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Cantley to speak at Wesleyan commencement
Dr. Lewis Cantley Jr. class of '71, American cell biologist and biochemist, will deliver the key-note address during West Virginia Wesleyan College's commencement ceremony, slated for 10 a.m. May 10 in the John D. Rockefeller IV Physical Education Center on the Buckhannon campus.
After graduating magna cum laude from West Virginia Wesleyan College, where he served as president of the Benzene Ring, Cantley earned his Ph.D. in biochemistry from Cornell University.
Upon his graduation from Cornell University, he became an assistant professor in chemistry at Harvard University, taught at Tufts Medical School for five years, and returned to Harvard Medical School where he led a lab of 30 post-doctorates and discovered a previously unknown enzyme in the human body. This enzyme, called PI3-E-kinase, provides a signaling pathway key to understanding cancer cells and is currently being used to develop treatments for various forms of cancer.
Cantley won the Jacobeaus Prize by the Novo Nordisk Foundation at the Karolinska Institute in Norway for this discovery and its role in diabetes and cancer in 2013.
Cantley ultimately became the director of Cancer Research for the Harvard Medical School, as well as director of signal pathways. He has won the award of Team Leader for Stand Up to Cancer and was featured in a 2013 issue of Time for the cover article "How to Cure Cancer."
He also was one of 11 inaugural winners of the Breakthrough Prize in Life Sciences, a $3 million award funded by Apple chairman Art Levinson, Facebook founder Mark Zuckerberg and others.
A co-founder of Agios Pharmaceuticals, Cantley is a member of the advisory board of AVEO Pharmaceuticals and the advisory board of TransMolecular, Inc. His work has been featured on national programming, including the '60 Minutes' segment "Is Sugar Toxic?"
Cantley's continued research has won him many accolades, including the Rolf Luft Award of the Karolinska Institute, Pezcoller-AACR International Award for Cancer Research, Caledonian Prize from the Royal Society of Edinburgh, Heinrich Wieland Prize for Lipid Research, and the ASBMB Advanti Award for Lipid Research. He also has been elected to the National Academy of the Sciences and the American Academy of Arts and Sciences.
Cantley will be receiving a Doctor of Science honorary degree at the commencement ceremony.


text: My daughter just turned 11months. I'm a teacher and will be done for the summer in a few days. My daughter has always slept in the same room as we do, sometimes in her crib and sometimes in our bed. I have very mixed feelings about moving her into her own room this summer. I plan to continue to nurse as long as she wants. I've noticed that I have trouble falling asleep when she's already asleep in her crib and I will toss and turn until she wakes up to nurse again. Once she's in our bed nursing I can fall asleep and will sometime leave her in the bed or put her back in the crib when she's done. I'm not sure about making the transition to her sleeping in her crib in her room. Any ideas?

subset: commoncrawl


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Native plants walk
May 5, 2011 —
DELAWARE TOWNSHIP, PA — Dr. Ann Rhoads, author and botanist, will lead a native plants walk at the Delaware Township's Akenac Park property, a part of the five-year anniversary celebration for the Pike County Scenic Rural Character Preservation Program on Saturday, May 7 from 9 a.m. to 12 noon. There will be light refreshments. The walk is free and open to the public, but registration is requested. Email email@example.com or call 570/226-3164.


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Panel rejects new massage regulations
MONTPELIER A House panel decided Tuesday against considering legislation to regulate massage therapists, introduced in response to criminal investigations last year into several spas that police believed offered sexual contact.
A trio of lawmakers introduced a bill seeking oversight of massage therapists across the state by the secretary of states Office of Professional Regulation. It calls for the licensing of massage therapists and lays out prohibitions against certain actions, including engaging in sexual activity with clients.
However, a majority of the House Government Operations Committee members said they did not favor taking up the bill this year.
Investigations took place in Bennington, Essex and Williston last year into massage parlors where local police and federal authorities believed prostitution and human trafficking were taking place. The investigations in Bennington did not result in charges, but authorities prosecuted a landlord in Williston on charges of allowing prohibited acts on his property.
The Senate Judiciary Committee is considering changes to the states prostitution laws after a Bennington County prosecutor testified this year that current law does not prohibit so-called happy endings at massage parlors.
Rep. Tim Jerman, an Essex Junction Democrat and sponsor of the bill, told the committee Tuesday that the legislation would help officials keep an eye on illicit activity that is taking place at some spas.
My interest in this bill comes from a local problem weve had in Essex Junction, a problem thats been in Chittenden County and Rutland County and other places. We have some illegal businesses, illicit businesses, and what I would characterize as sex trafficking going on, he said.
Essex Junction is considering instituting a local ordinance to prevent illicit activity in spas, Jerman said. However, that may not be the right approach, he said, for a problem that has sprouted up in several locations across the state.
I question whether this should be a town-by-town or village-by-village effort, he said. I hope that this committee, in addition to the Judiciary Committee, will be willing to talk about this.
Democratic Rep. Alison Clarkson, of Woodstock, another bill sponsor, said massage therapists in her district are interested in being regulated because they want to be differentiated from people who are not as professional.
It adds distinction and heightened professional profile, she said.
Clarkson said clients would be better served knowing that a massage therapist is licensed.
I would assume anyone who is licensed was vetted, was better, than somebody who wasnt. I would just assume that. I would never go to an unlicensed doctor, she said.
Still, she noted that the profession is divided, and not all massage therapists are eager to be regulated.
Chris Winters, director of the Office of Professional Regulation, said a study by his office in 2010 found no need to regulate the profession. However, that was before human trafficking and prostitution allegations became more widespread, he acknowledged.
The conclusion was there was not a need to protect the public from the unlicensed practice of massage therapy, Winters said. We could not find any public protection issue.
Secretary of State Jim Condos said the issues Jerman and others are looking to curb should be addressed, but not through his office.
Prostitution and human trafficking are serious criminal issues that need to be addressed by strengthening our laws and supporting our law enforcement officials, Condos said. Licensure should not be used to solve a criminal issue and would not fix the underlying problem.
@Tagline:neal.goswami @timesargus.comMORE IN Vermont NewsMONTPELIER Rep. Peter Welch, D-Vt. Full StoryVermont Attorney General Bill Sorrell plans to join the U.S. Full StoryAs Rutland prepares to welcome Syrian refugees to its community, some are continuing to voice... Full Story
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Talking Turkey
By Health Day
If you're still planning your Thanksgiving meal, we thought we'd help you out by talking a little turkey!
Here are the top 4 questions answered by USDA Meat and Poultry experts during the holiday season.
What size turkey should I buy?
Plan on one pound of turkey per person. However, if you've got a big crowd coming over, keep in mind that larger turkeys have more meat per pound every 16 ounces will feed two people.
When should I buy a fresh turkey?
If you want a fresh bird, wait until next Tuesday. Some grocery stores will let you reserve a fresh turkey, so you can try to call ahead now.
How long does it take to thaw a frozen turkey?
If your turkey is on ice, you'll need to make your move soon. The safest way to thaw a turkey is to slowly defrost it in the refrigerator, allowing one day for each five pounds of turkey. Translated, a 15 pound turkey will take three full days to defrost in the fridge. After it's defrosted, you need to plan to cook it within two days.
Finally, if you happen to have a frozen turkey on hand from last year...believe it or not, it's still safe to use. The experts say food poisoning bacteria can't grow in the freezer...and that turkey will still be in tip top shape, even after a full year in the deep freeze.
Any way you slice it, enjoy your holiday meal!
I'm Dr. Cindy Haines of HealthDay TV with the news that can help keep your family healthy.
Most Popular
Monday, December 5, 2016, Watertown, NY


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Enjoy the colour and drama of India's festive pageantry
Raksha Bandhan, North India
Raksha Bandhan or Rakhi is a Hindu sister's day when brothers and sisters reaffirm their bonds of affections. Sisters tie colourful threads or rakhis on their brother's wrists. The brothers in turn promise to protect their sisters and give them gifts. Raksha Bandhan is celebrated in different forms in different areas and it is also known by the names such as rakhi, rakhri and saluno.


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Is it up on youtube? Gonna have a look for it later
watched the latest episode, right before the Knicks got pummeled by the Bulls tonite.
this is an EXCELLENT show! as opposed to the Mike Antoni show that I couldn't bear to watch,
because I couldnt stand to see his smug face and attitude, Mike Woodson is one of the most
intelligent, caring coaches out there, and one of my favorite Knick coaches.
His rapport with Sheed has to be seen, and Alan Hahn actually does a great job interviewing
coach, and getting answers. I thoroughly enjoyed every minute of this program, and I encourage
all Knick fans to watch.
Is it up on youtube? Gonna have a look for it later
I saw some of it before the knicks game last night, good stuff from woody.
And did you see how he responded to the press after the game? He basically blamed himself, and only himself for the loss.
He said that it was "bad coaching" that lead to the loss.
Stupid reports tried to make him criticize some of our players, but he just refused to do so in such a classy manner.
Woody is brilliant at coaching, he treats the players in a smart way.
My Knicks are awesome, and this shall be the year of ultimate greatness
his winning record attests to him being right most of the time.
Sheed has been getting plenty of minutes, and Gumby has not been 100% since day one.
KT has gotten run but not really performed all that well, so you've got to trust the judgement
call of using the bigs when necessary.
I give Woody big-props for showing consistent winning B.ball to a confuse Knicks organization .. Knicks-Fans we have to be proud of Woody for doing something we havnt seen since having coach Pat Riley in MSG.
I havnt watch the Mike Woodson show on MSG channel, because the Mike Dantoni propaganda show turned my stomach to listen to a man without a plan.
I will check the Woody show after reading this thread.
Mike Woodson is a decent coach that need to man-up and start man-handling the so-call star players that were put on this roster ....
1) PG-Felton is a chucker PG that dont Gell with any of his teammates, and when faced with an oposition who have a decent PG & Center Felton is useless.
Evaluation after the first 25 games Felton earned 24 minutes of playingtime the rest of the season till he become more consistent at getting more than two teammates points, plus learn how to run a fastbreak, and put more effort on defending oposition PG.
2) SG-JR.Smith are an inconsistent chucker who need to move without the ball and learn to catch a pass while in movement, and start taking the ball inside the paint to score more than once a game, get to the free throw line more than one time every two games, run out infront of a fastbreak for a lob pass, plus learn to stay in front of oponents on defense, and switch quickly on a pick n roll.
Evaluation after the first 25 games JR minutes need to decrease to 24 minutes of playingtime too.
3) SF-Novak is a peremeter shooter who should only be put on the court at spurts with teammates who will provide Novak with double picks and double screens for open 3s.
Evaluation after 25 games Novak non-movement on offense does not get any of his defender tired or aghausted so Novak minutes should be decrease to 12 minutes of playingtime till he learn to be that 2nd screen or pick for teammates then keep it moving without the ball on offense.
4) SF-Rookie Copeland should get early minutes off the bench in the first-half in lineups with two other bigmen prefer Tyson & Kurt, or Kurt & Rasheed, or even Tyson & Melo .. Copeland is a future depth product that need playingtime with all our bigmen "Old-Heads" to prepare him for his original position at PF.
Evaluation after 25 games of mostly DNP, Copeland deserve consistent playingtime to gain confidence in self and teammates .. 24 minutes per game.
5) ???
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I saw the latest ep. Woodson does have a great rapport w the players. They really respect him. I was wrong bout this coach. He's a keeper and one of the better coaches in the league now imo. He's a real leader of men.
for those of you who do not get MSG (and miss out on the fantastic color commentary of
Clyde Frazier with most Knicks games), here is a link to the Mike Woodson show snippets.
[Only registered and activated users can see links. ]
I have watched every episode, and without doubt, he is one of my favorite coaches.
it is night and day watching him coach my favorite team, as opposed to Mike Clamtoni's
approach. Wood Son is warm, smart, sensitive, totally a player's coach, and has a
GREAT sense of humor, about himself, the team, his players, but above all, he is
a fantastic coach who is all about defense and getting the best out of his team.
props to Wood Son and the Mike Woodson show.
Really would love to be able to watch the whole thing


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2013 GMC Savana Cargo Van Values
Now offering navigation, rear park assist, rear-view camera, the 2013 GMC Savana Cargo Van has seating capacity for two and a cargo volume of 239.7 cubic ft. Engine options consist of a standard 4.3-liter V6 engine (195 hp) and an optional 5.3-liter V8 FlexFuel engine (310 hp). A 4-speed automatic transmission can be paired to standard RWD or optional AWD. Fuel mileage falls within an EPA estimated range of 13 mpg city to 20 mpg highway. Features include 145-amp alternator, satellite radio, 17-inch wheels, hands-free phone capabilities, and available remote start. Safety is comprised of advanced airbags, StabiliTrak stability control system, anti-lock braking (ABS), and tire pressure monitoring system. The Savana Cargo Van is backed by a 3-year/36,000-mile warranty.Read more Read less
Select a 2013 GMC Savana Cargo Van trim level
G1500 Van-V8
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That Plot Seems Familiar
A Thousand Acres
Aka King Lear in Iowa. A successful Iowa farmer decides to divide his farm between his three daughters. When the youngest objects, she is cut out of his will. This sets off a chain of events that brings dark truths to light and explodes long-suppressed emotions. An ambitious reimagining of Shakespeare's King Lear cast upon a typical American community in the late twentieth century, A Thousand Acres takes on themes of truth, justice, love, and pride, and reveals the beautiful yet treacherous topography of humanity.
Apocalypse Now
Retelling of Joseph Conrad's Heart of Darkness. A United States Army officer/trained assassin is sent into the depths of a southeast Asian jungle to seek out a renegade colonel and terminate his command during the Vietnam War.
An homage to Jane Austen's Emma. Cher (Alicia Silverstone) and Dionne (Stacey Dash) are pampered upper-class girls who care less about getting good grades than wearing the right clothes and being as popular as possible. But Cher also has an innate urge to help those less fortunate. Cher is looking for the perfect boyfriend, whom she ends up finding where she least expected.
Cold Mountain
Yet another take on Homer's The Odyssey. Inman, a young Confederate soldier, who is injured during the explosive 1864 battle of Petersburg, Virginia, is struggling to make his way home to Cold Mountain, NC, where his beloved Ada awaits him. In Inman's absence, Ada befriends Ruby, who helps her keep up her late father's farm. Meanwhile, in his travels, Inman encounters a menagerie of interesting and colorful characters.
O Brother, Where Art Thou?
Owes much to Homer's The Odyssey. Plus a little nod to the Preston Sturges film Sullivan's Travels. A successful Hollywood director disguises himself as a bum and sets off to see America from the bottom up. In the midst of the brutality and despair, he makes a valuable discovery-- that what the downtrodden need most is laughter.
On Beauty: A Novel
A retelling of E.M. Forster's Howard's End. Set on both sides of the Atlantic, Zadie Smith's third novel is a brilliant analysis of family life, the institution of marriage, intersections of the personal and political, and an honest look at people's deceptions. It is also, as you might expect, very funny indeed.
Based on King Lear by William Shakespeare. An aging warlord decides to split his kingdom between his three sons, who will live in three separate castles. The two eldest sons are quite happy, but the youngest thinks his father has gone mad, and predicts that it won't be long until the two older brothers are fighting with each other.
She's the Man
Based on Twelfth Night by William Shakespeare. Viola becomes furious when she learns that her high school, Cornwall, has just cut the girl's soccer team. So furious, in fact, that she takes advantage of her twin brother Sebastian skipping town for a few weeks to take his place at his school, Illyria, so she can join the soccer team there. But her disguise as her brother leads to major complications when she falls in love with her soccer-playing roommate and the girl he's in love with falls in love with "Sebastian".
State of Wonder
Female version of Joseph Conrad's Heart of Darkness. A researcher at a pharmaceutical company, Marina Singh journeys into the heart of the Amazonian delta to check on a field team that has been silent for two years--a dangerous assignment that forces Marina to confront the ghosts of her past.
Ten Things I Hate About You
Adaptation of Shakespeare's The Taming of the Shrew. Cameron is the new kid in school who becomes smitten with the beautiful Bianca. But Bianca's overprotective and domineering father forbids Bianca to date unless her older sister Kat, an surly and hostile senior, does. In a bid to get Kat a boyfriend, Cameron sets up a plan to have the school stud, Joey Donnar, bribe Patrick Verona, an outcast senior with a rumor-filled past, to take Kat out on dates so he can go to the school's homecoming dance with Bianca. However, neither Patrick or Kat expect their relationship to lead to something so much more.
The Hours
A reworking of Virginia Woolf's Mrs. Dalloway. The Hours tells the story of three women: Virginia Woolf, beginning to write Mrs. Dalloway as she recuperates in a London suburb with her husband in 1923; Clarissa Vaughan, beloved friend of an acclaimed poet dying from AIDS, who in modern-day New York is planning a party in his honor; and Laura Brown, in a 1949 Los Angeles suburb, who slowly begins to feel the constraints of a perfect family and home. By the end of the novel, these three stories intertwine in remarkable ways, and finally come together in an act of subtle and haunting grace.
The Story of Edgar Sawtelle
Hamlet with hounds. A tale reminiscent of Hamlet that also celebrates the alliance between humans and dogs follows speech-disabled Wisconsin youth Edgar, who bonds with three yearling canines and struggles to prove that his sinister uncle is responsible for his father's death.
Very carefully based on The Odyssey by Homer. Ulysses, published in 1922, is considered one of the greatest English novels of the 20th century. The book simply chronicles one day in the fictional life of Leopold Bloom, but it introduces stream of consciousness as a literary method and broaches many subjects controversial to its day.
West Side Story
Adaptation of William Shakespeare's Romeo & Juliet. This musical sets the tragedy of Romeo and Juliet against a backdrop of the rivalry of two street gangs, the Sharks and the Jets, in New York of the 1950s. A young woman who is sister to the Sharks leader has her first taste of love with the former head of the Jets.
What We Talk about When We Talk about Anne Frank
Perhaps the title sounds familiar? Like Raymond Carver's What We Talk about When We Talk about Love, perhaps? What We Talk About When We Talk About Anne Frank establishes Nathan Englander beyond all doubt as the heir to Roth, Malamud, and Babel. A tour de force. The title story, inspired by Carver's masterpiece, is a comic classic, a provocative portrait of two marriages in which the holocaust is played out as a devastating parlor game.


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Cookie Decorating Tips
Learn how to decorate cookies and work with royal icing in this video from EVERY DAY WITH RACHAEL RAY magazine. From our collection of Step by Step and Holiday cooking videos.
Hi, I'm Tracey Seaman, the test kitchen director for Everyday with Rachael Ray Magazine. Today, I'm decorating some cookies and I wanna show you a few techniques that I really like. I'm working on some Christmas trees here. The dough is raw and chilled and they're almost ready to go into the oven. I have one more to finish. I have beaten egg white here. I'm gonna lightly brush the egg white onto the cookie. Egg white is great. It helps the sprinkles adhere and leaves a nice shiny finish on the baked cookie. Just give it a nice generous sprinkling of green sugar sprinkles and it's so easy and it's really great. The next technique I have is dipping in chocolate. I have some hearts that I've already been working on. This is melted semi-sweet chocolate and the chocolate is still warm. Simply pick up the cookie in tilt the bowl and swipe the cookie in the bowl to try to get as much chocolate as you can up the surface of the heart. Then I'm gonna scrape off any excess and lay the cookie down on parchment paper. And then the last technique I wanna show you involves royal icing, which is really fun to work with because you can make it any color you want. Now I've already started outlining these cookies. I have a plastic disposable pastry bag. You can use washable plastic bags or the waxy coated canvas bags. These I really like 'cause you can just throw them away when you're done. And you're gonna use your dominant hand to stir and then your other hand to help you stay nice and calm as you go around. I'm slightly above the surface of the cookie and I let the icing drop down onto the cookie, and I'm close to the edge but about 1/8 inch from the edge. So, these have dried. I'm gonna show you how to make flow icing to fill these. It takes about 20 minutes to a half hour depending on the humidity of your kitchen for the royal icing to dry on the outside. Now you wanna make this as easy as you can because it can get kind of messy. I have a nice tall heavy glass and another pastry bag with the wider tip put on the end of the bag. I'm gonna fold the top of the bag over because this will prevent any spillage out through the top of the bag. I have the plain white royal icing here. I'm just gonna add some water to it so it'll thin out a little bit and be easy to work with. I would just start out with a couple of tablespoons of water and stir it with your rubber spatula just until it gets slightly runny. It's a good idea to use royal icing soon after you make it or cover it with plastic wrap right on the surface 'cause you don't want a crispy skin to start forming or it'll jam up the tip of the pastry bag and that'll be bad. Everyone will cry especially you. So now, I have my glass that's nice and sturdy and I'm gonna pour this right in. Then you're gonna unfold the fold. This way everything is nice and neat in the bag because if I try to fill it with the tip up like that, I could get it all out on the outside and all over my hands and it would be hard to deal with. I'm just gonna twist up the end. As you could see, it's flowing easily out of the tip. Twist the end so that the icing doesn't come out. We're just gonna go around in a heart shape. Now I'm gonna take a toothpick and use it to spread the flow icing to the edge of the royal icing. That's it. Thanks for watching.


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LOCATION IN MALL: Near SEA LIFE Arizona and guest services in neighborhood 1.
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Home List of Titles Highly ordered nanometer-scale chemical and protein patterns by binary colloidal crystal lithography combined with plasma polymerization
Please use this identifier to cite or link to this item: http://hdl.handle.net/1959.3/156536
- Title
- Highly ordered nanometer-scale chemical and protein patterns by binary colloidal crystal lithography combined with plasma polymerization
- Author(s)
- Singh, Gurvinder; Griesser, Hans J.; Bremmell, Kristen; Kingshott, Peter
- Abstract
- Surfaces with micro- and nanometer-scale patterns have many potential applications, particularly in lifescience. This article reports on a versatile, straightforward, and inexpensive approach for the creation of chemical patterns using fabricated binary colloid crystals, consisting of small and large particles, as masks for the deposition of an amino-functionalised ultrathin film by plasma polymerization. After removal of the binary colloidal mask, the characterization techniques [scanning electron microscopy (SEM) and atomic force microscopy (AFM)] reveal a surface contrast that depicts an ability of the small particles to allow diffusion of the plasma to the substrate. A plasma-polymer film is created under the small particles and the region of substrate in direct contact with the large particle remains uncoated. Numerous types of patterns and feature heights can be produced with good fidelity over areas of several cm2 by appropriate tuning of the binary colloid crystal mask morphology and the plasma-polymer deposition time. Finally, the amine groups of the patterned surface are used for covalent grafting poly(ethylene glycol) propionaldehyde (PEG-PALD) by reductive amination under conditions of reduced solubility to produce a patterned surface for directed adsorption of protein. AFM investigations show that the proteins are preferentially attached to the nanometer-scale regions of the pattern without PEG-PALD. Binary colloidal crystal lithography integrated with plasma polymerization, a versatile approach, is developed to generate highly ordered chemical nanopatterned surfaces. Several types of 2D to 3D patterned surface have been fabricated over large areas by appropriately tuning the binary colloidal mask morphology. The amine groups of the patterned surface are activated to induce the covalent binding of poly(ethylene-glycol) molecules for specific protein adsorption.
- Publication type
- Journal article
- Research centre
- Swinburne University of Technology. Faculty of Engineering and Industrial Sciences
- Source
- Advanced Functional Materials, Vol. 21, no. 3 (Feb 2011), pp. 540-546
- Publication year
- 2011
- FOR Code(s)
- 0303 Macromolecular and Materials Chemistry; 0904 Chemical Engineering; 0912 Materials Engineering
- Keyword(s)
- Binary colloidal crystals; Lithography; Plasma polymerization; Protein nanopatterning; Self-assembly
- Publisher
- Wiley-VCH Verlag
- Publisher URL
- Copyright
- Copyright © 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
- Peer reviewed


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Amir Qaseem, MD, PhD, MHA; Patrick Alguire, MD; Paul Dallas, MD; Lawrence E. Feinberg, MD; Faith T. Fitzgerald, MD; Carrie Horwitch, MD, MPH; Linda Humphrey, MD, MPH; Richard LeBlond, MD; Darilyn Moyer, MD; Jeffrey G. Wiese, MD; Steven Weinberger, MD
Disclaimer: This high-value care advice is a guide only and may not apply to all patients and all clinical situations. Thus, this advice is not intended to override clinicians' judgment.
Acknowledgment: The authors thank Dr. Douglas K. Owens for his critical review and comments.
Financial Support: Financial support for the development of this paper comes exclusively from the American College of Physicians operating budget.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2550.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.com.
Current Author Addresses: Drs. Qaseem, Alguire, and Weinberger: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Dallas: Virginia Tech Carilion School of Medicine and Research Institute, 1906 Belleview Avenue, Roanoke, VA 24014.
Dr. Feinberg: University of Colorado Health Sciences Center, 1635 Aurora Court, 13001 East 17th Place, Aurora, CO 80013.
Dr. Fitzgerald: University of California, Davis, Health System, 4150 V Street, Suite 2400, Sacramento, CA 95817.
Dr. Horwitch: Virginia Mason Medical Center, University of Washington, 1100 Ninth Avenue, Seattle, WA 98111.
Dr. Humphrey: Oregon Health & Science University, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97201.
Dr. LeBlond: University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242.
Dr. Moyer: Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140.
Dr. Wiese: Tulane University Health Sciences Center, 1430 Tulane Avenue, New Orleans, LA 70112.
Author Contributions: Conception and design: A. Qaseem, P. Alguire, P. Dallas, F.T. Fitzgerald, D. Moyer, R. LeBlond, S. Weinberger.
Analysis and interpretation of the data: A. Qaseem, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, L. Humphrey, D. Moyer, J.G. Wiese, S. Weinberger.
Drafting of the article: A. Qaseem, P. Alguire, P. Dallas, D. Moyer, S. Weinberger.
Critical revision of the article for important intellectual content: A. Qaseem, P. Alguire, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, L. Humphrey, R. LeBlond, D. Moyer, J.G. Wiese, S. Weinberger.
Final approval of the article: A. Qaseem, P. Alguire, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, L. Humphrey, R. LeBlond, D. Moyer, J.G. Wiese, S. Weinberger.
Provision of study materials or patients: A. Qaseem.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, P. Alguire.
Collection and assembly of data: A. Qaseem, P. Alguire, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, D. Moyer, J.G. Wiese, S. Weinberger.
Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149. doi: 10.7326/0003-4819-156-2-201201170-00011
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Published: Ann Intern Med. 2012;156(2):147-149.
Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests—meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions
to promote high-value, cost-conscious care.
Health care costs in the United States are increasing unsustainably: from $253 billion in 1980, to $714 billion in 1990, to more than $2.2 trillion in 2008 (1). In 2008, U.S. health care spending accounted for 16.2% of the nation's gross domestic product (GDP) and was approximately $7681 per person (1). Employee contributions to health care premiums have increased by nearly 150% in the past 10 years (2). The increase in costs has placed great strain on family, employer, and government budgets.
Although many factors have contributed to the increase in health care costs (3), new drugs, devices, procedures, and tests are the primary drivers of increased health care spending. However, because biomedical innovations are also often key factors in improved patient outcomes (4), it is critical that we use testing and medical technology judiciously and assess whether potential benefits justify the costs.
The distinction between cost and value is essential (5). A high-cost intervention may provide good value if its net benefits (the extent to which benefit outweighs harms) is large enough to justify the costs. Examples of expensive but high-value interventions include antiretroviral therapy for HIV infection and implantable cardioverter-defibrillators in patients who meet the clinical criteria for the therapy and have a reasonable expectation of survival with good functional status for more than 1 year (5). Conversely, low-cost interventions may provide low value if they have little or no net benefit. Examples of a low-cost, low-value tests include annual Papanicolaou smears (compared with Papanicolaou smears every 3 years) for low-risk women and preoperative chest radiography in asymptomatic, healthy persons. Because high-cost interventions may provide good value and low-cost interventions may not, efforts to control costs should focus on value rather than cost alone. The American College of Physicians' definition for high-value care stipulates that the health benefits of an intervention justify its harms and costs (5).
In light of increasing health care costs as well as overuse and misuse of tests and treatments, some have called for organized medicine to identify a list of "top 5" tests or treatments that are commonly overused (6). The American College of Physicians convened an ad hoc workgroup of experienced internal medicine physicians with the goal of identifying common screening and diagnostic tests relevant to internal medicine that they believe are commonly overused. Workgroup members represented a variety of internal medicine specialties, an array of practice environments, and diverse geographic locations in the United States. All members of the workgroup disclosed potential conflicts of interest.
Each member of the workgroup was asked to identify screening or diagnostic tests that he or she believed are commonly used in clinical situations where they are unlikely to be of high value. Workgroup members' initial suggestions were collated into a single document, and each member then provided an opinion about whether the candidate test represented a real-world example of a clinical situation where the target screening or diagnostic test was frequently used in a manner that resulted in low-value care. If the candidate test received unanimous support from the workgroup (all "yes" votes), the group retained the test in the list. If at least two thirds of, but not all, work group members supported a candidate test, the group discussed the test. If the group achieved unanimous consensus about the discussed test, was retained. If not, it was removed from the list. This process resulted in a list of 37 tests that the workgroup believes clinicians often use in a manner that does not reflect high-value, cost-conscious care and does not adhere to currently available clinical guidelines (Table).
Table. Clinical Situations in Which a Test Does Not Reflect High-Value Care
A careful assessment of benefits, harms, and costs of a diagnostic test to determine its value is critical to preserving quality of care while reducing costs. Appropriate use of screening and diagnostic tests is an important component of providing high-value health care because these tests are an important driver of costs. The high-value care suggestions (Table) are informed by systematic reviews and guidelines about the use of specific tests, and in part by general principles for appropriate use of diagnostic tests (7, 8). The first such principle is that diagnostic tests usually should not be performed if the results will not change management. For example, chest radiography 4 weeks after diagnosis of pneumonia in a patient who has responded clinically to treatment will not affect management because resolution of radiographic abnormalities may take as long as 6 to 8 weeks. In this situation, the test incurs costs but provides no benefit to the patient. We should discontinue the use of diagnostic tests that provide little or no benefit and can be classified as low value.
The second general principle is that when the pretest probability of disease is low, the likelihood of a false-positive test result is higher than the likelihood of a true-positive result. For example, a positive exercise stress test result in an asymptomatic 45-year-old man is more likely to be a false-positive result than is a positive result in a 55-year-old man with chest pain on exertion that resolves with rest. False-positive results are of concern because they often lead to further testing, which may be expensive and potentially harmful. They may also create anxiety for the patient and may lead to inappropriate treatment.
Finally, it is important to note that the true cost of a test includes not only the cost of the test itself but also the downstream costs incurred because the test was performed (5). For example, an exercise stress test in an asymptomatic patient may result in a false-positive finding that leads to cardiac catheterization, with its attendant costs and risks, but with no proven benefit. Thus, a seemingly inexpensive test can result in substantial costs because of subsequent testing, treatment, or follow-up. In assessing the costs of a diagnostic test, we must consider these downstream costs and savings.
The goal of this consensus-based exercise was to identify common clinical situations in which there are opportunities to both improve care and decrease expenditures by reducing the use of diagnostic tests that are unnecessary and do not improve patient care. The workgroup believes that in these 37 identified situations, more testing is not better but rather may provide no benefit or may be harmful. We hope that this list will promote thoughtful discussions among physicians, patients, and other stakeholders about how to apply medical technology in a manner that promotes high-value, cost-conscious care. We welcome comments on this list to refine and possibly expand it. The Clinical Guidelines Committee of the American College of Physicians has begun to address some of these situations in more detailed articles that fully analyze the evidence for the misuse, benefits, and harms of the individual interventions (5, 9).
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Zackary D.Berger, Assistant Professor
Johns Hopkins University School of Medicine
January 17, 2012
Qaseem et al. provide an important first step - where do we go from here?
To the editors,
The Good Stewardship Working Group of the National Physicians Alliance applauds Qaseem et al. (1) for their identification of screening and diagnostic tests which, when misused, discourage high-value, cost- conscious care. Physicians should be at the forefront of identifying inappropriate procedures, and such a consensus list represents an important contribution to this effort.
As was mentioned in the accompanying Annals editorial (2), our group used a similar consensus method to agree on "top 5" lists of inappropriate testing in several specialties, including internal medicine. (3) Based on our experience and the present Annals article, two further steps come to mind.
First, professional organizations should continue to identify inappropriate procedures (perhaps through regular member polling on-line), update and disseminate such lists, and bring them to the attention of policy makers. Second, our health care system should be realigned to reduce such waste. How to accomplish these steps is a topic for further discussion, which Qaseem et al. have made possible.
Zackary Berger, MD, PhD Johns Hopkins General Internal Medicine for the Good Stewardship Working Group
1. Qaseem A et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med 2012;156:147- 149.
2. Laine C. High-Value Testing Begins With a Few Simple Questions. Ann Intern Med 2012;156:162-163.
3. Good Stewardship Working Group. The "Top 5" Lists in Primary Care: Meeting the Responsibility of Professionalism. Arch Int Med 2011;171(15):1385-1390.
None declared
Patrick O.Oben, Resident
John H Stroger Hospital, Chicago, IL
January 18, 2012
One suggestion
Thank you for this thought-provoking work. It rightfully made me to consider my own ways in the hospital.
I have one suggestion to make for future versions of this work that may increase its clinical impact, at least from my perspective. I would suggest that the methodology of this work and the Suggested Principles address at least some of the major causes of inappropriate use of tests. Observing physician behavior and making suggestions based on observed behavior alone as portrayed in the methodology of this current work seems to leave out, if not underestimate, the value of the causes of these inappropriate clinical behaviors. There are reasons why physicians order lab tests, whether explicit or implicit.(1) If there is an inappropriate action because of a addressable cause, the impact of the suggestion would be considerable greater if it addresses both the observed action and the cause than if it merely suggest what should have been done.
An example is that of one of the minor causes of inappropriate use of tests is defensive medicine, which has been shown to the reason for performing about 5% to 10% of diagnostic tests and resulting in an annual cost of about $9 billion to $18 billion annually in the United States.(2,3,4) Suggesting to an Emergency Department Physician who is inappropriately ordering routine CT angiogram to rule out pulmonary embolism in a low risk patient presenting with chest pain for fear of malpractice lawsuit without professionally addressing the driving cause would clearly have minimal effects. This is just an example to illustrate the cause-behavior-suggestion proposal above.
1. Wertman BG, Sostrin SV, Pavlova Z, Lundberg GD.Why do physicians order laboratory tests? A study of laboratory test request and use patterns. JAMA. 1980 May 23-30;243(20):2080-2.
2. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005; 293:2609-17.
3. Defensive Medicine and Medical Practice. Publication OTA-H-602. Washington, DC: Office of Technology Assessment, US Congress, Jul 1994.
4. Anderson RE. Billions for defense. Arch Intern Med. 1999; 159:2399 -402.
Erik A.Wallace, MD, Associate Professor, John H. Schumann, MD, Associate Professor, University of Oklahoma School of Community Medicine
University of Oklahoma School of Community Medicine
January 19, 2012
Appropriate Use of Screening and Diagnostic Tests to Foster High Value, Cost-Conscious Care
TO THE EDITOR: As discussed by Qaseem et al (1), unnecessary testing ordered by physicians contributes to a significant proportion of increased health care spending. Although we agree that the 37 tests listed do not reflect high-value care, some of these tests, plus additional low-cost, low-value tests, are available for purchase by patients through commercial companies. These tests, including a variety of blood tests and ultrasounds, are being marketed to the general public as a way to find disease before symptoms present so that patients can avoid experiencing a catastrophic illness. Although patients can assess their risk for illness and whether a test is "indicated, " patients are encouraged to "consider" purchasing tests despite being asymptomatic and lacking other characteristics that would meet indications for the test based on current published guidelines. For example, if a patient is less than age 50 years and smokes but has no other clinical symptoms or risk factors, they are asked to "consider" purchasing an ultrasound of the carotid arteries and aorta (2), although the USPSTF clearly states that these tests, with moderate to high certainty, have "no net benefit or that the harms outweigh the benefits" in this particular patient (3,4). Also, the more tests that patients can purchase as part of a package, they more money they can theoretically "save."
In the accompanying editorial, Laine (5) provides a list of questions to help physicians judiciously order tests. This is certainly helpful if patients ask their physician beforehand whether they should purchase commercial screening tests. However, if patients have already purchased these tests and have obtained an abnormal result, then they likely have a different set of expectations and may be more insistent on additional testing or treatment that will certainly add additional cost, and potentially result in harm.
"Patient expectation can be a powerful force in promoting testing." (5) Commercial companies who sell unnecessary screening tests are creating a false sense of patient expectations that catastrophic illness can be avoided without ethically discussing the potential risks and lack of benefit of these tests. Direct-to-consumer advertising of commercial screening tests makes the goal of practicing high-value, cost-conscious care even more challenging.
1. Qaseem A et al. Appropriate Use of Screening and Diagnostic Tests to Foster High Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147- 149.
2. Life Line Screening. The power of prevention. http://lifelinescreening.com. Accessed on January 19, 2012.
3. U.S. Preventive Services Task Force. Screening for Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2007; 147:854-859.
4. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm. Ann Intern Med. 2005; 142:198-202.
5. Laine C. High-Value Testing Begins With a Few Simple Questions. Ann Intern Med. 2012;156:162-163.
Ronald N.Levy, MD
January 31, 2012
Fuller Disclosure of Health Benefits Needed
To the Editor:
Regarding your criticism of diagnostic tests, how about fuller disclosure on the question of "whether a test provides health benefits that are worth their cost?"
Postitive test results can save lives so should critics of tests consider not only test costs but also disclose what they estimate to be the value of lives saved?
Negative test results can in many cases reduce worry and increase quality of life so should "less testing" advocates disclose what value they ascribe to fear relieved and QoL enhanced?
Telling a patient "you don't need" a requested diagnostic test is like saying "you don't need a tranquilizer, mood elevator or annual check- up: if the patient doesn't die, the test wasn't needed for survival but is this the quality of medicine that doctors would want for their own families?
Just as hospitals can seem to "save" money by reducing staff and equipment, doctors can "save" by reducing tests but should doctors disclose to patients that such reductions may reduce overall survival and reduce peace of mind?
If America's hospitals sometimes keep on life support for days many hopelessly comatose patients including some who are brain dead, should these hospitals withold tests that could save lives and mental strain of brain-alive patients, providing drug-free tranquility?
If hospitals bear the cost of providing space for chapels and comfortable waiting rooms despite no clinical proof that these benefits are "worth their cost," should hospitals consider that if expert insurers are willing to pay and informed patients are eager for an annual test, the tests also provide benefits?
Should guideline groups like NCCN reason that if patients have a choice of whether to have surgery or other therapy that may help them, patients should also be allowed diagnostic tests that may also help and cost much less?
This patient question-"Can you reassure me that we have explored all the options" is suggested by The Wall Street Journal of 1/17/12 under the headline, "What to Ask When Seeking a Second Opinion." Would it make sense for diagnostic options to be presented by the first doctor entrusted with a patient's life and peace of mind?
Respectfully, Ronald N. Levy
Frank J.Rybicki, MD, PhD, Michael A. Bettmann, MD, Paul A. Larson, MD, Harvey L. Neiman, MD
February 2, 2012
Enthusiastic support
The paper by Qaseem et al, "Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care" (1), identifies common clinical situations for which screening and diagnostic tests may have limited utility. The American College of Radiology (ACR) enthusiastically supports the work of the American College of Physicians (ACP) in this arena. The ACR Appropriateness Criteria? (ACR AC) are clinical imaging guidelines that begin by asking: if I think an imaging study may be valuable in this specific clinical setting, which, if any, should be selected? The 20 ACR AC organ system-based panels span diagnostic and interventional radiology and radiation oncology; the AC use the best available peer-reviewed evidence and widely accepted, reproducible methodology to cover 850 specific clinical variants, and are freely available online (2). Each panel is composed of both private practice and academic radiologists with diverse representation in all relevant modalities, supplemented by non-radiologist representatives from other societies. Each variant is updated at no longer than two-year intervals.
Based on our experience with producing and deploying the ACR AC, we are not surprised that 20 of 37 highlighted situations are related to imaging (13 primarily in radiology, 7 in cardiology). All of these clinical situations can be mapped to specific ACR AC. We believe that more widespread implementation of these guidelines will foster high-value, cost -conscious care.
The clinical situations that focus on imaging have varying complexity that influences implementation. One good example is the evaluation of patients with low back pain. The most recent (October 2011) ACR AC release (2) includes five variants of this topic. At one end of the spectrum, no imaging is appropriate for patients without specific, defined "red flags". Conversely, for patients with specific risk factors, such as cauda equina syndrome, or advanced age and osteoporosis, specific imaging tests are usually appropriate. The use of sound evidence-based clinical guidelines in this and other examples discussed can and should direct practice to more rational, less costly approaches that both improve resource utilization and limit unnecessary radiation exposure, two major public health concerns.
Qaseem et al thoughtfully and meaningfully identify at-risk clinical situations that require high-quality guidelines to encourage appropriate use. The ACR AC provide the best available guidance for imaging studies. The ACR is committed to collaboration and distribution of specific guidelines for imaging that improve cost conscious appropriate use of imaging, since both over- and inappropriate use occur. We enthusiastically support the ACP effort to promote good stewardship of finite health care resources while improving care.
Frank J. Rybicki, MD, PhD Michael A. Bettmann, MD
Paul A. Larson, MD
Harvey L. Neiman, MD
1. Foster High-Value, Cost-Conscious Care. Ann Intern Med 2012 Jan 17;156(2):147-149. PMID: 22250146.
2. American College of Radiology. ACR Appropriateness Criteria?http://www.acr.org/SecondaryMainMenuCategories/quality safety/app criteria.aspx
James R.Johnson, MD
Infectious Diseases, Minneapolis VA Medical Center
February 7, 2012
Urinalysis and Urine Culture Testing Omitted
To the editor:
The clinical situations identified by Qaseem et al. in which a test does not reflect high-value care omitted what may be the most frequently misused infectious disease screening tests of all, the humble urinalysis and urine culture [1]. Such testing is almost always inappropriate when performed in patients without clinical manifestations of overt urinary tract infection, especially if positive results are interpreted as indicating the presence of urinary tract infection in need of treatment [2, 3]. Although the cost per test cost is low, the enormous numbers result in substantial aggregate costs. More importantly, unnecessary and potentially toxic antimicrobial therapy often follows the detection of (clinically irrelevant) asymptomatic pyuria or bacteriuria, which are quite common, especially among elderly, functionally impaired, and urinary -catheter-using patients [2, 3]. It would be of interest to know whether the work group considered these tests for inclusion in their list but rejected them (and if so, why), or did not even consider them, which would not be surprising, given their ubiquity as unrecognized drivers of gratuitous antimicrobial therapy.
James R. Johnson, MD Infectious Diseases (111F) Minneapolis VA Medical Center
1. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012;156:147-9.
2. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.
3. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambyah PA, Tanke P, Nicolle LE. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63.
I have received research support from Merck, Inc.; Rochester Medical Group; and Syntiron.
Robert C.Schutt, Resident
University of Virginia
The Evolving Role of Brain Natriuretic Peptide in the Management of Acute Decompensated Heart Failure
I would like to commend Qaseem et al. (1) on their recent efforts to identify diagnostic tests that are used in situations where they are not likely to be of high value. One of the clinical situations (#9) that the working group felt did not represent high value care was obtaining a brain natriuretic peptide level (BNP) on the initial evaluation of a patient who presents with the typical findings of heart failure.
Although BNP is classically used to help differentiate symptom etiology when uncertainty exists, there is an emerging and exciting role for BNP use in helping guide management of acute decompensated heart failure. Two recent large studies found that both the absolute value of BNP at discharge (2) and the percentage reduction during hospitalization (3) predicted death or readmission in patients admitted with heart failure and is superior to clinical variables alone. This recent evidence combined with prior work suggests that measurement of BNP may have an important role as an element of discharge criteria for patients admitted with acute decompensated heart failure.(4) In fact, BNP may be a significantly more cost-effective alternative when compared with echocardiography for risk stratification in patients admitted with heart failure.(5)
Although use the of this biomarker solely to confirm the diagnosis of heart failure in a patient where no diagnostic uncertainty exists is clearly not cost conscious, it is important to at least be aware that there is an evolving role for this biomarker in the management of acute decompensated heart failure and there is promising research that suggests an active role for this biomarker in potentially reducing readmissions for heart failure.
Rob Schutt, MD (email@example.com)
Department of Medicine
University of Virginia
1. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156(2):147-9.
2. Kociol RD, Horton JR, Fonarow GC, Reyes EM, Shaw LK, O'Connor CM, et al. Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE -HF) linked to Medicare claims. Circ Heart Fail. 2011;4(5):628-36.
3. Di Somma S, Magrini L, Pittoni V, Marino R, Mastrantuono A, Ferri E, et al. In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study. Crit Care. 2010;14(3):R116.
4. Caldwell MA, Howie JN, Dracup K. BNP as discharge criteria for heart failure. J Card Fail. 2003;9(5):416-22.
5. Dokainish H, Zoghbi WA, Ambriz E, Lakkis NM, Quinones MA, Nagueh SF. Comparative cost-effectiveness of B-type natriuretic peptide and echocardiography for predicting outcome in patients with congestive heart failure. Am J Cardiol. 2006;97(3):400-3.
AmirQaseem, MD, PhD, MHA, Patrick Alguire, MD, Steven Weinberger, MD, American College of Physicians
American College of Physicians, 190 N. Independence Mall W. Philadelphia, PA 19106
March 6, 2012
Overused Diagnostic and Screening Tests
We thank Dr. Rybicki and colleagues and Dr. Berger for their comments and their encouragement for this effort [1]. We strongly agree that professional organizations have an opportunity to play a critical role in reducing health care costs while maintaining, if not improving, the quality of care by educating physicians to avoid overuse and misuse of care. The American College of Radiology (ACR) and the National Physicians Alliance have indeed been leaders in this effort through the development of the Appropriateness Criteria for imaging studies and the efforts of the Good Stewardship Working Group in identifying several "top 5 lists" [2,3].
We believe Dr. Johnson's example of urinalysis and urine culture as overused tests is a good one that likely should have been included on our list. The list is not an exhaustive one, and a goal in developing it was to promote thoughtful discussions among all stakeholders (clinicians, patients, policy makers, etc.) regarding this issue. Consequently, we are pleased that the article has stimulated identification of other areas of screening and diagnostic testing that we missed.
In response to Mr. Levy, we must stress that our primary goal is to promote the best care for patients, which means providing testing and treatment that is of value, when weighing the benefits against the harms and costs of a test or treatment. Saying that "negative test results can in many cases reduce worry" is looking at only one side of the coin, as it does not consider the problems posed by false negative as well as false positive tests. This is just one reason why it is incumbent upon physicians to use the best available evidence and for patients to be informed partners in decision-making.
Authors: Amir Qaseem, MD, PhD, MHA American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
Patrick Alguire, MD American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
Steven Weinberger, MD American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
1. Qaseem A, Alguire P, Dallas P, Feinberg L, Fitzgerald F, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese J, Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012; 156: 147-149.
2. American College of Radiology. ACR Appropriateness Criteria. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/Overview.aspx
3. Good Stewardship Working Group. The "top 5" lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390.
Cardiology, Pulmonary/Critical Care, Healthcare Delivery and Policy, Cardiac Diagnosis and Imaging.
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Seatless Spring Training Crusade: Orioles vs Red Sox 3/20/10
Driving two-and-a-half hours to a game that I did not have tickets for was actually familiar territory. Last year, during Spring Training, my mother and I drove up to Jupiter, FL to catch a Red Sox vs Marlins Spring Training game. I bargained for the tickets myself, and I probably paid twice the actual price. You can read about that day here.
10 Comments
Nice article, Elizabeth. I decided to choose to root for the Red Sox this year instead of the Rays after all (Long story, if you're bored one day you can ready about why in my blogs first post.)
I wanted to say excellent writing as usual. It was nice Bowden remembered you and as a writer I know that special feeling a person gets when guys like Bowden remember your WRITING too.
I'm looking forward to your post about your first trip to Fenway (my wife and I went for the first time last year the day Papi finally hit that first home run of the season vs. Toronto. Just about every other Red Sox player jacked one out that night too), and the "top 10 reasons why you never go to a ball game with Elizabeth" to see if it is comprable to mine.
Later, kid. Keep up the excellent work.
~ Will
So Elizabeth, exactly how old IS this jar of salsa that you're carrying around to ST games? We've done standing room tickets twice, once at a game in Detroit, and once for a Phillies playoff game in '07. It's not something I'd do again – both games stayed packed till the last inning or two, so our feet were absolutely in agony! Sitting behind home plate is kind of fun, but it's not very good for photography, so I usually try to avoid it, and sometimes looking through the net the whole time makes my eyes go loopy!
Rants, Raves, and Random Thoughts
Your grandparents live in Stuart? I wish they (and, of course, you) had come to my talk at the library last week. Oh well. Sounds like you had yet another spring training adventure. Very cool that Bowden remembered you in such a specific way. By the time you're a pro covering the team, you'll have excellent contacts!
That's awesome that Bowden remembered you and checked out your blog. Must have made you feel good. Keep enjoying the games with freinds and family-that's what it's all about.
it was a colllege baseball game, the season started a few weeks ago if thats what you were asking lol. Anyways another great blog, Bowden must of thought so as well to.
Sounds like you had a great time. It was very nice of Bowden to talk to you, what a super guy.
Spring Training is so freaking great. Great job with the blog. Keep it up.
The Three Bs
My blog is not as wholesome and innocent (Which I love) as yours but you should find it entertaining.
the good times keep rolling for you. im glad its been a great spring. i bet those seats were awesome for good views of Wakefields pitches. there was a special on ESPN last sunday about Tim and the pitchers who were famous for throwing knuckleballs. including my very distant relative phil niekro. (he really is related to me somehow, was an honored guest at his induction in 1998)
Outstanding! I see you're educated on the "code"….very nice! I actually laughed out loud reading that one. Looks like you're having a spectaular time and the pics are dynamite!
Amazing how a small simple act of kindness like that of Bowden's could be a key role to your future, it's great that he read your blog and remembered you as well, great stuff Elizabeth….
Outside the Phillies Looking In


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Hollywood Insider1 of 12
Awards season is in full swing, with the Oscars just days away. Sure, we all tune into watch the red-carpet fashions and the big winners, but the afterparties are reserved for VIPs only. That is, until now. Here's a peek inside this year's hottest awards show afterparties and our suggestions to achieve the stylish design elements in your own home.
Award-Winning Eats2 of 12
After a long day of walking the carpet and smiling for cameras, the TNT/TBS Broadcasts The 17th Annual Screen Actors Guild afterparty was held at the Shrine Auditorium following the January 30th award show. Celebs dined on clear glass chargers dipped in gold trim, accompanied by gold-trimmed champagne flutes atop a black-and-gold runner.
SHOP NOW: Gold Chargers
Red-Carpet Relief3 of 12
Jon Hamm and Christina Hendricks of Mad Men nibbled on fresh shrimp, oysters and lobster at the AMC's 2011 Golden Globe Awards Party. The wall of wine offers a great, vintage backdrop to the buffet and complements the retro style of the show.
SHOP NOW: Wooden Wine Rack
Front-Row View4 of 12
The casts of 30 Rock and The Office partied the night away at the NBCUniversal/Focus Features Golden Globes Viewing and After Party outfitted with an all-you-can-drink bar and tassled chandeliers. While you may not have the space for this kind of sweeping bar, take note of the layout for your next bash.
SHOP NOW: Barware
Best Drama5 of 12
During the seated dinner portion of the evening, NBCUniversal/Focus Features guests enjoyed the black-and-white motif illuminated with the colors of the NBCUniversal logo. The stark contrast added drama to the tented affair, and can be simulated on a smaller scale with black-and-white furniture mixed with pops of color accents.
SHOP NOW: White Chair
Made for TV6 of 12
One accent we loved at the NBC bash was the oversize black lampshade chandeliers. Illuminated on the oval-shaped fixture are mod chandelier images which are playful and a recession-friendly version of real crystal chandeliers.
SHOP NOW: Black Lamp Shade
Supporting Actor7 of 12
Simplicity was in vogue at Dewar's Weinstein SAG After Party at Sunset Towers. The already-elegant taupe and cream space was simply enhanced with yellow orchids and tulips set at every table to complement the amber-colored whiskey.
SHOP NOW: Yellow Orchids
Relaxed Glamour8 of 12
Aiming for a luxurious outdoor/indoor living room space, the Weinstein/Relativity Media Golden Globe Awards After Party achieved an earthy elegance with tufted sofas in pea-green and distressed leather ottomans illuminated by linen lighting.
SHOP NOW: Tufted Sofas and Round Linen Ceiling Lamp
Natural Beauty9 of 12
What set this afterparty apart from the rest was its use of rugged-yet-refined wooden decor. From buffet-style tables to accent chairs and stools, the wood was highlighted by warm (electric) candlelight and potted palms.
SHOP NOW: Wooden Table
Sipping Pretty10 of 12
In addition to the champagne flowing freely, the Fox Searchlight 2011 Golden Globe Awards Party featured a specialty cocktail, thanks to Patron. Casts from two of the year's biggest films, Black Swan and 127 Hours, sipped on Searchlight Lemonade, a perfect blend of Patron Silver Tequila and cucumber mint lemonade.
SHOP NOW: Pilar Stemware and Patron Tequila
Fantasy Island11 of 12
Bright and tropical are the two words that come to mind with the decor of HBO's Golden Globe Awards After Party at the Beverly Hilton hotel. The hotel's poolside area was transformed with bold, modern colors and lights, with rings of fire floating in the water.
SHOP NOW: Floating Pool Candles
Green Party12 of 12
The Pucci-inspired print that was projected through the HBO bash and covered the table and chair decor is a bold choice for a party but definitely sets it apart from all the rest. Take a cue from HBO, and go all out for your next party with color and whimsy.
SHOP NOW: Tablecloths


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Home List of Titles Salinity and erosion: a preliminary investigation of soil erosion on a salinized hillslope
Please use this identifier to cite or link to this item: http://hdl.handle.net/1959.3/224881
- Title
- Salinity and erosion: a preliminary investigation of soil erosion on a salinized hillslope
- Author(s)
- Neave, Mel; Rayburg, Scott
- Abstract
- This study aims to determine whether increasing soil salinity levels promote higher rates of runoff induced erosion. Rainfall simulation experiments, with an average intensity of 75 mm h-1, were conducted on eight 1-m2 runoff plots in central New South Wales, Australia. A cross-design method was adopted using three soil salinity levels (low, medium and high) and two vegetation covers (<10% and >30%). Multiple regression analyses reveal that the sediment concentration of runoff is positively related to soil salinity levels and negatively related to vegetation cover (R 2 = 0.688; p > F = 0.048), suggesting a causal link between soil salinity and sediment mobilization. The results of this study will provide useful information to land managers seeking to redress salinity issues in terrestrial and aquatic ecosystems.
- Publication type
- Conference paper
- Source
- Proceedings of the Sediment Dynamics and the Hydromorphology of Fluvial Systems symposium, Dundee, Scotland, 02-07 July 2006 / John S. Rowan, Robert W. Duck and Alan Werritty (eds.), Vol. 306, pp. 531-539
- Publication year
- 2006
- Keyword(s)
- Computer simulation; Electrical conductivity; Hillslope erosion; Precipitation intensity; Rainfall simulation; Runoff; Salinisation; Salinity measurement; Soil erosion; Soils; Vegetation cover
- Publisher
- International Association of Hydrological Sciences Press
- 0144-7815 (series ISSN)
- 9781901502688, 1901502686
- Publisher URL
- Copyright
- Copyright © IAHS Press.
- Peer reviewed


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Outta Here!
Many baseballs left the ballpark today, as well as many players. Marcus Giles, who batted only .167 this spring, was given his release today. This was the best option for Giles who would not see a lot of action in the minors; this way, he has a chance to move on to another team. John Mayberry Jr. and Carlos Carrasco were both optioned back to the minors. Mayberry started off hot in camp this year, but struggled as the pitching became more difficult. He needs some more work to be big league ready, as does Carrasco. Three other players were told officially they would not make the team's 25-man roster, but they will stay with the Phils until Saturday to give Charlie Manuel a few more options during the On Deck Series. The three players are Philadelphia native, Mike Koplove, RHP; 2nd baseman Pablo Ozuna; and outfielder Jason Ellison.
This leaves Miguel Cairo as the only extra right-handed bat, unless a trade is pulled off in the next few weeks. Cairo has not hit as well as Ozuna this spring, but he can play multiple positions and has a great deal of experience. Also, the Phillies are required to release Cairo if he does not make the 25-man roster, which may play into the decision. Rumor has it also that Matt Stairs and Geoff Jenkins are up for grabs; however, the Phillies are going to have a hard time getting rid of either as Stairs is nearing retirement and Jenkins is well over-paid.
Also still up in the air is the 5th starter's spot. Chan Ho Park has made this a very difficult decision; today he pitched 5 2/3 innings, giving up 6 hits, 1 walk and only 1 earned run. Park also struck out 7 and now has an ERA of 2.53 in 21 1/3 innings. Lefty JA Happ currently stands at 20 innings with a 3.15 ERA. Things being fairly even, Happ is still the best choice to start as Park has a proven track record as a reliever and Happ is not so comfortable in that role. Plus with the addition of lefty Jack Taschner, there is less need for Happ, also a lefty, in the pen. Park would be horribly disappointed in the decision if it goes that way, especially since he gave up pitching in the WBC this year, so does his mental status play into this as well? That remains to be seen…
The Phillies bats are heating up in preparation for Opening Night as evidenced by four home runs today from Jimmy Rollins, Eric Bruntlett, Ryan Howard and Carlos Ruiz.
7 of the Phillies 13 runs in the 13-3 victory over the Astros came off the long ball. And Bruntlett in particular had a fun day against his former team, going 3 for 4 with 4 RBI. With all this power unleashed, it makes you wish these guys would save a bit for the real thing. Only 6 days left!
Brett Myers, now scheduled to start on opening day, will pitch tomorrow against the Blue Jays at 7:05pm. Cole Hamels got into a minor league game today and said he felt no discomfort. Hamels is tentatively scheduled to start with the Phillies on April 10th against the Rockies.
(All Photos by Jenn)
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4 Comments
Jenn – this time of year is hard with the dream ending for some of the players. Good luck to them all!
Just heard tonight that Cole Hamels is going to pitch in that Saturday game at Citizen Bank Park game. I guess they decided it was better to see if he has it against good competition than go into a minor league game down in Clearwater, Florida.
I actually think that would be great for attendance, and also be a treat for the crowd in Philly since they have not seen him since October on the mound.
It is going to be fun to watch that game Saturday now.
Rays Renegade
AW, I feel bad for Marcus. He's totally lost it. He's had some good years, but he hasn't been the best. Maybe another team will pick him up, though.


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Your kids will be stoked for a water park visit!
Bring the camera, sunblock, and plenty of laughs for these wet and wild adventures!
Coastal Virginia - Hampton Roads | Central VirginiaNorthern Virginia | Blue Ridge HighlandsShenandoah Valley | Virginia Mountains
Water Country USA, WilliamsburgVirginia's largest family waterpark features plunging water slides, twisting flumes, a free-floating river, surf-boggans, waterfalls, caves, water curtains, lagoons and a huge Surfer's Bay with real surfing waves. Make a bee-line for Vanish Point, the drop slide that's actually four -- two super loop slides and two free-fall slides!
Ocean Breeze Waterpark, Virginia BeachOffering 16 waterslides, a 1 million-gallon Runaway Baywave pool, the Buccaneer Bay children's area and other fantastic attractions, Ocean Breeze is perfect family fun at the beach!
Great Wolf Lodge, Williamsburg This 67,000-square-foot indoor waterpark has been named the Number One Pool in the USA by TripAdvisor, and is a year 'round favorite at a warm 84 degrees! From twisting tube slides that are both indoor and outdoor, to the family flume, lazy river and children's leisure pool, Great Wolf is optimum family fun.
JT's Grommet Island Park, Virginia BeachA 100% handicap accessible beachfront waterpark for everyBODY! All children and adults will enjoy this day at the beach.
Soak City at Kings Dominion, DoswellSoak City is included with admission to Dominion, and is 20 acres of great aquatic fun! The world's tallest enclosed dark tube slide is a highlight of the day, as well as a giant water-powered playhouse with a swinging bridge. NEW: Hurricane Heights, a 65' slide complex with three experiences * Splash Island, a play space for young children that includes small slides, water sprays and more
Pocahontas State Park, ChesterfieldStay at Pocahontas State Park and enjoy the pool. It's almost a waterpark ... a slide, enclosed tube, bubblers and sprays make it a pretty enjoyable attraction for camping kids.
SplashDown Waterpark, ManassasFive water areas spreading over 11 acres with "funbrellas" and pavilions, SplashDown is one of Northern Virginia's favorite summer chill destinations. Enjoy the 770-foot Lazy River, two fast slides, a beach with more than 250 tons of sand, and two 4-story waterslides, too!
Signal Bay Waterpark, ManassasSignal Bay is a 27,000 square foot aquatic fun zone in Manassas boasting slides, a lazy river, water cannons and a beach volleyball court.
Water Mine Family Swimmin' Hole, RestonThe Water Mine isn't just any old-fashioned swimmin' hole. This one takes you back to the Wild West with covered wagons, mountain slides and Pete the Prospector lookin' to strike gold!
Waterworks Waterpark, Dale CityWaterworks is all about climbing, sliding, sprays and splashin' good fun! Kids can climb on the hippo, take a ride down the enclosed speed slide, or take it easy by the beach pool entry.
Great Waves, AlexandriaThere's fun for everyone at Great Waves! Catch a wave in the Wave Pool or twist and turn down four-story water slides. Little tykes can enjoy the tad pool.
Atlantis Waterpark, CentrevilleMake a day of it! Multiple pools, a giant dumping bucket, waterslides, decks, pavilions, and a snack bar are all you need.
Volcano Island Waterpark, SterlingThis Polynesian themed park includes a giant pool, two waterslides, a separate kids' pool with a 500 gallon dumping bucket, water cannons, slides, sprayers and a sand play area. Enjoy the mini golf course, snack bar and more.
Ocean Dunes Waterpark at Upton Hill, ArlingtonOcean Dunes takes visitors to the Outer Banks with dune grasses, rustic beach theming and a relaxed, laid back attitude.
Pirate's Cove Waterpark, LortonCool off under the mega 300-gallon dumping bucket, fire the water cannons and splash down the waterslide!
Alexander Water Park, DublinTake a 38-foot long slide into the warm water or work it out with eight lanes for lap swimming. Shallow water entertains the little ones, and older kids will enjoy water basketball, spray toys and water drops.
Massanutten WaterPark, Massanutten Massanutten's indoor WaterPark is a unique multi-story interactive fortress with five slides, a giant tipping bucket, water falls, cannons, a lazy river and body slides!
Splash Valley Water Park, RoanokeCheck out this new outdoor family leisure pool with huge water slides, a lazy river, and children's playground.
Allegheny Springs at The Omni Homestead, Hot SpringsThe Omni Homestead's newest amenity, with a children's pool, water play zone, family pool and whirlpool. Take in Mountain Rush, with three 100-foot water slides and a 400-foot lazy river along with a sandy beach, pools and private cabanas.
Last Updated: 06/08/2016
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Much to the chagrin of the "moral majority" and the "religious right," it seems gay marriage may soon become a reality in my home state of New York. At the time of writing, we await a razor-thin vote in the State Senate that could make us the sixth state in the union to recognize your right to marry. And even if the upcoming bill fails, the tide is clearly turning in the favor of gays just like you.
Who's to say why? Maybe we're just tired of spouting off about you burning in hell for your sins when so many of you sinners are our brothers and sisters, sons and daughters, and clergymen. I mean, there sure are a lot of you out there, and all that finger-pointing and vilifying hasn't made you guys like girls any more, or you girls like Melissa Etheridge any less. And even though I keep hearing that the gay lifestyle is a nonstop hedonistic, immoral sinfest, for some weird reason you hedonist, immoral, sinners just keep wanting to get married to the people you love.
And good for you. But even if fewer straight people are filled with hatred and fear of gays, I'm not sure gays are filled with the appropriate level of hatred and fear of marriage. And since everyone at Cracked says I'm probably great at filling gays, I thought I'd impart a few tips.
So listen up. Before you get all excited about equal protection under the law and freedom; before you start rejoicing about being allowed to visit your partner of 40 years in the hospital because you're now considered part of the immediate family; before you start disco dancing about your possessions passing to your spouse as a matter of law upon your death; before you start body-waxing in delight that the state recognizes your love as, just that, love, there are some things you ought to know:
Once Marriage is Legal You Won't Have an Excuse Not to Commit
I don't care if you're straight or you're gay, in every relationship there's always one partner who wants to commit first. Through the centuries men have had to push off their girlfriends' attempts to get them to settle down. "Oh, now's not a good time, babe. When we're more financially secure. When we can go three weeks without fighting. When I'm sure I can't get someone hotter." (Actually, straight dudes usually leave that last one out.)
But you guys have it made. "Sorry, baby. You know I love you. I'd marry you in a second, but, y'know, my hands are tied. Damn government!" Perfect. You give your airtight justification, then you have hot gay sex and head off to work at the hair salon or the poetry factory or wherever you gay people work and have more hot deviant sex with your coworkers in the bathroom. It's awesome. I mean, don't get me wrong. Of course, we heterosexuals absolutely value the sanctity of marriage. I mean that's why adultery is almost completely unheard of in the straight community. But you guys! Damn, you have a "get out of marriage free" card. You can pretend to really want to marry your partner, but, then -- and this is the point that I'm not sure I've stressed enough -- totally not marry them. And it's OK. Have you overlooked this somehow? Look, I know filing joint taxes is awesome and everything, but are you sure you've thought this through?
"This will never work. I am so totally set."
Once You Get Married, Your Sex Won't Be Hot Anymore
Man, you guys don't know how good you have it! Your love is still illegal in some places. There are people who want to murder you because they find your sexuality physically disgusting and morally repugnant. Homosexuality has been associated with secret sex in closets and clandestine locations all for fear of being detected and with dire consequences. Do you know what that means? Gay sex is incredibly hot.
Do you realize straight dudes have to fuck their secretaries on their desk while their boss is just outside their door and their wife is on hold just to approach one tenth of that level of hot forbidden lust? Do you realize what you're giving up? Do you understand how many boring heterosexuals would just love to come home from work being able to say, "Damn, it feels good to be a Sodomite! Imma put on my leather chaps and bang some dude I just met." Or, hell, even if you're not into that freaky stuff. Even if you've been dating the same guy for years, you can get home from the office and say, "Honey, let's break some laws ... WITH OUR COCKS!"
"Sigh. I wish my erection had to the power to break laws while engaged in consensual sex."
But if gay marriage is legal? Wow, talk about erection poison. Picture it. You come home from a hard day of choreographing a Broadway show. Your boyfriend is in the kitchen cooking something gay, and you greet him with a kiss. (Totally legal!) Maybe you embrace. Then talk about your day. Maybe you two even make it to bed. Next thing you know, you're making love. State-sanctioned, love-based sex between two consensual adults who care deeply for each other. YAWN. I mean, fuck. If you were gonna do that, you might as well have married some chick. I know you don't dig women sexually, but married people don't have sex anyway so y'know, it's not like we're asking very much of you.