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July 26, 2012 —
Among the more enjoyable activities of summer are things like swimming in a nearby lake or river and enjoying a picnic under the trees. If you take a close look at the shoreline, however, you may see some snack-grabbing activity going on besides hamburgers and coleslaw.
Damselflies and their cousins in the odonata family, the dragonflies, are busily buzzing around the shoreline this time of year as they engage in courtship and breeding for the next generation of odonates. All of this family of insects has superb flying skills; they can go from a hover to full horizontal or vertical speed in a fraction of a second. All of this flying builds up an appetite.
With its superb flying ability and vision, a damselfly can snatch an insect out of mid-air, where it will then find a convenient perch and eat its prey. It is to our benefit that they dine in this manner; much of their diet consists of mosquitoes, gnats, "no-see-ums" and other nuisance bugs that would otherwise detract from our dining experience near nature's aquatic habitat. Bon appetit!

subset: commoncrawl


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Not all businesses can afford all benefitsDecember 31,2013
Recently Mari Cordes, president of the Vermont Federation of Nurses and Health Professionals and vice president of the American Federation of Teachers union, contends that every employee in Vermont is entitled to receive paid sick leave. She cited the National Federation of Independent Business as an ALEC-led business group whose opposition to her idea should be dismissed by lawmakers.
NFIB is a national organization representing small business owners in Washington, Montpelier and every other state capital across this country. It has roughly 1,600 members right here in Vermont whom I am privileged to represent. Ms. Cordes is simply ill-informed NFIB has no affiliation with ALEC.
Paid sick leave is a helpful benefit if a business can afford it, and NFIB appreciates public health risks. Many businesses offer it as a way to attract quality workers. NFIB fully supports and admires the practice of offering this benefit, but imposing it on all small businesses that are unable to absorb or pass on the additional cost will, in the end, hurt workers. Keep in mind that most small businesses operate on a shoestring while a majority fail after just three years of operation.
Imagine that you run a small business with 10 employees. If one calls in sick your workforce is depleted by 10 percent. So what are some of your options? You can either have another employee fill in or ignore the work the absent worker would have performed. Either way business efficiency is diminished, translating to squandered opportunities or sacrificed customer service. Many small businesses are opposed to mandating paid leave because they cant afford it. Its just that simple.
Even Ms. Cordes points out that 25 percent of private-sector companies dont currently offer paid sick leave. Having worked with the small business community for many years, I know that these companies are not penny-pinching Scrooges.
Many Vermont small business owners hire their neighbors, their neighbors children and their own family members. They have deep and personal relationships with their workers. They treat them well and pay them fairly based on business conditions. Arbitrarily increasing the cost of labor will force many to resort to layoffs or cutbacks for which their workers would ultimately pay. Small business owners dont want what Ms. Cordes is selling, and neither should our legislators.
Likely Ms. Cordes is a passionate, caring and sympathetic person, so I would urge her to take a drive beyond Chittenden County. The glamour of Burlington isnt found across the whole of our state. Much of Vermont is in economic decline, with small businesses struggling to maintain the jobs they currently offer. Some owners even go without a paycheck to ensure their employees receive their wage. I am certain Vermonts unionized nurses and health care professionals have the means to negotiate their benefits without slapping Vermonts small businesses with the heavy hand of another government. I hope lawmakers consider the consequences of affordability before they burden Vermonts small businesses further.
For more information about NFIB, please visit www.nfib.com.
Shawn Shouldice represents the National Federation of Independent Business in Vermont.MORE IN LettersA sixth-offense DUI gets plead down to a misdemeanor. A breathalyzer is refused. Full StoryBurr Morses recollection (Whats good for the goose, Nov. Full StoryMSNBC news analyst Rachel Maddows report on the election of Republican Rutherford B. Full Story
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INGREDIENTS:1 6.5 inch Little Charlie's frozen pizza crust Melted butter, as needed Cinnamon sugar, as needed Cinnamon roll frosting, optionalDIRECTIONS:1. Preheat Panini grill to medium high. Place frozen crust on a greased grill and cook for 4 minutes. Brush butter on grilled dough and sprinkle with cinnamon sugar. Cut into six sticks and serve plain or with a side of cinnamon roll frosting for dipping.SERVINGS:6 sticksFrom:David Lester, Cash Operations Manager, Luther College, Decorah, IA
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Seconds after Mayor Santiago "Jimbo" Martinez snipped a red and white ribbon, skateboards were soaring in all directions as about 50 youngsters, and a couple of crazy adults, started showing off their skills, or lack of them.
Martinez and Councilmen David Carabajal and John Fulghum were dodging skaters as they surveyed their pet project with smiles.
Improvements to the city's most visible park property have been underway for months as construction workers with Amstar, Inc. General Contractors took on the task.
"Flournoy Park has deep roots in our community," Martinez said just before cutting the ribbon. "And rehabilitating it for the community to enjoy will hopefully bring the community together to come out and walk, spend time with their children and, of course, skate."
"We owed it to the community to make this park a central place to gather and I believe we have," Martinez said.
"It will take time for the grass to grow out, flowers to bloom, but with tender loving care it will happen."
Flournoy Park is located just north of downtown between North St. Mary's and North Washington streets, the two, busiest north-south thoroughfares in the city.
But the park has never been developed to its potential, city officials believe.
Former City Manager Ford Patton had a plan to improve the property to make it more attractive but the Beeville Economic Improvement Corporation board of directors decided it wanted a more comprehensive project with improvements to all the city's recreational areas.
The city brought in Raymond Gignac of Gignac and Associates, a Corpus Christi firm, to work up a master plan. Right from the start, Flournoy was recommended for a skate park because of its high visibility and central location.
With the help of the BEIC board, which is paying off more than $3 million in bonds sold to finance the improvements, Flournoy was approved for the massive face lift.
One of the first decisions made by the City Council was to set aside $200,000 of the bond sale proceeds for the construction of the skate park.
Former Mayor Pro Tem John Longoria, who was at Flournoy Park for the ribbon cutting Wednesday, had told the City Council numerous times that he and some friends had asked for a skate park back in the 1970s.
Martinez reminded the young skaters waiting for the ribbon to be cut that they had been wanting a skate park for 33 years.
"Well, here it is," Martinez said, "your skate park to enjoy. Be careful, wear helmets, be safe, take care of it, keep it clean. It will be here for many years to enjoy."
It was the skaters themselves who had much of the input in the design of the facility. After the council hired the Austin-based firm, SPA Skateparks, to design and build the $200,000 structure, representatives from the company held public hearings to find out what local skaters wanted.
The result was the large, B-shaped structure at Flournoy. The concept was overwhelmingly approved by the skaters who attended the meeting and surveyed the artist's rendition of the final look.
SPA designers also chose to build the skate park on the south side of the property where it would better fit in with a new public restroom facility, walking trail, picnic facilities, a playscape for children and a butterfly garden that will be built by Beeville Garden Club members.
"I think it's a very positive thing for the kids and the community," Longoria said. "It should bring everybody together."
Longoria seems to be right about the impact the park will have on the community. The grounds were busy all day Wednesday, especially at the skate park.
City Manager Deborah Ballí said the city needs to get some rules posted at the park soon and the Martinez encouraged all skaters to wear helmets.
To set an example, Martinez wore a helmet as he made the first official run on the skate park pavement.
During his remarks before cutting the ribbon, Martinez told the skaters and others that they should come back to Flournoy on Aug. 11 between 10 a.m. and noon. The city is planning a "grand event" for that day that is expected to feature giveaways and skating demonstrations.
More details are expected to be announced next week.
Gary Kent is a reporter at the Bee-Picayune and can be reached at 358-2550, ext. 120, or at email@example.com.


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Please use this identifier to cite or link to this item: http://hdl.handle.net/1959.3/240058
- Title
- Laser fabricated ripple substrates for surface-enhanced Raman scattering
- Author(s)
- Buividas, Ricardas; Stoddart, Paul R.; Juodkazis, Saulius
- Abstract
- Femtosecond laser fabricated surface nanograting structures, referred to as ripples, are proposed as efficient substrates for surface-enhanced Raman scattering (SERS). Ripple substrates show order of magnitude higher sensitivity and superior reproducibility as compared to lithographically made commercial SERS sensing substrates. It is demonstrated that the SERS intensity from ripple substrates scales with the thickness of the Au coating. Ag coating on sapphire ripples showed > 2000 times higher sensitivity as compared to the same coating on the flat sapphire surface. The period, duty cycle and aspect ratio of the ripple textures can be adjusted by laser ablation conditions, which could be used for plasmon resonance tuning.
- Publication type
- Journal article
- Research centre
- Swinburne University of Technology. Faculty of Engineering and Industrial Sciences. Centre for Micro-Photonics
- Research centre
- Swinburne University of Technology. Faculty of Engineering and Industrial Sciences. Centre for Atom Optics and Ultrafast Spectroscopy
- Source
- Annalen der Physik, Vol. 524, no. 11 (Nov 2012), pp. L5-L10
- Publication year
- 2012
- FOR Code(s)
- 01 Mathematical Sciences; 02 Physical Sciences
- Keyword(s)
- Femtosecond laser fabrication; Plasmonics; Ripples; SERS; Surface-enhanced Raman scattering
- Publisher
- Wiley VCH Verlag
- 0003-3804
- Publisher URL
- Copyright
- Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
- Research Projects
- Peer reviewed


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Bluefield State College Fall Theatre Production "Common Ground" (w/photo)
CreatedTuesday, November 30 2010
Created byJim Nelson/Media Relations - (304) 327-4103 email@example.com
The Bluefield State College fall theatre production Common Ground was well received by audiences during three performances earlier this month. Pictured (seated, left-to-right) are cast members Laura Vidinha, Fatima Al Asadi, Yvette Burch, (standing, l-to-r) Alex Ledgerwood, Dr. Sharon Bebout-Carr (director), Kerrie Burley and Samba Camara. Common Ground is a compilation of personal narratives from Bluefield State College students that highlighted the challenges of being perceived as "different" and challenged its audience to form a community of welcome and inclusion.


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Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins, MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD; Donna E. Sweet, MD; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians*
* This paper, written by Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD; Donna E. Sweet, MD; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; Donna E. Sweet, MD; and David S. Weinberg, MD, MSc. Approved by the ACP Board of Regents on 19 November 2011.
Note: Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical guidance statements are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guidance statement comes exclusively from the ACP operating budget.
Potential Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm. Drs. Denberg, Hopkins, and Humphrey: Support for travel to meetings for the study or other purposes: ACP. Dr. Hopkins: Board membership: National Foundation for Infectious Diseases; Consultancy: Qualchoice of Arkansas, MedStudy Corporation; Payment for lectures including service on speakers bureaus: VEMCO MedEd Corp. Dr. Shekelle: Consultancy: ECRI; Employment: VA; Grants/grants pending (money to institution): AHRQ, VA, CMS, NINR-NIH, DHHS; Royalties: UpToDate. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3122.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Denberg: 275 Grove Street, Auburndale, MA 02466.
Dr. Hopkins: 4301 West Markham Street, Little Rock, AR 72205.
Dr. Humphrey: 3710 SW U.S. Veterans Hospital Road, Portland, OR 97201.
Dr. Levine: Academic Office Building 1, PO Box 6511, 12631 East 17th Avenue, Room 7614, Aurora, CO 80045.
Dr. Sweet: 1010 N. Kansas, Wichita, KS 67214.
Dr. Shekelle: 11301 Wilshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, R.H. Hopkins, D.E. Sweet, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, R.H. Hopkins, L.L. Humphrey, J. Levine, D.E. Sweet.
Drafting of the article: A. Qaseem, T.D. Denberg, R.H. Hopkins, D.L. Sweet.
Critical revision for important intellectual content: A. Qaseem, T.D. Denberg, R.H. Hopkins, L.L. Humphrey, D.E. Sweet, P. Shekelle.
Final approval of the article: A. Qaseem, T.D. Denberg, R.H. Hopkins, L.L. Humphrey, J. Levine, D.E. Sweet, P. Shekelle.
Provision of study materials or patients: A. Qaseem.
Statistical expertise: A. Qaseem, D.E. Sweet.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem.
Qaseem A, Denberg TD, Hopkins RH, Humphrey LL, Levine J, Sweet DE, et al. Screening for Colorectal Cancer: A Guidance Statement From the American College of Physicians. Ann Intern Med. 2012;156:378-386. doi: 10.7326/0003-4819-156-5-201203060-00010
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© 2016
Published: Ann Intern Med. 2012;156(5):378-386.
This article has been corrected. The original version (PDF) is appended to this article as a supplement.
Colorectal cancer is the second leading cause of cancer-related deaths for men and women in the United States. The American College of Physicians (ACP) developed this guidance statement for clinicians by assessing the current guidelines developed by other organizations on screening for colorectal cancer. When multiple guidelines are available on a topic or when existing guidelines conflict, ACP believes that it is more valuable to provide clinicians with a rigorous review of the available guidelines rather than develop a new guideline on the same topic.
The authors searched the National Guideline Clearinghouse to identify guidelines developed in the United States. Four guidelines met the inclusion criteria: a joint guideline developed by the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology and individual guidelines developed by the Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force, and the American College of Radiology.
ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
ACP recommends using a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.
Colorectal cancer is the second leading cause of cancer-related deaths among both men and women in the United States (1). The incidence of colorectal cancer was 102 900 people in 2010, and prevalence was 1 110 077 people in 2008, including 542 127 men and 567 950 women (2, 3). Americans have a 5% lifetime risk for colorectal cancer (2), and approximately 51 370 Americans die of the disease each year (3). However, the incidence of colorectal cancer has been declining in the United States by 2% to 3% per year over the past 15 years (4). Colorectal cancer is rare before age 40 years in both men and women, with 90% of cases occurring after age 50 years (2).
The usual pathogenesis of colorectal cancer is an adenomatous polyp that slowly increases in size, followed by dysplasia and finally cancer. Screening for colorectal cancer is valuable because early detection and removal of premalignant adenomas or localized cancer can prevent cancer or cancer-related deaths. Good evidence shows that screening reduces mortality from colorectal cancer (5). Several methods are currently available for colorectal cancer screening. They fall under 2 categories: stool-based tests, including guaiac-based fecal occult blood test (gFOBT), immunochemical-based fecal occult blood test (iFOBT), and stool DNA panel (sDNA); and endoscopic and radiologic tests, including flexible sigmoidoscopy, optical colonoscopy, double-contrast barium enema (DCBE), and computed tomography colonography (CTC) (virtual colonoscopy). Of these screening methods, only gFOBT and flexible sigmoidoscopy have been evaluated in randomized, controlled trials that showed that they are associated with decreased colorectal cancer–related mortality.
The purpose of this guidance statement is to critically review available guidelines to help internists and other clinicians in making decisions about screening for colorectal cancer. The target patient population for this guideline is all men and women. This statement is derived from an evaluation of current guidelines in the United States on screening for colorectal cancer.
The Clinical Guidelines Committee of the American College of Physicians (ACP) developed this guidance statement for clinicians, according to methods published previously (6), by assessing current guidelines from other organizations on screening for colorectal cancer. When multiple guidelines are available on a topic or when existing guidelines conflict, ACP believes that providing clinicians with a rigorous review of the available guidelines is more useful than developing a new guideline on the same topic.
We searched the National Guideline Clearinghouse (NGC) to identify all discrete guidelines on screening for colorectal cancer developed in the United States. After reviewing the titles and abstracts of each identified document, we excluded articles that simply restated guidelines from other organizations. The NGC included 4 U.S. guidelines on screening for colorectal cancer: the joint guideline developed by the American Cancer Society (ACS), the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF), and the American College of Radiology (ACR) (7) and individual guidelines developed by the Institute for Clinical Systems Improvement (ICSI) (8), the U.S. Preventive Services Task Force (USPSTF) (9), and the ACR (10). The 7 co-authors reviewed these guidelines independently by using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) appraisal instrument (11), which asks 23 questions in 6 domains: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. We selected 1 guideline to calibrate our scores on the 6 domains of the AGREE II instrument, scored each guideline independently, and then compared the scores. Although total quantitative scores varied somewhat, the qualitative assessment of guideline quality was consistent among the 7 reviewers; indeed, the overall rankings of the quality of the guidelines were similar (Table 1).
Table 1. Mean Guideline Scores and Scaled Domain Scores Across Domains of the AGREE II Instrument
Of note, the American College of Gastroenterology (ACG) published a 2008 update to its colorectal cancer screening guideline (12), but this guideline is not currently included in the NGC database. Because many clinicians involved in decision making about colorectal cancer screening consult the ACG guidelines, we chose to summarize this guideline despite its absence from the NGC. However, we did not formally evaluate it by using the AGREE II instrument because our predefined methods were to rate guidelines available in the NGC. In addition, the ACG was a contributor to the joint ACS/USMSTF/ACR guideline.
ACS/USMSTF/ACR recommends screening average-risk adults starting at age 50 years.
ACS/USMSTF/ACR recommends that individuals should have an opportunity to make an informed decision when choosing one the following screening tests: flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, double-contrast barium enema every 5 years, CT colonography every 5 years, annual gFOBT with high test sensitivity for cancer or annual fecal immunochemical testing with high test sensitivity for cancer, and/or fecal sDNA with high test sensitivity for cancer at an unspecified interval.
ACS/USMSTF/ACR recommends that tests that are designed to detect both early cancer and adenomatous polyps should be encouraged if resources are available and patients are willing to undergo an invasive test.
The stated purpose of the ACS/USMSTF/ACR guideline is to assess the data and comparative evidence for various screening tests for colorectal cancer and to assess when to screen adults who are at average risk for colorectal cancer. The guideline divides screening methods into tests that can detect adenomatous polyps and cancer and can therefore be considered preventive (flexible sigmoidoscopy, colonoscopy, DCBE, and CTC) and tests that primarily detect cancer (gFOBT, fecal immunochemical test [FIT], and sDNA). The ACS/USMSTF/ACR encourages using, when possible, the structural methods that are considered preventive techniques. The guideline presents a very clear rationale for the starting age of screening and acknowledges that none of the currently available screening tests is perfect for detecting cancer or adenomas. The guideline acknowledges the limitations of evidence related to sensitivity and specificity of various screening tests and relies on the judgment of the expert panel that developed the guideline. It presents information on the advantages, cost-effectiveness, limitations, and risks of each test. The strengths of this guideline include a collaborative effort; a good discussion on the benefits, harms, and limitations of various screening tests; and a discussion of the issues related to shared and informed decision making with patients. Limitations include that it did not use a systematic literature review of evidence and, in many situations, used expert opinion. In addition, the evidence that was presented did not include evaluation of the quality.
ICSI recommends routine colorectal cancer screening for all average-risk patients 50 years of age and older— age 45 and older for African Americans or American Indians. Patients with average risk for colorectal cancer are defined by: 50 years or older, or if African American or American Indian, 45 years or older with no personal history of polyps, colorectal cancer, or inflammatory bowel disease; no family history of colorectal cancer in: one first-degree relative diagnosed before age 60, or two first-degree relatives diagnosed at any age; and no family history of adenomatous polyps in one first-degree relative diagnosed before age 60.
ICSI recommends the following methods for colorectal cancer screening of average-risk patients based on joint decision making by patient and provider: stool testing: gFOBT annually or FIT annually; 60-cm flexible sigmoidoscopy every five years with or without stool test for occult blood annually; CT colonography every five years; or colonoscopy every 10 years.
ICSI considers the following for patients at increased risk of colorectal cancer and recommends different screening for these patients:
One first-degree relative with either colorectal cancer or adenomatous polyps diagnosed before age 60 years or two or more first-degree relatives diagnosed at any age: colonoscopy every five years beginning at age 40 or 10 years before the age of the youngest case in the immediate family.
Inflammatory bowel disease (chronic ulcerative colitis and Crohn's disease): colonoscopy every one to two years starting eight years after the onset of pancolitis or 12 to 15 years after the onset of left-sided colitis.
Genetic diagnosis of familial adenomatous polyposis (FAP) or suspected FAP without genetic testing evidence: annual flexible sigmoidoscopy beginning at age 10 to 12 years, along with genetic counseling.
Genetic or clinical diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC): colonoscopy every one to two years beginning at age 20 to 25 years or 10 years before the age of the youngest case in the immediate family.
The purpose of the ICSI guideline is to address the appropriate screening method for patients at average and increased risk for colorectal cancer. The guideline provides clear recommendations, discusses the benefits and harms of various tests, and presents various implementation strategies. However, the details regarding the development process are not very clear in the guideline or in the available information on the ICSI Web site. Although the evidence is graded, the scoring system does not adequately differentiate between the high-quality and low-quality randomized, controlled trials. The guideline does not provide an upper age limit to stop screening but recognizes that comorbid conditions may influence the decision.
USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient.
USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.
USPSTF concludes that the evidence is insufficient to assess the benefits and harms of CT colonography and fecal DNA testing as screening modalities for colorectal cancer.
The purpose of the USPSTF guideline is to update its 2002 guideline and present the evidence on the benefits and harms of screening technologies as well as a decision analytic model to compare the expected health outcomes and resource requirements of available screening methods. The strengths of this guideline include the use of rigorous methods, evaluation of evidence through a systematic literature review, and linkages between the evidence and recommendations. Recommendations have a very clear age specification for the purpose of screening. The USPSTF guideline is the only guideline we reviewed that does not recommend CTC as an option for colorectal cancer screening. It does not discuss specific patient populations, such as high-risk populations, or differences based on race, such as African American. In addition, the guideline did not discuss implementation-related issues, such as information on shared decision making with the patient.
ACR recommends CT colonography every 5 years after a negative CTC screen or X-ray colon barium enema double-contrast every 5 years after negative screen for average risk patients (age >50 years) and those with moderate risk (personal history of adenoma or carcinoma or first-degree family history of cancer or adenoma).
ACR recommends CT colonography or X-ray colon barium enema double-contrast for average risk patients following positive fecal occult blood test and for patients with average, moderate or high risk after incomplete colonoscopy.
ACR recommends colonoscopy for high risk patients with ulcerative colitis or Crohn's colitis and those with HNPCC.
The ACR guideline evaluates the evidence on whom and how to screen for colorectal cancer and focuses only on imaging tests. The guideline has a narrow focus and presents only information on radiologic tests. No information on the starting age for high-risk individuals, the upper age limit to stop screening, and whether this guideline supersedes the joint ACS/USMSTF/ACR guideline recommendations was included. The guideline is not based on a systematic literature review, does not account for harms, and demonstrates no clear linkage between the presented evidence and the recommendations. The guideline also does not include any information about conflicts of interests.
The ACG published an update to its colorectal cancer screening guideline in 2009. It recommends screening beginning at age 50 years in average-risk adults, age 45 years for African Americans, and age 40 years (or 10 years younger than the age at diagnosis of the youngest affected relative) in adults with a first-degree relative with colorectal cancer or advanced adenoma (an adenoma ≥1 cm in size, high-grade dysplasia, or villous elements) diagnosed at less than 60 years of age or 2 first-degree relatives with colorectal cancer or advanced adenoma.
The ACG recommends colonoscopy as the preferred colorectal cancer prevention test every 10 years in average-risk and 5 years in high-risk adults. In the event that colonoscopy is unavailable or if patients prefer an alternative test, they should be presented with the following options: colorectal cancer prevention tests (flexible sigmoidoscopy every 5 to 10 years, CTC every 5 years) or cancer detection test (FIT).
The purpose of the ACG guideline is to address the appropriate screening method for patients at average risk and increased risk for colorectal cancer. The guideline provides clear recommendations but lacks a discussion on the benefits and harms of various tests. In addition, the details regarding the development process or systematic literature review are not clearly presented. The evidence is not presented sufficiently in the tables to adequately differentiate between the high-quality and low-quality randomized, controlled trials.
The success of any screening program, especially colorectal cancer screening, depends on the appropriate testing and follow-up of patients with abnormal screening results as well as following up with patients for repeated testing at designated intervals. Colorectal cancer is a common disease with high incidence, prevalence, and mortality. Although the effectiveness of screening in reducing mortality is supported by the available evidence, only 60.8% of adults aged 50 years or older get screened in the United States (13). All of the guidelines evaluated in this guidance statement recommend screening average-risk adults starting between 40 and 50 years of age depending on ethnicity. The choice of screening method, however, varies among the guidelines we evaluated. The joint ACS/USMSTF/ACR guideline and the ICSI guideline encourage a shared decision-making approach with the patient when selecting a screening method. The USPSTF and ACR guidelines present the evidence on various screening tests but do not make any specific recommendations on selecting the appropriate screening test. For screening interval, the joint ACS/USMSTF/ACR guideline, the ICSI guideline, and the ACR guideline make specific recommendations, whereas the USPSTF guideline does not offer any recommendation.
On the basis of the review of the available guidelines, ACP concludes:
Guidance Statement 1: ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
Clinicians should perform individualized assessment of colorectal cancer risk in all adults to help in deciding when to begin screening. Risks for colorectal cancer include age, race, and family history (for example, diagnosis of colorectal cancer, hereditary nonpolyposis, or familial adenomatous polyposis). Diagnosis of colorectal cancer in a first-degree relative, especially before age 50 years, increases the probability of colorectal cancer in all adults; a thorough family history, including the age of diagnosis of colorectal cancer for primary and secondary relatives, is important for assessing this risk. African Americans have the highest incidence of colorectal cancer compared with other races.
Guidance Statement 2: ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
The evidence in the reviewed guidelines shows that colorectal cancer screening helps to identify undiagnosed premalignant lesions and reduces mortality with the provision of timely treatment. The benefit of reduced mortality outweighs the harms of screening for colorectal cancer in average-risk adults starting at age 50 years and high-risk adults starting at age 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed.
Guidance Statement 3: ACP recommends using a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
Shared decision making is important when selecting a screening test because the currently available colorectal cancer screening tests are believed to be similarly efficacious. Clinicians should discuss the benefits, harms, effectiveness, safety, and costs of the options available to screen for colorectal cancer. The sensitivity, specificity, costs, benefits, harms, and screening intervals for the tests are described in Table 2. The test quality also varies on the basis of the skill of the person performing the test (for example, ensuring correct stool preparation or having an experienced professional perform a colonoscopy), and stool-based test quality can also depend on the samples collected by the patient. Harms of endoscopic and radiologic screening tests include perforation and major bleeding with endoscopic tests and exposure to radiation with radiologic tests. Although few studies have evaluated the harms of stool-based tests, the probability of major harms is probably very small. The choice of test may also need to be made on the basis of the local availability of screening methods. For example, accessibility to endoscopic tests varies by region in the United States.
Table 2. Screening Tests for Colorectal Cancer
The screening interval for average-risk adults older than 50 years is 10 years for colonoscopy; 5 years for flexible sigmoidoscopy, DCBE, and CTC; annually for gFOBT and iFOBT; and uncertain for sDNA.
Although optical colonoscopy is generally regarded as the gold standard, it has limitations, including a false-negative rate of 10% to 20% (7, 14, 15). Also, evidence is not clear on the optimal frequency of screening using colonoscopy, but in average-risk patients, 10 years is usually regarded as a safe interval. Colonoscopy should be used as a follow-up for positive test results regardless of the noncolonoscopic screening test used. In patients who are at high risk because of family history, the ACG recommends screening every 5 years (7).
Computed tomography colonography is an option for screening in average-risk patients older than 50 years and is supported by some guidelines (7, 8, 10). However, the USPSTF found that the evidence is insufficient to assess the benefits and harms of CTC.
Guidance Statement 4: ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.
The harms of screening for colorectal cancer seem to outweigh the benefits in most adults older than 75 years or in adults who have a life expectancy of less than 10 years. Therefore, clinicians should not screen adults older than 75 years or those with substantial comorbid conditions (for example, diabetes, cardiopulmonary diseases, and stroke) with a life expectancy of less than 10 years.
Figure 1 summarizes the guidance statements and clinical considerations for colorectal cancer screening.
The American College of Physicians Guidance Statement on screening for colorectal cancer.
The goal of this best practice advice from the Clinical Guidelines Committee is to discuss the appropriate screening for colorectal cancer and to highlight how clinicians can contribute to delivering high-value, cost-conscious health care. Currently, no evidence shows that screening more frequently than recommended improves patient outcomes or reduces cancer-related deaths. On the other hand, screening more frequently than recommended can contribute substantially to avoidable health care costs. The benefit of screening is reduced mortality and possibly reduced incidence, whereas the harms include perforation and major bleeding with endoscopic tests and exposure to radiation with radiologic tests. A recent study suggests that colonoscopy is overused in elderly patients, including repeated screening at less than 10-year intervals and routine screening of patients older than 80 years (16). Overuse of colonoscopy in younger age groups is also a concern. Although the evidence is not clear to determine the optimal frequency of screening with colonoscopy, 10 years is usually regarded as a safe interval. Also, the repeated screening interval after normal results is 5 years for flexible sigmoidoscopy and DCBE, annually for gFOBT and iFOBT, and uncertain for sDNA. Screening should be reserved for average-risk adults starting at age 50 years and for high-risk adults starting at age 40 years or younger depending on their risk profile (Figure 2). Clinicians should not screen adults older than 75years or those with substantial comorbid conditions (for example, diabetes, cardiopulmonary diseases, and stroke) and a life expectancy of less than 10 years.
The American College of Physicians Best Practice Advice on screening for colorectal cancer.
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Video News Release - ACP Releases Colorectal Cancer Screening Guidance Statement
CharlesMaltz, Associate Professor of Clinical Medicine
Weill Cornell Medical College
March 10, 2012
Adenomas, Dysplasia, and Colorectal Cancer
The authors describe the evolution of colorectal cancer "as an adenomatous polyp that slowly increases in size, followed by dysplasia and finally cancer." However, an adenoma does not become dysplastic, but is already dysplastic. An adenoma of the colon is by definition a visible mass of dysplastic cells in the colon. The cells are determined to be dysplastic by cellular atypia as well as architectural abnormalities. These abnormalities reflect underlying genetic abnormalities in the cells. As long as the abnormal cells are above the muscularis mucosa, one is dealing with an adenoma. If additional genetic mutations develop these cells may penetrate the muscularis mucosa and then cancer is present. Colonoscopy is believed to prevent colon cancer by allowing the identification and removal of these dysplastic lesions (adenomas) before they can penetrate the muscularis mucosa and thus becomes cancer with the potential to metastasize.
None declared
David L.Keller, Internal Medicine Physician
Providence Medical Group
March 15, 2012
Comments on the Clinical Guideline on Colorectal Cancer Screening
1) Qaseem A, et. al. Screening for colorectal cancer, Ann Intern Med. 2012;156:378-386
2) Neri E, et al. CT colonography versus double-contrast barium enema for screening of colorectal cancer: comparison of radiation burden. Abdom Imaging. 2010 Oct;35(5):596-601
3) Johnson CD, et al. Comparison of the relative sensitivity of CT colonography and double-contrast barium enema for screen detection of colorectal polyps. Clin Gastroenterol Hepatol. 2004 Apr;2(4):314-21.
4)http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm accessed on 3/14/12.
Steven PArmbruster, Gastroenterology Department, Fouad Moawad
Walter Reed National Military Medical Center
March 22, 2012
Colorectal Cancer Screening in African Americans
To the Editor:
We read with great interest the recent article by Qaseem et al. (1) regarding a guidance statement for the screening of colorectal cancer (CRC). We agree that African Americans denote a higher risk population for the development of CRC, and should be screened earlier compared to other ethnicities as endorsed by the American College of Gastroenterology (ACG), the only society to date recommending early screening for African Americans (2). However, we are not in support of the statement that CRC screening should begin at age 40 in African Americans, as recommended in the guidance statement by Qaseem et al.
In 2009, the ACG published their consensus statement recommending CRC screening for African Americans starting at age 45 for several reasons. African Americans have the highest incidence of CRC of any racial group, and survival from CRC in African Americans is lower than other ethnicities (3). Further, African Americans may present with CRC at a median age 6 years younger than Caucasians (4) and are more likely to have a polyp greater than 9mm in size compared to age-matched Caucasians (5). Specifically, colonoscopy has been recommended as the preferred CRC screening modality in African Americans given their higher rate of proximal colon cancers compared to other races (6). However, despite the increased risks of CRC in African Americans, the current recommendation to screen at age 45 is based on only grade2 C evidence (weak evidence), and there is no evidence that screening this patient population with colonoscopy at age 40 is cost-effective, practical, or beneficial.
While it is clear that CRC is the 2nd leading cause of cancer death in the U.S. and colonoscopy reduces the mortality associated with CRC (7), resource constraints will probably not allow additional colonoscopy screening for the approximately 50% of the population who currently does not undergo CRC screening (8). Further, given the cost associated with colonoscopy screening, it is crucial that primary care providers refer the appropriate patient for screening, particularly when a colonoscopy may not be reimbursed by insurance companies in a 40 year old patient without alarm or high risk features. Thus, given these constraints of available resources, that on average African Americans appear to present with CRC younger than Caucasians, and the lack of evidence to support CRC screening at age 40, we would continue to recommend routine colon cancer screening in African Americans at age 45 years in the absence of alarm symptoms.
LCDR Steven P. Armbruster, MD MAJ Fouad J. Moawad, MD Walter Reed National Military Medical Center Bethesda, MD 20889
1. Qaseem A, Denberg T, Hopkins R, et al. Screening for Colorectal Cancer: A Guidance Statement From the American College of Physicians. Ann Intern Med 2012;156;378-386.
2. Rex D, Johnson D, Anderson J, et al. American College of Gastroenterology Guidelines for Colorectal Screening 2008. Am J Gastroenterol 2009;104:739-750.
3. Agrawal S, Bhupinderjit A, Bhutani M, et al. Colorectal Cancer in African Americans. Am J Gastroenterol 2005;100:515-523.
4. Karami S, Young HA, Henson DE. Earlier age at diagnosis: another dimension in cancer disparity? Cancer Detect Prev 2007;31:29-34.
5. Lieberman D, Holub J, Moravec M, et al. Prevalence of Colon Polyps Detected by Colonoscopy Screening in Asymptomatic Black and White Patients. JAMA 2008;300:1417-1422.
6. Rex D, Khan A, Shah P, et al. Screening colonoscopy in asymptomatic average-risk African Americans. Gastrointest Endosc 2000;51:524-7.
7. Zauber A, Winawer S, O'Brien M, et al. Colonoscopy Polypectomy and Long-Term Prevention of Colorectal -Cancer Deaths. N Engl J Med 2012;366:687-696.
8. Roy HK, Bianchi LK. Colorectal Cancer Risk Black, White, or Shades of Gray? JAMA 2008;300:1459-1461.
Ayokunle T.Abegunde, MBBS, MSc, DTM&H
John H. Stroger Jr hospital of Cook County, Chicago, Illinois
March 26, 2012
ACP CRC Guidelines
The evidence supporting the effectiveness of early screening of African- Americans at average risk of colorectal cancer (CRC) is scarce. It is surprising that the ACP guideline is recommending CRC screening at 40 years of age in African-Americans (1) when there is no evidence that such a strategy is effective. Gupta et al recently showed that increasing colonoscopy participation by 5% and 10% among African-Americans aged 50 years or older, detected 53% and 57% of CRC respectively, in contrast, early CRC screening of African Americans at 45 years of age detected 52% of CRC (2).
You et al, further demonstrate that young-onset CRC was more prevalent among patients with non-white race/ethnicity who were uninsured or insured by Medicaid (3). The results of these two studies have several implications, which feed into the wider debate on social determinants of health and access to healthcare by the underserved, who are often disproportionately African-American. Firstly, simply implementing race specific early age CRC screening policy for African- Americans is unlikely to increase early CRC detection rates significantly. Secondly, factors leading to reduced colonoscopy participation among AA need to be identified, and appropriately addressed. African -Americans are a diverse group of self- identified Americans with varying amounts of African genetic admixture. Classifying this group as above average risk for CRC presupposes that race, as a proxy of ancestral African genomic identification, predicts CRC disease clusters in the African-American population. If that is the case, biological markers, which make African-Americans more likely to develop CRC earlier should be identifiable, and would lend credence to the argument of those advocating for earlier screening. Furthermore, there should be a corresponding clustering of CRC in ancestral populations in Africa. However, this is not the case, because the available evidence shows that the incidence of CRC in Africa is low (4). Therefore, the observed increased incidence of CRC among African- Americans is more likely related to environmental, lifestyle, and socio-economic factors rather than biological or genetic factors (4). While the medical community eagerly awaits the outcome of ongoing studies on the effectiveness of initiating early CRC screening in African- Americans, strategies to improve access to CRC screening and colonoscopy participation among African-Americans aged 50 years and above should be actively pursued, in addition to timely case detection of symptomatic young adults, and sustained advocacy on healthier lifestyle choices.
Ayokunle T. Abegunde, MBBS, MSc, DTM&H John H. Stroger Jr hospital of Cook County, Chicago, Illinois, 60612
1. Qassem A, Denberg TD et al. Screening for Colorectal Cancer: A guidance statement from the American College of Physicians. Ann Intern Med. 2012 Mar 6;156 (5):378-386.
2. Gupta S, Shah J et al. Strategies for reducing colorectal cancer among blacks. Arch Intern Med 172(2)182-3
3. You YN, Yan X et al. Young-onset colorectal cancer: Is it time to pay attention. Arch Intern
Med .172( 3) 287-8
4. O'Keefe SJ, Chung S et al. Why Do African Americans Get More Colon Cancer than Native Africans ? J Nutr. 2007 Jan;137(1 Suppl):175S-182S
Tazia K.Stagg, preventive medicine physician
James A. Haley Veterans' Hospital
April 2, 2012
Screening for Colorectal Cancer: Guidance Statement 4
The authors' recommendation regarding when to stop screening for colorectal cancer is problematic. In seeking clarification, I was unable to trace the origin of Guidance Statement 4. Did it arise from the "rigorous review of the available guidelines"... or from new evidence not referenced? According to the summaries in the article, only one of the guidelines reviewed--that of the USPSTF--provided guidance related to when to stop screening. However, judging from the fact that the Qaseem et al. used different words to express Guidance Statement 4 (because I don't really know how to interpret it), it seems to depart from the USPSTF's recommendation statement. I believe that for the sake of everyone involved, most importantly patients', the best policy is to acknowledge and present good evidence to defend any such public disagreement. Otherwise, we risk undermining the credibility of the medical/scientific community... and, at least, not accomplishing adherence to the statement with the weaker support.
The statement as it is written is open to interpretation in a significant way because the authors did not specify "...whichever is earlier." If that was the intended message, this should be regarded as a very controversial statement. I intuitively want to instead interpret it in a way that actually means simply, "stop screening for colorectal cancer in patients with a life expectancy of less than 10 years." Since estimating life expectancy, one way or another, introduces uncertainty, and doctors tend to err on the side of being generous with screening tests (when we do remember to offer them), the impact of adherence to this latter interpretation would likely be to increase the upper age limit of screening. Whether this is net-beneficial might depend on how accurately we estimate life expectancy.
Effectively tailoring recommendations is a foundation of excellent preventive service delivery. The idea of basing the decision to stop screening on life expectancy, rather than on chronological age alone, is appealing. (The USPSTF's recommendation leaves room for doing this in their "C" statement and from the premise of what clinical guidelines are: just guidelines.) I don't know how to accurately calculate life expectancy, but if doing so is possible and worthwhile, I'd like to learn. The theory that basing screening on life expectancy is beneficial deserves to be tested. In order to test it, we would need to make it measureable.
Furthermore, I would expect the College to address challenges related to implementation, but the suggestion of a tool for estimating life expectancy, or a discussion of various types of such tools, is conspicuously absent from your Guidance Statement.
Guidance Statement 4 is less practical and more opinion-based than what preceded it; it fails to meet the objectives stated in your Reference 6, and I wonder what motivated it.
AmirQaseem, MD, PhD, MHA, Linda Humphrey, MD, Oregon Health and Science University, 3710 SW US Veterans Hospital Road, Portland, OR 97201, Thomas Denberg, MD, PhD, Harvard Vanguard Medical Associates and Atrius Health, 275 Grove St, Auburndale, MA 02466, Paul Shekelle, MD, PhD, Gr
American College of Physicians, 190 N. Independence Mall W. Philadelphia, PA 19106
April 26, 2012
Race and Upper Age Limit for Colorectal Cancer Screening
We thank Drs. Abegunde, Keller, and Stagg for their comments regarding the American College of Physicians' recent guidance statement on colorectal cancer screening (1).
In response to Dr. Abegunde, we agree that the evidence regarding the benefits of screening African Americans starting at the age of 40 is scarce. ACG recommends initiating screening at age 45 for African Americans, ACS/ACR/ USMSTF recommends beginning at age 40 for high-risk groups (with no mention of race), and the USPSTF does not address high- risk groups in their recommendations. Since this is a guidance statement, we based this recommendation on a review of the existing colorectal cancer screening guidelines, and we felt that it would be more straightforward to have one age to initiate screening for all high-risk groups. Using a different age for each risk group might make it more difficult for clinicians to practically implement the guidance statement and our intent was to simplify the recommendation. We agree that new evidence, such as the emergence of accurate biomarkers, would warrant a change in the recommendation.
We agree with Dr. Keller that the harms of a screening test exist regardless of whether a test is necessary or unnecessary. Since the Best Practice Advice figure focuses on overused testing, we included the word "unnecessary" to further emphasize that the potential harms outweigh the potential benefits. Regarding including double contrast barium enema (DCBE) as a potential screening option, although the USPSTF did not recommend DCBE, both the ACR and ACS/ACR/ USMSTF guidelines included DCBE as a screening option. We believe that the evidence is insufficient to assess the benefits and harms of computed tomography colonography. We agree that it was an oversight on our part not to include radiation exposure as a potential harm for DCBE.
Dr. Keller and Dr. Stagg both brought up the issue of the age to stop screening. We understand that estimating life expectancy can be a difficult task and that there are currently no validated tools available. However, we believe that the evidence does not show that the benefits outweigh the harms of screening for colorectal cancer in the majority of adults over the age of 75. Yet, a study showed that more than 45% of adults aged 75-79 were screened (2). Guidance statements are guides only and may not apply to all patients or clinical situations. The guidance statements do not override physicians' judgment, and if there is a 75 year old with a reasonable life expectancy who desires colorectal cancer screening, this guidance statement does not discourage physicians from screening such an individual.
Authors: Thomas Denberg, MD, PhD Harvard Vanguard Medical Associates and Atrius Health, 275 Grove St, Auburndale, MA 02466
Linda Humphrey, MD Oregon Health and Science University, 3710 SW US Veterans Hospital Road, Portland, OR 97201
Paul Shekelle, MD, PhD Greater Los Angeles VA Health Center/RAND, 1776 Main Street, Santa Monica, CA 90401
Amir Qaseem, MD, PhD, MHA American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
1. Qaseem A, Denberg TD, Hopkins RH Jr, Humphrey LL, Levine J, Sweet DE, Shekelle P. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Ann Intern Med. 2012. Mar 6;156(5):378-86.
2. Louise C. Walter L, Lindquist K, Nugent S, Schult T, Lee S, Casadei M, Partin M. Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans. Ann Intern Med. 2009. 150: 465-73.
SamirGupta, physician
UT Southwestern Medical Center
May 15, 2012
Re:ACP CRC Guidelines
Dear Editor,
I agree with the comments by Dr Abegunde raising concern that the ACP colorectal cancer screening guideline goes beyond supporting evidence in recommending earlier screening for African Americans.
High rates of colorectal cancer among African Americans need to be addressed, but, as our prior work suggests, think this is much more likely to be addressed effectively and efficiently by boosting screening among African Americans age 50 and older, rather than recommending screening at an earlier age(1).
Moreover, it seems very unlikely that insurance companies will consistently get behind a race specific recommendation for earlier age of screening for one racial/ethnic group, but not others.
In sum, I am concerned that the ACP guideline issues a guideline for African Americans that is neither evidence based, nor that can be readily implemented.
The ACP should focus efforts on promoting development and implementation of evidence based strategies to reduce colorectal cancer mortality among African Americans.
Samir Gupta, MD, MSCS UT Southwestern Medical Center Dallas, TX
1. Arch Intern Med. 2012 Jan 23;172(2):182-4.
Gastroenterology/Hepatology, Hematology/Oncology, Guidelines, High Value Care, Cancer Screening/Prevention.
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Wednesday, December 1, 2010
Carnival of Genealogy's100th: There's One In Every Family
In my family of origin, it might well be said, "love me, love my dog." Setters, Samoyeds, Mastiffs, Shepherds, Border Collies, Shih Tzus, Silky Terriers, Heelers,and just Dogs have graced our lives and kept us in tune with that bit of wonderment that gives you unconditional love and trust --- just to teach us how to give that back to the world in which we live.
8 comments:
You know you just won my heart. Enjoyed reading about your dogs. Thank you for sharing.ReplyDelete
Carol, I thought of you and your Yorkies as I was writing this little piece of fluff. Glad you enjoyed it.ReplyDelete
This world would certainly be much poorer without that "unconditional love" - what a great line of dogs have been your companions. I loved reading this.ReplyDelete
You have me beat by a mile with the dogs....but I also had cats....and lots of 'em!ReplyDelete
I, too, loved reading about your dogs. I grew up with a collie, Lassie of course, and she was a member of the family, guardian of small children, a good mother of puppies, and known in our area for producing good herding dogs. My life was much richer and more wonderful for that great, loving, big-hearted little dog.ReplyDelete
Aw, now I just wanna go cuddle up with my dog!ReplyDelete
Joan, this "little piece of fluff," as you described it, was great to read. I grew up with A dog - a boxer that we loved. As a young adult, I discovered Airedales and it was all over: they suited me perfectly.ReplyDelete
Anyway, I thought this was an interesting post because pets, especially dogs, are so big a part of our lives and it seems that we rarely think about the pets/dogs of our ancestors. I remember asking my aunt about dogs on the farm and she described one of them. And then in an earlier farm photo, there is a dog sitting amongst the men on the ground in front of the porch. It's very endearing to me. I guess it's hard enough to find our ancestors let alone learn about their pets!


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Ferne Clyffe State Park
Rt. 37 South, P.O. Box 10
Goreville, IL 62939
1. Directions to Ferne Clyffe State park from I-57?
Take exit 40, go east 5 miles, at stop sign (Il. Rt. 37) go south 1 mile, park entrance on your right.
2. Directions from I-24?
Take exit 7, go west 2 miles, at stop sign (Il. Rt. 37) go south ½ mile, park entrance on your right.
3. How big is the park and what are the most outstanding features?
The park is 2,430 acres. The most outstanding features are geologic formations such as the waterfall, Hawk's Cave and Round Bluff Nature Preserve. Marked trails lead to all of these areas.
4. What time does the park open and close?
8 a.m. - 10 p.m. - campers may enter at any hour, except campers needing access to the horseback campground should call ahead so staff can open gate.
Campers using backpack area - need to secure a camping permit prior to hiking to campground.
5. Can I bring my dogs?
Yes, but they must be kept on a leash no longer than 10 feet.
6. Where can we find gas, groceries, ice, firewood, restaurants, repair, fishing/hunting licenses, etc.?
7. Can we have a fire - where can we collect firewood?
Fires are allowed only in fire grills provided by the park. Only dead wood, unattached from the tree may be collected for fires. Wood may not be collected from Round Bluff Nature Preserve. Chain saws are not allowed.
Please help stop the spread of Emerald Ash borer. Purchase firewood locally and burn it where you buy it. For more info on the Emerald Ash borer visit stopthebeetle.info
8. Does the park provide horses and when can I ride?
The park does not provide horses. Horse trails are open from May 1st through October 31st.
9. Can I ride my bicycle or ATV on park trails?
Bicycles and ATV's are prohibited on park trails. Check out Tunnel Hill State Trail for bicycle riding.
10. Are alcoholic beverages allowed at Ferne Clyffe?
Yes, all state liquor laws apply.
1. Can I make a camping reservation?
Yes, you can make a camping reservation for site numbers 24-59 from April 1st through October 31st in the Deer Ridge Campground by using the Reserve America website at www.reserveamerica.com. You must make your reservation seven days before arrival. All campsites are first-come/first-serve after the seven day reservation window closes. In addition, site numbers 1-23 are first-come/first-serve all year long.
2. Ferne Clyffe camping facilities include:
3. How many people per campsite?
One family or 4 unrelated adults in Class A, B, C or D campgrounds.
4. How much does camping cost?
For a full description of campground fees at DNR-managed camping facilities, please refer to our fees website, or see the Daily Camping Fee Schedule posted on site.
1. How big is Ferne Clyffe Lake and what kind of fish are in it?
The lake is approximately 16 acres and 22 feet at the deepest spot. The lake has good populations of bluegill, channel catfish and largemouth bass. Other fish include crappie and redear. Rainbow trout are stocked twice each year. A fishing map is available on the Ferne Clyffe web page and is also posted at the lake parking lot.
2. When is trout season open?
Anytime - except the 3 weeks prior to the 3rd Saturday in October, and the 3 weeks prior to the 1st Saturday in April. Trout season opens at 5 a.m. on these two Saturdays.
3. Can I put in a boat or go swimming on Ferne Clyffe Lake?
Boating and swimming are prohibited. This small lake is open to bank fishing only. Ferne Clyffe Lake trail provides good fishing access to the lake bank.
For specific information on hunting, please refer to the Hunter Fact Sheet. Hunter Fact Sheets are available on the Ferne Clyffe web page or at the park office.
For specific information on trails, please refer to the park brochure. Park brochures are available on the Ferne Clyffe web page or at the park office.
Return to Ferne Clyffe State Park


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very cute :)
Printable View
very cute :)
Yes, very cute segment.
Very scary responses in the comments section, though.
I love the way the baby first goes for the breast, then backs off and looks up to find mom's face -- except she's upside down, so her face isn't up there! You can practically see the baby think "Oh well, whatever!" and go back to nursing.
I saw that and thought it was awesome! They showed it on VH-1's WebJunk20 actually. The part that really got on my nerves was the host saying "how OLD is that baby anyway? Shouldn't they be done with that by the time they're crawling?" Ugh.
Great clip, though! I think they were showing it to SHOCK people. I felt like it could have been my house!
very scarey responses beat a child for nursing how sad. :(
it's sad that people are so estranged from the nursing concept that they see it as "someone biting on a boob". No comments to the beating the baby note...
cute clip :)
We watched it over and over! Super cute and I guess have to be a breastfeeding family to appreciate the humor and the beauty!
I love it! The baby is so cute. :D
I made sure I left a positive comment!
:) Soo cute, any nursing mom would certainly appreciate it!:)
Very funny, but it's scary that some people commenting on it didn't even seem to realise that the baby was nursing!


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Margo Spann
Contact firstname.lastname@example.com
Hometown: Milwaukee, Wisconsin
High School: North Division (Home of the Mighty Blue Devils)
College: University of Wisconsin
Other Journalism Experience: Reporter at WSAW (Wausau) and WVTV (Milwaukee). Interned at WISN-TV, & WKOW-TV.
Started at WISC-TV on: June 2010
Twitter: @Margospann
Facebook: Margo Spann
What is your favorite part about living in Janesville?
It's a beautiful area, and is close to my family and my alma mater.
What is the biggest news story that you've covered?
The Inauguration of President Obama. I was proud to go to D.C to cover that for my station and to witness history.
What do you like to do in your spare time?
I love to make jewelry. I also enjoy singing, reading baking and trying new restaurants!
What is your family life like? Significant other, married, kids?
I'm the youngest of 8, and I have a dog named Waffles.
What is your favorite kind of ice cream?
It's a tie: Birthday cake or cookie dough, yum!
What is the funniest thing that's ever happened to you?
I went skydiving for my birthday one year and my tandem instructor looked just like Ned Flanders from The Simpsons. When it was time to jump out he says "Okaley Dokely."
Who is your hero and why?
My parents. I admire them for pushing me to dream big and to help others. They were entrepreneurs - we owned a gas station and my mother continued that legacy after my father passed away in 2001. She starting a non profit foundation in honor of him. We award college scholarships to students in my hometown. www.spannfoundation.org
What was your favorite band when you were in high school?
Hip Hop duo Outkast is still my favorite group.
What is your favorite sport to play or watch?
I consider myself a professional spectator. I played softball in high school and in some recreational leagues. But I love watching the Bucks and the Packers. And of course I'm a Badger Fan!
What is your most memorable travel experience?
I had a blast traveling around Europe with my mom. We went to Paris, Germany, Amsterdam, and Belgium. I've also been to the UK and the Canary Islands.
What is the worst job you have ever had?
I sold knives door to door but it didn't last long.
Who would you most like to interview alive or dead, and why?
Muhammad Ali. I used to watch boxing with my father and grandfather. I loved hearing them talk about seeing him fight. He is also responsible for one of my favorite quotes "If you even dream of beating me you'd better wake up and apologize."
What is your favorite tradition around the holidays?
Attempting to build a gingerbread house with my nephews. It usually doesn't come out correctly but we have a delicious time trying.
What is your favorite song of all time?
"I'm Bad" by LL Cool J.
What is your favorite movie of all time?
What is your favorite book of all time?
There are several: The Great Gatsby. Things Fall Apart, and The Alchemist.
What is the best piece of advice you have ever received?
From my mom: The best stands alone what makes you rise above the rest is because you are the best.
From my dad: A man that takes you to a restaurant where the menu is not on the wall is making an investment in you so he could be a keeper.
If you could relive any moment...what would that be?
The day I was crowned Miss Debutante and I won a college scholarship. I got to wear a pretty ball gown and dance with my father.
Where were you when September 11, 2001 occurred?
I was in college at the time. Everyone was standing around the TVs in the cafeteria watching the news coverage. I'll never be able to shake the stillness I felt in that room as we all watched the 2nd plane hit the towers.


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The UTEPCollege of Business Administration offers the only AACSB
Accredited business programs in the El Paso border region.
March 1, 2014
What: The University of Texas at El Paso will host a 3 Day Startup competition where students from undergraduates to doctoral candidates from various disciplines will generate an idea and develop it into a prototype by the end of the event.
When: 2 p.m. Friday, Feb. 21, to 7 p.m. Sunday, Feb. 23
Where: UTEP's Business Administration Building lobby and Texas Gas Service Student Center
Approximately 45 UTEP students with different academic specialties will form teams and be tasked with starting a high-tech company during 3 Day Startup, an intense entrepreneurial exercise at The University of Texas at El Paso.
These students, who range from undergraduates to doctoral students, will spend 53 hours conceiving and developing a prototype under the mentorship of top-notch faculty, entrepreneurs and investors. Among the project's goals is to build enough momentum to sustain the company beyond the weekend.
This interdisciplinary event will include participants from the colleges of Engineering, Business Administration and Liberal Arts who share an entrepreneurial spirit. It will provide them with the necessary resources to develop their ideas. Each team will have eight to 10 students. All activities will take place in the Business Administration Building's lobby and Texas Gas Service Student Center.
"We know many people with great ideas who fail to execute on them for a variety of reasons such as lack of time or money, no access to the right people, or not enough confidence to take the plunge. We provide all of the resources to bring an idea to life," said David Sterling, a College of Business Administration lecturer. He also is the adviser to UTEP's student Regional Economic Development Association, which organized the event.
The confirmed event sponsors are Rocky Mountain Mortgage, UTEP's Student Government Association and Kipp's Cheesesteaks. Planners continue to reach out for additional sponsors and professionals who could serve as mentors for the event that will conclude at 7 p.m. Sunday, Feb. 23.


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Home List of Titles Central mass and current density measurements in Tokamaks using the discrete Alfven wave spectrum
Please use this identifier to cite or link to this item: http://hdl.handle.net/1959.3/231671
- Title
- Central mass and current density measurements in Tokamaks using the discrete Alfven wave spectrum
- Author(s)
- Collins, G. A.; Howling, A. A.; Lister, J. B.; Marmillod, P.
- Abstract
- The spectrum of global eigenmodes of the Alfven wave omega < omega ci offers the possibility of a very simple method for diagnosing the centre of a Tokamak plasma. The frequencies of these modes depend on the central mass density and the current profile, and can be adequately estimated by MHD theory in cylindrical geometry including ion cyclotron effects. A simple unshielded bar antenna has been used to launch the waves at a power level of a few watts, detected by magnetic field probes in the boundary layer. Applications investigated on the TCA and PETULA Tokamaks include estimates of the core current density over a wide variety of discharges, measurements of changes of the effective mass during impurity puffing and the observation of profile changes during sawtooth activity. A method for the measurement of the deuterium-tritium ratio in a Tokamak is proposed.
- Publication type
- Journal article
- Source
- Plasma Physics and Controlled Fusion, Vol. 29, no. 3 (Mar 1987), pp. 323-339
- Publication year
- 1987
- FOR Code(s)
- 0202 Atomic, Molecular, Nuclear, Particle and Plasma Physics
- Keyword(s)
- Alfven wave; Instrumentation; Measurement; Plasma physics; Tokamak plasma
- Publisher
- Institute of Physics Publishing
- 0741-3335
- Publisher URL
- Copyright
- Copyright © 1987 IOP Publishing Ltd. and Pergamon Journals Ltd.
- Peer reviewed


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Glow-in-the-dark sheep born in Uruguay
Scientists used gene from jellyfish to produce distinct glow
Published On: Apr 26 2013 03:09:07 PM CDT Updated On: Apr 26 2013 09:08:23 AM CDT
Scientists in Uruguay have announced the birth of the first genetically-modified, glow-in-the-dark sheep.
The nine sheep were born at Uruguay's Institute of Animal Reproduction in an experiment done in partnership with the Institut Pasteur.
According to the scientists, the sheep developed normally, without showing any difference with their non-modified counterparts.
Uruguayan scientists used a gene from a jellyfish to produce a green fluorescent protein, giving the sheep their distinct "glow."
Distributed by Internet Broadcasting. This material may not be published, broadcast, rewritten or redistributed.


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What is in this article?:
- Agricultural technology critical to feed 9 billion people
- Collaborative sharing
- New crop protection products
- Global agriculture faces a daunting task to feed and clothe a world population expected to reach 9 billion people by 2050.
- To fill 2 billion more mouths, worldwide agricultural productivity must increase 70 percent to 100 percent, according to the United Nations.
More About:
Western farm leaders at the 2013 Southwest Ag Summit in Yuma, Ariz. include, front row from left: Steve Alameda, Yuma Fresh Vegetable Association; Rik Miller, DuPont Crop Protection President; and Bruce Gwynn, Helena Chemical. Back row - Jeff Johnson, YFVA; Kurt Nolte, University of Arizona Cooperative Extension, Yuma County; and Martin Reed, DuPont.
Global agriculture's challenge to feed two billion more people by 2050 on Planet Earth would have made a sensational episode of the 1960s-1970s hit drama television series Mission Impossible.
Agricultural technology innovations could have been the ultimate mission for lead actor Jim Phelps (Peter Graves) who amazingly accomplished a myriad of seemingly impossible missions.
Agriculture faces a daunting task to feed and clothe a world population expected to reach 9 billion people by 2050. The current population is about 7.1 billion people. Over the last decade, the global population increased by 12 percent.
To fill 2 billion more mouths, worldwide agricultural productivity must increase by 70 percent to 100 percent, according to the United Nations. Making the challenge even more…challenging…. is that agriculture will have to produce more food with less land and water.
DuPont Crop Protection President Rik Miller says global agriculture is up to the challenge. Technological innovations will lead agriculture to achieve significant yield increases.
DuPont is a farm chemical company, but also involved in nutrition, transportation, safety and protection, apparel, home and construction, plus electronics and communications. About 40 percent of its business is in agriculture.
"I believe agriculture is on the cusp of a critical era," said Miller, a keynote speaker at the 7th annual Southwest Ag Summit held in Yuma, Ariz., this spring. The event was attended by about 600 growers, pest control advisers, and other industry members.
If you are enjoying reading this article, please check out Southwest Farm Press Daily and receive the latest news right to your inbox.
Miller says feeding and clothing 9 billion people will require major technological breakthroughs and the collaboration of people and organizations worldwide.
"The growing demand for food can only be met by unprecedented technical and agronomic knowledge sharing across the globe," the DuPont leader said.


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Welcome to Local Race Chat.com A Community of Dirt and Asphalt fans, like most online communities you must register to post in our community, but don't worry this is a simple free process that requires minimal information. To take advantage of it immediately, Register Now or if your already a member Sign In, to remove this message.
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Select this option if you would like your search to look in the text of FAQ items as well as their titles.
Select an option here to specify how you would like your search query to be treated. 'Any words' will return the most numerous but possibly least relevant results, while 'Complete phrase' will return only results that contain exactly what you are searching for.


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My son is 2 1/2 weeks old. Lately hen he is nursing he scooches all around and wimpers like he is going to cry. Is he in pain? Is is gas? Does he have a sore throat? I try to burp him but he doesn't always burp.
Also, sometimes he spits up which I know is okay but then he seems to gag. Is he choking? Should I be concerned?
My other concern is that when he is latched on, he will pull his head back and stretch my breast. It hurts like crazy and has made my breasts very sore. Why does he do this?
I have been pumping some and giving him a bottle which he does great with. No moving around or wimpering. Does he just prefer the bottle? Should I just pump for him all the time? Please help, I could use any advice you have. Thanks.


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Tweed Bootcut Pant
Style: 570059899
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Menswear grey-and-black tweed looks modern with winter geos, florals and animal prints—goes on-the-town with sequins, satin and silk. Wide contoured waistband, bootcut leg and back flap pockets. Shell: 75% Poly, 24% Rayon, 1% Spandex. Lining: 100% Polyester. Machine wash; cold; tumble dry low. Or dry clean. Imported.
- Our universal fit. Eased through the hip and thigh, sits just below the waist with a bootcut leg.
- Wide contour waistband with decorative top-stitching at the sides. Three-button extended tab; anchor button. Slant front pockets. Darted in back with button-through welt flap pockets. Hematite-finish buttons.
- Fully lined.
- Inseams: 33" regular, 30.5" short, 35" long.
Read more… Read less…


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Sharrow pleads innocent to murder chargeSTAFF REPORT | July 08,2013Anthony Edwards / Staff Photo
Christopher Sharrow of Pittsford stands during his arraignment in Rutland criminal court today on a second-degree murder charge in the death of his girlfriend Kristen Parker.A Pittsford man charged with killing his girlfriend on Friday pleaded innocent this afternoon to a charge of second-degree murder.
Christopher Sharrow, 35, who entered Rutland criminal court with his hands and legs in chains and dressed in an orange jail jumpsuit, was ordered held on $750,000 bail. His attorney did not contest the bail.
Vermont State Police say they arrested Sharrow early Friday morning after discovering 32-year-old Kristen Parker his girlfriend and the mother of his two children dead on the floor of their home on West Creek Road in Pittsford.
Police say Sharrow killed Parker, who he had been dating for five years, during a domestic dispute at their home. Police have not revealed the manner in which Sharrow allegedly murdered Parker.MORE IN This Just InMONTPELIER A new report from a commission that studied the cost, availability and quality of... Full StoryVermont fish hatchery changes focus, looks inland
BETHEL, Vt. Full StoryHONOLULU (AP) A group of Hawaii musicians and a Hawaiian Airlines flight attendant provided... Full Story
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My 10 week old DS chokes at the breast during letdown and gets so upset he refuses to finish the feeding. We have been almost exclusively pumping (one nursing session per day) until recently when he finally stopped pinching my nipple with his tongue. Very frustrating since I was really excited to start bfding him all the time instead of pumping.
So I have a couple questions and would love any advice you ladies have.
First off, DS occasionally chokes while bottle feeding also so maybe he has a suck/swallow issue? He gets very upset whenever he chokes and often does not want to finish eating.
Second off, pumping about an ounce from each breast before feeding him seems to help tremendously...but he gets totally frantic if his feeding is delayed. When we warm up bottles we have to hold and comfort him the whole time. If I pump right before I feed him then I would have to lay him down which would cause hysterical crying. Argh. Would this cause him to hate breastfeeding? Or become a really insecure baby?
Thirdly- he was recently diagnosed with GERD and is on meds. Before he was diagnosed he would arch his back, turn red and cry about halfway through his feedings. Maybe he has a negative association with eating now, and won't tolerate any difficulty whatsoever? (like choking)
Please respond if you have any information or advice at all, even if it's just to share your own experiences with this. Thank you!!


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Headlines (Campus Updates)
Kinesiology & Physical Education
Kinesiology and Physical Education graduate program grows, attracts international students
Communications, Public Affairs & Marketing
Jan 5/11
When Martin Musalek, a PhD student at Charles University in Prague, attended a kinesiology conference in Toronto last year, he had no idea that the location of his conference poster would play such an important role in the success of his trip.
But Musalek's poster turned out to be next to that of Professor Pam Bryden, from Lauriers Kinesiology and Physical Education department, and after talking with his neighbour he realized she was an expert in his area of study. In fact, he already knew her work.
We had a long chat, Bryden said. Later on in the year he contacted me and said he had to do an internship as part of his program, and could he come to Laurier. I said sure.
Laurier's graduate program in Kinesiology and Physical Education (KPE) was founded in 2006, with an entering class of only six students. But the program, a two-year MSc., has grown quickly. Currently it has 30 students, 18 of whom entered this academic year, not including several part-time students. And the graduate faculty has recently been attracting more and more visiting international students like Musalek.
There has been interest from a variety of countries in our program, said Professor Mark Eys, the KPE graduate program co-ordinator. I think its a very positive sign of what people are doing here and of the visibility of the program.
There are currently three international graduate students working with faculty at KPE. Svenja Wolf, a PhD student from the German Sport University in Cologne, is studying the pre-competitive emotional states of athletes as a visiting researcher working under Eys.
Frederico Faria, from Brazil, is doing a full PhD at Laurier, working with KPEs Professor Quincy Almeida under the joint supervision of Professor Jeffery A. Jones in the Department of Psychology. A recipient of Brazils prestigious CNPq scholarship, he is studying Parkinsons disease and its effect on movement.
Musalek, whose PhD is in physical education and sport, is focusing on measuring and studying peoples preference for using their right or left hand and right or left foot for different tasks, like writing or kicking a soccer ball, and how that relates to the organization of the brain. Bryden has done extensive research on the subject.
The academic culture here is very collaborative, Musalek said. Ive been able to better understand a lot of things that were not clear for me in the past. Its helped me to better interpret my data.
Since Musaleks arrival at Laurier in early October, he has sat in on Brydens graduate motor control and statistics courses, presented his research to Laurier graduate students, visited labs on campus, consulted with Laurier faculty regarding the design of his statistical models, and attended a conference with Bryden in Ottawa. Bryden will also work with him on journal publications based on his PhD research.
Its certainly been a great experience for me to have Martin here, and I think its beneficial for the university community to have these students among us, said Bryden. Its very helpful when youre working with somebody who was trained under a completely different model, with different resources and different ways of thinking.
With Brydens help, Musalek has been meeting with senior Laurier officials and Laurier International staff about the possibility of formal exchanges between the two universities. Musalek will subsequently be meeting with officials at Charles University when he returns to Prague at the end of his internship later this month.
In continuous operation for over 660 years, Charles is one of Europe's oldest universities and one of the top-ranked universities in central and Eastern Europe. An international internship is a standard requirement for students in the university's physical education and sport PhD program.
Musalek says hes grateful for that. The support from Dr. Bryden and everyone else here was just amazing, he said. I would like others to have the same opportunity."
View all Kinesiology & Physical Education news |
View all Faculty of Science news
View all Laurier news


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« Back to Author Index
Robert D. Siefert .
Robert Siefert
Robert D. Siefert .
Articles by this Author
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Features »
Investing for Income in a Low Interest Rate Environment
Portfolio Strategies: The dilemma for retirees: How do you invest for a desired rate of return in excess of that which is attainable from interest and dividends?
February 1999 | Journal
Pages: ←1→


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Michigan is home to a ton of festivals year-round, but one of the most unique may just the Cheeseburger in Caseville Festival! Held every August as a tribute to Jimmy Buffett and delicious cheeseburgers, the festival is all about having fun in the sun whether you're 8 years old or 88! This year's event is happening now through next Sunday, August 18.
Below, festival chairman Steve Lowers answers on our questions on the annual event.
Q. Can you tell us more about your role in Cheeseburger in Caseville?
A. I have been president of the Caseville Chamber of Commerce for 10 years and am also Chairman of the Cheeseburger Festival. I am just one of the many volunteers that help to put the festival together and am involved in the overall planning of the event including scheduling the bands and details of events throughout the festival.
Q. The festival is now in its 15th year; are there any new additions?
A. Some of the new events this year include a larger kid's day and a book signing by "Michigan Killers" author Jonathan Rand. Throughout the festival we have several new kids' events. We also are bringing back the popular laser light show and have some new bands that will be taking the stages.
Q. Since the festival's start, it has definitely grown throughout the years. Can you tell us more about the history of the festival?
A. The festival has grown a lot since it all started in 1999. The first year it was only a three day festival and now lasts 10 days. When I took over as Chairman 10 years ago we decided to expand and because three days just wasn't enough time. The attendance has also jumped each year; the first year of the festival we sold 300 buttons for $3.00 and last year we sold over 10,000 buttons for $10 apiece. Each year thousands descend on our small town for 10 days of fun.
Q. Cheeseburger has won several "Michigan Fun Awards," what makes the festival so deserving of these awards?
A. We are a really creative bunch! We really enjoy planning the festival and take a lot of pride in the community and the festival. I believe that a group of decision makers is better than one and it shows in the festival.
Q. What other activities can festivalgoers do in Caseville outside of the festival?
A. Caseville has beautiful beaches, great golf courses, lots of campgrounds and some really great shops.
Q. Just for fun, can you tell us what would be on your perfect burger?
A. I really like blue cheese so for me it would have to be one of the black and blue burgers that some of the vendors sell. A black and blue burger is a cajun seasoned burger loaded with blue cheese.
Q. What's the most surprising thing you have learned or seen working in this event?
A. I've learned that there is a fine line between a festival and a party. A festival involves ages 1-100 and a party is for adults, through the years we have prided ourselves on remaining a great festival. Our festival is one of the best and biggest in Michigan because it is so family oriented. That's why I do it!
Q. Where can you go to learn more about the festival?
A. Visit www.casevillechamber.net, the Caseville Area Chamber of Commerce Facebook page or take a listen to the radio show below!
Steve Lowers is the President and Chairman of Caseville Area Chamber of Commerce and Chairman of the Cheeseburger in Caseville Festival. For more information about events going on across Pure Michigan visit michigan.org/events.


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PITTSBURGH, PA – Beginning Monday, November 3, the Allegheny County Airport Authority will continue to make improvements to the two "people mover" trains at Pittsburgh International Airport. These trains, which are located beyond the security check point, transport air travelers to and from the Airside Terminal, AIRMALL and airline gates.
These enhancements will consist of the installation of new flooring in each of the six train cars. There are three cars per train. During this upgrade, it is anticipated that a maximum of two cars out of the six will be out of service at any given time. The plan is to have these improvements completed prior to the Thanksgiving holiday travel rush.
Currently, both trains are running in the peak travel periods between the hours of 6:00 to 7:30 am and 3:00 to 7:30 pm. Operating four out of six train cars during those times may impact the traveling public. The Allegheny County Airport Authority is advising passengers to allow a little extra time for checking in and getting to their gates. Airport employees who work in the Airside Terminal should also allow extra time.


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I have been exclusively pumping for a week with the Medela Lactina hospital grade pump that I am renting from my pediatricians office. I got some conflicting information online about sizing. One website says that if too much of your areola is being pulled into the flange, it is too small for your breast and you need a larger flange but the Medela site says that if too much of your areola is being pulled in you need a smaller flange. This makes more sense to me but I wanted to be sure.
Don't have health insurance right now so I can't go to my LC to get sized. Some but not a ton of my areola is being pulled in but I still seem to be able to pump an ok amount ( about 3 oz in two hours). I am just trying to maximize my pumping and wanted to make sure everything was as good as it could be, plus there is a little rubbing on my areola and I don't want that to become problematic as I am pumping 8-10 times a day. Any suggestions?? Also if I need a smaller flange, where is a good place to purchase them online as I have looked around and no one seems to carry the smaller flange?


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In this section, you'll find invaluable resources related to every step of the grant-writing and application process. In addition to articles, videos, and webinars, we have created a comprehensive glossary of funding-related terminology to help you more easily navigate the funding landscape.
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