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Author Affiliations: Department of Emergency Medicine, Harvard School of Public Health (Dr Schuetz), and Department of Medicine, Inpatient Clinician Educator Service, Massachusetts General Hospital (Drs Chiappa and Greenwald), Boston, Massachusetts; and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (Dr Briel).
Previous randomized controlled trials suggest that using clinical algorithms based on procalcitonin levels, a marker of bacterial infections, results in reduced antibiotic use without a deleterious effect on clinical outcomes. However, algorithms differed among trials and were embedded primarily within the European health care setting. Herein, we summarize the design, efficacy, and safety of previous randomized controlled trials and propose adapted algorithms for US settings. We performed a systematic search and included all 14 randomized controlled trials (N = 4467 patients) that investigated procalcitonin algorithms for antibiotic treatment decisions in adult patients with respiratory tract infections and sepsis from primary care, emergency department (ED), and intensive care unit settings. We found no significant difference in mortality between procalcitonin-treated and control patients overall (odds ratio, 0.91; 95% confidence interval, 0.73-1.14) or in primary care (0.13; 0-6.64), ED (0.95; 0.67-1.36), and intensive care unit (0.89; 0.66-1.20) settings individually. A consistent reduction was observed in antibiotic prescription and/or duration of therapy, mainly owing to lower prescribing rates in low-acuity primary care and ED patients, and shorter duration of therapy in moderate- and high-acuity ED and intensive care unit patients. Measurement of procalcitonin levels for antibiotic decisions in patients with respiratory tract infections and sepsis appears to reduce antibiotic exposure without worsening the mortality rate. We propose specific procalcitonin algorithms for low-, moderate-, and high-acuity patients as a basis for future trials aiming at reducing antibiotic overconsumption.
The advent of antibiotic therapy led to dramatic reductions in mortality and morbidity rates due to bacterial infections and sepsis.1 However, overuse of antibiotics to fight infections may cause considerable harm by exposing individual patients to adverse events resulting from antibiotic use and by increasing the development of bacterial resistance. Combating the emergence of bacterial resistance to antimicrobial agents requires more effective efforts to reduce the inappropriate or unnecessarily prolonged use of antibiotics.2
Patients and physicians share the common goals of improving the patient's health and resolving infections as quickly as possible; they often believe use of antibiotics to be the most expeditious intervention to address these goals. This one-size-fits-all approach fails to consider the following basic questions: (1) Who truly benefits from antibiotic therapy? and (2) If treated, what is the optimal treatment duration?1
Considerable interest has been expressed in antibiotic stewardship programs aiming at reducing antibiotic overuse and the associated emergence of multiresistant pathogens.3,4 A previous cohort study3 of hospitalized adult patients illustrated the effect of antimicrobial-resistant infections on hospitalization duration, mortality rate, and cost. In this study, the 188 patients with antimicrobial-resistant infections stayed 6.4 to 12.7 days longer in the hospital, had attributable mortality of 6.5%, and incurred societal costs ranging from $18 588 to $29 069 (2008 dollars) per patient.
A novel approach for determining the necessity and optimal duration of antibiotic therapy is the use of biomarkers, such as procalcitonin (PCT) levels, which become upregulated during bacterial infections and appear to mirror the severity of infections.5,6Quiz Ref IDA growing body of literature supports the measurement of PCT levels to improve the ability to differentiate bacterial from nonbacterial infections because nonbacterial infections and nonspecific inflammatory reactions do not result in elevated PCT levels.7 Also, an initial study8 has shown that a decrease in PCT levels indicates a favorable patient response to antimicrobial therapy. Thus, PCT is a promising candidate marker to help physicians more rationally decide on prescription and duration of antibiotic therapy in patients with infections.
Procalcitonin, the precursor peptide of the hormone calcitonin, is released ubiquitously in response to primarily bacterial toxins and bacteria-specific proinflammatory mediators, particularly interleukin 1b, tumor necrosis factor, and interleukin 6.5 In previous studies,9,10 a strong correlation was observed between the concentration of PCT and the extent and severity of bacterial infections. Of particular interest, PCT levels are attenuated by the cytokines typically released in response to viral infections, namely, interferon-γ.10 Levels of PCT have been shown to increase within 6 to 12 hours of the initial bacterial infection, and circulating PCT levels are expected to decrease by half daily when the infection is controlled by the host immune system and antibiotics (Abx).11 A previous study12 has shown that the production of PCT, in contrast to other blood markers, is not attenuated by nonsteroidal and steroidal anti-inflammatory drugs. Based on these promising preclinical data, many studies have investigated the clinical usefulness of measuring PCT levels for different clinical settings and infections.7 However, owing to the diagnostic uncertainty associated with sepsis and other infectious diseases and the lack of a diagnostic criterion standard, the results of many observational studies have been inconclusive.7
To circumvent the limitations of observational studies, including observer bias, selection bias, sample availability, coinfection, colonization, and difficulty of pathogen identification owing to time constraints, several randomized controlled trials (RCTs) have been conducted focusing primarily on the outcomes of patients with or without the use of PCT-guided algorithms for antibiotic therapy. The clinical harm and benefit of using PCT thereby were measured by clinical outcomes, assuming that if the patient recovers without antibiotics, no relevant bacterial illness had existed, and if the patient recovers with fewer days taking antibiotics, the bacterial illness was adequately controlled with shorter antibiotic exposure.
The aim of this systemic review is to summarize the evidence based on previous RCTs for using PCT measurement in respiratory infections and sepsis from the clinical settings for which the most RCT data are available, namely, primary care, the emergency department (ED), the medical intensive care unit (MICU), and the surgical intensive care unit (SICU). Because most published studies were conducted in Europe, we also aim to propose clinical algorithms for use in future United States trials.
We searched EMBASE (from 1974 to the present), MEDLINE via PubMED and Ovid (from 1948 to the present), and the Cochrane Central Register of Controlled Trials (from 1991 to 2011) for articles regarding PCT levels taken into account when making decisions regarding Abx. The following search terms were included: procalcitonin (mp [multiple posting, in which the term appears in the title, abstract, or subject heading]) and calcitonin AND pneumonia (exp [explode, a search term that automatically includes closely related MeSH terms]), sepsis (exp), chronic obstructive pulmonary disease (exp), or respiratory tract infections (exp). We also included procalcitonin (mp) and calcitonin AND intensive care units, emergency services, hospital, or ambulatory care facilities. We restricted the search to RCTs performed only in adults. We also identified relevant systematic reviews, meta-analyses, and controlled clinical trials and reviewed their references; in addition, we searched trial registries (http://www.clinicaltrials.gov and http://www.isrctn.org) and contacted experts in the field for additional eligible studies. We included articles in any language and did not exclude articles based on other comorbidities.
Eligible trials had to be RCTs including adults with a diagnosis of respiratory tract infections (ie, pneumonia, acute exacerbations of chronic obstructive pulmonary disease [AECOPD] or other respiratory tract infections) or sepsis. Clinical settings included primary care, the ED, or the ICU. Interventions included measurement of PCT levels to inform decisions regarding antibiotic therapy (ie, regarding its initiation and/or duration). Abstracts or full-text articles for which no abstract was available were reviewed by 2 of us (P.S. and J.L.G.) to ensure topic appropriateness and adherence to inclusion and exclusion criteria. Disagreements were resolved by consensus.
Working in teams of 2, 3 investigators (P.S., V.C., and J.L.G.) independently extracted data from the included trials. Disagreements were resolved by consensus. A standardized data abstraction tool was used that included clinical setting, study design, number of study subject individuals, clinical outcomes, and study protocols. Also, an assessment of the methodological study quality was peformed, based on the following criteria: adequate sequence generation (eg, computer-generated random numbers, compared with inadequate approaches, which included the use of alternation, case record numbers, or days of the week); adequate allocation concealment (deemed adequate if a central randomization procedure [ie, telephone or Web-based] or the use of sequentially numbered, opaque, sealed envelopes was reported); adequate masking of physicians, patients, and outcome assessors; low risk of attrition bias (ie, minimal loss to follow-up and performance of adequate sensitivity analyses); and freedom from selective outcome reporting (eg, if all stated outcomes were reported).13 Two of us (P.S. and M.B.) who were coauthors of eligible studies14,15 were excluded from reviewing our own work.
For all included RCTs, we report summary data, including antibiotic prescription rate, duration of antibiotic treatment, mortality rate, and adverse event rate, as defined in the individual studies. We pooled results and calculated odds ratios (ORs) with 95% confidence intervals (CIs) for overall mortality rate using the Peto method.16 The Peto ORs are appropriate when intervention effects are small (ie, when ORs are close to 1), events are not particularly common, and studies have balanced numbers in intervention and control groups.17 We tested for heterogeneity with the Cochran Q test and measured the inconsistency (I2 [the percentage of total variance across studies that is due to heterogeneity rather than chance]) of intervention effects across trials.18 Also, we performed sensitivity analyses comparing trials with low risk of bias (ie, adequate sequence generation, allocation concealment, and unlikely attrition bias) vs trials at higher risk. We investigated the presence of publication bias by means of funnel plots.19 Concerning antibiotic treatment, the different studies were too few in number and lacked adequate consistency in reporting across study design and population for a pooled analysis of antibiotic treatment data for different diagnoses and settings. Instead, we summarized antibiotic exposure and outcome data from the different studies grouped by clinical setting. This report adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.20 All calculations were performed using commercially available software (STATA, version 9.2 [StataCorp LP, College Station, Texas] and RevMan, version 5.1 [Cochrane Collaboration]).
The literature searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials and mining of trial registries and references yielded 120 potential results (Figure 1). A total of 58 articles were then excluded owing to nonrandomization and/or not focusing on our population of interest. Also, we excluded 4 articles focusing on pediatric populations and 14 ongoing trials, leaving 44 articles that we further assessed for eligibility. After exclusion of 2 duplicate publications in different journals and redundantly identified articles from the different databases, 14 articles remained. Review of the reference lists from the 14 articles and those from selected meta-analyses and reviews regarding the topic yielded no additional trials. Thus, the final quantitative analysis includes 14 RCTs.
Figure 1. Flowchart depicting the process of article selection. RCT indicates randomized controlled trial.
Table 1 shows the quality assessment of included trials with regard to sequence generation, allocation concealment, masking, incomplete outcome data, selective outcome reporting, and other biases. The methodological quality varied across included studies; only 3 trials could be considered at low risk for bias, namely, 1 in the primary care,14 1 in the ED,15 and 1 in the ICU setting.32 The other studies lacked several quality criteria and need to be considered at high risk for bias. None of the studies managed to mask physicians with respect to treatment allocation of patients.
Table 2 summarizes clinical design and study setting. It also displays the underlying diagnoses of patients, the study question, the PCT algorithm used, and the outcomes investigated of all included RCTs.
Two studies in the primary care setting were found.14,21 Both were noninferiority trials with regard to clinical outcomes, focused on upper and lower respiratory tract infections, and used a similar PCT algorithm (ie, no antibiotics in patients with PCT levels of <0.25 μg/L). However, although the study by Briel et al14 used repeated PCT measurements and addressed subjects' activity limitations and antibiotic exposure as outcomes, the study by Burkhardt et al21 only measured PCT levels once on admission but also measured health impairment and antibiotic exposure.
A total of 6 studies in the ED setting were identified.15,22- 26 All studies used a similar PCT algorithm (ie, no initiation of Abx or, if already initiated, discontinuation of Abx in patients with PCT levels of <0.25 μg/L). Two studies22,26 measured PCT levels only on admission, and the remaining 4 studies15,23- 25 used repeated measurements. All studies reported antibiotic exposure and patient outcomes, but only the trial by Schuetz et al15 was powered for noninferiority with regard to clinical outcomes.
In the ICU setting, 6 RCTs were identified27- 32 that differed substantially in terms of underlying diagnoses (ie, postoperative infections in the SICU, severe sepsis and/or septic shock, and ventilator-associated pneumonia) and the PCT cutoffs used. All studies based their recommendation primarily on repeated PCT measurements and specified discontinuing Abx when PCT levels dropped to a range of less than 0.25 to less than 1.00 μg/L or by at least 80% to 90%. One study27 did not focus on de-escalation of antibiotics but specified to change antibiotics or to perform a diagnostic workup if PCT levels did not decrease by an adequate amount. Two studies were multicenter trials,29,32 and the trial by Bouadma et al32 was a noninferiority trial in terms of mortality rate and adverse outcomes. Antibiotic exposure, length of stay, and mortality rate were the most commonly reported outcomes.
Overall, a total of 4467 patients were included in the 14 RCTs (ie, 2240 in the control group and 2227 in the PCT group). Table 3 displays the detailed results of all RCTs with regard to the number of included patients and underlying diagnoses, mortality rate, absolute and relative antibiotic prescription rates, and duration between the 2 groups. Overall, no significant difference was observed in mortality in patients in the PCT groups (172 of 2227 [7.7%]) compared with the control group (186 of 2240 [8.3%]), with a summary OR of 0.91 (95% CI, 0.73-1.14) (Figure 2). We found no evidence of relevant heterogeneity among trials. The analysis for publication bias indicated no evidence of such bias for mortality rate (eFigure 1).
Figure 2. Mortality rate in the procalcitonin (PCT) and control groups. The forest plot depicts the Peto odds ratios (ORs) with 95% confidence intervals (CIs), comparing patients treated in the PCT and control groups in different trials and clinical settings.
The 2 primary care trials included a total of 1008 patients with upper and lower respiratory tract infections. The study by Briel et al,14 which used repeated PCT measurements, found a 74% reduction in antibiotic prescription and a 13% reduction in mean antibiotic duration. However, the study by Burkhardt et al21 only used a single PCT measurement at admission and found a 42% reduction in antibiotic exposure but not a reduction in treatment duration. In both trials, no differences were observed in the primary safety end points (ie, days with restricted activities and days with health impairment within a 14-day follow-up) between the controls and the PCT-group patients. The mortality rate in both trials was similarly low in both groups (OR, 0.13; 95% CI, 0-6.64) (Figure 2).
The 6 ED trials15,22- 26 included a total of 2449 patients, mostly with community-acquired pneumonia and AECOPD. For community-acquired pneumonia, the main effect of using PCT was to shorten the duration of antibiotic treatment. Trials using only a single initial PCT measurement had less effect on duration of antibiotic therapy (ie, a 15% reduction in the first study by Christ-Crain et al22) compared with those requiring repeated PCT measurements (ie, a 55% reduction in the second study by Christ-Crain et al,23 a 40% reduction in the study by Long et al,25 and a 34% reduction in the trial by Schuetz et al15). The study by Kristoffersen et al26 had similar antibiotic prescription rates but a 25% reduction in the duration of antibiotic therapy. Those authors noted, however, that physicians were not asked to wait for PCT results before initiating antimicrobial therapy. Therefore, PCT values were, in most cases, used to motivate cessation or continuation of already-initiated treatments.
For patients with AECOPD, the trial by Stolz et al24 found a 44% reduction in prescription rates. The patients with COPD guided by a PCT-based algorithm included by Christ-Crain et al22 and Schuetz et al15 also had lower prescription rates compared with controls (ie, 87% vs 38% and 70% vs 49%, respectively). In none of the ED trials was an increase in adverse outcomes noted, although only the trial by Schuetz et al was powered for this end point. Within all ED trials, mortality in PCT groups was 5.2% (63 of 1214) compared with 5.4% (67 of 1235) in control groups (OR, 0.95; 95% CI, 0.67-1.36) (Figure 2).
The 2 ICU trials that focused on patients with severe sepsis/septic shock (ie, Nobre et al28 and Bouadma et al32) found reductions in antibiotic exposure of 37% and 33%, respectively. The trial by Svoboda et al27 did not report antibiotic exposure because it only focused on patient outcomes. The trial reported by Stolz et al29 included only patients with ventilator-associated pneumonia and found a 27% increase in antibiotic-free days alive. Two trials30,31 focused on patients with postoperative infection and sepsis; they reported reductions of antibiotic exposure by 20% and 25%, respectively. None of the studies reported a difference in mortality rate or adverse outcome, but only the study by Bouadma et al32 was powered for noninferiority. Within all ICU trials, mortality in the PCT group patients was 21.5% (109 of 506), compared with 23.4% (118 of 504) in standard group patients (OR, 0.89; 95% CI, 0.66-1.20) (Figure 2). A sensitivity analysis contrasting the 3 trials at low risk of bias14,15,32 with the remaining higher-risk trials yielded similar results (eFigure 2A and B).
Within this systematic review, we address the question of the safety and efficacy of using a PCT-based algorithm for antibiotic therapy decisions in patients with respiratory tract infections and sepsis using data derived from previous RCTs. Quiz Ref IDWe found a marked reduction in antibiotic exposure in all settings, levels of disease acuity, and patient populations. This reduction occurred because of lower prescription rates in low-acuity infections such as bronchitis, exacerbation of AECOPD in primary care and ED settings,Quiz Ref IDand shorter duration of antibiotic courses in moderate- and high-acuity patients, such as those with pneumonia and sepsis in the hospital and ICU settings. Critically, none of the trials reported an increase in adverse outcomes, including mortality rate, although only a subset of the included trials were powered to detect changes in clinical outcomes.
Given the limited number of studies included across a breadth of diagnoses and settings in this analysis and the limited methodological quality of many of the included studies (ie, their being at high risk for bias), caution must be used when generalizing these findings. Although it is reassuring to note the uniform absence of adverse events paralleling the similarly uniform presence of antibiotic use reduction across the studies, further data are needed before PCT-based algorithms should be considered the criterion standard of care, especially for diagnoses such as ventilator-associated pneumonia or postoperative infection, in which randomized trial data are limited. Clearly, the most robust data are for pneumonia; in this diagnosis, as with the others, the findings are promising.
Previous meta-analyses have investigated the use of PCT levels for detection of sepsis in adult patients33- 37 and children38 from observational studies. Also, 3 previous meta-analyses focused on randomized trials only to investigate the measurement of PCT levels for antibiotic decisions in the critical care setting39,40 and in patients with suspected bacterial infections.41 Our systematic review included all published RCTs that investigated PCT algorithms for antibiotic treatment decisions concerning escalation and de-escalation of dosage in adult patients with respiratory tract infections and sepsis from primary care, ED, and ICU settings. We focus our analysis on the differences in PCT algorithms used for low-, moderate-, and high-acuity patients; this is a basis for future trials aiming at reducing antibiotic overconsumption and it may be of particular importance for practicing physicians who want to include PCT findings in their hospital protocols. Owing to differences of PCT levels in different clinical settings and patient populations, the correct and safe practical use of this marker will likely vary with the level of disease acuity in patients.
The algorithms in the included studies varied moderately. Nevertheless, a few commonalities can be identified. Quiz Ref IDFirst, regarding the most severe diseases (eg, sepsis and pneumonia) or the highest-acuity care settings (ie, the ICU and the hospital), PCT levels were not used to determine whether antibiotic therapy should be initiated but when to discontinue it. Second, the decrease of elevated PCT levels appears to correlate adequately with sufficient resolution of bacterial infections to allow for the safe discontinuation of antibiotic therapy, even if this discontinuation occurs before the traditional length of a typical course of antibiotics has elapsed. Third, in lower-acuity settings (eg, the primary care setting) or with clinical entities that are generally less imminently dangerous (eg, bronchitis), PCT values may be used to assist in the initial determination of whether antibiotics should be prescribed at all. However, all patients should undergo reassessment in cases in which Abx are withheld to ensure that the clinical condition improves spontaneously in a clinically appropriate period.
Most of the studies of PCT-based algorithmic approaches to antibiotic management of respiratory tract infections have been conducted in Europe. Despite the recognized importance of antibiotic stewardship and health care cost containment in the United States,3,4 further studies in a US population may be needed to assuage concerns regarding practice and population differences. Therefore, we recommend the PCT algorithms described herein for use in future US studies. However, algorithms for PCT use, much like those for other biomarkers, should supplement and not supplant clinical impressions.
For patients with a low pretest probability of contracting a bacterial infection (eg, patients with nonpneumonic upper and lower respiratory tract infection treated in the primary care setting), a single measurement of PCT level and a cutoff ranging from less than 0.10 to less than 0.25 μg/L appears to be an appropriate, safe, and simple approach in this setting to determine the need for antibiotics. Clinical follow-up with remeasurement of PCT should be performed in all patients in whom Abx were withheld and who show no clinical improvement (Figure 3A).
Figure 3. Proposed algorithms for use of procalcitonin (PCT) values to determine antibiotic treatment of infections. A, An algorithm for low-acuity nonpneumonic infections (ie, low risk) in primary care and emergency department (ED) settings. B, Algorithm for moderate-acuity pneumonic infections (ie, moderate risk) in hospital and ED settings; C, Algorithm for high-acuity infections (ie, high risk; sepsis) in intensive care unit settings. Abx indicates antibiotics; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; PSI, pneumonia severity index.
For patients who are clinically stable and are treated at the ED or are hospitalized with pneumonia, the initiation of antibiotic therapy should be based on clinical grounds and a PCT threshold of at least 0.25 μg/L, assuming the PCT results can be obtained expeditiously. In patients with an initial PCT level of no higher than 0.25 μg/L, alternative diagnoses (eg, viral infection and pulmonary embolism) should be considered. Thereafter, repeated measurement of PCT levels every other day should occur, with directions to discontinue antibiotic therapy when PCT levels drop to less than 0.25 μg/L or by at least 80% to 90% of the peak value and when the patient has improved clinically. If Abx are withheld initially, algorithms should suggest retesting PCT levels 6 to 12 hours after the initial measurement (Figure 3B).
In high-risk or ICU patients with suspected sepsis, algorithms should dictate that empirical antibiotic therapy not be delayed for PCT measurement. Periodic monitoring of PCT levels after initiation of antibiotic therapy may be the preferred strategy, and a drop of PCT levels to less than 0.50 μg/L or by at least 80% to 90% from baseline in patients who show a clinical improvement after therapy are reasonable thresholds for cessation of antibiotic therapy in this fragile population (Figure 3C). For postoperative patients in the SICU, a decrease in PCT level to less than 1.0 μg/L may be sufficient to discontinue Abx. As with moderate risk/moderate acuity algorithms, if Abx is withheld initially based on a low PCT level, a second measurement should be obtained within 6 to 12 hours.
Our review has a number of limitations. First, because it is limited to RCTs in an attempt to minimize bias, it excluded a reasonably large body of literature pertaining to PCT that did not derive from RCTs. This exclusion may have led to the inadvertant omission of relevant findings. Second, although we conducted an extensive literature search for RCTs on the topic and a funnel plot did not suggest the presence of publication bias, such a bias cannot definitely be ruled out. Quiz Ref IDThird, the methodological quality of most included trials was low to moderate. However, a sensitivity analysis focusing on 3 trials at low risk for bias yielded similar results, and no evidence was observed of heterogeneity among effects on mortality rate.
In conclusion, this systematic review of mostly moderate-quality RCTs suggests that the use of PCT-guided algorithms for antibiotic therapy decisions in patients with respiratory tract infections, including bronchitis, AECOPD, and pneumonia and in patients with sepsis appears to be effective at reducing use of Abx without sacrificing patient safety. These types of algorithms also appear to be useful in different clinical settings. Based on the available evidence, we have proposed PCT algorithms based on clinical acuity levels, which should be used in future large multicenter trials within the United States, powered for patient outcomes and aimed at reducing antibiotic overconsumption.
Correspondence: Philipp Schuetz, MD, MPH, Department of Emergency Medicine, Harvard School of Public Health, 667 Huntington Ave, Boston, MA 02115 (firstname.lastname@example.com).
Accepted for Publication: May 10, 2011.
Author Contributions:Study concept and design: Schuetz, Greenwald, and Chiappa. Acquisition of data: Schuetz, Greenwald, Chiappa, and Briel. Analysis and interpretation of data: Schuetz, Greenwald, Chiappa, and Briel. Drafting of the manuscript: Schuetz and Greenwald. Critical revision of the manuscript for important intellectual content: Schuetz, Greenwald, Chiappa, and Briel. Statistical analysis: Schuetz and Briel.
Financial Disclosure: Dr Schuetz was supported by research grant PASMP3-127684/1 from the Swiss Foundation for Grants in Biology and Medicine and received support from BRAHMS USA Inc and bioMérieux to attend meetings and to fulfill speaking engagements. Dr Briel is supported by grants from santésuisse and the Gottfried and Julia Bangerter-Rhyner Foundation.
Additional Contributions: Qing Wang, PhD, of the Basel Institute for Clinical Epidemiology, University Hospital Basel, Switzerland, helped with the translation of an article published in Chinese. Carole Foxman, MA, MS, Coordinator for Education and Database Services/Research Liaison at the Treadwell Library, Massachusetts General Hospital, assisted with the EMBASE and Cochrane Central Register of Controlled Trials database searches.
This article was corrected for typographical errors on August 18, 2011.
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on February 3, 2013 - 5:14 PM
, updated February 4, 2013 at 8:29 AM
By Jeff Miers
News Music Critic
Well, she certainly wasn't lip-synching. Beyonce played the Super Bowl XLVII Halftime Show, and her appearance, at the midpoint of a game during which emotions ran high, brought a feminine touch to a testosterone-fueled party. She very well may have blown a main fuse, too; the power at the Superdome in New Orleans went out shortly into the third quarter. A coincidence? Yeah, probably. But maybe not.
Make that a decidedly feminine touch, now that you mention it. Perhaps the most notable aspect of Beyonce's halftime performance, aside from the astute blend of choreography and visual effects, was the fact that every dancer, musician, and guest artist appearing on the stage was a woman. That's right — no men, not a one. This was both interesting and cool, but was it a statement?
I hope so. Though I'm not exactly sure what the statement might be.
The all-women rules meant that Beyonce's husband, Jay-Z, didn't make an appearance either. That was the most hotly rumored possibility during the week running up to the Super Bowl, followed in close second by the possible reunion of Beyonce's first group, Destiny's Child. The latter did indeed happen, as the star's former group-mates Kelly Rowland and Michelle Williams arrived on platforms that shot up from beneath the stage, to rapturous applause.
The Destiny's Child reunion was nicely done, Rowland's and Williams' harmonies mixing beautifully with Beyonce's, as they always did. "Single Ladies" was the peak of the reunion mini-set. Beyonce sought praise for her cohorts, got it, and seemed eager to move on — surely the 12-minute time limit coming into play.
Early on, during "Crazy In Love," the spotlight swerved to Beyonce's right, and centered on guitarist Bibi McGill, who took a solo while her guitar shot sparks from either end. This was pretty awesome. Of course, it was awesome when Ace Frehley of Kiss did it back in 1976, too.
Particularly breathtaking was the stage itself. Shot from above, the layout revealed lights forming a male and female face, aimed directly toward each other, though not touching. This was striking, as was another from-above shot revealing Beyonce on her back, surrounded by video projections of similarly clad dancers mimicking her moves. (The star was dressed in a black leather bodysuit with lace trim, ankle boots with six-inch heels, and knee socks.)
The choreography, the visual accompaniment, and the pace of the show with hits like "Love On Top," "End Of Time" and "Baby Boy" running together in a rapid-fire medley — were flawless. Musically, the high point was the Destiny's Child mini-set, with "Bootylicious" and "Independent Woman" framing the aforementioned "Single Ladies."
As Super Bowl Halftime performances go, this one certainly had its merits. An energetic, fast-paced, and gorgeously illuminated set seemed to thrill the crowd. It all whipped by in a blur, but Beyonce was able to pack an awful lot into her 12 minutes, and the well-rehearsed show certainly presented a spectacle.
All told: An A for the choreography, an A for visuals, an A for Beyonce's ability to sing soulfully while performing a ceaseless series of complex dance moves.
But only a C+ for the music, which failed to differentiate itself from run-of-the-mill 21st century pop-R&B.
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Since 1997, the Maine Affiliate of Susan G. Komen For the Cure has worked tirelessly toward the goal of ending breast cancer. This is the 3rd Annual Race for the Cure in Portland! Raise money, awareness, and support for women (and men) undergoing treatment for breast cancer and survivors. Many participants walk or run in memory of a loved one who lost their battle with cancer - they are not done with the fight!
For much more information about the Race on September 9, signup, volunteering, etc, go to KomenMaine.org


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What if Betty White isn't so crazy about Ryan Seacrest after all?
Amid much publicity, the star of the new NBC show Off Their Rockers finally started Tweeting at age 90, posting a flirty message about the American Idol host on her verified account.
But the next morning, Valerie Bertinelli, who costars on White's other show, TV Land's Hot in Cleveland, stirred up the Twitter-verse by suggesting White's account (which now has more than 144,000 followers) was not legit.
"Just spoke with Betty and she is VERY upset!" wrote Bertinelli. "@BettyMWhite is NOT her. Don't know how they got verified, but it is not Betty. Please RT!"
And many followers did in fact re-Tweet as the phones started ringing and emails starting flying at the offices of White's reps.
Minutes later, Bertinelli suggested the account heralded as "The Official Twitter Page of Betty White" was opened without White's knowledge.
"Stop the presses!" she wrote. "Betty just got a call. An account was opened on her behalf by her people. More to come..."
The "more" took the form of a retraction and a profanity.
"It's all a misunderstanding," wrote Bertinelli. "@BettyMWhite IS Betty's twitter account! Now follow me back, b----! ;-)"
She added, "I think @BettyMWhite pranked me but good! #blushing."
No response yet from Seacrest.
Betty White Twitter Confusion: Did She Know She Was Tweeting?
Steve Granitz/WireImage


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"hey Jed and Kohl, why are you such duggets using my abbreviation all the time?"
av yo yo yo! hippity hip hopper 2 januari 2012
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Can you define these popular missing words?
a dugget is the solution to all problems one may ever be faced with in one's life
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That Duggets been standing there for a while, lets wait so he doesn't watch us fail.
av 067849067 5 februari 2015


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Residents of a Charleston apartment complex were simmering Saturday after a teenager was shot to death during an encounter with a Charleston police officer Friday night.
Denzel Curnell, 19, of Charleston died of a gunshot wound, Charleston County Deputy Coroner Kimberly Rhoton said.
The shooting was reported about 10:30 p.m. at Bridgeview Village, a 300-unit apartment complex near the recycling center on North Romney Street. Investigators were working to determine what happened
Handmade paper signs were visible throughout the complex Saturday demanding "Justice for JaBa," the name Curnell's friends called him. A memorial with silk flowers was attached to a utility pole near where he was shot.
A note from a girl named Sunshine summed up the general consensus of the community.
"JaBa was always a good person. He never bothered anyone. One day he was walking in the back of Bayside (Bridgeview's former name) and he heard a voice that said put your hands behind your back, and he did that, and then the police shot him in the back, and we want justice for JaBa."
None of the half dozen residents who were interviewed were willing to give their names, but they all had the same story. They all believed that Curnell was shot while kneeling and had no weapon. Several said they saw it happen.
Charleston police refused to say anything about the incident, other than to say the officer involved was put on administrative leave, which is standard procedure during an investigation. Police spokesman Charles Francis referred all other questions to the State Law Enforcement Division, which is handling the investigation.
WCSC-TV reported that Francis sent out an email to city officials and council members Friday night that police were investigating "a possible suicide." Francis did not confirm or deny it when asked about it Saturday.
SLED spokesman Thom Berry said the Charleston Police Department contacted his agency at 11:35 p.m. Friday and was told that an officer was involved in an incident.
"We were told there was a struggle, and a shot or shots were fired, and an individual is deceased," Berry said. "The officer is OK."
SLED sent three agents to the scene, where they remained until about 3 a.m., Berry said.
"We are trying to determine exactly what happened, and who fired the shot or shots that resulted in the fatality," Berry said. "We are conducting it as an investigation so far. If it turns out to be an officer-involved shooting, it would be the 23rd officer-involved shooting so far this calendar year."
Bridgeview Village has been a challenge for police for years. Somebody was getting shot there every couple months or so until police increased patrols in the area and put up barricades at some of the entrances to control traffic in 2010.
Police blamed the trouble on outsiders coming in to conduct drug deals. Many of the residents protested the barricades, but violent crime dropped dramatically.
Curnell did not have a police record, according to an online check of Charleston County court records. Residents said he graduated from Burke in 2013, was living with his sister because his mother died recently and he was planning to enlist in the military.
Charleston NAACP President Dot Scott was in the complex talking with residents Saturday. She said they all told her Curnell was shot while he was down on his knees.
"They were enraged about what had happened," she said. "I don't know enough to say the officer was wrong. There are too many unanswered questions. We're gravely concerned about the number of killings by police officers in Charleston. Hopefully we'll feel better when we get all the facts."
Elder James Johnson of the National Action Network was talking with residents late Saturday afternoon.
"We want people to stay calm until we find out all the facts," he said. "We will see justice served if the police were negligent."
About a dozen people in their 20s stood at King and Spring streets late Saturday afternoon holding up signs with slogans such as "Justice for JaBa" and "Stop the Violence." They said the protest was organized on Facebook and declined to give their names.
An online petition at change.org calling for "the officer who shot Curnell" to be prosecuted had drawn more than 1,600 signatures Saturday night.
About a dozen protesters stood at King and Spring streets Saturday holding signs with slogans such as Justice for JaBa and Stop the Violence.×
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DELAND, Fla. –The Stetson University women's tennis team has announced the signing of Swede Arijana Korac and American Ashley Dean for the 2014-15 season. Korac is a native of Örebro, Sweden and Dean comes to DeLand from Bradenton, Fla. The duo will begin attending classes in the fall and add a dynamic component to the 2015 squad.
"To have players like Arijana and Ashley joining our program is another step in the right direction," Director of Stetson Tennis Pierre Pilote said. "They are players that, when added to our returners and Alizee Michaud, will shape the future of our program for years to come".
Korac and Dean will join Alizee Michaud, who signed on in November, as incoming freshmen in 2014-15. Michaud, an Orlando, Fla., native was ranked as high as No. 10 in the US and is currently No. 6 in the state of Florida among incoming freshmen.
Korac excelled on a national level during her final year of high school competition as she won the Swedish National Championship in doubles during 2014 and placed second in singles play. The soon-to-be Stetson freshman is currently carries a No. 6 ranking in her home country.
"Arijana keeps improving in the Swedish national ranking and her ascent is the kind that we look for in our players prior to joining our program," Pilote added. "Her recent results in the national championship are testament of that."
Korac's other accolades include first place finishes at her school's 2012 and 2013 conference championships as well as a second place doubles finish at the 2013 Swedish National Championships. She also finished fourth in singles during that same year.
Dean will begin play for Stetson with a number of honors already to her name. The Sunshine State native is currently ranked 847 in the world by the ITF and was 121st in the nation among high school seniors entering the 2014 season.
"Ashley is playing great tennis right now and I anticipate that she will keep improving," Pilote said. "She has improved her ranking in the US by 60 positions in one month and her world ranking by 300 positions in the same time span."
During the last two seasons, Dean compiled a 17-5 record in singles play and a 4-2 mark in doubles competition. She is currently rated the 23rd best player in the state of Florida.
"Ashley's coach, Petar Danolic is doing wonders for her game, I expect her to continue her ascent this summer," Pilote explained of his incoming freshman.
Dean has had a number of marquee wins during her high school career, including three singles victories over players in ranked in the United States' Top 100.


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Wall Street Decline Takes Its Toll...
As Immunotherapy Revolutionizes the Cancer Treatment...
Quadruple Helices Appear To Have Role...
Expanding Use of NGS Has Largely...
On the first of this year, clinical laboratories began billing for more than 100 molecular pathology tests using new CPT codes, which replaced the previous stacked-code system.
The transition has already been rocky—the U.S. Centers for Medicare & Medicaid Services (CMS) has asked local administrative contractors to develop their own payment rates. The change has also stirred up concern over the fate of molecular testing in the clinical setting as R&D initiatives press on in the pursuit of personalized medicine.
"It is very exciting to see how much progress we are making so, in the future, we can end up with better patient care. To make these tests available to a wider audience they need to move from a Research Use Only (RUO) status to a clinical one," says Olive Joy Wolfe, president, Clinical Consultants, of the speakers at CHI's recent "Biomarkers and Diagnostics World Congress".
"This may require collaboration across laboratories, working with groups like the NCI [National Cancer Institute], and working closely with the FDA early on to facilitate the process. The first question is defining the use of the test. Is it for diagnostics, therapy choices, patient intervention, or something else?"
Biomarker assays can be multiplexed and performed on complex platforms and instrumentation that the average laboratory technician may be unfamiliar with. In addition, if the assay is multistep, it may require a combination of instruments and techniques.
As MD Anderson Cancer Center's Samir Hanash, Ph.D., notes, in a discovery mode, the sensitivity that can be achieved for cancer protein biomarkers by mass spectrometry is quite deep. The challenge is to come up with implementable assays that achieve the same level of sensitivity.
"You need samples first to test the process, then if you are taking it to the next level and looking at further development for determining biomarker values in the clinical setting you have to go through validation, just as for any other assay under the CLIA rules," adds Wolfe.
"It is not as simple as it was before, but there are guidelines. It will not be as foreign to researchers who went through several of these necessary steps when we first came up with other methodologies, such as the RIA [radioimmunoassay], because they are aware of the work involved," she says. "Yet, it is more complicated because we may be looking at multiplex proteomic-based tests."
Simply put, the question of clinical utility asks: Does the test actually work and provide value to the patient, the physician, and the system?
As the number of biomarker assays available for the study and evaluation of human disease increases so does the need to understand their clinical utility.
"If you are applying a biomarker to determine if a patient has a better outcome, less toxicity, or a better quality of life, that is different than asking about the observed biological phenomena, the pathways, and mechanisms of action," explains Steven Gutman, M.D., strategic advisor at Myraqa. "They are both valuable pieces of information, they just play in different arenas."
The FDA looks for a circumspect demonstration that the product is either substantially equivalent to a predicate for products requiring 510(k) review, or safe and effective for products reviewed as a premarket approval (PMA) application.
"A company does not need to establish clinical utility to market a test. Insurance coverage decisions and physician test usage drive clinical utility. Both are more likely to respond to evidence that a test works and that it does not just generate a number," Gutman adds.
In the past, less attention was paid to clinical utility; the recent reimbursement changes have brought this issue to the forefront.
"There is unfamiliarity with the language of design of clinical utility and a lot of hard questions on the table," he says. "It is a question of will. We do not want regulation to block but, rather, to foster clinical utility. It is a messy complicated field."
"Multiple professional groups are now worried about clinical utility. It is conscious and visible. If you raise the standard for payment but assure tests with demonstrated clinical utility are fairly reimbursed, there is potential that things could work out very well," Gutman says.
From an analytical perspective, a robust biomarker assay can accurately differentiate a positive signal from a negative one time and again.
"However, a successful biomarker relies not only on a robust assay that can be implemented easily, but also, more importantly, on the underlying biological hypothesis," says Tammie C. Yeh, Ph.D., oncology biomarkers team lead at Merck. "The most notable success stories recently are the identification of BRAF mutations in melanoma for vemurafenib and the identification of ALK translocations for crizotinib."
The clinical setting incurs additional challenges—specimen variability, equipment limitations, varying levels of technical expertise, and laboratory personnel availability. Some clinical assay decisions are based on logistical feasibility, not strictly science. Keeping sample collection and processing as simple as possible is key to high data quality, especially when working across multiple clinical sites.
For example, developing a patient-selection biomarker is a huge undertaking. The principal challenge is identifying the right biomarker to justify the resources and risk. Other requirements include identifying a CLIA laboratory for prospective patient enrollment, establishing that the biomarker is predictive and not prognostic, and co-developing a companion diagnostic, which brings additional regulatory hurdles.
For patient-selection biomarkers, the final assay platform ought to be compatible with FFPE-processed tumor tissue simply because that is what is most often available.
Contrast this with pharmacodynamics (PD) biomarkers, which are used to establish that the compound is hitting its biological target. A variety of assay platforms can be used; tumor biopsies can be fresh, frozen, or FFPE-processed, or surrogate tissue can be used. The challenge in this case is knowing which combination of tissue/readout/assay platform to use, so the expected biological effect significantly overcomes the expected intradonor variability arising from both technical and biological sources.
"Next-gen sequencing is already starting to have an impact in the medical field and will continue to do so. The immediate challenge is to ensure consistency of data quality and interpretation, as well as alignment with regulatory agencies and payers," Dr. Yeh says.
"As biomarker-driven therapeutics increase, there will not be enough tumor biopsy tissue to support independent screening, let alone the costs associated with each individual test," she adds.
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Ohio State University: One Cog in a More Efficient Wheel
Every generation has its distinguishing threats. For the Silent Generation, it was the Great Depression. Baby Boomers grew up under the shadow of a mushroom cloud and a mounting Cold War, which also helped define the world Generation X was born into. Today's Millennials face global warming and terrorism, not to mention more repetitive themes of a stagnant economy, rising oil prices, spiking inflation and so on.
Depressing, yes, but every generation has overcome its challenges, and ours should be no different. Look closely, and many of the problems we face today have a common thread: vehicles that run on petroleum-derived fuels. At least one of our generation's challenges is to lessen our dependence on oil.
Experts across the country — automotive enterprises, technology firms, the government — are chipping away at this problem, but it's in universities that our generation can make its mark. Take, for example, Ohio State University. The largest college in the country, it has a strong history in automobile research, spanning back a century when it helped develop the original Jeep. Today, OSU is working on the world's fastest hydrogen car, a plug-in hybrid initiative and a biodiesel hybrid, just to name a few.
After Michigan, Ohio employs the most people in the automotive industry, and it's the second largest manufacturer of automobiles in the U.S. That's why Giorgio Rizzoni, a professor of mechanical and electrical engineering at the university, said the school needs to be involved in and aware of what's happening in this vital industry.
Already a chief supplier of engineers to the automotive industry, OSU set up a dedicated facility for automobile research in 1991. Seventeen years later, the Center for Automotive Research has hundreds of undergraduate students and about 50 graduate students working on projects that include future propulsion systems (i.e. hybrids), autonomous or intelligent vehicle systems, hydrogen refueling stations, and the more mundane but important work of refining existing combustion technologies.
As the director of CAR, Rizzoni has helped the 35,000-square-foot facility become a nearly self-funded unit.
"Nearly 95 percent of our funding comes from external sources," he said. "We're currently working on 70 to 80 projects contracted from 25 to 30 different sponsors."
With sponsors like GM, Ford, Hyundai and the U.S. Army, the research going on at CAR isn't merely theoretical; it produces results that may end up in your car somewhere down the line.
To prove the school's chops and recruit undergrads to join CAR, the Buckeyes are involved in several academic-based competitions, including the recent Challenge X.
Challenge X, sponsored by GM and the Department of Energy, is a competition based on improving fuel economy and lowering vehicle emissions without inhibiting comfort or performance. Participants' innovations are integrated into a regular Chevy Equinox. CAR's submission was a 1.9-liter direct-injected turbo biodiesel engine with a belted alternator starter hybrid system (similar to what's found in the Malibu Hybrid) and a rear electric motor. The all-wheel-drive hybrid delivered more than 30 mpg in a crossover that typically gets around18 mpg.
John Neal, a graduate student at OSU and a Challenge X participant, said the biodiesel hybrid powertrain made the most sense.
"The torque of the diesel can come in quite handy if you're pulling a trailer; a small turbo gasoline engine will have to rely too heavily on battery power during an extended hill climb, resulting in a weakened overall performance," Neal said.
Seventeen universities participated in the competition, which featured many takes on how to propel the vehicle, ranging from fuel cells to plug-in hybrid powertrains. Mississippi State earned first place, and OSU came in third. Mississippi State opted for the same engine as OSU, but without the belted alternator starter in front. It still used an electric motor to power the back wheels, but had a six-speed manual transmission and a traditional diesel-emission filtration system.
Neal credited MSU with a great entry, but argued that OSU's product was more consumer-friendly, with its six-speed automatic and a nitrogen-oxide trap that doesn't need replacing, similar to Honda's clean-diesel technology (conventional urea-injected traps need regular replacing). This helps reduce the difference between gasoline and diesel engines, making them more acceptable to average consumers.
He's not the only one who thought OSU had a strong entry; GM and the DOE invited the school to participate in the more difficult EcoCAR challenge, in which teams re-engineered a 2009 Saturn Vue to make it more fuel-efficient. This time, all teams had to use an automatic transmission.
Neal said OSU's acceptance into EcoCAR was a "validation of how good our students, staff, faculty, facilities and engineering program really are."
GM's Cindy Svestka, manager of the Milford Proving Grounds where GM tests future vehicles, said that's true of all the competing teams; the company hired 50 students who participated in Challenge X, both as interns and as full-time employees.
The OSU team proved its worth at the EcoCAR competition in June 2009. Not only did it win first place overall, it also won other top honors for its report and presentation. This time, Mississippi came in third place, with the University of Victoria, Embry-Riddle Aeronautical University and the University of Waterloo also in the top five.
In addition to increasing the efficiency of gas-powered vehicles, CAR has challenged itself with making progress in the field of hydrogen technology, and how better to do that than by setting a land-speed record?
In the summer of 2008, students prepared a 700-plus-horsepower hydrogen-electric vehicle called the Buckeye Bullet 2 for an official run at the Bonneville Salt Flats in northwestern Utah. The original Buckeye Bullet was purely battery-operated and able to achieve an electric land-speed record of 315 mph. Although it fell short of expectations, the Buckeye Bullet hit an impressive 224 mph on the Flats.
Of course, while fuel-cell cars were once the darling of the automotive industry, they've lost some of their luster recently. Fortunately for CAR, its pragmatic researchers didn't put all their eggs in one basket. A new initiative called Sustainable Mobility Advanced Research Team will focus on developing plug-in gas-electric hybrid vehicles, all-electric vehicles and intelligent charging systems.
Many people at CAR say the intelligent charging aspect is of utmost importance because, without it, electric vehicles simply won't work.
"It takes one kilowatt of electricity to charge a [typical] hybrid car for nine hours," Neal said. "To put that in perspective, the Niagara Falls plant, which provides 25 percent of [New York's] energy needs, would only be able to charge about two and a half million cars with its biggest power source."
There are more than 10 million vehicles registered in New York.
In 2008, CAR and OSU organized a consortium of companies to help build an electric test bed throughout Columbus, Ohio, installing a plug-in grid and offering incentives for "smart" use of electricity, like charging during off-peak hours. The program will test the life cycle, vehicle-energy management and integration into a conventional car of plug-in car batteries. CAR will convert regular vehicles into plug-in electric vehicles to plug in around town as part of the experiment.
The consortium is also looking to further develop a plug-in grid based around renewable energy, and will study governmental and regulatory issues involving plug-in electric cars. Rizzoni predicts that Columbus will soon be home to the largest plug-in electric test bed outside California.
While schools like OSU have their eyes trained on the nation's vehicular future, the fact remains that the vast majority of the more than 250 million vehicles in the U.S. right now remain dependant on gasoline. The recent climb in gas prices, though, has begun to shift American driving habits.
Neal said the solution to purging U.S. oil dependency will not be one new technology that will miraculously solve all our problems, but it will come through a future based on what he called a "portfolio of solutions that are regional, geographical and climate-based."
Indeed, solutions for past threats like the Great Depression and Cold War were multipronged approaches, none of which were painless or quick. They were time-consuming, costly and required generous amounts of heavy lifting from multiple players to solve. The distinguishing threat of our time may remain a daunting one, but OSU and schools like it prove the lifting is already well under way.


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Active as a conductor, teacher, author, and clinician, Tony Thornton received his Bachelor of Music degree
in Music Education and Voice from Westminster Choir College, a Master of Music degree in Choral Conducting from Louisiana
State University, and his Doctor of Musical Arts degree in Choral Conducting and Historical Musicology from the University
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He has studied conducting with Joseph Flummerfelt, Kenneth Fulton, Frauke Haasemann, Margaret Hillis, Bruce Chamberlain,
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Trained first as a singer, Dr. Thornton has performed as a tenor soloist throughout the United States,
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Dr. Thornton is currently Director of Choral Activities at the University of Massachusetts Amherst, where he
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Inmate escapes for third timeUPDATED 11:13 AM CST Dec 28, 2012
Deputies say an inmate jumped out of a 3rd floor window to break out of jail in Downtown Jackson.
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on July 1, 2013 - 4:22 PM
LOCKPORT – A Depew woman who was charged with stealing customers' credit card numbers while she was working at a Niagara Falls mattress store pleaded guilty Monday.
Donna L. Liberatore, 40, of Seabert Avenue, admitted to third-degree grand larceny and was assigned to the judicial diversion program of court-supervised drug treatment by State Supreme Court Justice Richard C. Kloch Sr. If she succeeds, her charge will be reduced to a misdemeanor with a probation sentence; if she fails in the program, she faces up to seven years in prison.
Liberatore must repay $15,468 in restitution to the four victims, who made purchases at the Metro Mattress store in the Falls in May and June of last year. She was accused of using the card numbers to make purchases at Metro Mattress and from Mary Kay Cosmetics.


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Ketra Bitting, of Mifflintown, and Keith Forry, of Port Royal, were married on May 19, 2012, at the Arboretum at Penn State in State College.
The bride is the daughter of Cyndi and Doug Bitting, of Mifflintown. The groom is the son of Tammy and Doug Forry, of Port Royal.
Aleisha Esh, of Lewistown, sister of the bride, was matron of honor.
Article Photos
Mr. and Mrs. Keith Forry
The best man was Cole Dysinger, of Juneau, Alaska.
Bridesmaids were: Abby O'Shura, of Middletown; Kala Bell, of Thompsontown; Caitlan Lupolt, of Mifflintown; and Lauren Crawford, of Mechanicsburg.
The flower girl was Jacee Price, of Thompsontown.
Groomsmen were: Nicholas Spece, of Thompsontown; Matthew Miller, of Mifflintown; James Shirk, of Mifflintown; and John Esh, of Lewistown, brother-in-law of the bride.
Ushers were: Lucas Foltz, of Mifflintown; Tyler Seiber, of Lewistown; and Travis Yoder, of Richfield.
Pastor Gregory Tyree performed the ceremony.
A reception followed at the Ramada Conference Center in State College.
The bride is a 2006 graduate of Juniata High School, a 2009 graduate of Penn State University, and a 2012 graduate of Penn State University, Harrisburg. She is employed as a TSS at Pennsylvania Counseling Services.
The groom is a 2002 graduate of Juniata High School and a 2009 graduate of Penn State University, Harrisburg. He is employed as an associate service operations specialist at Coventry Health Care.
Following a wedding trip to Ocho Rios, Jamaica, they live in Middletown.


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Agreed. But I don't think Holland has trouble understanding this. To me, it just sounded like he was cautioning against expectations that Nyquist was going to be the answer to The Wings current problems. He did say, short of bringing in a game-changing superstar that no one player can fix what;s broken, that this is a team-wide issue and that they have to play better (secondary scoring and defense) "as a team".
I can live with this sentiment. Personally, I'm pumped that Nyquist is most likely getting called up, and is here to stay. But Red Wings fans have got it so band these days, that #freenyquist has become a thing, like he was the Nelson Mandella or ***** Riot of hockey. Goose can only do so much.
I agree. And I am calling Nyquist ***** Riot from here on out.
Err, Kitty Riot I guess


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|A Spintronic Semiconductor with Selectable Charge Carriers
The ultimate goal of spintronics is to utilize electron spin—in addition to charge—for the storage and processing of data. However, the manipulation of spin typically requires magnetic materials. While commonly found in components used for data storage, magnetic materials are not generally suitable for semiconductor devices used in data processing. Now, with angle-resolved photoemission spectroscopy (ARPES) at the ALS, researchers have shown that two properties crucial for enabling semiconductor-based spintronics—a large Rashba effect (splitting of degenerate spin states) and ambipolarity (conduction via both electrons and holes)—are present in the semiconductor BiTeI. Furthermore, they found that it is possible to control whether the charge carriers are electrons or holes by engineering the surface layer.
A fundamental law of quantum physics states that, in a crystal lattice possessing space-inversion symmetry, degenerate spin states cannot be separated in the absence of a magnetic field. However, the key property of most Rashba systems is that they are two dimensional—typically surfaces or interfaces—so that space symmetry along the normal direction is broken by definition and spin separation can in fact happen. Unfortunately, this means that the spin-split states available for conduction are only those confined to the surface of the material. However, there is another class of nonmagnetic materials in which spin separation is possible because space-inversion symmetry is broken in the bulk.
BiTeX compounds consist of alternating layers of bismuth, tellurium, and a halogen atom, like chlorine, bromine, or iodine. The layer sequence is such that the axis normal to the layers is chiral, meaning that the crystal is not symmetric with respect to an upside-down flip. In addition, they contain Bi and Te as heavy elements, which induce a strong spin-orbit interaction, an essential ingredient for obtaining a sizeable spin separation. Previous ARPES experiments had revealed that the electronic structure at the Fermi level consists of two separate bands, with spin-up and spin-down states clearly split in energy. Using ARPES on Beamline 7.0.1, a collaboration between groups from the Swiss Federal Institute in Lausanne (EPFL) and the ALS has now found that BiTeI presents another crucial quality: the material is ambipolar, meaning that it can support conduction by both negative (electron) and positive (hole) charges.
While the original purpose of the study was to disentangle the surface versus bulk origin of the different electronic states, in measuring a series of samples, something even more interesting was noticed: there seemed to be two different sets of data, with some resemblance but overall distinct structures. In one case, the low-energy states were electron-like, while in the other they were hole-like. A close look at the core levels helped to clarify that the two data sets were associated with the two surface layers found on the samples, either Te or I. (Strong covalent bonding between the Bi and Te layers prevented exposure of the Bi layer when the material was cleaved.)
In other words, the orientation of the sample determined the sign of the charges at the Fermi level, similar to p or n doping in conventional electronic semiconductors. Therefore, not only did the surface-related states host charges of opposite sign, but thanks to the semiconducting nature of the material, the team showed that they could move the chemical potential (Fermi level) from the conduction band to the valence band by controlling the surface termination, which is equivalent to selecting either spin-polarized electron or hole states as the conducting states. The observation is even more interesting because such layered samples are typically suitable for making epitaxial films. In that case, the surface termination could be controlled at the growth stage and, in principle, a device could be patterned with different paths for the two terminations.
Research conducted by: A. Crepaldi, G. Autès, C. Tournier-Colletta, S. Moser, N. Virk, H. Berger, Ph. Bugnon, K. Kern, O.V. Yazyev, and M. Grioni (Ecole Polytechnique Fédérale de Lausanne, Switzerland) and L. Moreschini, Y.J. Chang, A. Bostwick, and E. Rotenberg (ALS).
Research funding: Swiss National Science Foundation. Operation of the ALS is supported by the U.S. Department of Energy, Office of Basic Energy Sciences.
Publication about this research: A. Crepaldi, L. Moreschini, G. Autès, C. Tournier-Colletta, S. Moser, N. Virk, H. Berger, Ph. Bugnon, Y.J. Chang, K. Kern, A. Bostwick, E. Rotenberg, O.V. Yazyev, and M. Grioni, "Giant Ambipolar Rashba Effect in the Semiconductor BiTeI," Phys. Rev. Lett. 109, 096803 (2012).
ALS Science Highlight #278


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"Dylan-tinged vocal and
introspective lyrics that spin out
big-picture stories imbued
with chilling small details."
"Bill Mallonee... [has] remained
fascinated with the shadowy
emotional toils and struggles inherent
in the American experience, compelling,
insightful, [he] continues to probe through
Americana rock and roll proving that
sometimes the only story worth telling
is that of the journey."
~Rolling Stone
Photo: Ben Slaboda


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Join Club Z! and cash in on the
$10 billion tutoring and test prep market.
Watch our franchise opportunity video and learn what Club Z! has to offer!
For a free, no obligation, information package call:
or fill out our electronic rapid response form.
No experience necessary
Our owners don't tutor or teach. They manage a staff of tutors that provide one-on-one instruction for students in the comfort and convenience of the student's home at an extremely competitive rate. If you have a desire to start a business of your own, follow a proven plan and want to team up with industry leaders, then Club Z! could be for you.
The opportunity
The private tutoring market continues to boom, even in a soft economy. The tutoring market in the United States is estimated at over $9 billion per year. Worldwide, the tutoring market is projected to be $100 billion by the year 2017. The main reason for growth is colleges and universities becoming increasingly selective in who they will admit. This is and will continue to be a key market driver for years to come.
3 growing profit centers
- K-12 1 to 1 tutoring - Our tutoring is conducted in the home of the student or another mutually agreed location. Club Z!'s program is extremely effective; our average student improves two letter grades in just 60 days.
- Test Prep - We offer proprietary programs for the PSAT, SAT, ACT and Study Skills. Our average student improves 240 points on the SAT and 3-4 points on the ACT. Club Z! also offers test prep programs for the SSAT, ISEE, GMAT, GRE, LSAT and MCAT. These Programs may be offered online, 1-to-1, or in small groups.
- Online Tutoring - Club Z! franchise owners can offer online test prep, subject tutoring and our ON-Demand homework help program to capture additional revenue.
Club Z! has made Entrepreneur Magazine's Annual Top 500 Franchise List for the last 7 years
- Low-Cost - #19 (2014), #23 (2013), #41 (2012)
- Top Home-Based - #24 (2014), #35 (2013), #68 (2012)
- America's Top Global - #165 (2014), #149 (2013), #184 (2012)
- Franchise 500® - #116 (2015), #114 (2014), #173 (2013), #236 (2012)
The Club Z! advantage
We have designed the cost of a Club Z! franchise to be among the most reasonable in the tutoring industry. Our franchise package is currently $27,250. An additional $10,000 is needed for start-up expenses and advertising. Some highlights of your investment are:
- Home-Based/Low overhead - No storefront needed. Work out of your home! By eliminating the high overhead associated with a storefront or learning center, Club Z! owners can focus their resources on advertising, marketing and management.
- We furnish qualified tutors - We provide franchisees with pre-screened tutors; all with certifications and/or degrees with 2+ years of proven tutoring experience.
- All Subjects/Grade levels - Club Z! also has proprietary curriculum such as SAT, ACT and Study Skills programs so that franchises can offer top quality programs to its students and schools.
- National Advertising/Marketing support - Club Z! spends hundreds of thousands of dollars on national advertising programs each year for our franchisees.
- Our call center, your competitive advantage - Our call center can answer all incoming calls for our franchise owners during business hours. This one-of-a-kind service "sells" your potential clients on using our service, and even schedules your enrollment meetings using a web-based calendar.
- Government contracts - Franchisees, if qualified, may have the ability to provide tutoring services to students and/or school districts through Federal, State and Local government-funded contracts that are already secured by the corporate office and neighboring franchisees.
- Corporate Training - Club Z! provides intensive training at our corporate location in Tampa, Florida. For your convenience, on-line training (with an instructor) is also available for franchisees that wish to begin operations within a quicker time-frame, or need more time to complete our training program. Franchise owners that elect to receive online training are also welcome to participate in our in-person training program in Tampa at a future time.
- Unparalleled ongoing support - You will have unlimited access to our staff during business hours and 24/7 access to our Club Z! intranet; including databases, documents, conferences, conference calls, real-time forums and many other tools to assist with the growth of your franchise.
If you have the motivation and desire to make a difference in your life, as well as the lives of others, and would like to own a business of your own, consider joining Club Z!
Don't just take our word for it; hear what our franchisees have to say...
"The training and support I received from corporate were second to none. Your 3-step training program gave me all the confidence in the world that I was ready to succeed in this business. Your call center is amazing and always makes me look so professional. I couldn't have done it without you. Thanks!"
Jennifer Fahey - Chicago, IL
"As a former business broker, I looked for an opportunity with low overhead and high profitability. The support and guidance is everything I expected and more. If you follow the steps and take advantage of their expertise along the way, you will be successful."
Dennis Mullen - Boston, MA
"After 6 years of running a successful Club Z!, we are still pleased with our decision to invest in the franchise and pay royalties because of the support we receive from the corporate office. Just recently they offered extensive training and support on internet marketing; the time and money we saved by following their step-by-step training was invaluable. Our internet leads are up already! Our accountant recently told us that Club Z! is the only franchise she can confidently recommend"
Joseph & Peggy Thomas - Fayetteville, GA
Ready for more information about our tutoring franchise opportunity? We'd be happy to speak with you. All you have to do is give us a call or click on the link below to fill out the contact form.
Great territories are still available!
For a free, no obligation, information package call:
or fill out our electronic rapid response form.
International Master Franchise Opportunities are also available. Please visit
http://clubztutoring.com/franchise-info/international-master-franchise for more information.
Disclaimer: The information on this website is not an offer to sell, or a solicitation of an offer to buy a Club Z!® franchise. An offer to buy a Club Z!® franchise is made by Franchise Disclosure Document only.
This offer is not being directed to any resident of any State, Province, Country or jurisdiction where Club Z!® is not currently registered to offer or sell, unless otherwise qualified or exempt. Contact us for additional information by dialing 1-800-434-2582.


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2013 Artist of the Year2013 Artist of the Year Akiko Kotani will present a diverse range of her current work. On view are two large-scale installations and numerous other 2D and 3D pieces made from plastic, silk, and glass. Her work is renowned for capturing the essence of form and the illusion of space. 2013 Emerging Artist of the Year Lenka Clayton will present a series of new works created during her current project, she calls "An Artist Residency in Motherhood." This includes 200 hand-made shoes, 30 framed drawings, three videos, and a collection of felted tools. In addition, Master Visual Artists: Preserving the Legacy honors artists in their later years and hopes to bring awareness to the region's history and wealth of outstanding artists.09/07/2013 - 11/03/20136300 Fifth Avenue Pittsburgh, PAwebsite | map
Sounds Upstairs - Leal & WhiteheadViolinist Sandro Leal-Santisesteban and cellist Hannah Whitehead take listeners on a musical journey from Bach to Gershwin and beyond.09/08/2013Time: 3:30 pmLocation: Music Department, CLP Main Library, 4400 Forbes Av., Pittsburgh, PAwebsite
A Skull in ConnemaraFor one week each autumn, Mick Dowd is hired to disinter the bones in the local cemetery to make way for new arrivals. As the time approaches for him to dig up the bones of his own late wife, strange rumors regarding his involvement in her sudden death seven years ago resurface. Martin McDonagh, author of The Lieutenant of Inishmore, brings you part thriller-whodunit and part farce, accented with flying skulls and bloody scenes. Martin Giles directs.09/11/2013 - 09/28/2013Stephen Foster Memorial Pittsburgh, PAwebsite | map
Tobias Picker's Therese RaquinTherese Raquin is Tobias Picker's 2001 two-act opera to a libretto by Gene Scheer based on the novel by Emile Zola. Picker's operas include Emmeline ('96) and The Fantastic Mr. Fox ('98). A cast including QED's Anna Singer performs with an 18-piece orchestra and video by Joe Seamans.09/13/2013 - 09/21/201309/13 - 8:00 pm09/15 - 8:00 pm09/17 - 8:00 pm09/19 - 8:00 pm09/21 - 8:00 pmLocation: CAPA Theater, 111 9th St., Pittsburgh, PAwebsite
Conductors FestivalJeffery Meyer (St. Petersburg Chamber Philharmonic) and Walter Morales (Edgewood Symphony Orchestra) lead a field of visiting conductors including JJ Pierce, Jacob Kallman, and Daniel Curtis in four premieres by Pittsburgh composers.09/13/2013Time: 7:30pmLocation: PNC Recital Hall, Duquesne University, Pittsburgh, PAwebsite
Symphony EastSymphony East, which raises funds to support the Pittsburgh Symphony, holds a meeting and performance featuring a quintet from the River City Brass.09/13/2013Time: 1:00 pmLocation: Redstone Highlands, 4951 Cline Hollow Rd, Murrysville, PA
Such Morning SongsFor its 40th anniversary, the Pittsburgh Camerata pays tribute to founding Artistic Director Arthur Wenk with works by Guillame Dufay, Tomas Luis de Victoria, Paul Hindemith, Maurice Ravel and "Jesu Meine Freude" by J.S. Bach.09/14/2013 - 09/21/201309/14 - 8:00 pm09/20 - 8:00 pm09/21 - 8:00 pmLocation: 3 locationswebsite
Hugo Wolf's Italian SongbookDirector and pianist Benjamin Binder, soprano Sari Gruber and baritone Daniel Teadt perform Hugo Wolf's Italian Songbook, one of the crowning jewels of the art song repertoire. Composed during the 1890s in the artistic and sexual hotbed of fin-de-siecle Vienna, these 46 tiny yet exquisite songs explore the pleasures, perils, and pitfalls of love from every possible angle – the war between the sexes never sounded so good.09/14/2013Time: 7:30 pmPappert School of Music, Duquesne University, Pittsburgh, PA Pittsburgh, PAwebsite | map
PB&J Session: Five Flavors of FolkChatham Baroque's wildly popular Peanut Butter & Jam Sessions are designed especially for preschool children and their accompanying adults. Based on a model developed by the Linton Chamber Music Series in Cincinnati, PB&J is hosted by certified Kindermusik teacher Lynda Wingerd, and encourage young children to become active and enthusiastic listeners through music, dance and games. Chatham Baroque performs live, often with guest artists.09/14/201309/14 - 10:00 am09/14 - 11:30 amLocation: McClintic Hall, Calvary Episcopal Church, 315 Shady Ave, Pittsburgh, PAwebsite
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The striking debut from Irish/Italian singstress Eileen Rose, featuring backing from Alabama 3 (The Sopranos). Edgy, poetic, and gritty, Shine Like It Does is a powerful first step for the Massachusetts-born, London-based Rose.
"Eileen Rose shows the single-minded spirit and int...more
In the opening lines on Eileen Rose's debut album Shine Like It Does she sings: "I was sure enough to come. I was dumb enough to stay." And therein hangs a tale. Over the next 45 minutes this gifted songwriter, guitar player and singer offers up 11 happy-sad songs about her Irish-Italian American background and the life she's lived for the last ten years in England. Through the thinly-veiled autobiography we follow Rose's drift across the North Atlantic, from the poor north Boston suburb of Saugus (bordering on the notorious Lynn) where she grew up the youngest of six sisters and three brothers - via Salem, Massachusetts and on to, first, rural Essex and subsequently north London.
Q Magazine described Rose's voice as "an earthy, expressive thing conveying lived-in loveliness and battered vulnerability somewhere between Stevie Nicks, Patti Smith and Michelle Shocked." On the opening track Shine Like It Does, Rose's father accepts her career of choice as a singer providing she "never learns to sing the blues". It's a fond quip set to a tune that sounds like an instant classic. Second up is Still In The Family and here she shifts through emotional gears like only a real singer can. The feelings of bone-tiredness and barely coping, transition into feelings of high hope by the time the chorus rolls around, thanks to Rose's gorgeous phrasing. Lines like "Why are you crying? You said you wanted to know!" offer tender glimpses of domestic situations without ever laying things prosaically bare. These poetic portraits of blue collar America set the tone for much of what is to follow. That is, until you reach Silver Ladle, the album's hymnal centerpiece, which does the strong, vulnerable thing to a "T", and ends up seeming like nothing short of a gilded dream of a better place, or a tiny, very significant light slowly disappearing over the horizon. And so it goes.
Eileen Rose's heroes: Tom Waits, Patti Smith, Creedence, Paul Simon (another wandering American who found creative inspiration in England; famously writing 'Homeward Bound' on Widnes station), Neil Diamond (Eileen's song 'Lincoln Park' refers to his 'Sweet Caroline'), Kate Bush, Janis Joplin and Fleetwood Mac, all provide clues but no real hard evidence of where all this comes from. For that you have to go back to "Lynn, Lynn, city of sin, you never come out the way you went in". Lynn's the kind of place where Rose's immediate ancestor, John L. Sullivan: "The Boston Strong Boy", could get by on his bar-room catchphrase "I'll lick any son-of-a-bitch in the house", while cradling the biggest fists of any heavyweight boxing champion ever. It was there and elsewhere around Boston that Rose first came to prominence, fronting Daisy Chain, Medici Slot Machine and Fledgling, who were signed to Nine Inch Nails launchpad TVT Records.
Shine Like It Does was recorded in Monnow Valley studios in South Wales with Jerry Boys, who began his career as second engineer for the Beatles and Stones and most recently recorded Buena Vista Social Club with Ry Cooder. The album was mixed by Mark Freegard (Breeders, Madder Rose, Marilyn Manson). Eileen Rose's group is comprised of three current members of Alabama 3 (A3 from HBO's 'The Soprano's) - keyboard player Orlando Harrison, drummer Sir Eddie Real and guitarist Mark Sams - plus Fledgling survivor Davey Bull on guitar, and Barry Payne (once of Wreckless Eric's band) on bass.
Rose's voice is the key tool in her music, cutting through the sweet fog of sound, wavering between waifish, vulnerable innocence and a bruised but unbroken experience. Eileen Rose is tattooed, fearless in song, sheer, sensual and true.


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Why not rest your feet and legs on our Optimal Custom Ottoman Cushion? Our Optimal Comfort cushions will help you alleviate your aches and pains.
We start our comfort cushion making off with our quality upholstery foam as the cushion core. The core is layered with MicroGel Memory Foam on top and bottom which provides the cushion the option of reversibility. We then wrap the cushion on the bottom, top and front with 1" poly fiber batting for further plushness (see note below). By placing the batting in these specific areas, we can ensure that the cushion may be placed side by side if needed, without bulging, giving your seating a clean uniform appearance. Next, the cushion filling is enclosed inside weather-resistant, Hanes cotton/polyester ticking. This ticking features a Teflon finish, making it perfect for the outdoors and indoors.
Customers who have purchased this item have also been interested in the following items.
Select from our hundreds of in-stock fabrics or send us your own fabric by selecting Customer Fabric (COMFAB) in our Fabric Gallery.
There is a one-time (per order), non-refundable $25.00 charge for the handling of your material. Please be sure to read our important Customer's Own Material (COM) Procedures.
Fabric requirement estimates will be shown in your cart and on your invoice.


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The home water treatment systems that produce wastewater in the treatment process are reverse osmosis systems and water softeners. Point-of-use water filters that attach to the kitchen sink faucet do not produce wastewater as part of treatment. The amount of wastewater produced by a home water treatment system will vary depending upon the type and size of the system. The manufacturer should be able to provide wastewater amounts. Ways to reduce the amount of wastewater produced can be seen at Best Ways to Save and Drought Tips.
Wastewater from water treatment systems is typically drained to the sewer/septic system. However, emerging technologies have begun to look at ways to reuse wastewater from the reverse osmosis process. Unfortunately, the mineral content of home water treatment wastewater may be too high to use for most irrigation purposes.


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Top Definition
When a Some Fag Gives Toilet Paper, Pudding, and Green Olives to you and tells you to TP Somebody Elses Home. You get the people in the house you are suppose to TP and go back to the Supplier Fags house and TP it.
Yea This will be the best Reverse TP ever!
додав No Jew Fro For You 01 Липня 2010
Trending Now
Can you define these popular missing words?


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Amusement Ride Safety Board to Hold Public Meeting September 20th
BALTIMORE, MD (September 13, 2012) – The Amusement Ride Safety Advisory Board will hold a public meeting on Thursday, September 20, 2012 at 1 p.m. to discuss issues related to amusement ride safety. The meeting will be held at the Great Frederick Fair located at the Frederick Fairgrounds, 797 East Patrick Street, Frederick, Maryland 21701. Interested persons should contact Ms. Debbie Stone, Administrative Officer, at (410) 767-2225 or email@example.com to confirm the meeting.
The Department of Labor, Licensing and Regulation protects and empowers Marylanders by safeguarding workers, protecting consumers, providing a safety net and cultivating a thriving workforce that can meet the demands of Maryland's dynamic economy. Follow DLLR on Twitter (@MD_DLLR) and Facebook.


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Top Definition
A non-independent bitch. A female who always rely on her man for ANYTHING and EVERYTHING, always having her hand out for gifts and money. Always asking for something.
Damn Kim a "Thirsty Bitch" always asking her man for something.
ayon kay Vally J ika-01 ng Hunyo, 2011
Trending Now
Can you define these popular missing words?
A cock whore. A girl who will suck your dick till blood comes out.
The thirsty bitch crammed two cocks in her mouth and swallowed the cum.
ayon kay urban pervert ika-29 ng Marso, 2003
Greedy People
Man...look at all these Thirsty Bitches after my shit.
ayon kay Slam_i_am ika-10 ng Marso, 2003
a female that is buggin' for a beer
damn there were some thirsty bitches at the club last night
ayon kay Scott ika-29 ng Marso, 2003
1. a male/female who hates on an individual because of their clothes, money, or style.
Shane is a thirsty-bitch towards Jamie.
ayon kay DeShantia Ballard ika-23 ng Marso, 2007


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Network Neutrality: A Research Guide
Christopher Marsden
University of Sussex Law School
May 26, 2011
HANDBOOK OF INTERNET RESEARCH, I. Brown, ed., Edward Elgar, 2012
The conclusion in a research handbook should emphasise the complexity of the problem than trying to claim a one-size-fits-all solution. I have categorised net neutrality into positive and negative (content discrimination) net neutrality indicating the latter as potentially harmful. Blocking content without informing customers appropriately is wrong: if it says 'Internet service', it should offer an open Internet (alongside walled gardens if that is expressly advertised as such). The issue of uncontrolled Internet flows versus engineered solutions is central to the question of a 'free' versus regulated Internet. A consumer- and citizen-orientated intervention depends on passing regulations to prevent unregulated nontransparent controls exerted over traffic via DPI equipment, whether imposed by ISPs for financial advantage or by governments eager to use this new technology to filter, censor and enforce copyright against their citizens. Unraveling the previous ISP limited liability regime risks removing the efficiency of that approach in permitting the free flow of information for economic and social advantage. These conclusions support a light-touch regulatory regime involving reporting requirements and co-regulation with, as far as is possible, market-based solutions. Solutions may be international as well as local, and international coordination of best practice and knowledge will enable national regulators to keep up with the technology 'arms race'.
Number of Pages in PDF File: 19
Keywords: Network neutrality, Quality of Service, Internet law, regulation, research method
JEL Classification: H41, K00, K23, L13, L44, L96
Date posted: May 28, 2011
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Source: Detroit News
quote: In Germany they have a couple simple laws which fix this. You are not allowed to pass on the right. And if you see a car approaching you from behind in your lane, you have to yield and move over to the right. It does a remarkably good job of keeping traffic flowing when there can be a 2:1 or greater difference in speed between the left-most and right-most lanes. That's the real goal here - keeping traffic flowing. Not who is driving too fast or too slow.
quote: The passing line is for PASSING, not the "fast" lane.