simply plead guilty to the charge before I make any further judgments as to how she ended up in jail for this. I'm as pro-life as they come, but I hate emotional stories that don't tell the whole story. It puts the pro-life side in the same light as the other side.
I wonder which political party the good judge belongs?
Ok, so she is Pro Se. She is representing herself. That's why she's in jail. She waived a lawyer. That is just stupid.
How about Isaiah 5:20: Woe to those who call evil good, and good evil?
This is a link to another story (old). Is it the same person?
*in favor of the
Meanwhile, the WBC Phelps clan is free to spew their vile sewage to their heart's content.
Beat me to it. Was going to say, Psych test is the first step to a re-education camp.
UNBELIEVABLE! I have read a lot here in the years my husband was a poster. I have never read anything so ominous. Why don't they just assign a deputy to tase her whenever she says or does something the court doesn't like?
Any idea why she didn't go for a jury trial?
Even a public defender is better than representing yourself. I still wonder why she chose a bench trial. As a pro-lifer I'd only do that if the judge was very conservative.
Also potentially the first step to losing your Second Amendment rights - a bill re mental treatment, involuntary OR VOLUNTARY, is going to the Virginia General Assembly this session. I don't know if any other states have enacted something similar.
Just another example of giving a moron a little authority who answers to no one.
Elect a Democrat for Pres (especially the Witch) and America will get leftist, stalinist judges for years to come.
Where to begin?!?! Let me say working for Johnson Co I have seen this county be nothing, but OVERLY accommodating to Mrs. Holman! And 'her people' have been nothing, but mean and rude to myself and others. I can't believe these people. I feel like I have to stand up for these so-called Christians because of the negative words and attitudes they are using towards myself and co-workers. I'm getting tired of making excuses for you all. Grow up please.
I am a Christian. I am pro-life. I do believe for speaking up and standing up for what you believe in. I also believe in following laws. I also believe in not harassing others. I believe that maybe serving this time in jail could be a benefit to Mrs. Holman. Ever heard of a man called Paul? Remember all the time he spent in prison and the work the Lord provided for him while he was there? God said there is a reason for every time in our life and this is just another season and challenge in Mrs. Holman's life.
Oh and sure like the deputies would tase her. Are YOU kidding me purpleraine? Get your facts straight first. These deputies, judges, and other officials are people too. Why don't you try and treat them like one?
And oh! My husband and I are retired peace officers, so save the sermon.
Thank you for your information.
Putting a 72 year old woman in jail for 30 days because she would not submit to a psychiatric examination and any drugs that were prescribed as a result is not being accomodating to Mrs. Holman, is it?
Doesn't your county/judge understand that subjecting a very SANE woman to a psychiatric examination is a Stalinist/KGB tactic that has been used in communist nations for decades to silence voices of protest in their countries?????
It is the HEIGHT of insult, degradation, and ignominy to even suggest that this woman needs psychiatric care for speaking to mothers of unborn children before they go in to have their very much ALIVE babies aborted/killed.
The mystery is why tens of thousands of Christian/Jewish/caring Americans are not at Abortatoriums every day doing what Mrs. Holman was doing.
Women in crisis pregnancies do NOT get the full story at Planned Parenthood or other abortatoriums regarding the viability of their unborn child, regarding the health risks of having abortions both at the time of the procedure and in later life, or the emotional/spiritual tragedies that result in the lives of women who have had abortions!!!!!!!
And why would Planned Parenthood TELL women these facts? They do NOT tell them because Planned Parenthood MAKES MILLIONS ON THE DESTROYED BABIES AND DAMAGED LIVES OF THE MOTHERS. Follow the money. Yet the abortion "industry" is NOT REGULATED like every other health facility/procedure is in this country.
For shame to Johnson county for your treatment of this woman. Please reconsider these actions and set this woman free!!!!!
How interesting to have joined the same day this article was posted. Welcome to FR.
Im getting tired of making excuses for you all. Grow up please.
You need not make excuses for us. Thanks for the thought nonetheless.
Are YOU kidding me purpleraine? Get your facts straight first.
FReepers go out of their way to treat newcomers well. However, those welcomed might consider whether they or those of longer standing have the greater credibility at this juncture.
Maybe she knows she has an Advocate in the Supreme court.
While not artful in some respects, her motion gets her point across. Most attorneys would try to ingratiate themselves in some way with the judge. Mrs. Holman did not. Now she's in jail. Somehow I think she knew she might be called upon to make this sacrifice, and was willing.
LOL! Tell it like it is!!!
Too bad her pleading isn't going to go anywhere with this judge.
Prayers for this woman. Looks like her right to free speech were squelched.
Now maybe you can explain to us why a 72 year old grandmother is in jail for a misdemeanor of legally protesting at an abortion center?
Also please explain what right a judge has to order her to undertake a psychiatric evaluation and be drugged for this misdemeanor?
And don't take that tone with me that you used here earlier!
i think YOU need to see a shrink.
St. Paul was a man of God and was incarcerated by a bunch of immoral pagans, is that what you are the judge are? very poor analogy to say the least.
We have a first amendment and the people have a right to do sidewalk counseling at abortion mill, they have a right to show what an abortion looks like and a right to educate people to show what abortion is.
you sure you don't work for planned parenthood?
Cameras. Always have at least one person videotaping throughout the day while a protest is being held. It's evidence of the truth of any encounter.
Not surprising that liberal American judges eventually get around to using the same tactics that communist Russian judges used to quelch dissent.
She denounces one form of genocide and eugenics, only to be subject to another tool of eugenics, a psych test.
Satan's so predictable. He can't create, only twist and destroy.
To Donna, thanks for your witness, courage and strength.
Many of my teens and young adults (two busloads), will think of her and others at the March in D.C. Tuesday.
Did you send this to ACLJ, Thomas More and Ave Maria Law?
It seems her husband is the subject.
Johnson, as in Johnson and Johnson?
Pray, pray, pray.
We are in the time that Christ referred to as "the beginning of sorrows," referring to the last days (Matthew 23:8; etc.).
More and more Christians will be brought before courts and so forth during these last days, as prophesied by Christ 2 thousand years ago
"But take heed to yourselves: for they shall deliver you up to councils... and ye shall be brought before rulers for my sake, for a testimony against them." - Jesus Christ, Mark 13:9
Jesus is coming soon; halleluiah.
God bless.
Please. People have been saying that for 2000 years, and they've all been wrong. What kind of arrogance does it take to believe that they all messed up, but you've got it figured out, and to state it as if it's a plain fact? You're looking at the same kinds of coincidental similarities that the rest of the end-times prediction set was looking at, but it wasn't about them, and it's not about us.
It reminds me of the old song: "You're so vain, you probably think this verse is about us."
Anyway if you read the end of the passage in Matthew 24, you'll see that Christ was telling his followers that all those things were to happen in that generation. They did.
So much for due process of law and being entitled to a fair trial. This is a judicial railroading. I'll bet $10 the judge is pro-abortion.
If this episode doesn't prove our Constitution and the judicial system is in the toilet waiting to be flushed, what will.
May the Lord use this to His Glory. In the name of Jesus, Amen.
The Holy Spirit wrote that one. This whole case should be dismissed. The Judge is way out of line. She's trying to get Donna Holman committed, this is the first step.
Find out who all these legislators are and vote them OUT this year.
*Prayer ping*
Donna Holman
can you add donna holman to the keywords, for some reason it won't work for me.
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Featured Consultation: From waste to resource
Over the last 18 months Birmingham City Council has worked with citizens and other partners around the city to develop a vision for how Birmingham deals with its waste. In this vision we, the city council, see waste as a valuable resource so we want to find ways of throwing away as little waste as possible.
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Admission Number Variation 2016 - The International School
- We Asked:
We asked you for your comments on our proposal to request a variation to the admission number at the International School from The Office of The Schools Adjudicator.
- You Said:
During the consultation period which ran for six weeks from 18th April 2016 - 27th May 2016 we received no comments or objections to this proposal.
- We Did:
We submitted a request to The Office of The Schools Adjudicator to consider our application to reduce the admission number at The International School.
The Office of Schools Adjudicator has approved the request to vary the admission number at The International School to 120 in Year 7 from September 2016.
Please see the attached determination letter.
Consultation on establishing a community library service in West Heath/Wychall Farm area of the city
- We Asked:
We asked residents to give their views on Oddingley Hall as the preferred option for providing a library service in the West Heath/Wychall Farm area of the city.
- You Said:
There were 12 responses to the consultation:-
5 responses were in support of the library provision to be located in Oddingley Hall. 6 responses stated that the provision should be in West Heath 3 of these responses would like the library on the original site of the Fordrough. 1 response stated that they would like the Library to be in Small Heath, and 1 response did not want to re-provide the Library but to improve the facilities at Northfield and Kings Norton libraries.
26 written comments were collected from Oddingley Hall and Hampstead house. 21 responses were supportive of the proposal to co-locate the library into Oddingley Hall.
The 4 staffed sessions during the two week period were attended by 20 members of the public.
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The findings will now be presented to the Deputy Leader who holds the portfolio for Library services.
Birmingham Cycle Revolution: Local Links Package 3 - Brook Lane
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We asked for your comments and views on the proposals for Brook Lane / Robin Hood Lane between Wake Green Road and Coleside Avenue which included:
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There was an overall acceptance to the requirement of a crossing facilities but some minor amendment to the proposals were identified/suggested.
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The comments have been reviewed and presented in the Business Case for the scheme. We are currently awaiting approval to progress to the detailed design and construction phases
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Written on: 17/06/2013 by Leonico (5 reviews written)
I have used this site to promote competitions I am running as well as take part in a few competitions myself.
This site is constantly updated every days and thankfully is not over run with adverts, one of the better competition sites.
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Mr. Quiet Library Binding – Apr 9 2009
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About the Author
The late Roger Hargreaves created the Mr. Men series for his son, Adam, who currently oversees the estate and creates illustrations for new Mr. Men books. --This text refers to the Paperback edition.
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By W. Hobbs - Published on Amazon.com
Format: Paperback
I have read this as well as the other Mr. Men books. Mr. Quiet lives in Loudland, where everybody and everything is noisy. This place would be suitable for Mr. Noisy, but not for Mr. Quiet. Mr. Quiet cannot do errands because the townspeople are too loud for him. But one day Mr. Quiet gets a letter from Mr. Happy to stay in Happyland where it is quieter. Mr. Quiet gets a job in a library(because everybody must be quiet in a library) and is so happy he laughs out loud. In terms of other Mr. Men being featured in the later books, this is one that mentions one(Mr. Noisy) but he is not seen. Hey, maybe Mr. Noisy moved into Mr. Quiet's old house in Loudland!
By Richard and Liz - Published on Amazon.com
Format: Paperback Verified Purchase
Poor Mr Quiet lives in Loudland. He goes shopping to get some food but none of the shopkeepers hear him so he goes away very sad & without food. One day he gets an invitation from Mr Happy to go for a visit. He eats his first decent meal in weeks & tells Mr happy all about his troubles. Mr Happy invites him to stay on with him & offers to get him a job. Mr Quiet says he is no good at a job as he is so quiet but Mr Happy gets him the perfect job at the local library & Mr Quiet is thrilled.
Our kids love ALL these books.
Our kids love ALL these books.
By Patricia K. Goodrich - Published on Amazon.com
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My children and I loved the Mr. and Little Miss books while they were growing up. They are all over 25 now and they still remember these books and have gotten them to share with their children ! Mr. Quiet was without question our very favorite throughout the years. It's a fun story and has memorable characters ! Highly recommended !
By D. Strickland - Published on Amazon.com
Format: Paperback Verified Purchase
So glad to find the Mr. Men books again. I read them to my sons years ago until they were able to read them themselves. A few were lost in moves and a few new ones have been added over the years, so I am a happy grandmother now ready to introduce them to my grandson. Thank you.
By E. Fiske - Published on Amazon.com
Format: Paperback Verified Purchase
who would not love these little miss and mister books? I have taught for over 20 years,and everyone loved these books!esp.mr.messy,or miss woops,mr.troible,etc.We can all see ourselves in these books,and they learn,too,of whom they would like to be,or not.thanks
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Garcinia Cambogia is one of the supplements that promises weight loss. It is believed to work so well that is often referred to as the Holy Grail of weight loss. Even though this supplement proves to work effectively, some people are often skeptical about it. This weight loss supplement mainly works in two ways. First, it suppresses the appetite and second, it prevents fat from forming. Due to this reason this weight loss supplement is also known as a dual fat buster.
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You are in South Asia
|Brent S. Steel
|Oregon State University
|© 2014
|632 pages
|CQ Press
|Individual Purchasers
|Buy Now
Unable to find the book you are looking for!
Recent partisan squabbles over science in the news are indicative of a larger tendency for scientific research and practice to get entangled in major ideological divisions in the public arena. This politicization of science is deepened by the key role government funding plays in scientific research and development, the market leading position of U.S.-based science and technology firms, and controversial U.S. exports (such as genetically modified foods or hormone-injected livestock).
This groundbreaking, one-volume, A-to-Z reference features 120-150 entries that explore the nexus of politics and science, both in the United States and in U.S. interactions with other nations. The essays, each by experts in their fields, examine:
Science and Politics: An A to Z Guide to Issues and Controversies is a must-have resource for researchers and students who seek to deepen their understanding of the connection between science and politics.


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Our friends say we have a lip balm addiction (we've got 'em in our jacket pocket, glove compartment, and on our bedside table, to name a few places), but we like to think we're just prepared. We'll be stashing one of each of these lip balms in said locales, including prime purse real estate—they're packed with moisturizing ingredients like shea butter, and as a bonus, each is infused with one of five pretty hues, ranging from a flattering nude to a bright raspberry.
This is a great pixi product, if you never tried pixi before start with this one! It smooths lips and makes them feel silky and leaves a beautiful pink color. Makes lips so kissable! I use it in place of gloss and lip sticks it is like having the best of both worlds in one! Nice glossy look and a nice matte stay! ⭐⭐⭐⭐⭐5
I have been a Burt's Bees girl for years, but I have never been completely enamored with their tinted lip balm. I took a change and tried this one in the Honey Nectar. What can I say? It's amazing. It smells delicious but doesn't have an overpowering taste. Glides on smooth and the color is just enough without being too lipsticky and it's not too glossy. It softened up my perpetually dry, flaky lips in no time. I need to buy more shades.5
After reading the reviews for this product, I just HAD to try it! I received it, applied it and was excited to see the Pixi Pink color was actually a different shade of pink, one like I've never worn before (it almost has subtle purplish undertones rather than pink and orangey pink colors). The formula is smooth and nice feeling, the pigment was a bit more than I expected but still nice. After about half hour without eating or drinking, it had already worn off though. Not long-lasting but an ok product nonetheless.3
I received a sample of coral crush a while back - probably one of my favorite lip products received from Birchbox. My lips are often very dry, so I often have to choose between using a medicated type of balm, or using a lipstick. This butter balm by Pixi is great because it is very hydrating and the color was gorgeous (I love coral lips!) Have bought again and will probably pick the coral shade up again for this Summer.5


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Elmrich Villas Ammunition
1. Ireton Sports
If you have been to a gun show then you have heard his speal and have been handed one of those bright cards. He is honest to what it sais. 10 perce…
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From Business: Here At The New Gun Traders, We Also Offer Dillon Reloading Precision Products. If You Have Any Questions, Please Feel Free To Contact Us Or Stop By Our Shop!
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From Business: Full service pawn broker with large warehouse. Talk to us about loans on vehicles, motorcycles, or ATV's!
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Largest selection, best prices and friendliest staff of any gun shop I have ever been to. The dogs that hang around the shop and pretty awesome too…
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Bad as it gets. Do not walk away. RUN away!
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I love great northern guns. When I was homeless they took me in. I am able to roam around and climb on the counters. People come in and pet me, the …
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All the smithing I have had done at WWG has been excellent.
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From Business: Gun Runners is an online platform for buyers and sellers for trading firearms and gun-related items. It is a classified and auction Web site that offers membership …
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I brought in a pistol needing to have it repaired. Was very friendly, helpful and had it back to me in about half the time promised. Thanks. This is…
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From Business: ,
All the smithing I have had done at WWG has been excellent.


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Outback Spirit: Inspiring True Stories of Australia's Unsung Heroesby Sue Williams, Catherine Milte
View All Available Formats & Editions
Cheryl flies sick patients from rural areas to emergency medical
In the great Outback traditions of mateship, resilience and generosity comes these stories of ordinary people who, against seemingly insurmountable odds, help out those who inhabit Australia's vast untamed frontiers. No task is too great and no sacrifice too much for these everyday heroes.
Cheryl flies sick patients from rural areas to emergency medical treatment in cities; Sue is often the only one between life and death for her patients in the Kimberley; Ricky trades city comforts to connect with kids through sport in remote communities while Eileen overcomes great challenges to protect remote land for generations to come – these are some of the characters who embody the spirit of the Outback.
Product Details
- 9781743157954
- Publisher:
- Bolinda audio
- Publication date:
- 04/08/2013
- Edition description:
- Unabridged
- Product dimensions:
- 5.40(w) x 6.50(h) x 1.10(d)
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I have studied and taught Karate off and on for many years and have had the good fortune to partake in many Martial Arts schools and Ohana Academy is the perfect place for my family and myself. They have world class instructors who are down to earth people and very accepting of all talents and abilities. Even though the staff trains and competes at the highest level there is, there are no egos, no critics or negative vibes, just honest hard work and training. I have only been there a short while and already have lost 10 lbs, feel and look stronger and faster and this is great for anyone's self esteem both young and old alike. Ohana has a great work ethic and family atmosphere and all of the trainers are easliy approachable, 5 stars for Ohana!!!
San Antonio Ohana Academy
Ohana Academy
8318 Jones Maltsberger Rd Ste 109, San Antonio, TX 78216
- (210) 307-4274
1. Ohana Academy
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12118 Valliant St Suite 101San Antonio, TX 78250
From Business: Personal training should be "personal"training. Not a one size fits all training regimine. If you want to learn some boxing fitness techniques or try a cross-fit st…
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830 Ewelling LaneNew Braunfels, TX 78130
From Business: New Braunfels Training Center (NBTC) part of TMT Athletic Center provides a complete sports facility, catering to the recreational and professional athlete. NBTC of…
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147 S Interstate 35New Braunfels, TX 78130
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