text:
dont get it
dont get it
he selling books on anabolics?
Nothing is so common as the wish to be remarkable.... ~ Shakespeare
Oldest trick in the book. Make a bunch of gimmicks and beg for free gear using each gimmick then gin up the gimmick threads with more gimmicks....Azza style....
next youll tell me, chino = heavyiron
youre all crooks !!
but i though that waters guy had vids
http://i910.photobucket.com/albums/a...psf75f970a.gif...PASSION IS MY FUCKING PASSION
wasnt there a thread recently about OSL having some back luck or we need to pray for him...?
Nothing is so common as the wish to be remarkable.... ~ Shakespeare
I have a vile of test I infected with aids..... Slap a lucky 7 sticker on that shit and its on its way. FREE GEARS!!!!
All characters appearing in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
i like turtles
having abs because you are skinny is like a women having tits because she's fat
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Are you fucking kidding me sil?
Seriously, If your being funny awesome, great! I get this is anything goes, but with all the shit currently going on in my life, and my wife, I really hope this is a joke.
Anything I receive I have provided a service for, a design, a contest, or provide an unbiased review on elite. And now with my daily dealing with my wife, I'm way behind on articles and posts..
I really don't appreciate this, Normally id laugh this off, but there is some very life changing things going on in my families life right now, and I do not need this.
I'll get there or Die trying...
I think Sil and Heavy are one in the same...
I'll get there or Die trying...
im sure chino is mildly retarded
http://i910.photobucket.com/albums/a...psf75f970a.gif...PASSION IS MY FUCKING PASSION
Bwahaaa you kidding me? The coke thing is that old pedophile xyz repeater joke. Your 6' 180 lol I said the beer belly thing before I learned you look like an aids patient. Call OSL and tell him to teach u to not be such a bitch! Do you cry and punch the keyboard every day when I neg you? I hope you don't snap your twiggy wrist!
I was pretty sure everyone in AG was Prince's gimmick and I was the only real person here
Aussies and Philadelphians are the only people here
^^this except swfl. He really is that weak


text:
Night Court
This December, Los Angeles-based artist Ry Rocklen unveils his installation Night Court, produced in collaboration with Absolut as the setting for a pop-up art bar during Art Basel in Miami Beach. Night Court is at once a bar, a performance venue, a sports arena and a showroom for Rocklen's new line of furniture, 'Trophy Modern'.
Night Court is the latest and most ambitious incarnation of a project that began in 2011 when Rocklen came across a haul of second-hand sports trophies for sale in a thrift store. Rocklen spends a lot of time in junk shops and flea markets, trawling for those objects that were once cherished but which are now almost at the end of their lives. In the purgatory of the second-hand store, these ex-possessions have one last chance to be valued again.
3D renditions by: Ry Rocklen Photo by: Alexa Karolinski
In previous projects, Rocklen has made floor tiles from amateur paintings, and paintings from sections of stained carpet. He has covered futon cushions and mattresses found at the side of the road with tiny mosaic tiles, matching their colors and patterns to the faded designs on the fabric beneath. He has applied epoxy putty to the surfaces of a tattered parasol and a dead potted plant, rendering them hard and smooth and permanent. Rocklen has called these processes "devotional mummification". His interventions are protests against entropy, and ar-guments for a renewed respect towards those things that once gave their owners comfort and pride.
"Night Court is at once a bar, a performance venue, a sports arena and a showroom for Rocklen's new line of furniture, 'Trophy Modern'. "
Rocklen's collection of sports trophies began to grow. Most were inscribed with the names of the winners and the spurious events for which they were awarded: "Hawaiian Tropic 2005 Personality Plus" or "America: Our Tribute, CVAS Talent Show". Despite the ecstatic emblems of conquest, speed and power that adorned the diverse awards, their forlorn status, deaccessioned from their once-proud owners' collections, told a different story.
Second to None (2011), now in the collection of the Los Angeles County Museum of Art, is the sculpture that reincarnated Rocklen's trophy collection. Using wood and marble-effect shelves along with holographic columns (the kind used in the tallest, most bombastic trophies) he fused them together into a single hybrid object: a gleaming altar to the god of winning.
When, in the course of making the sculpture, Rocklen discovered the wholesale catalogs of the companies that supply the componentry to trophy-makers, it struck him that he could use the parts to build any object he chose. The first public presentation of the furniture that he branded as 'Trophy Modern' was in early 2013, at an art fair in Los Angeles. Installed in an otherwise empty booth were Rocklen's couch, chairs and coffee table, made almost entirely from trophy parts. Aside from the gold and silver cushions, and boards laminated with a white marble-pattern, the furniture is a colorful array of dazzling columns supporting eagles, soccer balls, globes, stars and laurels – all coated in gold paint.
'Trophy Modern's basic model is the American Diner chair; the Emerald Club is a wider club chair, while the World Couch is adorned with miniature globes. Absolut's commission of Night Court has provided Rocklen with the opportunity to add new pieces to the line. A horseshoe bar, built around a central island, is accompanied by barstools featuring large gold basketballs beneath their padded seats. Benches and bleachers will provide additional seating for guests who – if the competitive spirit moves them – will also be able to challenge each other across 'Trophy Modern' table-tennis tables and chess tables. The entire venue is arranged over a fullscale basketball court, which Rocklen will mark out on the carpet; while no actual balls will be thrown, Night Court will encourage guests to reflect on the competitive aspects of the space. In an art fair, schmooze and socialization is a serious business.
Photos by: Alexa Karolinski
Right from the start, Rocklen intended 'Trophy Modern' to be a mass-produced line. The first objects he made were prototypes; since all the components were readily available in bulk quantities, there was no reason why he shouldn't manufacture the furniture as unlimited editions, or adapt it for special commissions such as Night Court. The pieces are designed to be fully functional, and the artist is pleased that their owners put them to use in their homes rather than display them as artworks.
He has plans for diffusion lines too: 'Trophy Modern Wood' will replace the faux-marble laminates with solid wood, and the cushions with rich brown leather; 'Trophy Modern Black' will be a monochrome version; 'Trophy Ultramodern' would be the most luxurious edition, in which holographic columns are removed to reveal the chromed steel rods that hold the furniture together. Rocklen has also imagined a flat-pack, self-assembly edition of the standard line, in which owners would build the chairs themselves. The possibilities for creating hierarchies and customizations within 'Trophy Modern' are endless.
That is not to say that this furniture is not conceptual, or critical. Just as with previous projects in which Rocklen has forced new evaluations of materials and subjects, so too in 'Trophy Modern' he elevates these relatively inexpensive trophy parts into chic designer furnishings. But there is a not-so-subtle irony at play too (a quality essential to the very highest tiers of intelligent style). The kinds of personal achievement that provide collectors with the means to invest in 'Trophy Modern' furnishings are certainly not the kinds of achievements that are typically rewarded with gold-coated plastic cups mounted on faux-marble bases.
Rocklen's artworks and furnishings poke fun at themselves and, indeed, at the system of value that they inhabit and rely on for their very existence. They are never spiteful or judgmental. They are humane and self-aware, realistic and honest. It is this that bestows on them their real worth, whether one is relaxing in a 'Trophy Modern' chair at home, looking at one of Rocklen's sculptures in a gallery, or calling for another round of vodka shots at one of the most frenzied and flamboyant events in the art world's calendar.
Photos by: Alexa Karolinski
Text: Jonathan Griffin Still Photo: Keaton Ventura & Elisabeth Toll
Movie: Alexa Karolinski

subset: commoncrawl


text:
Hmm, I ran it 3 times, Knicks get past Boston once. Although I think the 24% chance of a NY upset is a little low.
The 76ers beat Miami all 3 times.
They have this fun little app on Espn.com that allows you to filll out a bracket manually, from the current standings or 2 other sources. Then you hit the redbutton to let the series playout and go onto next rounds all the way to nba finals. Its different everytime and i got it to predict an upset of Boston on my 2nd try, however it had us losing in 2nd round..
here is the link for anyone who would like to try it out:
[Only registered and activated users can see links. ]
Also I see where there is some confusion with people thinking it is a best of 5 and some saying best of 7. First Round Format was changed in 2003 from 5 to 7 game series. Reason being it reduced the chance of a First Round upset by a lower seed, because the better seeded team normally will win 4 over course of 7. In a 5 the lower seed could get hot and eliminate all the hard work a High seed put in all season.
For some reason i think the 7game format benefits this years Knicks. I dont see them doing what they did in 90s losing first 2 and coming back and sweeping celts 3 in a row. If we lost first 2 in boston i think that would take us out of the series. In a 7 game series it is still very bad to lose first 2 but you still have time to recover and push it to 7th game. I think this would benefit us vs boston or miami. I see us winning this in 6. we will get game 5 in boston and win it at home
Hmm, I ran it 3 times, Knicks get past Boston once. Although I think the 24% chance of a NY upset is a little low.
The 76ers beat Miami all 3 times.
I tried it a bunch, a few times we got out of first round but never past the second.
Besides Boston is really tough.
Let's...Go...Lottery! Let's...Go...Lottery!!! Say it with me Knicks fans!
Hollinger's 'abacus' approach excludes the present 'human factor' of any situation. His playoff simulation is only as accurate as the ESPN trade simulator: it's apart from non statistical circumstance.
Even with fan bias in consideration, I think this RealGM poll is more accurate considering what's current in New York and Boston.
Which team will win their first round series of the 2011 NBA Playoffs?
Apr 12, 2011
52.38% of RealGM votes chose Celtics over Knicks.
Total votes: 3950
Read more: [Only registered and activated users can see links. ]
Hollinger's a gimmick.
I played about 9 times and only once did the Knicks get past the first round, but we did move on to the conference finals and lost to the bulls.
Damn, I had us going to the East Finals...I wish
Well we got to the NBA finals but lost to the spurs... again.. boooooo.
Lost to the Bulls in the EC finals
Wow... I got us winning it all against the SPURS on the 3rd try!!! Each time I got us upsetting the Celts and at least getting to the 2nd round. I like...
Of course my prediction also had Philly beating the Heat and then losing to us.
Thank god the games aren't played and won inside a computer simulator... That was too much stress and something I'll never try again. Tried the thing five times and the Knicks only made it out of the first round once only to lose to the Heat during the 2nd round.
I had Lakers vs Chicago the first time. Lakers won it. Lakers vs Celtics the second time. Lakers won it. Thunder vs the Celtics the third time. Celtics won it. San Antonio vs Boston the 4th time. Spurs won it. Spurs vs the Heat the last time... Spurs won it. Thank god, because if the Heat would have won it I would have broke the computer screen.
WUUUUPPPPPPEEEEEEEEE!!!! 8th try. NBA champions!
1st Round- 24% chance- upset the celtics
2nd round- Sixers upset heat. 61% favorites
3rd round- Knicks upset Magic. Only 14%? Really ESPN? Well F you
Finals- Knicks upset Spurs- 27% chance
holy hell people. Never play this when ur high. It's 415 right now and i can't stop. ****. Trying to get Indiana all the way. BTW. 10+ head to head matchups with Lakers against Heat. Lakers win EVERY TIME. I think a fix is in. Updates in a bit.
ESPN=Discriminating against Heat/Lebron
I've officially played this game until I've had the Heat against the Lakers 15+ times in the finals. It says it's a 50/50 chance. EVERY time the Lakers have won. No way thats a coincidence. Hidden message by ESPN saying Lebron can never beat Kobe. BASTARDS.


text:
What is in this article?:
- Ethanol study points to major savings at the gas pump
- Feed versus fuel savings
- Updated study finds that between 2000 and 2011, benefits of ethanol included reducing U.S. wholesale gasoline prices by 29 cents per gallon nationwide.
- Study authored by economists at Iowa State University's Center for Agricultural and Rural Development.
- Touted by the Renewable Fuels Association.
More About:
Several years ago, a study produced by Iowa State University's Center for Agricultural and Rural Development found that, between 2000 and 2010, the benefits of ethanol included reducing U.S. wholesale gasoline prices by nearly 28 cents per gallon nationwide.
"That study wasn't funded by anyone -- it was done because we were academically interested in the subject," said professor Dermot Hayes, who authored the study with then-graduate student Xiaodong Du. "We sent it to a peer-reviewed journal, Energy Policy, and it was accepted and published."
Du, said Hayes during a Tuesday (May 15) press call, "was interested in the whole crude oil market, in general, for his dissertation. He and I were trying to understand the link between corn prices and the energy value of corn. We were tracking those markets looking at historical data and had originally linked the price of corn to the price of crude oil via the relationship between gasoline and crude oil."
The pair noticed the historical relationship between gasoline and crude oil was "breaking down. Crude oil was strong but gas prices weren't as strong. In particular, the price of diesel continued to track crude oil but the price of gasoline fell below its historic relationship."
They decided to see what might explain observed patterns. "There are hundreds of issues that influence gasoline prices and the price of gasoline relative to crude oil. In our paper, we tried to control for all other forces such as hurricanes that might occur in a month and the stocks being held in the United States and elsewhere. … We took those out of the equation and what was left was the impact of ethanol on gasoline prices.
"We hypothesized that in areas of the country where ethanol penetration was greatest, the impact would be largest. We discovered that nationwide the impact of ethanol on gasoline was to reduce prices by about 28 cents per gallon. The impact in the Midwest was much greater – in excess of 40 cents."
Understandably, the study caught the eye of the Renewable Fuels Association (RFA) and the advocacy group funded an update to include 2011 data.
"Last year, we were careening toward $5 gasoline," said Bob Dineen, RFA president and CEO. "Because of ethanol, because of the Renewable Fuel Standard requiring refiners to use renewable fuels, consumers were given some measure of relief."
The RFA's frustration, explained Hayes, "was that the original work was done for the period of 2000 to 2010. They knew the amount of ethanol had grown tremendously since then and they asked us to continue to update the work. We've done that for the last two years."
Now, on a nationwide basis, the impact measured is greater by about 2 cents per gallon – 29 cents.
That figure, said Hayes "seems like a large number on a nationwide basis. What helped me understand why that number is so large is that we used to have big spikes in gasoline prices when the refining industry approached capacity…
"We haven't seen such spikes in gasoline (lately) because we've found a new way to produce 'gasoline.' We don't have a refinery capacity problem anymore because we've added 10 percent to that capacity. … In any market, if you increase supply, you'll get a price reduction."
What impact would more ethanol production – say, 12 billion to 14 billion gallons -- have on the nation? "In our update, we hypothesize that the impact of each billion gallons on the price of gasoline was linear. We took the … 29 cents and multiplied it by the proportion increase in ethanol. (That provided) the much larger numbers" in the updated report.
Those burgeoning numbers "forced" Hayes to three possibilities.
- From net importer to net exporter.
"At the beginning of the (considered) period, the United States was a net importer of gasoline and now it's a net exporter. Whenever a country moves from being an importer to an exporter, the domestic prices go from world price plus transportation costs to world price minus transportation costs."
- Refining capacity.
"Think about the world before ethanol occurred," said Hayes. "Every time a gasoline refinery shut down, the price of gasoline would go up 10 or 20 cents. That was because the United States was at its refining capacity. Ethanol has, essentially, increased the U.S. refining capacity by about 10 percent."
- The magic bullet.
Lastly, "imagine that instead of producing gasoline, the refineries had found a magic bullet that could squeeze 10 percent more gasoline – not more diesel -- out of every barrel of crude oil. You'd expect a big effect on gasoline prices with no effect on diesel. That's what we've observed historically. Back in the late 1990s, gasoline sold at a premium to diesel. Now, the opposite is true and that's because we've found the magic bullet – we produce an amount of ethanol equal to about 10 percent of the gasoline we consume."


text:
Name: Tristan Chamberlin
Age: 30
Hometown: All over the place. "I'm a Navy brat."
Neighborhood: Brewery District
Job: Mortgage banker at JP Morgan Chase
Describe your style: "Esoteric"
Shoes: By Wolverine from Repertoire
Red, white and blue bracelet: From Starbucks
Earrings: Flathead screw-shaped style by jewelry designer Philip Crangi
Glasses: By Warby Parker
Watch: From Brooks Brothers
Raw ring: By G-Star
Diesel ring: "This was the first accessory I ever bought for myself. It's from a Japanese Diesel store. Inside it says 'Only the Brave.' I look at it whenever I'm thinking about an adventure or doing something new."
Jeans: Drop Crotch style by G-Star. "I own about 20 pairs of jeans. … G-Star is my favorite label. I fell in love with it when I was teaching in Japan. When Brigade [in the Short North] opened, they had a billboard that said it was going to sell G-Star. I wrecked my bike looking at the billboard."
Anchor bracelet: By Miansai from J.Crew. "I grew up in a military family. My style is heavily influenced by the military."
Bow tie: From Brooks Brothers. "The best part about a bow tie is that when it comes untied, you know the party has started."
Tattoo: By Scott Santee at Memento Tattoo. Chamberlin, his brother and their dad got these matching tattoos on Labor Day weekend. The fouled anchor represents his father's time as a senior chief petty officer in the Navy, and the swallows, one for each son, represent sailor lore that says birds bring seamen's souls home to their families if they die at sea.
SBB card: Chamberlin's favorite local places to shop for menswear are Brigade, Milk Bar and Tigertree.
Camo shirt: By Mark McNairy


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Kel-Tec PF9 Chrome slide w/ Green frame
This PF-9 has a
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Dimitri M. Drekonja, MD, MS; Mary Butler, PhD, MBA; Roderick MacDonald, MS; Donna Bliss, PhD, RN; Gregory A. Filice, MD; Thomas S. Rector, PhD; Timothy J. Wilt, MD, MPH
Note: A clinician's guide and consumer guide, produced by AHRQ, are available online (Supplements).
Disclaimer: The authors are responsible for the content of the report. Statements should not be construed as endorsements by AHRQ or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Indulus Rutks and James Tacklind for their technical expertise in the preparation of this manuscript.
Grant Support: By contract HHSA 290 2007 10064 I from AHRQ, U.S. Department of Health and Human Services, and a Veterans Affairs Career Development Award through the Minneapolis Veterans Affairs Center for Epidemiological and Clinical Research (Dr. Drekonja) and Veterans Affairs Health Services Research and Development Service grant HFP-98-001 (Dr. Rector).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1356.
Requests for Single Reprints: Dimitri M. Drekonja, MD, MS, Infectious Disease Section (111F), Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417; e-mail, email@example.com.
Current Author Addresses: Drs. Drekonja and Filice: Infectious Disease Section (111F), Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.
Dr. Butler: Division of Health Policy and Management, University of Minnesota, D330-4 Mayo Building, Minneapolis, MN 55455.
Mr. MacDonald and Dr. Wilt: Center for Chronic Disease Outcomes Research (111-0), Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.
Dr. Bliss: University of Minnesota School of Nursing, 6-189A WDH, 308 Harvard Street SE, Minneapolis, MN 55455.
Dr. Rector: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 152/2E, One Veterans Drive, Minneapolis, MN 55417.
Author Contributions: Conception and design: D.M. Drekonja, M. Butler, D. Bliss, G.A. Filice, T.J. Wilt.
Analysis and interpretation of the data: D.M. Drekonja, M. Butler, R. MacDonald, D. Bliss, G.A. Filice, T.S. Rector, T.J. Wilt.
Drafting of the article: D.M. Drekonja, M. Butler, R. MacDonald, D. Bliss, G.A. Filice.
Critical revision of the article for important intellectual content: D.M. Drekonja, M. Butler, D. Bliss, G.A. Filice, T.S. Rector, T.J. Wilt.
Final approval of the article: D.M. Drekonja, M. Butler, D. Bliss, T.S. Rector, T.J. Wilt.
Provision of study materials or patients: R. MacDonald.
Statistical expertise: R. MacDonald, T.S. Rector, T.J. Wilt.
Obtaining of funding: T.J. Wilt.
Collection and assembly of data: D.M. Drekonja, M. Butler, R. MacDonald, D. Bliss.
Administrative, technical, or logistic support: T.J. Wilt.
Drekonja DM, Butler M, MacDonald R, Bliss D, Filice GA, Rector TS, et al. Comparative Effectiveness of Clostridium difficile Treatments: A Systematic Review. Ann Intern Med. 2011;155:839-847. doi: 10.7326/0003-4819-155-12-201112200-00007
Download citation file:
© 2016
Published: Ann Intern Med. 2011;155(12):839-847.
Clostridium difficile infection is increasing in incidence and severity. The optimal treatment is unknown.
To determine whether, among adults with C. difficile infection, treatment with certain antibiotics compared with others results in differences in initial cure, recurrence, and harms.
MEDLINE, AMED, ClinicalTrials.gov, and Cochrane databases (search dates: inception through August 2011, limited to English-language reports); bibliography review.
Randomized, controlled trials of adults with C. difficile infection, independent of outcomes, who were treated with medications available in the United States. Observational studies reporting strain were included.
Study design, inclusion and exclusion criteria, quality and strength of evidence as assessed by 2 reviewers, study definitions, and duration of treatment and follow-up. Outcomes included initial cure, recurrence, and treatment harms.
11 trials that included 1463 participants were identified. Three trials compared metronidazole with vancomycin; 8 compared metronidazole or vancomycin with another agent, combined agents, or placebo. Strain was analyzed in 1 trial and 2 cohort studies. No study comparing 2 antimicrobial agents demonstrated a statistically significant difference for initial cure; all comparisons were of low to moderate strength of evidence. Moderate-strength evidence from 1 study demonstrated that recurrence was decreased with fidaxomicin versus vancomycin (15% vs. 25%; difference, −10 percentage points [95% CI, −17 to −3 percentage points]; P = 0.005). Subgroup analysis of a single study comparing metronidazole with vancomycin for patients who have severe C. difficile infection showed no difference by intention-to-treat analysis; this was rated as insufficient-strength evidence. Harms, when reported, did not differ between treatments in any study.
Definitions of diarrhea, C. difficile infection, initial cure, and relapse varied. Some studies reported insufficient detail to allow assessment of all randomly assigned participants or of harms.
No antimicrobial agent is clearly superior for the initial cure of C. difficile infection. Recurrence is less frequent with fidaxomicin than with vancomycin.
U.S. Department of Health and Human Services.
Several antibiotics are available for treatment of Clostridium difficile infections.
This comparative effectiveness review of 11 randomized trials involving adults with C. difficile found that initial cure rates did not statistically significantly differ for fidaxomicin, vancomycin, and metronidazole. Recurrent disease was common with all agents but was less frequent with fidaxomicin (15%) than with vancomycin (25%).
There were few studies, and most had small sample sizes. Studies used heterogeneous definitions for cure. Potential harms were inconsistently reported.
Any of several agents could be used for initial treatment of C. difficile infection. Fidaxomicin may be a superior agent for recurrent infection.
—The Editors
Clostridium difficile infection is a common infection that usually causes diarrhea but occasionally more severe disease, including pseudomembranous colitis and toxic megacolon (1). Antibiotic use precedes most episodes of this infection, and nosocomial acquisition is common (1). Attributable mortality increased from 5.7 to 23.7 deaths per 1 million persons from 1999 to 2004 in the United States (2). Therapy for C. difficile infection has been studied for more than 3 decades, with numerous randomized trials evaluating multiple agents and dosing strategies (3-17). Table 1 presents current treatment options available in the United States. Authors of a 1995 position paper found that comparative clinical trials demonstrated equivalent rates of clinical cure for metronidazole and vancomycin (6-7); however, they stated that metronidazole may be preferred because of concerns regarding the emergence of vancomycin resistance, particularly vancomycin-resistant enterococci (18-19), and costs (20). A 2007 Cochrane review concluded that no antibiotic was clearly superior for the treatment of C. difficile infection (21).
Table 1.
Coinciding with increasing incidence and severity of C. difficile infection (22), further treatment studies have been published (3, 17. Largely on the basis of these new data, recent reviews and guidelines endorse vancomycin as the preferred treatment for this severe infection (23-24), and vancomycin use for it has increased (25). More recently, data from a large trial comparing vancomycin with fidaxomicin has led to U.S. Food and Drug Administration approval of fidaxomicin for treatment of C. difficile infection (26). Because of these changes, an updated assessment of the evidence evaluating antimicrobial treatment of C. difficile infection is necessary. Accordingly, as part of an Agency for Healthcare Research and Quality (AHRQ)–funded review (27), we conducted a systematic review of the literature regarding C. difficile infection therapy, including updating the AHRQ review to include the current literature. Specifically, we assessed the comparative effectiveness and harms of different antibiotic treatments in prospective randomized trials, including whether effectiveness varied according to disease severity or strain.
This topic was nominated by the Medicaid Medical Directors Learning Network and selected by AHRQ for systematic review. The Minnesota Evidence-based Practice Center followed a standardized protocol. Details of the protocol can be found elsewhere (27).
We searched MEDLINE, AMED (Allied and Complementary Medicine), Cochrane databases, and ClinicalTrials.gov for studies of C. difficile infection published from database inception through August 2011. We used keywords to identify condition (difficile) and interventions and used a filter to identify study design. Appendix Table 1 shows our search strategy. In addition, we reviewed bibliographies, received suggestions regarding possibly relevant literature from topic experts, and searched the U.S. Food and Drug Administration Web site for relevant study data.
Appendix Table 1.
Two extractors independently screened all abstracts, then screened all potentially relevant, full-text articles for final inclusion. We included randomized, controlled trials published in English of adult patients with C. difficile infection treated with medications available to clinicians in the United States. We anticipated that there would be few controlled trials for the subquestions of whether treatment efficacy differed when stratified by disease severity or strain; accordingly, for these questions we included studies of less robust design, including retrospective cohorts. We excluded studies presented only at professional meetings.
Two trained extractors abstracted study and patient characteristics and clinically relevant outcomes, including initial cure, recurrence, duration of diarrhea, and overall mortality. We used the definitions of initial cure and recurrence reported in the individual studies and recorded between-study differences. We also abstracted data on clearance of organism or toxin. When possible, we used a strict intention-to-treat analysis, defined as including all randomly assigned patients who met inclusion criteria.
We evaluated the overall strength of evidence using methods developed by AHRQ and the Effective Health Care Program (28). Evidence quality is rated as high (further research is very unlikely to change the confidence in the estimate of effect, meaning that the evidence reflects the true effect), moderate, low, or insufficient (evidence is unavailable or does not permit a conclusion). Domains evaluated to rate the strength of evidence included 1) risk for bias, 2) consistency, 3) directness, and 4) precision (28). Study quality was assessed for allocation concealment (whether treatment assignment remains unknown until randomization), blinding, and type of analysis (29).
The limited number of studies and study heterogeneity precluded a pooled analysis. Accordingly, we present qualitative summaries and data syntheses of individual studies.
Funding was from AHRQ, U.S. Department of Health and Human Services. A representative from AHRQ provided technical assistance and provided comments on draft versions of the full evidence report. The AHRQ staff did not directly participate in the literature search; determination of study eligibility criteria; data analysis or interpretation; or preparation, review, or approval of the manuscript for publication.
The search identified 1078 possible relevant articles (Appendix Figure). After initial abstract review, we excluded 1065 articles. The remaining 13 articles met eligibility criteria. Two were observational studies comparing the efficacy of different antimicrobial agents based on strain of C. difficile(30-31), whereas 11 were randomized trials evaluating different antimicrobial agents (or different doses of a single drug) for the treatment of C. difficile infection (3-8, 11, 13, 15, 17, 26. The 11 randomized trials enrolled 1463 patients and reported efficacy analysis on 1239 patients. A total of 1324 patients met inclusion criteria and had data available for an intention-to-treat analysis (Appendix Table 2). Vancomycin, the most frequently assessed antimicrobial agent, was included in 9 of 11 studies (3, 4, 6, 7, 11, 13, 15, 17, 26. Metronidazole was the next most frequently studied antimicrobial agent (5 studies) (3, 6-8, 10, followed by bacitracin (4, 15 and nitazoxanide (8, 17 (2 studies each), then fidaxomicin (26) and rifampin (with metronidazole) (10) (1 study each).
Appendix Table 2.
The 11 trials varied considerably for several characteristics, including location; methods; allocation concealment; demographic characteristics; duration of treatment and follow-up; and definitions of C. difficile infection, initial cure, and recurrence (Appendix Tables 2 and 3). Six studies were conducted in the United States (3, 7, 8, 13, 15, 17, whereas a single study each was conducted in Australia (4), Austria (6), Canada (10), the United Kingdom (11), and both the United States and Canada (26). Most studies were direct comparisons between 2 drugs (8 studies) (3, 4, 6-8, 15, 17, 26; the remaining 3 compared different doses of the same drug (13), the same drug with another antimicrobial agent added (10), or a drug with placebo (11). Table 2 documents study quality elements (allocation concealment, blinding, and presence of an intention-to-treat analysis). Although an "intention-to-treat analysis" was presented in 5 studies (4, 10, 11, 17, 26, patients were removed in 4 studies after being randomly assigned because exclusion criteria were later discovered (7, 15, 17, 26. Patients were predominantly inpatients. One study included a single infant (13); otherwise, all patients were adults. In 2 studies, all or most patients reportedly were on a surgical service (7, 11, whereas the type of service was not specified in all other studies. The definition of C. difficile infection invariably included a test for C. difficile toxin or organisms combined with diarrhea; however, definitions of diarrhea varied, and some studies required an additional manifestation of C. difficile infection, including fever, abdominal pain, or leukocytosis.
Appendix Table 3.
Table 2.
All randomized trials reported the outcomes of initial cure and recurrence, although definitions varied (Appendix Table 2). For instance, Teasley and colleagues (7) considered a patient initially cured if "diarrhoea resolved within 6 treatment days," Lagrotteria and coworkers (10) defined initial cure as the patient becoming "asymptomatic during the treatment course," whereas Zar and associates (3) defined initial cure as "resolution of diarrhea and a negative result of a C. difficile toxin A assay at days 6 and 10 of treatment." This last definition is notable for including a test for C. difficile toxin in the determination of initial cure; most studies used clinical assessment only, although 3 did incorporate C-reactive protein or peripheral leukocyte measurements (6, 8, 17. Definitions of recurrence were similar in that most required both reappearance of symptoms and a confirmatory microbiological test result; however, the duration of follow-up varied from 21 to 60 days. Authors were inconsistent in their reporting of duration of diarrhea and clearance of organism or toxin. Mortality was also inconsistently reported; 8 studies reported overall mortality stratified by treatment received, 2 reported overall mortality without specifying treatment received, and 1 reported incomplete mortality data.
The most frequently compared antimicrobial agents were vancomycin and metronidazole, which were compared in 3 studies (3, 6-7). Study size ranged from 62 to 172 patients, totaling 335, all inpatients. Dosage of study medications varied (Appendix Table 2), but duration was uniformly 10 days. Each study reported initial cure, recurrence, and mortality; however, mortality was not reported by treatment received in 1 study (6). Reports of duration of diarrhea and clearance of organism or toxin varied.
The percentage of patients initially cured with vancomycin ranged from 84% to 94% among individual studies (Figure 1); the percentage of patients initially cured with metronidazole ranged from 73% to 94%. No study demonstrated a statistically significant difference between treatments. A single study reported a prespecified subgroup analysis on patients with severe disease, with severity based on a clinical score and classification occurring before randomization (3). By strict intention-to-treat analysis of all 82 randomly assigned patients with severe disease, the percentage with initial cure was not significantly different for vancomycin compared with metronidazole (79% vs. 66%; P = 0.22), corresponding to a risk ratio for initial cure with vancomycin of 1.20 (95% CI, 0.92 to 1.57).
The percentage of participants meeting the various definitions of recurrent disease (after meeting criteria for initial cure) ranged from 7% to 17% with vancomycin (Figure 2). For metronidazole, the range was 5% to 21%. No difference was statistically significant.
Death was rare; 5 patients died in each group among the 335 patients enrolled in studies comparing vancomycin with metronidazole. Death was not reported by treatment group in 1 study, which included 2 other antimicrobial agents (fusidic acid and teicoplanin) that are not discussed here because they are unavailable in the United States (6).
Among studies that reported these outcomes, there were no statistically significant differences between vancomycin and metronidazole. Mean duration of diarrhea was 2.4 to 3.2 days, and toxin or organism cleared in 60% to 74% of patients.
Eight studies, ranging in size from 21 to 629 patients, compared metronidazole or vancomycin with a different antimicrobial agent, placebo, or the same drug with another antimicrobial added (Appendix Table 2). Two studies compared vancomycin with bacitracin (4, 15, and 1 each compared metronidazole with nitazoxanide (8), vancomycin with nitazoxanide (17), high-dose with low-dose vancomycin (13), metronidazole with metronidazole plus rifampin (10), vancomycin with fidaxomicin (26), and vancomycin with placebo (11). Dosages, therapy duration, definition of outcomes, and reporting of outcomes varied among studies. Patients were inpatients except for 3 studies with 5%, 14%, and 41% outpatients, respectively.
Figure 3 presents results of the 6 studies comparing vancomycin with other agents. Except for the study comparing vancomycin with fidaxomicin, all analyzed fewer than 60 patients. The single statistically significant difference in percentage of patients initially cured was in a study of 21 patients comparing vancomycin with placebo (11). In contrast, in the 4 comparisons of vancomycin with an active alternative regimen, the frequency of initial cure did not significantly differ between groups. Likewise, in the 2 studies comparing metronidazole with other agents, the percentage of patients initially cured did not differ significantly by treatment group (data not shown).
The percentage of patients experiencing recurrence ranged from 9% (17) to 37% (4) in individual studies. Only the comparison between fidaxomicin and vancomycin showed a statistically significant difference (15% vs. 25%; difference, −10 percentage points [CI, −17 to −3 percentage points]; P = 0.005); in all other trials, the percentage of patients with recurrence did not significantly differ. Between-trial comparisons for the percentage of patients with recurrence are of uncertain relevance because of the variable definitions of recurrence and duration of follow-up.
In 1 study (10), 32% of patients (6 of 19) receiving metronidazole and rifampin died compared with 5% of those (1 of 20) receiving metronidazole alone (P = 0.044). The authors attributed this high mortality rate to elderly patients with multiple severe comorbid conditions. In the 6 remaining studies, the mortality rate ranged from 0% to 9% and did not differ between groups.
Although authors inconsistently reported duration of diarrhea, there were no statistically significant between-treatment differences in duration among studies comparing metronidazole or vancomycin with other agents (4, 6, 7, 10, 13. In 2 studies comparing vancomycin with bacitracin (4, 15, stool specimens obtained 7 to 10 days after initiation of treatment were less likely to contain toxin (risk ratio, 1.68 [CI, 1.14 to 2.47]) or viable C. difficile organisms (risk ratio, 1.67 [CI, 1.12 to 2.49]) among patients receiving vancomycin than among those receiving bacitracin. Vancomycin was also superior to placebo for both clearance of toxin (risk ratio, 2.75 [CI, 1.17 to 6.44]) and organism (risk ratio, 8.25 [CI, 1.29 to 52.77]).
Authors inconsistently reported harms attributed to study medications, with some authors reporting only adverse events leading to cessation of therapy (3, 7, others reporting all adverse events (6, 10, 17, 26, and others including a statement to the effect that all medications were well-tolerated (11, 13, 15. One study reported unspecified serious adverse events in each treatment group, but the investigators stated that none was judged to be due to study medications (8). One study did not address harms in any way (4). The study reporting the highest mortality rates also reported the highest rates of adverse effects, with 15 of 39 patients (38%) experiencing rash, nausea, or vomiting (10). There were no statistically significant differences between treatments in any study reporting adverse events by therapy received. Four studies assessed resistance to the studied antimicrobial agents (4, 8, 13, 26; no resistant C. difficile isolates were detected. No studies assessed the development of resistance in non–C. difficile organisms (such as vancomycin-resistant enterococci).
A single trial included data on efficacy stratified by strain, which was available for 415 of 602 patients (26). Initial cure and recurrence were assessed by strain, categorized as North American pulsed-field gel electrophoresis type 1 (NAP1) vs. non-NAP1. For initial cure, no significant difference was observed between patients treated with fidaxomicin and those receiving vancomycin, regardless of strain. However, among patients with non-NAP1 strains, those treated with fidaxomicin experienced recurrence less frequently than those treated with vancomycin (10% vs. 28%; P < 0.001), whereas recurrence was similarly frequent regardless of treatment among patients with the NAP1 strain.
Because trial data addressing the effect of strain on treatment were limited, we also looked for less robust studies stratifying efficacy of treatment by strain type. We identified 2 studies that attempted to address this question. One was a prospective observational study of 52 patients receiving metronidazole or vancomycin for C. difficile infection, in which the authors categorized patients as having the "epidemic" strain (specified as NAP1) or a "nonepidemic" strain (31). In this study, in which 60% of patients had the epidemic strain, a significantly greater proportion of vancomycin recipients had resolution of diarrhea at day 5 compared with patients receiving metronidazole. However, between days 5 and 10, almost all patients who continued taking either agent had symptom resolution, and response rates did not differ between epidemic and nonepidemic strains. A larger retrospective study looked at the incidence of severe or complicated C. difficile infection during a period that included the widespread emergence of the NAP1 strain, stratified by initial treatment with metronidazole or vancomycin. From 1991 to 2002 (defined as the preepidemic strain period), vancomycin use was associated with a lower probability of developing severe or complicated C. difficile infection compared with metronidazole use, but this difference disappeared in 2003 to 2006 (defined as the epidemic strain period) (30).
We rated the strength of the evidence as moderate for comparisons of metronidazole with vancomycin for the initial cure of C. difficile infection, of fidaxomicin with vancomycin for both initial cure and recurrence, and of vancomycin compared with placebo for initial cure. We rated the strength of the evidence for the remaining comparisons as low or insufficient (Table 3); no comparison received a high rating in strength of evidence.
Table 3.
In this systematic review of antimicrobial treatment for adults with C. difficile infection, we found moderate-strength evidence that fidaxomicin and vancomycin did not differ for the outcome of initial cure but that recurrence was less frequent with fidaxomicin. We also found moderate-strength evidence that outcomes did not differ among patients treated with metronidazole or vancomycin, the two most commonly used agents. Almost all other comparisons resulted in imprecise estimates of comparative effectiveness and frequently were from a single study of relatively small size. We found insufficient evidence that vancomycin is superior to metronidazole for the outcome of initial cure in patients with severe disease, with a per-protocol subgroup analysis of a single study demonstrating a significant difference. Of the other active agents compared with metronidazole or vancomycin, we found low-strength evidence that there was no difference in the outcomes of initial cure or recurrence. Definitions and timing of outcome assessment varied between studies.
The available evidence suggests that for patients with nonsevere disease, fidaxomicin, metronidazole, and vancomycin all provide effective treatment. Recurrence is common with all agents but develops less frequently with fidaxomicin when compared with vancomycin. Whether this decrease in recurrence will lead to widespread use of fidaxomicin is unknown. Multiple factors will probably influence use, including the willingness of providers to prescribe a new medication, safety data as use becomes more widespread, local patterns of incidence and recurrence of C. difficile infection, and costs (including both drug costs and those associated with recurrent C. difficile infection).
Currently, metronidazole and vancomycin are the most commonly used drugs to treat C. difficile infection, and despite no evidence for superior efficacy in mild to moderate disease, vancomycin use is increasing (25). This increase has multiple potential causes, including the finding that both metronidazole and vancomycin have been linked to the emergence of vancomycin-resistant enterococci (32), the availability of intravenous vancomycin compounded as an oral suspension that provides a less costly alternative to vancomycin capsules (33), and an increased incidence of severe disease (22, 34. Clinicians may also be extrapolating the reported superiority of vancomycin in severe disease (3) to patients with mild to moderate disease, or may have clinical experience that influences their decision making.
The only comparative evidence for vancomycin versus metronidazole in severe disease comes from a per-protocol subgroup analysis of 69 patients in a single trial (3). Whether vancomycin was superior to metronidazole depends on the method of data analysis; a strict intention-to-treat analysis yielded no significant difference in the percentage of patients initially cured, and the authors did not report a statistical test of interaction for this subgroup. However, both per-protocol and modified intention-to-treat analyses (presented in a subsequent response (35) to several letters to the editor (36-38)) identified a statistically significant difference favoring vancomycin. Finally, this study was the only included trial incorporating toxin-detection tests into the definition of initial cure, although subsequent letters addressed this by reclassifying 2 participants who met the definition for initial cure but were toxin-positive (35-36). However, because severe C. difficile infection is associated with considerable morbidity, mortality, and costs (22, 23, 39, more liberal use of vancomycin treatment is reasonable, especially because of decreased drug costs (Table 1) and lessened concerns regarding vancomycin resistance (32).
Two other studies assessed disease severity by using different definitions, with neither showing any statistically significant difference in outcomes. Because of the low level of evidence regarding the most effective treatment of severe C. difficile infection, we recommend that future trials address the comparative effectiveness of different treatment options in patients with severe C. difficile infection, preferably with a validated and easily applied definition of severity. One such definition has been presented in conference proceedings (40), but further validation of this or other classification systems is needed.
Information on the effect of C. difficile strain on treatment response comes from a single trial and 2 observational studies (26, 30-31). In the trial, only patients with non-NAP1 strains had a decrease in recurrent disease with fidaxomicin (compared with vancomycin), whereas the observational studies provide indirect and partially conflicting data on the comparative efficacy of metronidazole and vancomycin. Although future studies in this area would be of interest, the clinical relevance of such data are currently limited because strain typing of stool isolates is rare in practice.
Few studies compared other agents with metronidazole or vancomycin. In addition to the finding that fidaxomicin use resulted in less recurrence than vancomycin, the only significant difference that emerged was the superiority of vancomycin to bacitracin for clearance of organism and toxin. The clinical relevance of this finding is uncertain because bacitracin is rarely used to treat C. difficile infection, clearance of organism or toxin in an otherwise-well patient is of unknown benefit, and assessment of multiple outcomes may lead to identification of statistically significant findings by chance.
Most studies did not show a mortality difference between study drugs, although few deaths occurred. An exception was the study that added rifampin to metronidazole, in which the mortality rate was greater among rifampin recipients. The authors clarified that 1 patient died before receiving any drug and that none of the deaths was attributed to rifampin (10). However, the higher mortality rate is consistent with another report describing increased mortality associated with use of adjunctive rifampin (41).
Limitations of the available evidence include substantial variability among studies, including the definitions used for C. difficile infection, initial cure, and recurrence, and the durations of treatment and follow-up. In aggregate, these differences make between-study comparisons difficult, and we caution against drawing definitive conclusions. Particularly problematic are the differences in initial cure definitions, because some studies used clinical assessment alone, whereas others included laboratory variables. Similarly, differences in follow-up duration make comparisons of recurrence difficult because patients followed for 60 days after treatment (15) have a longer period at risk for recurrence than do those followed for 21 days (3, 7, 8, 17. A standard approach to defining disease, outcomes, and duration of follow-up would enhance future trials of treatment of C. difficile infection by making between-trial comparisons more valid. In addition, few trials reported outcomes on all randomly assigned patients, although most provided sufficient detail as to which group the excluded patients were assigned. Finally, harms were variably reported, although it is encouraging that the more recent studies include systematic collection and enhanced reporting of harms.
In summary, we found that the strength of evidence regarding the comparative effectiveness and harms of treatment for C. difficile infection is generally low to moderate. Only a few clinical trials are available to help establish the most effective treatment for this common and serious illness, and follow-up studies to reevaluate findings from initial studies are even scarcer. We found moderate-strength evidence that fidaxomicin, metronidazole, and vancomycin are effective for initial cure and that no agent is clearly superior for this outcome. Recurrent C. difficile infection is frequent with all agents, but we found moderate-strength evidence that fidaxomicin, recently approved for this infection in the United States, leads to fewer recurrences than vancomycin for non-NAP1 strains. Although alternative agents are available, limited data available suggest that none differs significantly from metronidazole or vancomycin for any assessed outcomes. For patients with severe disease, there is insufficient evidence that vancomycin is superior to metronidazole (3).
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Martin H., Floch, Clinical Professor of Medicine
Yale University School of Medicine
December 30, 2011
Probiotics and fecal microbial transplants are treatments for Clostridium difficile infection
To the Editor:
Probiotics and fecal microbial transplants are treatments for Clostridium difficile infection.
In the December 20, 2011 issue of the Annals, the article entitled "Comparative Effectiveness of Clostridium difficile Treatments. A Systemic Review" as published by Drekonja and colleagues reports on a systemic review of antibiotic therapy but makes no mention of other treatments for recurrent and severe Clostridia difficile diarrhea infection. It is surprising that their discussion does not mention these treatments. Although there is controversy, the literature and studies in many institutions revealed that Saccharomyces boulardii and Lactobacillus GG have been reported repeatedly to be helpful in recurrent Clostridia difficile infection (1-3). Furthermore, the use of fecal microbial transplant (FMT) is now demonstrating surprising cures in patients with severe and resistant C. difficile infection. The review article published in the Annals leaves the reader with the impression that only antibiotics are treatments for this severe infection. Certainly, these other modalities of treatment, probiotics and FMT, are important and at times have been shown to be life-saving (4,5). They certainly should be mentioned at least in the discussion, and I would hope that the authors will correct the erroneous impression from this systemic review of antibiotics that only antibiotics are helpful in the treatment of Clostridia difficile.
1. Floch MH, Madsen KK, Jenkins DJA, et al. Recommendations for probiotic use. J Clin Gastroenterol 2006;40:275-278
2. Floch MH, Walker WA, Guandalini S, et al. Recommendations for probiotic use-2008. J Clin Gastroenterol 2008;42:S104-S108
3. Floch MH, Walker WA, Madsen K, et al. Recommendations for probiotic use -2011 Update. J Clin Gastroenterol 2011;45:S168-S171
4. Brandt L, Reddy SS. Fecal microbiota transplantation for recurrent Clostridium difficile infection. J Clin Gastroenterol 2001:45:S159-S167
5. Persky SE, Brandt LJ. Treatment of recurrent Clostridium difficile- associated diarrhea by administration of donated stool directly through a colonscope. Am J Gastroenterol 2000;95:3283-3295
None declared
Gastroenterology/Hepatology, Infectious Disease, Healthcare Delivery and Policy, High Value Care, Diarrhea.
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1 of 5 photos
Kiwi Whoo "Owl" BreathableSack
2 of 5 photos
Pink Hip "Hippo" BreathableSack Back of BreathableSack
3 of 5 photos
Blue Splash "Elephant" BreathableSack
4 of 5 photos
Front of BreathableSack Tag
5 of 5 photos
Tag with DATE OF MANUFACTURE 04/17/2012 and Lot No. 124
BreathableSack wearable blanket for infants
The zipper pull tabs and sliders can detach posing a choking hazard to infants.
BreathableBaby toll-free at (877) 827-4442 from 9 a.m. to 4 p.m. CT Monday through Thursday or online at www.breathablebaby.com and click on Recall Information.
About 15,000
The BreathableBaby BreathableSacks are sleeveless, wearable blankets. They come in two sizes: small (10-18 pounds) and medium (16-24 pounds) and come in three colors: kiwi Whoo, pink Hip, and blue Splash. There is one animal stitched on the left chest of each blanket of an owl, hippo or elephant. Only BreathableSacks from Lot No. 124 with a manufacture date of 04/17/2012 are included in the recall. A tag sewn inside the recalled units where the infant's right foot would be located states the "Date of Manufacture: 04/17/2012, Lot No. 124," along with the washing instructions on the back of the tag.
None reported
Consumers should immediately stop using the BreathableSacks from Lot No. 124 and contact BreathableBaby to request a replacement garment.
Various stores and online retailers, and at www.breathablebaby.com, nationwide from June 2012 to August 2013 for about $20.
BreathableBaby LLC, of Minnetonka, Minn.
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WASHINGTON — The race to construct an online insurance exchange by Oct. 1 spurred the Obama administration to use an expedited bidding system that limited its choice of a builder to only four companies, including CGI Group Inc.
Eighteen months elapsed after passage of the 2010 health-care overhaul before CGI was selected to begin work, government documents show. That left the Montreal-based vendor two years to create a website, HealthCare.gov, designed to link consumers with insurers while drawing data from a variety of U.S. agencies, including the Internal Revenue Service.
The relatively short time frame for the work and the political controversy surrounding the law probably signaled that the project was "doomed from the start," said Larry Allen, head of a McLean, Va., consulting firm.
Now, CGI and the administration are sorting out what went wrong and how to fix the site by the end of the month, when uninsured Americans will have weeks to sign up for coverage that begins in January.
"I am sure there are companies that looked at this specific opportunity and said, 'You know, I'v e got other things in the pipeline,'" said Allen, the president of Allen Federal Business Partners.
The online federal exchange was created to help the uninsured access medical coverage under the Affordable Care Act of 2010. Since the website's
Oct. 1 debut, it has been overwhelmed by software flaws, breakdowns and delays. Initially, U.S. officials blamed the turnout of millions of Americans on the first day for the problems, saying the unexpectedly high numbers overwhelmed the system.
Since then, the Obama administration has identified a number of software flaws that led to the problems, criticized CGI's handling of the work, named another software company to supervise their work and pulled in engineers from Google, Red Hat and Oracle to help get the website working smoothly by the end of this month.
In House hearings last week, Kathleen Sebelius, the secretary for Health and Human Services, and Marilyn Tavenner, the head of Medicare, both testified that CGI failed to meet expectations outlined in its contract. In earlier hearings, CGI said it got late instructions from the government to make changes to the site and that end-to-end testing, the responsibility of Tavenner's agency, didn't begin until about two weeks before launch.
CGI's choice for the job came as the result of a bidding shortcut that might have cut as much as nine months from the time usually required, said Rod Benson, a former procurement director for CMS.
"It's a greatly streamlined process," Benson said.
The decision, however, limited the companies that could bid to build the website to a pre-approved list of 16 vendors selected in 2007 for an umbrella contract to work on unspecified systems for the Centers for Medicare and Medicaid Services.
Only four of the 16 companies bid for the work, including CGI. The other bidders haven't been identified.
CGI has been paid $104 million already but while no penalties are built into its contract, Sebelius said on Wednesday that "paying for work that isn't complete is not something that we will do."
The Canadian company is due $197 million through the end of March, Sebelius said. The entire website project was budgeted to cost $630 million, said Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services.
Linda Odorisio, a CGI spokeswoman, said the company is focused on improving the site. She declined to address Tavenner's and Sebelius' criticisms.
The company's work is now being supervised by Quality Software Services Inc., a unit of UnitedHealth Group Inc.


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To recognize outstanding service by an adult or an organization for demonstrated involvement in the development and implementation of
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What is in this article?:
- House leadership lambasted for farm bill intransigence
- More drought-related assistance
- Prolonged drought has left farmers and ranchers in an increasingly precarious financial situation.
- The need to ease pressure on bottom lines is providing lawmakers with the impetus to loudly call for the full House to debate a new farm bill.
- White House announces new measures to ease drought-casued burdens on farmers/ranchers.
A prolonged drought across a wide swath of rural America has left farmers and ranchers in an increasingly precarious financial situation. And the need to ease pressure on bottom lines is providing lawmakers with the impetus to loudly call for the full House to debate a new farm bill.
Following the full Senate's passage of its farm bill, on July 11 the House Agriculture Committee passed its version of the farm bill out committee on a bipartisan vote.
For more, see here.
House leadership – Ohio Rep. John Boehner, Speaker, and Virginia Rep. Eric Cantor, Majority Leader -- has so far refused to schedule floor time for the farm bill. The bill will see no action this week and faces an unfavorable timeline for passage and conference. Following this week, only four legislative days will remain prior to Congress' August recess. Current law expires on September 30.
For more, see here.
Warnings and complaints about the consequences of not passing a new farm bill have so far left Boehner and Cantor unmoved. Proponents of the legislation hope that bringing the current drought to the argument will goad more action.
Asked during a Monday morning briefing why the House hadn't taken up the new farm bill, Agriculture Secretary Tom Vilsack wasn't charitable to House leadership. "That's a question you should direct specifically to (Boehner and Cantor). The Majority Leader indicated he had his finger on the 'pause button' the moment the farm bill passed through the Senate. (Boehner) has indicated his belief that crop insurance is all that's necessary in terms of drought assistance. But that leaves out all the livestock producers – literally hundreds of thousands of people – in the country.
"I don't know what the motivation is, what the decision-making is. All I can tell you is there's no more serious work to be done in the House between now and the August recess – or during or after the August recess – for rural America, for farmers, producers and ranchers who are struggling than getting a (farm bill) through the process…
"Whatever their reasons, they aren't good enough to justify delay," said Vilsack.
What would an extension of the 2008 farm bill mean to those hurt by the drought?
"Let's be clear: extending the 2008 farm bill will not revive the disaster programs," warned Vilsack. "Because they've expired, it would take affirmative action to revive them…
"There are budget implications connected to a continuation … of those disaster programs. That's why it's important to have it in the context of the overall (farm bill)…
"The concern and risk run as we delay every day is that the chances become greater that this gets wrapped up in a much larger conversation Congress is likely to have on tax policy and additional budget cuts. I fear agriculture will be asked to do more than its fair share."
Meanwhile, the White House is touting new measures to deal with the drought fallout.
"We announced a series of steps last week to try and provide some help and assistance: expanding emergency haying and grazing to areas designated under the Drought Monitor of D2/D3/D4 counties; additional relief on repayment on CRP (Conservation Reserve Program) payments for use of CRP land for haying and grazing; and lowered the interest rate on emergency loans and created a streamlined disaster declaration process," said Vilsack.
For an explanation of Drought Monitor designations, see here.


text: Stalin's Communications Bunker (3) tv-pg Play video Select your TV provider to log in to have full access to videos Select your TV provider See all providers Don't see your TV provider? Learn more You can access this video on the free HISTORY® app. *You must verify your TV provider towatch this video on the App Your Parental Control settings do not allow you to view this content. Stalin's Communications Bunker (3 min) tv-pg Don Wildman shows us a top secret military bunker built under Stalin's orders in 1952.


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ayo famlay!!
New album from Pragmatic Theory Collective, check it out
featuring STBB homies DJ Sapien, Jondis, and myself and a whole gangload of other dope cats yo!
please check it and share!! international compilation, this one is strong!
Pragmatic Theory Collective: Phonaesthetics
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Thom Tenery's website. His blog.
Keywords: concept spaceship video game concept art by thom tenery thomlab conceptships
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Jo Long..... :)
I have noticed she is slowly getting more face time on TV. Who knows maybe she can land a better ride for next year by the time it is all over. Although I have no idea what her contract is so not even sure it is possible.
Good to see she is getting some mentions from the media though.


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The keyword here is what-if. What if some of our favorite athletes chose a different life path somewhere along their road to professional athletics. If so, they'd probably be working at some of the stores you frequent in the local shopping malls. The Foot Lockers and Modell's Sporting Goods are a no brainer, but what about some athletes that have a more unique style or charisma.
We've complied a list of athletes and the shopping mall store that best compliments their personality.
DeSean Jackson: Foot Locker
A natural – put the zebra stripes on him and he looks exactly like every 17 year old you've ever purchased a pair of Nike's from.
Nick Swisher: Foot Action
The go-getter- his overly aggressive attitude might make a sale or crash and burn. "Bro, I could totally picture you in a new pair of these fire Reebok Zig Zags. What are you a size 10, 10.5? I'll be right back, dude." Brings back 6 boxes ranging from sizes 9-11.5.
Tim Lincecum: Zumiez
Even if the guy can't grind a rail, you can tell he's no stranger to Vans or the Nike SB collection. Don't be surprised when he disappears for an extended amount of time. Can usually find him outside in the employee smoking section.
Metta World Peace: Brookstone
Metta's qwerky personality lends itself perfectly to a role which requires you to sell a $4,000 massage chair, a wireless weather forecaster, and a motorized steam cleaning brush for your grill… all in the same day.
Shane Battier: Barnes & Noble
Three-time employee of the month, Shane Battier is known for his world class customer service. Whether you need a novel recommendation or someone to debate 19th century existentialism with, he's your guy. The Duke grad, with a religion degree, even hosts a Bible study every Wednesday night called "Out of shame with Shane."
Prince Fielder: Cinnabon
It's incredible the way this guy gets on top of a high fast ball, but what's really special is what he does with warm dough, cinnamon, and sweet cream cheese frosting.
Joe Mauer: Gap
When this clean-cut, all-American boy puts on a pair of "lived in" slim fit khakis, they practically sell themselves.<
Wes Welker: Baby Gap
Wes has been quoted saying that he simply saw a "now hiring" sign in the window and it led him to fill out an application, but rumor has it, he holds the job simply for the employee discount.<
Dustin Pedroia: Johnny Rockets
He started his Rocketeer career bussing tables, but you know this man is known for his work ethic. After just a few short weeks, he was given his opportunity to wait tables. He hasn't looked back.
Pablo Sandevol: Panda Express
Too easy.
Tom Brady: Abercrombie
While Tom fits the Abercrombie look, he's on the verge of being fired because he refuses to wear his shirt when working weekends and also insists on wearing Uggs, which is a violation of the company's "look policy." Yes that's a real thing.
Brian Wilson: Seasonal Halloween Store
It's a win-win for Brian. He only has to work 2 months out of the year and he can stock up on beard dye during the end of season sale.
Tony Parker: Perfumania
Cause he's French.
Bryce Harper: Sunglass Hut
Customer: "Excuse me, do you carry Oakley?" Bryce: "That's a clown question bro… of course we carry Oakley."
Colin Kaepernick: Lids
He has quite the collection of caps and we all know the controversy that Colin stirred up after wearing a Dolphins hat… Sorry Niners' fans, teal and orange are so in right now.
Drew Brees: GNC
If you are going to start a proper workout and supplements regimen, you better have the facts and there's no better person to learn from than AdvoCare's former national spokesman.
Birdman: Spencers
He obviously fits the bill, but his manager has told him to "take it down a notch" on more than one occasion.
Dirk Nowitski: Yankee Candle
Oh the irony! Well, the big fella fills out the apron nicely. Admittedly, Dirk struggled in the early goings at the candle shop, but he's recently come into his own and is even taking the initiative to drive change in the organization – he asks each one of his customers to sign a petition if they'd like to see a "German Chocolate Cake" scent introduced in the winter of 2014 collection.
Derek Jeter: American Eagle
DJ may have graced the cover of GQ a few times, but if you've seen his paparazzi photos, you know he's more comfortable in a pair of boot cut jeans and a comfortable sweater.
Eli Manning: Jackson Hewitt
After throwing a pick or three, Eli usually looks like he'd rather be at a desk job with reasonable hours. And the way this season is starting off, Eli might be able help open the office in early January. Note for customers: While his tax returns are a bit sloppy early in the season, this guy is a high performer the week of April 15th. Some guys thrive when the pressure is on!
Andrew Luck: Sears (Hardware Section)
Something tells us Andrew would be quick to throw on a pair of Mom jeans and help you find the perfect leaf blower or ratchet set. His "giant voice" will be a sure way to help him seal the deal for a tire rotation.
Ben Roesthilsburger: Hand Cream Kiosk Guy
He has a history of harassing girls and while he rarely gets any play, every once in a while someone is going to fall for "Ma'am, can I try something on you?"
Written by Contributing Editor: Sean O'Neal


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To print the full map detail, use the "Print" button located in the toolbar at the top right of your screen.
Locations can be a business, landmark or street address, e.g.
Tick boxes to select favourites to email or delete. Select Edit to rename or set as default.
AA Member travel benefits


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The Cardinals' Magic Number is One
Wow, I can't believe we could win the World Series tonight in front of our home crowd. I never expected the season to end up this way, and I don't think anyone really did – even the team. The resilience and heart of this team is truly inspiring. I think their confidence is shining through in all facets of their play. Of course, Detroit has self-destructed defensively, which has certainly contributed to why we're sitting with a 3-1 lead, but I hope that people won't point to that and take things away from our team. Our playoff experience has been a true advantage. We just haven't shown nervousness. We have been playing to the best of our ability – and really over our ability if you look at players like Molina and Eckstein who aren't known for their batting prowess. The team seems so relaxed, too – I've even caught Tony smiling a few times in the dugout during a game – unheard of!
My attention to the series has really been limited this week by circumstances beyond my control. I missed Games 1 and 2 due to being out of town for a wedding, and I watched Games 3 and 4 on tivo due to being swamped with a big offsite meeting at work. But tonight I have nothing to do other than come up with The Edgar Winter Dog's costume for tomorrow's Bow Wow Ween, so the game is going to get my full attention.
Come on, Cards – let's get 'er done!
3 Comments
Larry at VEB summed it up best by saying that the Cards are playing with poise; something you didn't see much of during the regular season.
"…I never expected the season to end up this way, and I don't think anyone really did…"
…well, hardly anyone😉
lets win tonight and celebrate what do you say?I am sure the cardinals may agree.i love not going to school


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Mayor Vaughn Stewart
Mayor Vaughn Stewart
P.O. Box 2168
Anniston, AL 36202
Welcome to Anniston—a city of arts and parks, of excellent public and private schools and livable neighborhoods. Led by a brand new city council and city manager, Anniston is on the move.
The Anniston Advantage means unmatched recreational opportunities, including nationally recognized bike trials, mountain climbing, and rafting. It is small town charm combined with interstate access to nearby Birmingham, Atlanta, and Chattanooga. It is a vibrant city committed to the enhancement of economic development which stands ready to accommodate the needs of new and expanded business.
Our thriving arts community exemplifies the Anniston Advantage. Home to world-class museums, concert series, and community theatre, Anniston is the region's hub for arts and culture. Our restaurants and nightlife options provide a strong entertainment base for downtown employees and local residents alike. Our historic downtown plays host to annual bike races and music festivals.
This former industrial and military city is transforming into a quality of life mecca. Community residents have rallied behind the process to create the city's first strategic plan, which will serve as Anniston's blueprint into the 21st century.
As Mayor, I welcome you to our city and invite you to discover the many great things that comprise the Anniston Advantage. We look forward to adding your business to the list.
Please contact the City Manager, Brian Johnson, at City Hall for more information at firstname.lastname@example.com or 256-236-3422.
Vaughn Stewart
"Anniston, 2015"
Written by Mayor Vaughn Stewart, and published in the Sunday, Jan. 4, 2015 edition of The Anniston Star.


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High School Nanotechnology Summer Camp Framework
This program describes a weeklong summer camp for high school students. The camp does not assume any previous knowledge of the field and thus is open to students from all backgrounds. It is hands‐on; application based and also gives a broad overview to nanoscience/nanotechnology as a field with many career opportunities. Students are able to gain a comprehensive understanding through activities that introduce them to the unique


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Reese Witherspoon through the years
Published On: Mar 21 2012 03:46:16 PM PDT Updated On: Apr 01 2015 09:13:12 AM PDT
Reese Witherspoon is nominated for Best Actress for her role in "Wild." Take a look back at her career.
The views expressed are not those of this company or its affiliated companies. By posting your comments you agree to our Terms of Use.


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Media Menu
|Research Center
The Tahuayo River Amazon Research CenterIn 2007 Amazonia Expeditions' launched its new Tahuayo River Amazon Research Center (TRARC), a long-term conservation initiative undertaken in consultation with government offices in Iquitos (Loreto, Peru), Yale University's School of Forestry and Environmental Studies, the Missouri Botanical Garden, and the Chicago Botanic Garden. Tahuayo River villages' Comite de Gestion approved the TRARC undertaking at its March 2007 meeting in return for the facility's sharing of project findings with the region's indigenous villages.
The TRARC initiative was developed to promote new collaborative projects in conservation biology, environmental studies, cultural anthropology, and more at the Area de Conservacion Regional Comunal de Tamshiyacu-Tahuayo (ACRCTT). Auxiliary support is provided by TRARC projects that bear particular promise toward helping promote sustainable developments among ribereños culture in this large and precious portion of western Amazonia. Work with TRARC scientific board members, for example, will augment villagers' knowledge of their rainforest plants, while progressively illuminating the spectacularly diverse plant communities of ACRCTT for modern science.
Primate ResearchCurrent research on primates is helping to safeguard Tamshiyacu-Tahuayo's spectacular primate fauna: 16 species representing every South American primate family and spanning the continent's range of body size. Recent observations suggest that the new approaches to conservation at ACRCTT will be important for area primates. Primate census of the trail grid was initiated in 2007 and continues to the present time. Students and tourists can choose to assist in the census or in habituation of particular social groups of each of six large-bodied species of monkeys: Cebus apella, C. albifrons, Saimiri sciureus, Lagothrix lagothricha, Alouatta seniculus, and Cacajao calvus. This work is occuring on a research trail grid located behind the TRARC. During all-day follows of particular social groups, volunteers' work includes progressively more systematic and detailed records of data for contribution to cumulative TRARC databases.
The trail grid behind the research center lodge covers 52 miles spread over 1000 acres. It is the largest trail system offered in the Amazon. It is the best hike known in the Amazon for viewing primates in their natural environment. Twelve species of primates have significant populations on the grid:
95 squirrel monkeys
170 tamarins (2 species)
90 titi monkeys (2 species)
25 brown capuchins
15 white-fronted capuchins
25 pygmy marmosets
25 night monkeys (2 species)
35 saki monkeys (2 species)
Other mammals living on the grid include: coati, tamandua, giant anteater, tapir, peccary (2 species), deer (2 species), ocelot, jaguar, paca, agouti, agouchi, armadillo, pygmy tree squirrel, Amazon tree squirrel, opossum (many species), rat (many species), sloth (2 species), kinkajou, tayra, and bat (approx 70 species).
Click here for a map of forest ecosystems represented on the trail grid.
Current and recent scientific studies.
Our motion activated night vision cameras have documented a large population of jaguar living on the trail grid as well as puma.


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Cornell Maple Marketing Webinars
September 6, 2012 —
LIBERTY, NY — Starting on Thursday, September 6, Cornell Cooperative Extension Sullivan County will offer the Cornell Maple Marketing Webinar Series at its office in the Gerald J. Skoda Extension Education Center. Webinars are presented on the first Thursday evening of the month from 7 to 8 p.m. These webinars from Cornell University are designed to help you design your retail, wholesale, bulk or other marketing strategy. Coffee and refreshments will be served. Email firstname.lastname@example.com or call 845/292-6180 to RSVP.


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Black Sateen Cotton Crop Cargo Pant
Style: 570047636
Out of Stock
Slender cargo pant has front pockets notched at a rounded corner, grosgrain ribbon trim and button tabs at rolled cuffs. 97% Cotton, 3% Spandex. Machine wash, inside out, cold. Imported.
- Sits below the waist.
- Front zip with signature silvertone shank closure.
- Silvertone and crystal rivets.
- Grosgrain ribbon trims belt loops and pockets.
- Button flap cargo pockets on the sides and in back.
- Topstitched contour seaming.
- Button tabs at rolled cuffs.
- 24" inseam cuffed; 28" uncuffed.
Read more… Read less…


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Ray Odom is radio host Crazy Ray on WRXQ-FM 100.7. He has worked at WLUP-AM, WBVS-FM, WLLI-FM and WONC-FM in the Chicago market and was morning show host at WXLP-FM in the Quad Cities. He began his radio career as an intern for Chicago radio legend Fred Winston at WPNT-FM.
North Central Now Winter 2012


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Hello, I have a baby girl who is just 11 weeks old. I've been breastfeeding her exclusively (no bottles or pacifier) since birth. I realize now that I've always nursed her to sleep and she has rarely if ever fallen asleep on her own, even in her carrier or car seat, etc.
Until she was 6 weeks old it wasn't a big deal because I could nurse her and put her down for naps and bed and she would sleep between 1 - 3 hours straight. But starting at 6 weeks (and it's been especially bad these last couple of weeks) she will only sleep for about 20 - 40 minutes for naps and is becoming very overtired.
By about 4 or 5 pm she's cranky and when I try to nurse her to sleep it can take 3 - 5 hours of constant nursing. She has very jerky movements and is in a sort of daze the entire time and every time I try to move her from my breast to my chest or to put her down she cries. I now think she might actually be partially sleeping the entire time that I'm nursing her and has now become dependent on nursing while sleeping.
Once she's finally asleep I usually go to bed with her (we co-sleep) and she'll sleep anywhere from 2 - 5 hours straight. She'll wake up a couple of times in the night and it is now taking up to 2 hours to nurse her back to sleep.
Is this normal for this age? Will she start to sleep longer and go down easier with time if I keep nursing her to sleep, or should I be trying to get her to sleep other ways (we've tried everything except letting her cry with no luck).
Also, when she's in the jerky overtired mode while nursing in the evening, is it better to wake her up fully and then try to nurse her to sleep again even if it means she cries a bit and is disoriented? Or should I just keep nursing her until she falls asleep on her own? I don't mind nursing for such a long time, I'm just wondering if this is good for her? She's in pretty good spirits for most of the day and is developing normally. Is this just a phase? How long should it take for a baby to nurse to sleep?


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As a full service Automotive Auction, we have been in business since 1969, serving many of the leading Oil & Gas and Service Companies in the disposal of their surplus fleet Cars, Trucks and Equipment. Such companies include Apache Corporation; Carter Blood Care; Champion Technologies; City of Stafford,Tx; City of Richmond,Tx; Dominican Sisters Convent; Environcon Systems;Geokinetics; Global Geophysical Services,Graco Mechanical; Jetta Operating; Oil States Energy Service; Pappas Restaurants, Inc.; Quail Valley Utility District; Scott Macon, Ltd.; Severn Trent Environmental Service; Texas Iron Works; Waukesha Pearce Industries; Weatherford; and Williams Brothers Construction, to name a few.
Our standard service includes picking up your surplus vehicles within a 700-mile radius from Houston, Texas, and transporting them to our 3-acre Auction facility located at 4621 Gasmer Drive, Houston, Texas 77035. After arrival, a detailed condition report is prepared for each vehicle. After the paperwork is completed, we determine if any minor repairs, such as a battery being replaced or if a flat tire repair is needed, and make these repairs as necessary. If more than $50.00 in repairs is required and we feel it will be beneficial to the sale of the vehicle, we will contact you for the approval to go forward with these repairs. These charges will then be deducted from the gross sales price at the time of settlement. The vehicles are then thoroughly cleaned inside and outside in preparation for inclusion in our next auction.
We conduct an auction every 4 weeks at our auction facility at 4621 Gasmer Drive, Houston, Texas 77035. In order to assure maximum exposure of your vehicles to potential buyers, an Auction flyer is mailed one week in advance of the auction to over 1000 of our permanent buyers nationwide, thus ensuring a large number of serious bidders at each auction.
After the auction, a detailed, computer-generated sales invoice is prepared for each vehicle sold. This sales invoice and a check for the net proceeds are then presented to you in exchange for the titles. We perform all title work, and copies of these transactions are kept on file for future reference.
C.J. Stommel & Associates carries substantial liability insurance as well as collision, comprehensive and workmen's comprehensive insurance. These policies take effect at the time we pick up your vehicle.
The fee for our services within the 700-mile radius of Houston, Texas is 10% of the Gross Sales Price of each vehicle sold plus a $75.00 fee for cleanup and transportation per vehicle. In the event your vehicles are located outside the 700-mile radius of Houston, Texas, we would be happy to quote the transportation charge upon your request.
By our company in effect acting as an extension of your Fleet Department, the necessity of personnel to transport vehicles to the home office, spending valuable field time in collecting and evaluating local bids, collecting and processing payment, and processing title work is virtually eliminated.
Thank you for the opportunity to introduce C.J. Stommel & Associates Automotive Auctioneers. Please feel free to call us any time with questions concerning your vehicle and transportation needs. We look forward to being of service to you.


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June 9, 2011 —
Lately, I have been lucky to encounter three different porcupines during walks in the Ten Mile River area. The passive and slow-moving woodland inhabitant is a treat to see, as its inability to flee quickly or to harm the respectful observer allow for close study of its unique characteristics.
The most obvious are its quills, which are specialized hairs, covering the upper parts and sides of its body, head and tail. One to four inches long, they are yellow, cream or white, tipped with black and lined with foam-like air cells. One porcupine can have up to 30,000 quills, with needle-shaped tips covered with hundreds of overlapping scales that slant backward and act as barbs.
According to the Pennsylvania Game Commission (PGC), when a quill lodges in tissue, actions of the victim's muscle fibers engage the tips of the scales, drawing the quill inward up to an inch a day.
Adult porcupines can grow to 30 inches in length, weigh up to 20 pounds and have a life expectancy of 10 to 12 years. They den in caves, rock crevices, hollow logs and trees, deserted fox dens, brush piles and abandoned buildings.
Porcupines can swim, are vegetarians and crave salt. As such, they may use their four orange incisors to gnaw on objects that have been in contact with human perspiration like tool handles, ropes, work gloves and leather boots.
Porcupines grunt, groan, shriek, bark and whine, especially during breeding season in September through November. Courting may include rubbing noses, chattering teeth, walking on hind feet or displaying weaving body movements. Females give birth in April, May or June to 10-inch "porcupettes" which weigh about a pound and are fully furred and able to see.
Chuck Fergus of the PGC has prepared a highly informative series of Wildlife Notes that appear on the PGC's website. See the one about porcupines at www.portal.state.pa.us/portal/server.pt?open=512&objID=9106&mode=2&PageI... [2].