text:
Roger Chou, MD; Elizabeth C. Clark, MD, MPH; Mark Helfand, MD, MPH
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Acknowledgments: The authors thank Susan Wingenfeld and Kathryn Pyle Krages, AMLS, MA, for administrative support, and Heidi Nelson, MD, MPH, for reviewing the manuscript.
Grant Support: This study was conducted by the Oregon Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality, Contract #290-97-0018, Task Order No. 2, for the U.S. Preventive Services Task Force.
Potential Financial Conflicts of Interests: None disclosed.
Requests for Single Reprints: Reprints are available from the Agency for Healthcare Research and Quality Web site (http://www.preventiveservices.ahrq.gov) and through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295).
Current Author Addresses: Drs. Chou and Helfand: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239.
Dr. Clark: University of Iowa College of Medicine, 200 Hawkins Drive, 01293-F PFP, Iowa City, IA 52242-1097.
Chou R, Clark EC, Helfand M. Screening for Hepatitis C Virus Infection: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:465-479. doi: 10.7326/0003-4819-140-6-200403160-00014
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Published: Ann Intern Med. 2004;140(6):465-479.
Hepatitis C virus (HCV) is the most common bloodborne pathogen in the United States and is an important cause of patient morbidity and mortality, but it is unclear whether screening to identify asymptomatic infected persons is appropriate.
To synthesize the evidence on risks and benefits of screening for HCV infection.
MEDLINE (through February 2003), Cochrane Clinical Trials Registry (2002, Issue 2), reference lists, and experts.
Controlled studies of screening and antiviral therapy and observational studies on other interventions, risk factors, accuracy of antibody testing, work-up, harms of biopsy, and long-term outcomes.
Using preset criteria, the authors assessed the quality of included studies and abstracted information about settings, patients, interventions, and outcomes.
There are no published trials of screening for HCV infection. Approximately 2% of U.S. adults have HCV antibodies, with the majority having chronic infection. Risk factor assessment could identify adults at substantially higher risk. Antiviral treatment can result in a sustained virologic response rate of 54% to 56%, but no trials have been done specifically in asymptomatic patients likely to be identified by screening. Data are insufficient to determine whether treatment improves long-term outcomes. There are no data to estimate the benefit from counseling or immunizations. Although risks of biopsy and treatment appear minimal or self-limited, data on other adverse effects of screening, such as labeling or anxiety, are sparse.
Antiviral treatment can successfully eradicate HCV, but data on long-term outcomes in populations likely to be identified by screening are lacking. Although the yield from targeted screening, particularly in intravenous drug users, would be substantially higher than in the general population, data are inadequate to accurately weigh the overall benefits and risks of screening in otherwise healthy asymptomatic adults.
Hepatitis C virus (HCV), the most common chronic bloodborne pathogen in the United States, is acquired primarily by large or repeated percutaneous exposures to blood (1). In the United States, approximately 2.3% of adults 20 years of age or older are positive for anti-HCV antibody. Between 55% and 84% of these have chronic infection (1-6), but only 5% to 50% of infected adults are thought to know their status (7-9).
In the United States, HCV is associated with approximately 40% of cases of chronic liver disease and 8000 to 10 000 deaths each year (1). Chronic HCV infection can also cause fatigue and decreased quality of life in the absence of cirrhosis or other complications (5, 10, 11).
The natural course of chronic HCV infection varies. Some patients never develop histologic evidence of liver disease even after decades of infection (12, 13). In a meta-analysis of community-based cohort studies, 7% of patients with chronic HCV infection developed cirrhosis after 20 years (14). Factors that may be associated with a more progressive course include older age at acquisition (14, 15); comorbid medical conditions, such as heavy alcohol use (14, 16-21), HIV infection (22-24), and other chronic liver disease (25-27); male gender (14); and longer duration of infection. Mode of acquisition, viral load, aminotransferase levels, and viral genotype have not been consistently established as predictors of disease progression (28-31). The effects of ethnicity on the course of HCV infection have not been well studied in the United States (32).
In this systematic review, commissioned by the U.S. Preventive Services Task Force (USPSTF), we focus on whether it is useful to test for anti-HCV antibodies in asymptomatic adults who have no history of liver disease.
The analytic framework, definitions used, key questions, literature search, and data extraction methods are described in detail in the Appendix. Briefly, relevant studies were identified from searches of MEDLINE (1989 through February 2003) and the Cochrane Clinical Trials Registry (2002, Issue 2) and from the reference list of a recent evidence report commissioned by the National Institutes of Health (33). Reference lists of retrieved articles, periodic hand searches of relevant journals, and suggestions from experts supplemented the electronic searches.
Two readers reviewed all English-language abstracts. We selected studies that provided direct evidence on the benefits of screening and studies on risk factors for HCV infection and the performance of third-generation HCV enzyme-linked immunoassay (ELISA) alone or followed by confirmatory recombinant immunoblot assay (RIBA). We focused on third-generation ELISAs because they are thought to be slightly more sensitive than second-generation tests but included data on second-generation ELISAs from large, good-quality observational studies (34). We also selected studies evaluating noninvasive methods to evaluate active HCV infection and the harms associated with biopsy. For treatment, we focused on trials of pegylated interferon with ribavirin but included studies that examined the effect of other interferon-based treatment regimens on long-term clinical outcomes. We also reviewed studies evaluating effects of counseling on high-risk behaviors and benefits of immunizations. Good-quality meta-analyses were reviewed when available. We excluded studies of pregnant patients; children; and patients with occupational exposures, end-stage renal disease, or HIV infection, as well as studies focusing on patients who had already developed complications of chronic HCV infection.
We used predefined criteria developed by the USPSTF, described in detail elsewhere (35), to assess the internal validity of included studies, which we rated as "good," "fair," or "poor." We also rated the applicability of each study to the population likely to be identified by screening. We rated the overall body of evidence for each key question using the system developed by the USPSTF (35).
This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the U.S. Preventive Services Task Force. Agency staff and Task Force members participated in the initial design of the study and reviewed interim analyses and the final manuscript. Additional reports were distributed for review to content experts and revised accordingly (36). Agency approval was required before this manuscript could be submitted for publication, but the authors are solely responsible for the content and the decision to submit it.
We identified no randomized trials or longitudinal cohort studies comparing outcomes between patients in the general adult population who were screened and not screened for HCV infection.
The identification of risk factors for the presence of HCV infection could aid in the development of selective screening strategies (8). We identified 4 large population-based studies from the United States and Europe that evaluated rates of HCV infection and risk factors associated with HCV status (2, 3, 37, 38). Among these, the National Health and Nutrition Examination Survey III (NHANES III), a good-quality nationwide sample of U.S. households that was conducted from 1988 to 1994 and had 21 241 participants, found that the prevalence of positivity for anti-HCV antibodies was 1.8% overall and 2.3% in adults older than 20 years of age (3). Although NHANES III provides the most reliable estimate of prevalence of HCV infection in U.S. households, it probably underestimates the overall prevalence of the disease because it excluded persons without addresses, institutionalized persons, and those in military service.
Independent risk factors for HCV infection found in the 4 large population-based studies are shown in Table 1(2, 3, 37, 38). Intravenous drug use was the strongest independent risk factor in 3 of these studies (adjusted odds ratios, 18.4 to 29.2). The fourth study, NHANES III, did not assess intravenous drug use. However, it found that cocaine and marijuana use were associated with HCV infection, perhaps because they are surrogate markers for intravenous drug use (Table 1) (3). Many other smaller, cross-sectional studies in a variety of specific populations support the strong association between HCV infection and intravenous drug use (39-51). Cross-sectional studies in intravenous drug users have reported prevalence rates ranging from 50% to more than 90% (52-56).
Table 1.
All 4 large population-based studies also found an independent association between HCV infection and high-risk sexual behaviors (variably defined, but usually considered sex with multiple partners or sex with an HCV-infected person). In most settings with a low prevalence of intravenous drug use, high-risk sexual behaviors are the strongest risk factor for HCV infection (56-60). It is not clear whether this association is due to a high rate of sexual transmission in specific situations (61-66) or because high-risk sexual behaviors are a marker for unacknowledged drug use.
Since 1992, transfusions have not been an important mode of HCV transmission (56, 67, 68). There is insufficient evidence to determine the importance of tattoos, body piercings, shared razors, and acupuncture as risk factors (2, 67, 69-75). Nonpercutaneous risk factors such as gender, ethnicity, and socioeconomic status have inconsistent or weak associations with the prevalence of HCV infection (3, 38, 76).
In large U.S. cross-sectional studies, between 33% and 81% of patients with HCV infection reported intravenous drug use (38-40, 77). Other retrospective studies have found that 53% to 88% of infected patients had identifiable risk factors (78, 79). Sample differences, varying stringency of risk factor ascertainment, or variation in the risk factors examined could explain some of the discrepancies between studies (79). No study has prospectively applied a selective screening strategy and determined how many patients were correctly identified by it.
The terminology and interpretation of tests used to diagnose HCV infection are reviewed in the Appendix. A recent fair-quality systematic review of third-generation ELISA (7 studies) and RIBA (3 studies) found that only 10 of 150 studies used appropriate methods for evaluating a diagnostic test (80). We applied the USPSTF quality criteria to 9 of these 10 studies and found that all 9 had at least one important flaw: inclusion of a narrow patient spectrum, failure to perform a reference standard test in all samples, or lack of clarity about whether the reference standard test was interpreted independently of the screening test (81-86). The tenth study, a study of RIBA in 51 patients receiving hemodialysis, was not referenced in the systematic review and we could not find it.
Of 7 studies that evaluated the sensitivity of third-generation ELISA and involved 4674 patients, sensitivity ranged from 97.2% to 100% compared with the results of polymerase chain reaction (PCR) (a reference standard for active infection) or RIBA (a reference standard for exposure). We identified 3 additional studies of the sensitivity of third-generation ELISA using PCR as the reference standard (Table 2) (87-89). One of these was a good-quality study that found a sensitivity of 94% (107 of 114) (87). The specificity was 97% (946 of 976), and the positive predictive value (prevalence, 10%) was 78% (107 of 137). Second-generation ELISAs are thought to be slightly less sensitive than third-generation tests but may be more specific (34). In data collected by the Centers for Disease Control and Prevention in 24 012 lower-prevalence (2%) patients, the positive predictive value of current second- and third-generation ELISAs without confirmatory RIBA was 42%, using PCR as the reference standard (90).
Table 2.
To minimize false-positive results in low-prevalence populations, positive results on ELISA are usually followed by confirmatory RIBA tests (90). Patients with positive results on both tests are considered to have confirmed evidence of HCV exposure, although they may not have active infection. In 4 large population-based studies (prevalence, 1.2% to 3.2%), the proportion of patients with positive results on ELISA confirmed by RIBA who were found to have viremia was 73% to 86%, using second- or third-generation ELISAs (2, 3, 37, 91).
False-positive results on screening tests could cause harms that are difficult to measure (for example, labeling, anxiety, and detrimental effects on close relationships). There are few data regarding harms in patients who have false-positive test results or HCV-positive patients who do not receive treatment, although one fair-quality observational study suggests worse quality of life in patients who are aware of their status (92). We found no studies investigating whether harms associated with knowledge of HCV status could be reduced by effective patient education and counseling. However, data from one small trial in 34 patients found that a counseling program improved sense of well-being in women with HCV infection (93).
In addition to viral load and aminotransferase testing, the National Institutes of Health currently recommends pretreatment liver biopsy (67). Several blood tests have been proposed as noninvasive methods of predicting biopsy findings, but in a recent good-quality systematic review, no blood test predicted liver biopsy findings accurately, particularly for intermediate stages of fibrosis (94).
In clinical practice, the number of referred patients who receive antiviral treatment depends on the degree of liver damage, the presence of serious comorbid conditions, and patient preferences regarding treatment. Antiviral therapy is recommended for patients with chronic HCV infection who are at the greatest risk for progression to cirrhosis. These persons have HCV viremia, persistently elevated aminotransferase levels, or liver biopsy findings showing significant fibrosis or inflammation and necrosis (1, 67, 95-98). In patients with minimal or no biopsy abnormalities, the benefits of treatment are not clear, and decisions about therapy are individualized (67, 69, 98, 99). Many patients identified by screening are likely to be in this category. In 3 community-based cohort studies, the rate of chronic hepatitis of minimal grade or with no inflammation was 43% to 61% (4-6). Patients with cirrhosis or serious comorbid medical or psychiatric conditions also must have the risks and benefits of antiviral treatment carefully weighed.
We identified 3 fair-quality observational studies in referral centers (involving 100, 327, and 557 patients, respectively) that evaluated the number of patients referred for HCV infection who received treatment (100-102). In these studies, 30% to 40% of evaluated patients received treatment. Common reasons for ineligibility were ongoing substance abuse (13% to 44%) and serious comorbid medical or psychiatric conditions (12% to 34%). Nonadherence to the protocol (37%) and declining to receive therapy (10%) were also reported in one study (102).
In the work-up of patients with chronic HCV infection, percutaneous liver biopsy has the highest risk for complications. The most common complication of liver biopsy is pain; approximately 30% of patients require strong analgesic medications (103). More serious but less common complications include bleeding (the most frequent major complication), biliary rupture, intestinal perforation, vasovagal hypotension, or infection.
Most data on the risks of percutaneous liver biopsy come from large, fair-quality series of patients undergoing liver biopsy for a variety of reasons (104-109). The study of highest quality (independent assessment, standard assessment form) evaluated consecutive percutaneous liver biopsies in a nationwide sample in the United Kingdom (107). A bleeding rate of 26 of 1500 (1.7%) was found, with 11 of 1500 patients (0.7%) requiring transfusion. Death was definitively associated with biopsy in 2 of 1500 patients and was possibly associated with biopsy in another 3, yielding a mortality rate of 0.13% to 0.33%. Because a substantial proportion of patients in this study had malignant disease, the risks associated with percutaneous biopsy in asymptomatic patients with chronic HCV infection may have been overestimated (109). The rates of major complications in other large series were 0% to 3.7% (mortality rates were typically <0.1%) (104, 106, 110). In large series, the material obtained was inadequate for diagnosis in 1.5% to 5% of cases (107, 108).
Two small studies involving 126 and 166 patients, respectively, reported complication rates from percutaneous biopsy specifically in patients with HCV infection (111, 112). In both studies, which included patients with known or suspected cirrhosis, no major complications were reported.
Small studies suggest that ultrasonography-guided biopsies may be associated with fewer complications than blind biopsies (110, 112-115). Increased experience of the person performing the liver biopsy has also been associated with fewer complications (105, 107, 108).
Because of the large number of patients and long duration required to demonstrate improvements in long-term clinical outcomes, intermediate outcomes have been the most common measure of treatment benefit. Sustained virologic response rates (absence of viremia 6 months after completion of a treatment course) are currently considered the best indication of successful treatment (116).
Antiviral treatment began in 1986 with the use of interferon-α (117). Meta-analyses of interferon trials report sustained virologic response rates of 6% to 21% for interferon monotherapy, compared with approximately 2% in untreated controls (118-121). Combination interferon plus ribavirin was approved in 1998 and was found in 3 good-quality systematic reviews to be superior (sustained virologic response, 33% to 41%) to interferon monotherapy (119-121). Treatment with pegylated interferon, alone or in combination with ribavirin, has been used for only a few years. For all interferon-based regimens, factors associated with successful treatment include genotypes other than 1, lower baseline viral load, less serious biopsy findings, and smaller body surface area or lower weight (67).
We reviewed 3 randomized, controlled trials of pegylated interferon plus ribavirin versus pegylated interferon alone for 24 to 48 weeks (Table 3). Two trials (122, 123) were large, multicenter, good-quality randomized, controlled trials, involving 1121 and 1530 patients, respectively, and the other was a small, fair-quality study involving 72 patients (124).
Table 3.
The 2 good-quality trials found that 54% to 56% of all patients achieved a sustained virologic response with pegylated interferon plus ribavirin versus 44% to 47% with pegylated interferon monotherapy (P≤ 0.01) (122, 123). One of these trials also found a higher sustained virologic response rate with pegylated interferon plus ribavirin compared with nonpegylated interferon plus ribavirin (56% vs. 44%; P< 0.001) (122). Table 4 summarizes the relative effects of each interferon-based regimen, with estimated numbers needed to treat for benefit.
Table 4.
Treatment studies may not be directly applicable to the population that would be identified by screening because they evaluate patients who probably have more serious disease. In addition, a significant proportion of patients identified by screening would not meet inclusion criteria used by antiviral trials. For example, 6 (122, 123, 125-128) of 7 (124) trials of pegylated interferon used elevated aminotransferase levels as an inclusion criterion. In large, population-based studies, 46% to 67% of patients with viremia had normal aminotransferase levels (2, 37, 91).
The long duration required for important complications to develop and the relatively short period that treatments have been available complicate our ability to assess the long-term benefits of antiviral treatment. There are no data on long-term benefits after treatment with pegylated interferon alone, pegylated interferon combined with ribavirin, or nonpegylated interferon combined with ribavirin (119).
One recent good-quality systematic review of 3 randomized, controlled trials and 13 cohort studies evaluated the long-term effects (viremia or clinical outcomes) of monotherapy with nonpegylated interferon (120). The studies were heterogeneous in design, had some methodologic limitations, and did not consistently show that treated patients had better long-term clinical outcomes than untreated patients.
We independently reviewed the 2 randomized, controlled trials that reported long-term clinical outcomes after treatment with interferon (Table 5). In an unblinded, fair-quality Japanese trial, 90 patients were randomly assigned to receive interferon-α for 24 weeks or symptomatic treatment. After 8.7 years, rates of hepatocellular carcinoma (27% vs. 73%; P< 0.001) and mortality (11% vs. 58%; P< 0.001) were significantly reduced in the interferon-treated patients (129). The relative risk for progressing to Child B cirrhosis was 0.250 (95% CI, 0.124 to 0.505) in the treatment group versus the control group. In a fair-quality Italian randomized, controlled trial, no significant differences in long-term outcomes were found up to 5 years after randomization to interferon-β or placebo (5.3% vs. 4.3% for hepatocellular cancer) (130).
Table 5.
The single randomized, controlled trial and many of the cohort studies showing significantly improved long-term outcomes after interferon monotherapy were conducted in Japan and may not be applicable to settings in the United States. Some evidence shows that chronic HCV infection in Japan is associated with substantially higher rates of serious complications (33, 129, 131, 132).
Quality of life has generally been evaluated by comparing results in patients who achieved a sustained viral response and those who did not. We identified only one randomized, controlled trial that analyzed quality-of-life outcomes according to whether patients received antiviral treatment or placebo (133). This study was rated as poor quality because results were available for only 53 of 106 patients randomly assigned to interferon, baseline quality-of-life scores appeared significantly different between groups, and it was unclear whether patients were blinded to markers of response to treatment. Patients randomly assigned to interferon had no significant change in total Sickness Impact Profile score compared with baseline.
Counseling asymptomatic patients found to have HCV infection might help prevent spread of disease or decrease the likelihood of progressive disease (70). Specifically, patients could be counseled to obtain immunizations for hepatitis A virus or hepatitis B virus, avoid excess alcohol, or avoid sharing needles or engaging in other risky practices (134).
Hepatitis A and hepatitis B vaccinations in patients with HCV infection have been found to be immunogenic and safe (135). We identified no studies evaluating the effect of vaccinations after diagnosis of HCV infection on subsequent clinical outcomes. Although a widely publicized Italian study (136) reported high rates of fulminant (7 of 17) and fatal (6 of 17) hepatitis in patients with HCV infection who acquired hepatitis A infection, other studies (137, 138) have reported much lower rates. According to data from the Centers for Disease Control and Prevention, mortality rates from hepatitis A virus infection are higher in patients with underlying chronic liver disease (4.6% [107 of 2311]) than in those without it (0.2% [247 of 113 009]), but it is not clear how many of these deaths were associated with HCV infection (135).
We identified no studies that evaluated the effect of postdiagnosis counseling regarding alcohol consumption or other high-risk behaviors on subsequent clinical outcomes or spread of disease. We also did not identify any studies that estimated rates of spread of disease in patients aware of their status compared with those who were unaware. One poor-quality French observational study found less "excessive" alcohol consumption after diagnosis of HCV infection, but the results may have been affected by recall bias or patients' unwillingness to admit to current heavy alcohol use (139). One small U.S. study found no significant differences in behaviors in young injection drug users aware of their HCV status compared with those who were unaware (140).
Interferon-based treatments are commonly associated with self-limited adverse events. The most common adverse event is an influenza-like syndrome involving myalgias, fevers, and fatigue. A good-quality systematic review found that serious or life-threatening side effects occurred in 1% to 2% of patients receiving interferon monotherapy (118). Patients with significant comorbid conditions were generally excluded from randomized, controlled trials. Because of the long duration (6 months) of interferon regimens, adverse effects of treatment can have significant (although usually self-limited) effects on quality of life.
Three randomized, controlled trials provided data about adverse effects associated with combination therapy with pegylated interferon plus ribavirin or pegylated interferon monotherapy (Table 3) (122-124). In all of the studies, rates of adverse events were similar in both groups (50% to 60%). No serious complications or deaths from treatment were reported. In addition to dose-related influenza-like symptoms, psychiatric, gastrointestinal, dermatologic, and mild self-limited hematologic adverse effects were also common. Withdrawal rates in the pegylated interferon plus ribavirin group in 2 good-quality studies (122, 123) were 14% and 22%, compared with 13% to 32% in the nonpegylated interferon plus ribavirin group. Two good-quality systematic reviews found withdrawal rates of 8% to 9% in trials of patients receiving nonpegylated interferon monotherapy (119, 121).
In 5 uncontrolled retrospective and prospective studies of patients who received antiviral treatment, complete responders (sustained virologic response and sustained biological response) had a moderately lower risk for hepatocellular cancer and cirrhosis than those who had relapses or those who did not respond (33, 120, 141). However, these studies did not consistently find a decreased risk for hepatocellular cancer in nonresponders compared with untreated controls. These studies were heterogeneous in design and had some methodologic limitations. Specifically, this body of literature does not exclude the possibility that favorable, unknown underlying prognostic factors led to a better response to treatment and better long-term outcomes.
In 4 clinical trials of treatment-naive patients with HCV infection, 3 of which were fair quality (142-144) and 1 of which was poor quality (133), a sustained virologic response was associated with better functional status 24 weeks after treatment (Table 6) (142-144). The 3 fair-quality studies found that sustained responders had better scores than nonresponders on the 36-Item Short-Form Health Survey (SF-36) in 5 to 8 of 8 domains. In all of these studies, patients could have been aware of the results of biochemical or virologic testing before SF-36 testing was repeated.
Table 6.
The results of the evidence review are summarized in Table 7. No direct evidence shows benefits of screening for HCV infection in the general adult population. There are inadequate data with which to accurately weigh the benefits and risks of screening for HCV infection in otherwise healthy asymptomatic adults. Although screening can accurately detect chronic HCV infection and antiviral treatment can successfully eradicate viremia, there are inadequate data with which to estimate benefits of treatment for long-term clinical outcomes such as death, cirrhosis, hepatocellular cancer, and quality of life. There are also no data with which to estimate benefits from vaccinations or counseling about alcohol use and high-risk behaviors.
Table 7.
Clinical trials of antiviral treatment have been performed in referred patients, who generally have more serious and progressive disease than patients followed in community-based cohorts. Even if treatment is equally effective for virology end points in patients identified by screening and those studied in clinical trials, the overall clinical benefit would be expected to be smaller since the underlying progression rate is lower. Although the proportion of screened patients found to have chronic HCV infection in selected high-risk populations, particularly intravenous drug users, would be substantially higher than in the general population, there are also no data with which to accurately weigh the risks and benefits of selective screening. Table 8 estimates the yield from screening in hypothetical cohorts of 1000 adults in the general population and 1000 intravenous drug users.
Table 8.
Important gaps remain in our understanding of the natural history of untreated patients with HCV infection who are likely to be identified by screening. If untreated chronic HCV infection causes important morbidity in the absence of cirrhosis, there may be other important goals to be obtained from treatment, but few studies have adequately assessed the impact of treatment on quality of life or symptoms. Additional studies are needed to define the progression from asymptomatic to symptomatic HCV infection and how long symptomatic patients remain unidentified without screening.
Many studies showing improvement in long-term clinical outcomes have been conducted in Japan. Chronic HCV infection appears to follow a substantially more aggressive course in Japan than in the United States. Although lead-time bias could explain some of the observed differences in disease progression rates, the case for screening would be greatly strengthened by data showing that treatment in earlier, asymptomatic stages of disease in western countries is associated with improved outcomes compared with treatment reserved for patients who have become symptomatic and could be identified without screening. Studies demonstrating important individual or public health benefits from counseling, immunizations, and behavioral changes after a diagnosis of HCV infection would also greatly strengthen the case for screening. Little is known about the benefits and risks of treatment in patients typically excluded from or underrepresented in randomized trials, such as those with ongoing substance abuse, those with comorbid conditions, elderly persons, and persons of nonwhite ethnicity (145).
No studies have adequately assessed the potential harmful effects of screening for HCV infection, such as anxiety, labeling, or damage to close relationships, and whether these factors can be minimized by appropriate counseling. Additional studies on the long-term effects of antiviral treatment in nonresponders are important because studies have not consistently found an improved outcome in this group compared with untreated controls.
Reasonable screening strategies might be to screen adults with established risk factors, adults in settings with a high prevalence of HCV infection, or all adults in the general population. Studies that adequately assess the usefulness of risk factor assessment to guide selective screening strategies and the harms and benefits of selective versus universal screening are needed. A potential barrier to screening patients on the basis of risk factors is the difficulty in obtaining accurate histories of intravenous drug use or high-risk sexual behaviors. Little is known about patient preferences for screening. There are no data with which to estimate risks and benefits of one-time screening versus other screening strategies.
Complications from chronic HCV infection present an enormous health burden that is expected to increase 2- to 4-fold over the next 2 to 4 decades. Further research to more accurately determine the benefits and harms of screening is of paramount importance.
This section summarizes terminology describing the tests used to identify patients with HCV infection, the results of these tests (Appendix Table), and the response to treatment. The Centers for Disease Control and Prevention has recently published detailed guidelines for performing laboratory testing and reporting results of anti-HCV antibody and supplemental testing (90).
Appendix Table.
Enzyme-linked immunoassay (ELISA) or enzyme immunoassay (EIA): The ELISA (also referred to as EIA) detects antibodies against recombinant HCV antigens. First-generation ELISAs used a single antigen; later tests added additional antigens (146-148). Second- and third-generation tests are both in standard use. Because of concerns about false-positive test results, particularly in low-prevalence populations (such as blood donors or asymptomatic adults), the Centers for Disease Control and Prevention has recommended confirming positive ELISA results with a supplemental test (recombinant immunoblot assay or polymerase chain reaction), unless the signal-to-cutoff ratio is above a predetermined threshold that has been shown to be confirmed as positive more than 95% of the time (90).
The ELISA is the least expensive diagnostic test for HCV infection, with an average charge of about $60.00 (34).
Recombinant immunoblot assay (RIBA): The RIBA is a supplemental test that also detects antibodies against HCV antigens. In these assays, multiple HCV antigens are individually displayed on a nitrocellulose strip as bands. Positive RIBA results have at least 2 reactive bands; indeterminate results have one reactive band. Because positive RIBA results require reactivity to more than one HCV antigen, they are considered more specific (but not more sensitive) than ELISA for past HCV infection and are used to confirm positive ELISA results in low-prevalence populations (34). However, RIBA is not an independent gold standard for ELISA because the 2 tests use similar antigens to detect anti-HCV antibodies.
Currently available third-generation RIBAs are thought to be more specific than earlier-generation tests because they produce fewer indeterminate results (149). The interpretation of indeterminate RIBA results remains uncertain (90, 150, 151). The relative proportion of RIBA-positive, RIBA-indeterminate, and RIBA-negative test results in patients with positive results on ELISA varies according to the patients studied.
The RIBA is typically 2 to 3 times more expensive than ELISA; usual charges are approximately $140.00 (34).
HCV core antigen testing: Recently developed tests to detect HCV core antigen may aid in diagnosing acute infection in the "window period" before HCV antibodies develop (152, 153). The role of HCV core antigen testing in screening has not yet been established.
Reverse transcription polymerase chain reaction (RT-PCR or PCR): This is a laboratory method used to detect circulating HCV RNA in blood. A PCR can be quantitative or qualitative, and under optimal conditions qualitative PCR can detect 100 IU of circulating virus per mL or less (34, 116). Because the absence of viremia in patients who test positive for anti-HCV antibodies is associated with little or no risk for HCV infection (154) or complications related to chronic HCV infection, sustained PCR-detected viremia has become the gold standard for chronic HCV infection (6, 132, 155-157). In patients who have positive results on PCR, the degree of viremia correlates poorly with degree of liver damage (157-161), although these results may help predict the likelihood of response to treatment (162).
Strict quality control is necessary for PCR testing to be reliable. False-negative test results can occur because some patients with active infection have intermittent viremia, and a small portion of patients with chronic HCV infection can become nonviremic, particularly if they develop hepatocellular cancer (163-165). For this reason, repeated PCR testing is suggested in high-risk patients who are positive for anti-HCV antibodies but have negative results on initial PCR. False-positive PCR test results may also occur because of contamination of samples (11% in one early quality-control study), but this appears to be much less frequent since standardization of assay techniques (164).
Testing with PCR is associated with charges of approximately $130.00 for a qualitative test and $200.00 for a quantitative test (34).
False-positive ELISA results: Patients who have positive results on ELISA but negative results on RIBA or negative results on both RIBA and PCR are usually considered to have false-positive results (that is, they have no evidence of past or current HCV infection). False-positive ELISA results may occur in patients with autoimmune diseases and in neonates born to mothers with chronic HCV infection, who frequently pass on antibodies to their children but usually do not pass on the virus (34, 116).
False-negative ELISA results: Patients who have negative results on ELISA but positive results on PCR are usually considered to have false-negative results. False-negative results are probably most common very early after infection (it takes 6 to 8 weeks for third-generation ELISAs to yield positive results vs. 2 to 3 weeks for PCR) or in patients who have an impaired immune system (34).
Cleared or resolved HCV infection: Patients who have positive results on ELISA and RIBA but negative results on PCR on repeated testing are generally considered to have cleared or resolved HCV infection. This is usually not considered a false-positive finding because the positive RIBA test result provides specific evidence of past exposure to HCV (166). Patients who have positive results on ELISA, indeterminate results on RIBA (or no RIBA performed), and negative results on PCR may either have false-positive results or have cleared their HCV infection. False-positive test results are more common in low-prevalence settings (167, 168).
Chronic or active HCV infection: Patients who have persistent positive results on PCR are said to have chronic HCV infection. Chronic infection may present with or without symptoms, abnormal aminotransferase levels, or abnormal biopsy findings. In this review, the term asymptomatic chronic HCV infection refers to patients who report no symptoms of HCV infection. Like symptomatic patients, asymptomatic patients may or may not have abnormal biopsy results or aminotransferase levels.
Liver biopsy results: The Histologic Activity Index is used to grade histologic findings. The Knodell score and the METAVIR scoring system are common methods used to report the Histologic Activity Index (169, 170). The Knodell score is a semi-quantitative scoring system in which fibrosis and portal, periportal, and lobular necrotic and inflammatory components are assessed separately and their coding values are added. Maximum scores vary depending on exactly how the scores are totaled (171). The METAVIR system reports both the inflammatory and the fibrosis scores using separate standardized scores for activity and fibrosis (170).
Early responders: Patients with HCV infection who receive treatment and clear their viremia (viral load undetectable by PCR) or have a significant response (usually defined as a 2-log drop in HCV RNA level) in the first few months of treatment are referred to as early responders. People who are not early responders (usually measured at 12 weeks of therapy) have a low chance of successful treatment and may not benefit from further therapy (116). Normalization of aminotransferase levels (biochemical response) was reported in earlier trials of HCV treatment but has been replaced by assessments of virologic status, which are thought to be more accurate predictors of successful treatment.
End-of-treatment responders: Patients with HCV infection who receive treatment, clear their viremia, and maintain this response until the end of treatment are referred to as end-of-treatment responders. Presence of HCV RNA at the end of treatment is highly predictive of relapse when therapy is stopped (116).
Sustained responders or sustained virologic responders: Patients with HCV infection who receive treatment and clear their viremia and maintain this response 6 to 12 months after the completion of treatment are referred to as sustained responders or sustained virologic responders.
Nonresponders: Patients with HCV infection who do not clear their viremia during treatment are considered nonresponders.
The analytic framework in the Appendix Figure indicates the strategy we used to evaluate screening for HCV infection in adults without known or suspected liver disease or abnormalities on liver function tests. The key questions, which guided our literature review, were determined in conjunction with USPSTF liaisons.
KQ 1 = Does screening for hepatitis C virus (HCV) infection reduce the risk or rates of harm and premature death and disability? KQ 2 = Can clinical or demographic characteristics identify a subgroup of asymptomatic patients at higher risk for HCV infection? KQ 3 = What are the test characteristics of HCV antibody testing? KQ 4 = What is the predictive value of a positive screening test result and what are the harms associated with screening for HCV infection? KQ 5a = What are the test characteristics of the work-up for active disease? KQ 5b = In patients found to be positive for HCV antibody, what proportion of patients would qualify for treatment? KQ 6 = What are the harms associated with the work-up for active HCV disease? KQ 7a = How well does antiviral treatment reduce the rate of viremia, improve aminotransferase levels, and improve histology? KQ 7b = How well does antiviral treatment improve health outcomes in asymptomatic patients with HCV infection? KQ 7c = How well do counseling and immunizations in asymptomatic patients with HCV infection improve clinical outcomes or prevent spread of disease? KQ 8 = What are the harms (including intolerance to treatment) associated with antiviral intervention? KQ 9 = Have improvements in intermediate outcomes (liver function tests, remission, histologic changes) been shown to reduce the risk or rate of harm from HCV infection? *Excluding pregnant women, HIV-positive persons, transplant recipients, and patients with renal failure.
The analytic framework shows the target samples, interventions, and intermediate and health outcome measures we examined. We narrowed the scope of the literature review after a preliminary search. We excluded children from the review because of the low prevalence of anti-HCV antibodies (0.2% to 0.4% in those 6 to 19 years of age) (3) and the unclear safety and efficacy of treatment in this population (172). We also excluded pregnant women because of unclear safety of treatment and insufficient evidence regarding ability to lower vertical transmission rates (estimated at approximately 5% in mothers without HIV infection) (173-176). We excluded other specific populations, such as patients who had received transplants, HIV-infected patients, and patients receiving hemodialysis. In these patients, screening test characteristics and natural history of HCV infection may differ from those in the general population (23, 177-180). In addition, these populations have generally been excluded from large trials of treatment, and data regarding clinical outcomes are lacking. Patients with occupational exposures were also excluded because of clear consensus about screening after percutaneous exposures (1).
Our review evaluated the screening strategy in which a second- or third-generation HCV ELISA is the initial test, with confirmatory RIBA. These are the screening tests that are currently in standard use for the diagnosis of current or resolved HCV infection (90). Testing with PCR, aminotransferase testing, and liver biopsy were considered the standard work-up to determine presence of chronic HCV infection and eligibility for treatment in patients who tested positive for anti-HCV antibodies.
For treatment of chronic HCV infection, we focused on evidence regarding efficacy and safety of pegylated interferon with ribavirin, the treatment regimen found in good-quality trials to have the highest efficacy. Because this treatment regimen has been available for evaluation for only a short time, we also reviewed evidence regarding the effect of other interferon-based treatment regimens on long-term clinical outcomes. Ribavirin alone, amantadine, and corticosteroids were not included because they have not been found to be efficacious (1, 98, 181).
For outcomes, we were particularly interested in reviewing any literature on the benefit of early antiviral treatment of chronic HCV infection in asymptomatic patients. Clinical outcomes that we evaluated were mortality, end-stage liver disease, cirrhosis, and hepatocellular cancer. Quality-of-life outcomes were also evaluated. Intermediate outcomes were loss of detectable viremia, improvement in histologic findings, and normalization of aminotransferase levels. We also reviewed adverse outcomes from screening and treatment, including side effects from treatment, adverse events from liver biopsy, and effects of diagnosing chronic HCV infection on quality of life.
Other reasons for screening for HCV infection might be to prevent spread of the disease or to identify those who might benefit from hepatitis A or B virus vaccination, alcohol cessation counseling, or other interventions. We performed an additional literature search and review to identify potential benefits from screening that leads to these types of interventions in patients with chronic HCV infection.
We searched the topic of HCV in MEDLINE (1989 to July 2002, updated search in February 2003) and the Cochrane Clinical Trials Registry (2002, Issue 2). We originally performed 3 MEDLINE searches, one for screening for HCV infection, one for work-up of HCV infection, and one for treatment of HCV infection. For screening, the Medical Subject Headings (MeSH) terms hepatitis C and hepacivirus were combined with the terms mass screening, hepatitis C antibodies, predictive value of tests, and sensitivity and specificity and the text words antibody testing. For work-up, the MeSH terms hepatitis C and hepacivirus were combined with the terms ultrasonography, liver function tests, liver biopsy, and viral load. For treatment, the MeSH terms antiviral agents, interferons, and ribavirin were combined with the terms hepatitis C and hepacivirus. We conducted a search for controlled studies of treatment of HCV infection in the Cochrane Library databases, using the phrase hepatitis C in title, abstract, or keywords combined with terms for clinical trials. We retrieved the complete reference list from a recent Agency for Healthcare Research and Quality evidence report commissioned by the National Institutes of Health to update its consensus statement on management of HCV infection (33). Periodic hand searching of hepatology, gastroenterology, and major medical journals; review of the reference lists of retrieved articles; and suggestions from expert reviewers supplemented the electronic searches.
We performed an additional MEDLINE search in February 2003 on counseling on alcohol use, immunizations, and risky behaviors in patients with HCV infection. For this search, we combined the MeSH terms hepatitis C, hepacivirus, or hepatitis C, chronic with the MeSH terms patient education, counseling, alcohol drinking, viral hepatitis vaccines, hepatitis A, or vaccination.
One reader reviewed all English-language abstracts. Papers were selected for full review if they were about HCV infection, were relevant to key questions in the analytic framework, and met other inclusion criteria specific to the key questions. Reviews, policy statements, and other papers with contextual value were also obtained from the searches. Studies published as abstracts were not included in the search; although pertinent abstracts may be referred to in the text, they are not included in evidence tables.
For all key questions, articles were limited to those that evaluated the general adult population with chronic HCV infection. We excluded studies that focused only on patients with end-stage liver disease, cirrhosis, or hepatocellular cancer. Although the population of interest was asymptomatic adults with chronic HCV infection who would be identified by screening, we included studies of patients with a broad spectrum of chronic HCV disease to get a picture of the benefits and adverse effects of screening and treatment in patients with different degrees of liver disease. Studies on persons with HCV who had undergone transplantation were excluded, as were studies of pregnant patients, children, or those with end-stage renal disease or HIV infection. Studies of nonhuman subjects were also excluded, and studies had to include original data. Foreign-language papers were considered if they were clinical trials and an abstract was available in English. We searched for relevant systematic reviews for all key questions.
For individual key questions, additional inclusion criteria were as follows. For key question 1, articles were included if they were clinical trials or observational studies that evaluated clinical outcomes in patients screened and not screened for HCV infection.
For key question 2, we included large observational studies that used appropriate statistical methods to assess associations between various risk factors and the presence of HCV infection. Representative smaller observational studies were also reviewed.
For key questions 3a, 3b, and 4, we included observational studies and systematic reviews that evaluated third-generation ELISA (the most recent generation) and used a credible, current reference standard (third-generation RIBA or PCR). We did not include studies that evaluated third-generation ELISA only in relationship to an earlier-generation ELISA or performed the reference standard only in "discordant" samples from 2 screening tests. We also included data from large, good-quality observational studies on diagnostic test characteristics of second-generation ELISA.
For key question 5a, we included studies that evaluated the ability of blood tests to predict liver biopsy results and performed liver biopsy as the reference standard.
For key question 5b, we included clinical trials and observational studies that reported the number of patients referred or considered for HCV treatment after a positive result on an HCV antibody test and that also provided detailed information about the reasons patients were considered ineligible for treatment.
For key question 6, we included observational studies that reported complications from percutaneous liver biopsy specifically in patients with chronic HCV infection. We also included representative large, higher-quality observational studies of complications from percutaneous liver biopsy performed for a variety of indications.
For key questions 7a and 7b, we included controlled trials of antiviral treatment that evaluated relevant intermediate or clinical outcomes in treatment-naive samples. We included studies that evaluated pegylated interferon with or without ribavirin versus another treatment or placebo and studies that evaluated nonpegylated interferon plus ribavirin compared with interferon alone or placebo. For question 7b, controlled trials of nonpegylated interferon without ribavirin were also included if they had more than 5 years of post-treatment follow-up and evaluated clinical or histologic outcomes. We reviewed clinical trials that were previously included in good-quality systematic reviews to ensure accuracy and reproducibility of the findings of the systematic reviews.
For key question 7c, we included controlled trials and observational studies that evaluated the effectiveness of counseling and immunizations in patients with HCV infection for improving clinical outcomes related to hepatitis A or B infection, alcohol use, or preventing spread of disease.
For key question 8, we included controlled antiviral trials and observational studies that reported adverse events in treatment-naive samples. We included studies of pegylated interferon with or without ribavirin versus another treatment or placebo and studies of nonpegylated interferon plus ribavirin versus another treatment or placebo.
For key question 9, we included controlled antiviral trials and observational studies in which long-term outcomes were stratified by intermediate responses to treatment.
For all key questions, we reviewed meta-analyses and systematic reviews when available.
We used predefined criteria from the USPSTF to assess the internal validity of included systematic reviews, trials, and observational studies, which we rated as good, fair, or poor. We also rated the applicability of each study to the population that would be identified by screening. The rating system was developed by the USPSTF and is described in detail elsewhere (35). For included trials and systematic reviews, we also abstracted information about setting, patients, interventions, and outcomes. For clinical trials, when possible we recorded the difference between the probability of a response in the treatment and control groups for each outcome studied. We evaluated the applicability of reviewed studies to the population likely to be identified by screening. We developed evidence tables for those key questions related to antiviral treatment of HCV infection (key questions 7a and 7b). We rated the overall body of evidence for each key question using the system developed by the USPSTF (35).
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text:
A note from David Hardwich, who used to preside over Sunday chapel services for the old Syracuse Chiefs at MacArthur Stadium:
Greetings from the Desert Southwest. I have long enjoyed your columns and had the pleasure of meeting you a number of years ago when I was involved in the Chiefs' Sunday chapel services at Big Mac.
I agree with the frustration over the delays, if not downright failures, in getting things done in Syracuse, things that will better the community. The problem seems endemic, and it has only gotten worse in recent years.
Blame can be pointed in almost any direction one wants, but as one who has lived in various parts of the country, I can say Syracuse has the "Can't Do" attitude down to a science. It is a darn shame.
There are several significant points in your discussion of the stadium location controversy that I did not see in your article:
a) Another proponent of the downtown location was state Senator John De Francisco. I am not a big DeFrancisco fan, but I think it only fair to point out that he did favor a downtown site.
b) One of the main proponents of the north side location was none other than former Assemblyman Mike Bragman, who at the time was an extremely influential member of the State Legislature.
c) You mention the opposition expressed by Chasz Parker, the current Rescue Mission Director, to the location of the sewage facility (across the creek from) Armory Square. Yet you do not mention the opposition by Mr. Parker's predecessor, Clarence Jordan, to the location of a stadium (on the trolley lot) near the Mission. Mr. Jordan's opposition was given considerable publicity at the time it was expressed.
I understand you are a neighbor of my good friends, Heyward and Nonie De Bose. They are wonderful people. If you see them, please give them my best.
Dave Hardwich
Thanks for all those points. The issue of the Rescue Mission is especially interesting. It is understandable that Chasz Parker does not want a sewage treatment plant, as Mayor Matt Driscoll suggests, built right next to his grounds downtown.
But it is hard to understand why the Rescue Mission would not also oppose a sewage plant at the nearby trolley lot, when 13 years ago mission officials held a high-profile news conference to express worries about the way a baseball stadium on that exact location would affect their fragile clientele. If that was the case, how could a sewage treatment plant possibly be a preferable option?
It also begs the question of why similar concerns about the homeless did not receive higher priority when the county started building its Midland Avenue treatment plant, a close neighbor of the Oxford Inn, which shelters roughly 80 homeless men every night.
- Sean
Respond at firstname.lastname@example.com or on the forum.

subset: commoncrawl


text:
1. Thick pins and double stop dog system for long life and large unsupported length 2. Snap open at the outer radius (Series B15) and/or at the inner radius (Series B15i) combinable! 3. Mounting bracket with integrated strain relief 4. Dirt-resistant outer contour 5. Interior separation available
* The required clearance height is HF = H + 20 mm (at 0,5 kg/m additional load), this should be observed for all types of applications.Please consult {SEA} if space is particurlarly restricted
** The calculated length corresponds to the chain length without mounting brackets.
A= Moving end, B= Fixed endPitch: 30,5 mm per linkLink per m: 33Travel: SChain length = S/2 + K
The unsupported length is dependent on the additional load X-axis: Unsupported length in m FLB/FLG Y-axis Additional load in kg/m Lower scale: Travel S in m FLB = unsupported with permitted sag FLG = unsupported with straight upper run Reference example A:
Fill weight = 0,75 [kg/m]
Unsupported length FLB = 0,85 m
Travel = 1,70 m
Application examples
Samples and catalog order
E-Chain® Expert call
Service life calculation
PDF file
Ask the product expert
Designing with igus®
Interior separation possible
Mounting bracket with and without strain-relief teeth
Quickfix: Mounting bracket with screw anchor
7 widths, 8 bending radii
Assembly instructions
Other installation types
Technical specifications
Strain reliefs
Option 1: Separators
Option 2: Full-width shelves
Call configurator
Variant 1 - Separators Separators can be placed anywhere in the chain's cross-section in order to divide up the interior of the e-chain® - As a standard feature, separators are fitted every 2nd chain link! Standard division with slotted separator 154, for combination with full-width shelves 111.X
Option 2 - Full-width shelves are required when using many thin cables with similar or equal diameters.Side plate 156 combinable with separator, slotted 154 and full-width shelf 111.X
Polymer, pivoting
Polymer, locking
Top: 1015.34.P(Z) - 1050.34.P(Z)Bottom: 105.34.P(Z) - 107.34.P(Z)
Top: 1015.12.P(Z) - 1050.12.P(Z)Bottom: 105.12.P(Z) - 107.12.P(Z)
Aluminum "SuperTrough", Basic Version
1. Trough side parts, aluminum, 2 m
2. Glide bar, plastic, 2 m
3. Glide strips*, lateral, 2 m
4. Bottom clamp, aluminum
5. C-profile, steel galvanized
6. Screw M6 x 16
7. Sliding nut M6
8. Interface connector "Basic", plastic
10. Silencer profile, rubber
*without glide strips on request
Aluminum "Super Trough"- the igus® standard
The Aluminum "SuperTrough" is a modular guide trough system for long travels (when e-chains® glide on themselves, as per sketch). Aluminum "SuperTrough" is available in low cost "basic versions" and can be upgraded for heavy duty applications. This universal usage makes it the igus® recommended new standard trough system.
Design specificationFurther information on "gliding application"
1. Connection element
2. Plastic glide bar
3. Bottom clamp
4. Glide strip
5. C-Profile
Personal contact
General notes
Data protection declaration


text:
We love cooking with fire, and we want to bring professional results and ease of use to home chefs everywhere!
Home wood and charcoal grills don't achieve the commercial temperatures needed to get professional results with ease at home. They can be intimidating to novices, and don't have the flexibility to cook the full gamut of fire-cookable foods.The Quad cooker is the first naturally fired home cooker that lets you achieve professional temperatures of 900˚F+, and is outfitted with attachments for wok frying, oven baking, a reinvented grill top for grilling, and paella pan/flat-bottom griddle for paella.


text:
This deal has ended.
Get a Nintendo 3DS XL and a free $40 Gift Card for $199.96 at Walmart.com. Plus, the shipping is free. We found this console in select colors for $20 less elsewhere, (like the $180 Mario & Luigi Dream Team edition at Best Buy) but the included $40 gift card makes this the best deal. The 3DS XL is 90% larger than the 3DS and has 4GB of storage. It's offered in Black, Pink, Red, Blue or in the limited edition Mario & Luigi styling and orders placed now are guaranteed to arrive before Christmas. Sales tax is charged in most states.No longer available


text:
Exploring family histories has never been easier with Internet sites like Ancestry.com
However, since 1965, a group of Marshall County residents have been working diligently to make resources available to those with, or without a computer.
"Your family tree might still be a mystery, but how you find them isn't," said Central Iowa Genealogical President Jay Carollo of Marshalltown.
Article Photos
Members of the Central Iowa Genealogical Society are shown organizing obituary clippings Saturday at Marshalltown's Historical Society museum. From left are Pauline Smith, Daniel Brandt, Jay Carollo, all of Marshalltown, and Kay Gill of Albion.
Located in the Historical Society of Marshall County's complex, 202 E. Church St., is the CIGS library.
In it are hundreds of organized, neatly stacked books and materials for both beginner and seasoned genealogical researchers.
Included are "how to" genealogy books, atlases and maps, central Iowa family histories, county histories, Daughters of the American Revolution index, Marshall County cemetery records, obituaries and periodicals.
Several, tall, thick and sturdily bound books contain immigration records from Ellis Island and other points of entry.
CIGS board member Dan Brandt of Marshalltown said in recent years CIGS' efforts have focused on Marshall County as neighboring counties established their own organizations.
"We'll help anyone who has a question related to central Iowa genealogy," said Carollo, who is eager to let others know what the organization can do.
"If we don't have the information, or limited information, we'll suggest other resources. Additionally, we have cemetery records for Grundy, Hardin and Jasper counties."
CIGS volunteers have access to valuable military data.
"The 150th anniversary of the Civil War has sparked many an inquiry," Carollo said. "We'll help folks, if necessary research - military or other - for $10 per hour, plus expenses for copies, mileage and related work," Carollo said.
"If it appears a project will take much work - such as an out-of-state request - we will tell people up front."
Brandt compares genealogy to detective work.
"In both fields you follow leads," he said. "One thing may lead to another. It has been exciting to learn about my own family, and it is gratifying to help others learn about their families as well."
Brandt and fellow members Pauline Smith, Jay Carollo and Kay Gill spent part of Saturday clipping, pasting and organizing obituaries.
Their deliberate and systematic efforts were not for themselves, bur for others, who someday may wish to know more about family histories.
CIGS has recorded most obituaries of Marshall County residents from 1960 through 2006.
Obituaries hold much family information, or serve as keys to other sources.
Clyde Eisenbeis of Marshalltown has been researching his family tree since 1979. Central to Eisenbeis' effort was tracing his German ancestry. He discovered German relatives had moved to Russia in the late 1700s and early 1800s. With additional research, he discovered they later emigrated to the United States in the late 1800s, settling in North Dakota and Nebraska.
"My work led to the first International Eisenbeis Family Reunion in 1982," he said. "We had folks attend from the U.S. Canada, Russia and Switzerland. And it has been held every three years."
He published a soft cover of the family history and genealogy which coincided with the reunions.
"One book has over 10,000 names," he said. "I've met and recently corresponded with relatives who stayed in Russia. It has opened up a whole new world for our family."
Carollo emphasized HSMC and CIGS are separate, not-for-profit organizations, but share the library and other resources cooperatively.
CIGS meets the third Sunday of each month from January through May and September through November at 1:30 p.m. in the Fisher Community Center.
Annual dues are $7.50.
The library is open Tuesday through Thursday from 10 a.m. to 4 p.m. and first and third Saturday from 10 a.m. to 2 p.m.
For more information, contact Carollo, 641-351-4102 or firstname.lastname@example.com


text:
Windows Internet Watchdog - How to remove?
Windows Internet Watchdog is another rogue antispyware program from FakeVimes family, which breaks into computers through system vulnerabilities with a help of Trojan viruses. Once inside, the program makes some changes in the Windows Registry and it is configured to start automatically with every computer restart. The application imitates features of antivirus programs and tries to persuade computer users into purchasing its full version for $99.90.
Windows Internet Watchdog runs its scanner right when you login to Windows. Unfortunately, the program only imitates looking for infections on your computer and in a couple of minutes it generates a list of threats. These scan results are completely fake and they do not correspond to reality. However, the program tries to convince the opposite and it recommends purchasing a full version of Windows Internet Watchdog in order to protect your computer.
This malicious application also tends to block some of your legitimate programs, including your security tools. Usually it claims that they are infected and suggests activating Windows Internet Watchdog in order to fix the problem. Last but not least, you will be receiving numerous security notifications every time you browse the Internet or try using other applications, for example:
Firewall has blocked a program from accessing the Internet
Internet Explorer
is suspected to have infected your PC.
This type of virus intercepts entered data and transmits them
to a remote server.
Potential malware detected. It is recommend to activate the protection and perform a thorough system scan to remove the malware.
System data security is at risk!
To prevent potential PC errors, run a full system scan.
Make sure to remove Windows Internet Watchdog right after its detection on your computer. If you have also made a payment for this scam application, do not hesitate to contact your credit card company and dispute the charges. Otherwise your money will go straight to the bank accounts of cyber criminals. Below you can find removal instructions for this type of parasites:
- Launch the Windows Internet Watchdog, go to Settings and press allow unprotected startup.
- Open File explorer (any folder will do). Enter %AppData% in the location bar and press enter.
- Rename the file named guard-agas or similar to malwareguard-sdgsd.
- Reboot and scan with Spyhunter (http://www.2-viruses.com/downloads/spyhunter-i.exe).
Video removal instructions for Windows Internet Watchdog
Automatic Windows Internet Watchdog removal toolsWe might be affiliated with some of these programs. Full information is available in disclosure
Manual Windows Internet Watchdog removal
Important Note: Although it is possible to manually remove Windows Internet Watchdog, such activity can permanently damage your system if any mistakes are made in the process, as advanced spyware parasites are able to automatically repair themselves if not completely removed. Thus, manual spyware removal is recommended for experienced users only, such as IT specialists or highly qualified system administrators. For other users, we recommend using Reimage or other tools found on 2-viruses.com.
It is impossible to list all file names and locations of modern parasites. You can identify remaining parasites, other Windows Internet Watchdog infected files and get help in Windows Internet Watchdog removal by using Reimage scanner.


text:
Yeah, it isn't, I'm glad you noticed, but, where is this obvious in the story?Originally Posted by Cpt.McCloud
Looking forward to it, this one is pretty nice and it is mixed which is my only point.Originally Posted by {Axtlár}
The next one will be very good
English is not your first language I believe?
Yeah, it isn't, I'm glad you noticed, but, where is this obvious in the story?Originally Posted by Cpt.McCloud
The end is near....Or is it the beginning?
it's THE BEGINNING of an endless fall into a precipice of epic Brawling fun.
Add me to Brawl:
User name: AXTLR
if you added me, send me a pm with your code too, please.
No No I didnt notice in the story, it is just something I think is worth mentioning.Originally Posted by {Axtlár}
You wrote this very well even though it is your second language.
Thanks! I have been studying since 1st grade back in Mexico...Well if you haven't read the second chapter, it's above, so be sure to read it.
The end is near....Or is it the beginning?
it's THE BEGINNING of an endless fall into a precipice of epic Brawling fun.
Add me to Brawl:
User name: AXTLR
if you added me, send me a pm with your code too, please.
Considering it's a 'novel', those are remarkably short chapters.
Enoch was right.
Second Chapter was pretty interesting, keep up the good work
Brawl Friend Code
If you add me make sure you PM me so we can play
Yes I know, it is a prototype(if you'd like) of a short novel, if you guys like it, I will make it a full novel with many pages and even will attempt to publish it. So what do you think so far Dr Mario? aside from that?
Oh thanks, Marioman!
Here's the third chapter by the way:
Chapter 3: Encounters
The next morning, everyone had a special banquet of different foods like caterpillars and worms for breakfast but Oruba refused to eat, for she feels guilt to eat smaller creatures than themselves. Xinté is accustomed to eating this kinds of foods, even though his favorite is meat, Vatlin ate them without a problem, he even enjoyed them, as the rest of the infants, nevertheless, Conito caught some fish and ate them as they're his favorite food. Vatlin has been cured thanks to Tekhorii and Oruba, and so he departed after saying farewell and giving them a promise of a return someday to repay the favor.
The 6 infants continued on their journey, they walked and walked through the forest, and quite suddenly, they notice something far away that looks back at them, and they all halt in silence.
Xinté:*quietly* He's from the…killer tribe.
Oruba: I would call cannibalism to what that tribe does.
Tekhorii: Xinté's point was to get out of here before "that" begins his "cannibalism" act.
*Muñiña hides behind a bush*
Licheca:*in a tough manner* I will take him! *Walks forward to him*
Conito: *Stops and carries her back with the rest quickly while she kicks* No, Licheca, this one is too big for you to handle.
The native is from the Vimillo tribe; he's long and with a vile and vicious face.
Tekhorii: The secret is to not show fear, remember that divided we fall, while united we stand.
The Vimillense native climbed a tree and everyone was tranquil and let their guard down. Conito put Licheca down and Oruba stood, since she was crouching. They heard the noise of branches moving, turned around, and there he was; the native ready to devour Muñiña from behind as she stood still in fear trembling a bit hiding behind the bush, still, Conito quickly took him down the tree with his limbs and stumped his face, knocking him out as he was fallen in the ground, then he put him inside a deep hole from which he could not get out.
Everyone relaxed again, but now more than ever; they kept their eyes wide open.
As they arrive at a small pool of water naturally formed, Conito immediately went in and swam happily.
Conito: Ahhh, I could not stand not being in water.
And everyone went in afterwards except for the shy Muñiña, and Xinté, who dislikes the water. As the couple watched them have fun, they began to chat.
Xinté: So, what do you think there will be out of this forest, Muñiña?
Muñiña: I don't knooow…Maybe a very pretty paradise, with so many flowers, and waterfalls, and beautiful butterflies. *she giggles sweetly*
Xinté: *smiles* I think the same, and we will all be happy there.
Everyone passed the night together below the stars, and each one of them told a tale, they laughed, enjoyed and slept.
The next day, after the infants had fully woken up, they continued on until they had finally began to enter the outdoors of the forest; the trees seemed uglier, almost dead, and there was an obvious foul aroma in the air which they had never smelled in their lives.
They were now at the edge of the forest, where there lied what seemed to be a long river going across their path, it was between their world and the paradise they are willing to venture, but it was a strange river indeed; it was gray, fractured, and it shined.
Licheca: What Erlood is that?
Conito: First the trees, then the air, and now the water is dirty, too? *touches it with the tip of his lower limb and gasps shocked* It is hard!
Everyone was surprised at this but they proposed to go through it.
Xinté: let us pass quickly; it looks like it will thaw.
Everyone passed through, but now, what captured their sights and petrified them, was something in front very far away, or very immense, or the two combined, it looked bigger than the trees, waterfalls, and mounts from heir lands, it was something burning with a face of agony spitting smoke from its various mouths.
The infants could not move, they were fearful and they began to feel extreme inner transformations, and then they saw the worst: the beasts…Standing there near the enormous fire breathing monster, no infant could speak of their fears, and without thinking, they ran, from every side the beasts appeared; they were big, white with inexpressive black eyes like a fly's, big noses, and large limbs. They captured the 6 infants, Muñiña could not even move, Oruba would kick, even though she has strong lower limbs, nothing happened, Conito also defended himself; they had him by his upper limbs, covering his speaking area, but he bit them..With no result, Tekhorii also attacked in the same manner, but one of the beasts began to act viciously and so he hid his face to avoid any harm, Licheca tried to escape by running and jumping as fast as she could, but they still took her, Xinté was the rebel in this ocassion, he was furiously attacking, trying to get away, so they stabbed him with something he recognized instantly: Vatlin had it in his right limb, and then, Xinté fainted.
Various clouds have passed now, and Xinté woke up feeling the night, but the place he was in was day, he did not understand, he looked around and saw his friends separated in small cells. Muñiña was hiding between her limbs, Tekhorii was either sleeping or fainted, but couldn't quite be analyzed, Licheca was trying to get out, neither Oruba nor Conito appeared to be inside the strange chamber unlike anything they have ever seen.
Xinté:Conito…Oruba! *Starts to cry with much feeling* what is this? *Says with cracked voice*
Muñiña sees him crying and begins to cry also, accompanying him. Screams and Yells from other tribes can be heard as they are being tortured, everything as Vatlin told it, then loud cries coming from Oruba from another place.
Xinté: Oruba!….ORUBAAAA!!!!
And night ends with suffering.
Last edited by {Axtlár}; 09-23-2007 at 11:44 AM.
The end is near....Or is it the beginning?
it's THE BEGINNING of an endless fall into a precipice of epic Brawling fun.
Add me to Brawl:
User name: AXTLR
if you added me, send me a pm with your code too, please.
To be quite frank, I didn't read it.
But I do believe that if one were to write a book, write it first off. Spend lots of time, but don't make a LONG draft, or prototype like you just claimed.
Enoch was right.
All right, thanks for your observations.
The end is near....Or is it the beginning?
it's THE BEGINNING of an endless fall into a precipice of epic Brawling fun.
Add me to Brawl:
User name: AXTLR
if you added me, send me a pm with your code too, please.
Hm, I don't read, but I do like to write... Don't judge me.
First of all, I noticed that it was very hard to read like the structure, your paragraphs need to be spaced out more clearly because my eyes kept jumbling up words and lines. To some people, spacing matters, and it really messes up my point in the story.
Another thing, you've written it like a script, fair enough if you were going to write a play, but as the Cappin' has kindly pipped me to my post I think that you should incorporate speech as if it wasn't an internet language. Describe their actions and use more words rather than 'said.' Just totally forget that the colon key exists and try to make the story flow, reading out the names of people who are talking, that shouldn't be a problem in a novel, they can direct it very well who is talking to who.
As I've said, I don't like to read, I'm a playwrite. =/
You're going into much more depth, I like that.
I love you, Adam.


text:
Job Overview
Our mission: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle, and for his widow, and his orphan," - by serving and honoring the men and women who are America's Veterans.
Every job at the VA impacts the Veterans that we serve. You can be part of that team, helping to make sure that our Veterans receive the top-quality care they deserve.
Location: This position is within the National Acquisition Center in Hines, IL.
More selection(s) may be made from this announcement should the need arise.
Area of Consideration. To be eligible under Merit Promotion, you must have an eligibility listed below:
Competitive Merit Promotion:
*Transfer or Reinstatement eligibles: current Federal or former employees with career or career-conditional appointments in the competitive service that hold, or have held a career or career-conditional position at a lower grade level as the position being announced. An SF-50 must show appointment in the competitive service.
*Veterans Employment Opportunity Act (VEOA) eligibles.
Non-Competitive Merit Promotion:
*ICTAP/CTAP eligibles
*Disabled veterans receiving 30% or more disability compensation from the VA
*Individuals with severe disabilities (eligible for Schedule A appointments)
*Individuals eligible under other non-competitive appointment authorities such as: Military spouses under E.O. 13473; Certain former overseas employees; Present and former Peace Corps, Vista or Action volunteers; Former White House staff; Present and former Foreign Service officers and employees; Certain National Guard technicians.
*Current and former Federal employees who meet the established criteria outlined in an Office of Personnel Management Interchange Agreement
*Transfer or reinstatement eligibles that hold, or have previously held a career or career-conditional position at the same or higher grade level with the same or higher promotion potential as the position being announced.
*Veterans Recruitment Authority (VRA), allows appointments of eligible veterans up to the GS-11 level.
Special Employment Consideration: VA encourages persons with disabilities to apply, including those eligible for hiring under 5 CFR 213.3102(u), Schedule A, Appointment of persons with disabilities (i.e. intellectual disabilities, severe physical disabilities, or psychiatric disabilities) and/or Disabled Veterans with a compensable service-connected disability of 30% or more.
Major Duties:
- Responsible for the solicitation, analysis, negotiation, award and administration of a group of contracts, such as definite quantity, indefinite quantity, indefinite delivery, requirements, multi-year, option year, direct vendor supply, task or delivery orders, national preferred and Federal Supply Schedules, some containing economic price adjustment provisions. The incumbent performs the full range of contract or contract administration duties related to complex contracts under minimal guidance of higher level contracting personnel and supervisor.
- Participate in various work teams to ensure the best possible acquisition outcomes to include Contract Review Boards, Integrated Project Teams, and negotiation teams.
- Makes final determination relative to price adjustment, deviations from contract terms and conditions, delivery schedules and changes, supplemental agreements, change orders, disclosures, and other related contract matters upon analysis with minimal guidance from senior level contract personnel and/or supervisor.
Travel Required
- Not Required


text:
No. 1 vs. No. 2.
Not much else needs to be said.
When the acknowledged best team takes on the acknowledged second-best it piques and tweaks everyone's interest.
That's what will take place Saturday when St. Edward, the top-ranked basketball team in The Plain Dealer Top 25, plays host to undefeated and second-ranked Mentor in front of what is expected to be a sold-out and raucous crowd of approximately 1,800 fans.
This is more than just No. 1 vs. No. 2, though. It is East Side vs. West. It is public vs. private. It is a matchup of guards. It is a matchup of St. Edward's "big men" vs. Mentor's "little big men." It will be St. Edward's talented stable of Division I prospects vs. Mentor's talented close-knit group of Division II hopefuls. And, it could be a preview of a postseason rematch on someone's road out of the Cleveland State regional tournament.
"I fully expect a tournament atmosphere," said Mentor coach Bob Krizancic, whose team could be riding a 15- game winning streak when it crosses the Cuyahoga River if it defeats Shaker Heights tonight. "And, we are hoping for a close game and a big crowd. Once the postseason starts you know you are going to be playing close games. You know you will play in front of big crowds. So, we want as many of those experiences as we can get."
A misconception of many is that St. Edward vs. Mentor will be a tug-of-war between Mentor's backcourt of junior Cole Krizancic (26.8 points per game) and senior Jaron Crowe (19.8, 6.6 assists) against St. Edward's frontcourt of Louisville-bound 6-10 junior James Price (nine points, seven rebounds) and 6-9 senior Matt Stainbrook (11.5 points, 5.7 rebounds). Krizancic and St. Edward coach Eric Flannery, whose team will tuneup for Mentor by playing ninth-ranked Garfield Heights tonight, are not in that group.
Both men believe players such as St. Edward guards Delbert Love and Myles Hamilton and Mentor's Justin Fritts, Matt Solden and Cameron Aloisio will play significant roles.
"I like to look at it as two well-rounded basketball teams," said Krizancic. "Based on just the statistics people might think we're a two-man team. But, I think we have about seven or eight guys who can play very well. Our bigs are playing as well as anyone right now."
Flannery, whose team began the week with an 11-3 record, said, "I think both teams are OK playing fast and both teams are OK playing halfcourt. Everyone talks about Mentor's 3-point shooting but the reality is that you still have to stop their dribble penetration. Our kids are playing well. When you have the target on your back you usually get everyone's best game and that's what we've been getting."
Justin case: Parma guard Justin Roth, regarded as one of the area's top shooters, displayed his talents last week when he made 13 3-point shots in a win over Aurora and a loss to Twinsburg. In the two games Roth, a 6-3 senior who averaged 22 points a game last year, scored 73 points, had 15 rebounds, eight assists, three steals and two blocked shots.
Hurrying back: Brunswick coach Joe Mackey reports Tyler Ferrell was able to practice at full-go Wednesday after injuring his shoulder Friday in a triple-overtime win at Brush. Ferrell, who is closing in on the school's all-time scoring record, was unable to lift his arm on Monday but responded to treatment and was able to practice by Tuesday.
NBA-like: Cloverleaf and Tallmadge, two Suburban League teams with a combined record of 10-18, put on an entertaining display of endurance Tuesday when host Cloverleaf emerged with a 95-93 victory in four overtimes.
Cloverleaf's Colin Wray had 46 points when he made 15 of 31 field goal attempts, including, 5-of-10 shooting from 3-point range, and 11-of-16 shooting on free throws. Tallmadge sophomore Tucker Linder finished with 44 points, making 20 of 35 shots.
Cloverleaf had a lopsided advantage at the free throw line, making 29 of 43 attempts to 6 of 13 for the Blue Devils.
Wray's 46 points broke a school record that had stood for 38 years. Mark Chrislip set the old record of 41 points during the 1971-72 season. Wray, a 6-1 guard, scored 17 of the Colts' 28 points in the overtimes. Linder, the son of Kent State softball coach Karen Linder, scored 16 of his team's 26 points in the overtime periods.


text: uninsured Uninsured Rates Drop Nationwide, Though TX and OK Trails U.S. By Jonathan Baker • Sep 20, 2016 The Washington post The number of uninsured Americans has dropped to its lowest level since before the Great Recession, reports The Washington Post. The gains in insured citizens came primarily among people buying individual policies, rather than getting health benefits through a job. This includes, but is not limited to, those obtaining insurance under the Affordable Care Act. Texas Nonprofits Recieve Federal Funds to Help Insure Children By Jonathan Baker • Jun 16, 2016 Carl Juste / MBR/Houston Chroncile Five nonprofit organizations in Texas have been awarded almost $5 million by the Centers for Medicare and Medicaid Services, reports The Houston Chronicle. The money will go toward boosting efforts to enroll the state's nearly three-quarters of a million uninsured children. Texas Has High Rates of Uninsured Latino Children By Jonathan Baker • Apr 13, 2016 Chan Lone / Texas Tribune Despite lower uninsured rates that in previous eras, Texas still has one of the highest rates of uninsured children in the country, reports member station KUT. And those rates seem to differ according to racial and ethnic lines, according to new evidence. Marketplace insurer's departure creates enrollment concerns By Jim McLean • Nov 3, 2015 KHI Groups working to boost health insurance enrollment in Kansas are concerned their efforts could be undermined by the last-minute departure of one of the state's largest insurers. ACA Enrollment Period Extended for Those Who Were Uninsured in 2014 By Cindee Talley • Mar 17, 2015 A special enrollment period for health insurance through the federal marketplace started Sunday. But, not everyone's eligible. Gallup survey shows Kansas as lone state with rising uninsured rate By Cindee Talley • Feb 25, 2015 According to a recent survey, Kansas is the only state with an increased number of uninsured. The Texas Health Care Budget: Four Things to Know By Cindee Talley • Jan 27, 2015 Bob Daemmrich / texastribune.org Public health care costs are rising in Texas… as a matter of fact.. to the tune of about $1.3 billion over the next two years reports the Texas Tribune. As you take a look at the Senate's budget, here's a look at the health care issues lawmakers will be struggling with for the next four months. Texas: Most Uninsured Children and Poor Adults in the Nation… Again By Cindee Talley • Sep 20, 2013 texastribune.org Once again, estimates recently released by U.S. Census Bureau say Texas has the most uninsured in the nation according to a recent article from The Texas Tribune. Uninsured: How things look on the high plains By Cindee Talley • Sep 1, 2013 michaudinsurance.com The latest report from the U.S. Census Bureau reveals the percentage of uninsured people under the age of 65. Here's how things look on the high plains: Colorado: 17% Kansas: 14.4% Oklahoma: 21.8% Texas: 25.7%


text:
I dig this guy's sketching style, also agree with the box comment up top lol
New Videos
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April 9, 2012 BY John Kim / 6
It's clear that some of the most creative and visionary minds of footwear and apparel design are centralized in Beaverton, OR. One such individual is Nathan Van Hook, who has created quite the list of achievements in his run as Senior Footwear Designer for NSW; Sneaker News had the opportunity to pick his brain when his Aina Chukka released in early Summer 2010, and during the two years that passed, Van Hook has penned some of the sickest NSW offerings, like the Nike Zoom Meriwether and Nike Lunar MacLeay. Today, we get a visual exploration of Van Hook's design concepts, as seen in his preliminary sketches and 3-D renderings. Just how does an idea become a sneaker? A quick look at Van Hook's sketches below might answer that question.
Filed under: Lifestyle Sneakers Nike ACG Nike Free
Tags: Nate Van Hook Nike Aina Chukka Nike Lunar Flow Nike Lunar MacLeay Nike Zoom Meriwether
Pages: 1 2
I dig this guy's sketching style, also agree with the box comment up top lol
Nice to see SN articles on designers. It really shows the talent and makes me proud to rock someones work of art.
Truthfully Nike Sports Wear comes out with alot cool and great products but, they really need to upgrade that box. I understand there going Green but that box is very fragile. Other then that there sketches are fucking cool
i think i want to go into shoe design as a career. seems amazing i mean how cool would it be to design a shoe and see people actually wearing it
man thats boxhead talk.. are you ever gonna wear the box out?
industrial design is what you'd want to study in college, i'm going into my sophomore year for industrial design next semester, the only problem is that not many schools have the program, also it's getting pretty popular and competitive.
Subscribe to the Sneaker News Youtube Channel


text:
BIRMINGHAM, Alabama -- A 13-year-old boy armed with a loaded gun and his face covered with a T-shirt was shot to death Friday night, Birmingham police said today.
Sgt. Johnny Williams gave this account:
A car pulled into the parking lot of an apartment complex at 407 Skyview Drive shortly after 11 p.m.
The driver later told police the teen approached the car and ordered him to get out. A passenger was also in the car.
The driver pulled a gun and shot the teen at least one time. The teen ran 30 feet, collapsed and died. The teen's gun was cocked and ready to fire, Williams said.
Williams refused to name the teen and said the case remains under investigation. No charges have been filed. "It's still ongoing. We still have to present this case to the district attorney's office," Williams said.
View Slayings in the Birmingham area, 2012 in a larger map


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2000 Mercedes-Benz SL-Class SL500 2dr Convertible
Buying this car 16 year old car has been a joy. It turns heads, drives like a dream, corners likes its on rails, and the speed -- well it's breathtaking. Went out early one morning to the turnpike with the top down and my wife reading emails in the passenger seat. Got it to 105 and she didn't notice. Just a little stretch of the legs for this rocket. I'm 6' 4" and it's one the of few cars in which I'm really comfortable. Maintenance is expected and keeps her running great.
I love my Mercedes, the fact that you can go from hard top to soft top in a few easy minutes. There is room for a couple of bags in the back "seat", unlike other sports cars where you don't even have room for a purse. The ride is like sitting home in your livingroom. The gas mileage on mine is 30-32 mpg on a trip. It's an all around beautiful car. I am not an engineer, but I see no improving on perfection here. I have driven them all, I wanted to before I made an educated purchase and this was the only one standing at the end of the tests, all things considered, gas mileage, comfort, style, class.
The back "seat" area. All the others, Audi TT, BMW Z3 or Z4,Porsche, etc, no room for anything else. This car leaves nothing to want. Still more room in the amazing trunk, I can take everything I need for a week or more.
I have admired the Mercedes Roadster
since it was a 190SL. Finally decided
this was the time. I am not a sportscar
person. This car is a luxury car that
happens to look sporty. Perfect! Plenty
of power to spare and love the handling
on corners. Mercedes service has been
The powerful engine. Also the power top.
A more resliant back window.
German solid engineering at its best.
This model superseeded in 1990 the
classic 106, which only lacked the
power top.
My car is 'Sport' version, It seems
bulky, in spite of its modest
dimensions. It is more of a luxury
convertible 2 seater limousine then a
nimble sports car.
Seats are better then most American
cars. Everything works with monotonous
regularity - it is not an exciting car
to drive, but to be seen in!
Impressive looks and reliability- an
old pair of good shoes.
Plastic rear window a disaster ! The
model has been replaced by an
overpriced, a little more lithe,
inconspiquous looking technologically
complex model.
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text:
If you happen to come across the hkcmd.exe free running in your system and you've asked the question if you have nothing to worry about or not, you have the right place (to solve the problem or calm waters as appropriate or preferences: P).
Hotkey Command Module (Also called hkcmd.exe) is installed drivers for chipsets Intel VGA (graphics 81x) and most likely you have installed on your system when you buy the PC (if it was bought OS preinstalled). This process allows the configuration and / or diagnosing various Intel devices and activates shortcuts (hotkeys) To access certain applications / programs with the touch of a button (or keyboard shortcut).
hkcmd.exe is located in C: \Windows\ System32. If in doubt on this process (especially if it is running in multiple instances or have misspelled the name) then recommended an immediate full system scan! Viruses si trojanii have a bad habit of "borrow" legitimate processes names and their presence in C: \Windows is extremely risky. In addition, we recommend disabling this process and (in Control Panel) If not accustomed to using shortcuts to avoid dilemmas when running observed in task manager hkcmd.exe.Google Chrome OS - Screenshots - To be, or not to be »»
Old: «« wuaudt.exe / wuauclt.exe (Windows AutoUpdate)
IT Tips - Windows, Mac OS X, Linux & Mobile - hkcmd.exe (Hotkey Command Module)
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