text:
Major Recommendations
ACR Appropriateness Criteria®
Clinical Condition: Radiologic Management of Iliac Artery Occlusive Disease
Variant 1: Elderly patient with long history of mild claudication presents with acute-onset left lower-extremity pain. Absent left femoral pulse on palpation. Faint dorsalis pedis and posterior tibial pulses by Doppler.
|CTA pelvis with runoff
|May be more readily available in cases of imminent limb threat.
|MRA pelvis with runoff
|May be preferable in diabetic patients and those with impaired renal function.
|Anticoagulation adjunctive therapy
|Antiplatelet adjunctive therapy
|Catheter-directed thrombolytic therapy
|Therapy of choice if local expertise available.
|Catheter-directed angiography
|Consider noninvasive imaging if local expertise is available.
|Surgical revascularization
|Secondary option to be pursued if thrombolysis is contraindicated or immediate revascularization is necessary.
|Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: 60-year-old patient with known atrial fibrillation. Angiogram demonstrates isolated filling defect in right common iliac artery. Patient had recent spine surgery.
|Anticoagulation adjunctive therapy
|Anticoagulation is potentially contraindicated in the setting of recent spinal surgery; clinical assessment of relative risk is imperative.
|Antiplatelet adjunctive therapy
|Catheter-directed thrombolytic therapy
|Probably not indicated but need to individualize depending on patient parameters.
|Catheter-directed mechanical thrombectomy
|Need to individualize depending on patient parameters. Less appropriate for larger clot burdens.
|Surgical revascularization
|Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Elderly patient with worsening claudication and small ischemic ulcers on digits of both feet. Angiogram demonstrates diffuse disease involving distal aorta and both iliac vessels with multiple stenoses >50%. Bilateral 75% mid superficial femoral artery stenoses and two-vessel tibial runoff bilaterally. (TASC D)
|Anticoagulation adjunctive therapy
|Antiplatelet adjunctive therapy
|Indicated in chronic lower-extremity arterial occlusive disease.
|Best medical management including supervised exercise program only
|May be used as adjunct to more definitive therapy.
|Catheter-directed angioplasty (aortoiliac only)
|May be a first step. TASC C/D lesions may require stents or surgery.
|Catheter-directed stent placement (aortoiliac only)
|Catheter-directed stent placement (aortoiliac plus femoral angioplasty)
|Should be part of a complete surgical plan for the patient.
|Surgical revascularization
|Need to individualize depending on patient parameters.
|Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: 50-year-old female smoker with severe claudication, but no symptoms at rest. Angiogram demonstrates bilateral 90% common iliac artery stenoses. (TASC A)
|Anticoagulation adjunctive therapy
|Antiplatelet adjunctive therapy
|Indicated in chronic lower-extremity arterial occlusive disease.
|Best medical management including supervised exercise program only
|May be appropriate for initial therapy with intervention for refractory patients.
|Bilateral angioplasty only
|With selective stenting for suboptimal result.
|Bilateral stent placement
|Done primarily for some lesions depending on lesion morphology and length.
|Surgical revascularization
|Secondary therapy, especially in event of failed endovascular procedures.
|Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: 65 year-old sedentary male nonsmoker with no symptoms at rest, but mild left lower extremity claudication. Asymmetrically diminished left femoral pulse. Initial physician visit.
|CTA pelvis with runoff
|Depends on local expertise. Generally reserved for patients who fail medical management or have significant vascular abnormalities.
|MRA pelvis with runoff
|Depends on local expertise. Generally reserved for patients who fail medical management or have significant vascular abnormalities.
|Catheter directed angiography
|Secondary to noninvasive imaging. Often done at time of definitive endovascular therapy.
|Risk factor analysis, lipid profile, and ABIs
|Combined with best medical management.
|No further treatment or evaluation needed
|Best medical management including supervised exercise program only
|Anticoagulation adjunctive therapy
|Antiplatelet adjunctive therapy
|Indicated in chronic lower extremity arterial occlusive disease.
|Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Summary of Literature Review
This discussion of iliac artery occlusive disease reviews the broader topic of peripheral vascular disease. Several recent consensus documents provide valuable overviews of this complex topic. The consensus recommendations can be modulated by more recent literature with specific attention to iliac disease.
Acute Ischemia
Acute iliac ischemia may be due to thromboembolism, atheroembolism, in situ native arterial thrombosis, or thrombosis of a surgical bypass graft. Patients presenting with suspected acute iliac occlusion should be evaluated immediately by a vascular specialist. History should be obtained to determine the duration and severity of symptoms and any history of prior interventions or surgery. Physical examination will reveal diminished common femoral artery (CFA) pulses. In addition, confirmatory Doppler examination should be obtained at time of presentation to detect presence of distal pulses. The ankle-brachial indices (ABIs) may be normal at rest in the setting of isolated iliac occlusive disease. Patients presenting with acute limb ischemia without contraindications to anticoagulation should be immediately anticoagulated, typically with heparin. All patients, and particularly those with atypical presentations, should be considered for hypercoagulability evaluation. Evaluation may be initiated concurrent with anticoagulation therapy and may include prothrombin time, partial thromboplastin time, platelet count, factor V Leiden, factor II (prothrombin) C-20210a, anticardiolipin antibody, protein C, protein S, and antithrombin III levels.
Imaging evaluation is indicated to define underlying anatomy and extent of disease. In general, catheter-directed digital subtraction angiography is indicated in both endovascular therapy and surgical candidates. Other anatomic imaging options such as magnetic resonance angiography (MRA) or computed tomography angiography (CTA) can be considered, but may pose some delay in starting definitive therapy or pose a risk of additional contrast load. Dilute iso-osmolar contrast, hydration with sodium bicarbonate solution, and pretreatment with N-acetylcysteine sodium bicarbonate drip may be useful in patients with marginal renal function. Time-of-flight MRA may be used when contrast cannot be administered.
The goal in the setting of acute ischemia is prompt restoration of distal blood flow. Endovascular and surgical options exist. The most widely studied and used endovascular option is catheter-directed pharmacologic thrombolysis. Alteplase, reteplase, and urokinase are the most commonly used agents, and a wide variety of infusion protocols have been described. There is evidence that the glycoprotein IIb/IIIa antagonist abciximab may reduce distal emboli. Ultrasound (US)-assisted pharmacologic thrombolysis, suction embolectomy, and rheolytic therapy are recognized options and may be used in conjunction with other therapies. US-assisted techniques may reduce overall thrombolysis infusion times, and suction embolectomy and rheolytic options may be particularly useful when thrombolysis is contraindicated. Surgical options include catheter embolectomy and bypass. While there is no convincing evidence for the universal superiority of endovascular or surgical approaches, it may be useful to distinguish embolic from in-situ lesions for therapy planning. Furthermore, the severity of ischemia and ability to tolerate surgery are important considerations.
For native vessel thrombosis, it is recommended that a trial of thrombolytic therapy be used for viable limbs. In those cases where a guide wire can be passed across the lesion, intrathrombus lysis may be instituted. In cases where a guide wire cannot be successfully passed, a trial of regional lysis should be attempted. Prospective, randomized trials have demonstrated that 1-year limb salvage rates with endovascular techniques are similar to those of surgery, with lower mortality rates but higher rates of recurrent ischemia and amputation. The endovascular approach will allow treatment of the underlying lesion following thrombolysis, and gradual low-pressure reperfusion may avoid reperfusion injury. The use of mechanical techniques may allow more prompt restoration of flow and therefore expanded use of endovascular techniques in the threatened limb. Surgical approaches should be reserved for failure of attempted thrombolysis or endovascular thrombectomy, for cases where an unacceptable delay due to attempted endovascular techniques may jeopardize the viability of a limb, or for nonviable limbs.
For embolic occlusions, a consensus document has recommended that isolated suprainguinal emboli be removed surgically. If embolic fragmentation and distal embolization into peripheral vessels have occurred, endovascular thrombolytic therapy is the preferred therapeutic option. Echocardiography is not necessary prior to thrombolytic therapy for embolic disease.
For occluded aortoiliac or aortofemoral bypass grafts, catheter-directed thrombolysis is the preferred therapeutic option in grafts occluded <14 days. Despite a higher risk of amputation, catheter-directed therapy allows underlying lesions to be defined and treated. Furthermore, surgical risks related to reoperative anatomy and wound complications can be avoided.
Chronic Ischemia
Chronic limb ischemia can be clinically divided into asymptomatic, claudication, and critical limb ischemia (CLI). Claudication is reproducible lower-extremity muscle discomfort brought on by exercise and relieved by rest. CLI refers to chronic rest pain, ulcers, or gangrene secondary to arterial occlusive disease. While iliac occlusive disease is commonly a component of CLI, it seldom exists as an isolated lesion. Clinical evaluation of chronic ischemia should include history, physical examination, and ABI or segmental arterial pressures. Medical management should include risk factor modification such as smoking cessation and control of hyperlipidemia, and a lipid profile should be obtained covering total cholesterol, low-density lipoprotein (LDL) cholesterol (>100 mg/dL), high-density lipoprotein (HDL) cholesterol, triglycerides (TG), and homocysteine level in younger patients. Hypertension (blood pressure >140/90 mm Hg) and diabetes (glycosylated hemoglobin [HbA1c] >7.0%) control should be implemented in all patients with intermittent claudication and chronic limb ischemia. Other medical strategies such as a supervised exercise program or antiplatelet therapies such as cilostazol or aspirin should be implemented in all appropriate patients, but patients with iliac lesions in distinction to infrainguinal disease may be considered for revascularization without undergoing extensive medical therapy.
Arterial imaging is indicated in patients with abnormal resting ABIs or abnormal postexercise ABIs in whom revascularization would be performed if an amenable lesion is demonstrated. Patients with CLI should have expedited evaluation. Noninvasive anatomic imaging can be obtained with US duplex, MRA, or CTA, but catheter-directed digital subtraction angiography should be obtained in most patients where revascularization is being considered. Intra-arterial pressure measurements may be of value, with gradients >10 mm Hg, either at rest or following pharmacologic challenge, considered significant.
Extensive literature exists describing the results of both surgical and endovascular interventions. Surgical interventions include bypass grafts, endarterectomy, and combination procedures. Endovascular interventions include angioplasty, stents, stent grafts, and plaque excision techniques. The Trans-Atlantic Inter-Society Consensus (TASC) document on Management of Peripheral Arterial Disease described anatomic classification and therapeutic recommendations for iliac occlusive disease. TASC II has modified these recommendations (see Appendix 1 in the original guideline document). Endovascular therapy is the treatment of choice for TASC A and B lesions, and recent studies confirm an expanded role for endovascular therapy in TASC C and D lesions.
Surgery Versus Endovascular Therapy
The durability of endovascular therapy in TASC A and B lesions has been established, and it is generally accepted as preferable to surgery. Cumulative assisted patency rates of 71% at 10 years and limb salvage rates of 95% at 5 years and 87% at 10 years have been reported. For TASC C and D lesions, surgery has been recommended. However, more recent data suggest an expanded role for endovascular therapy. Long-term durable results for aortofemoral bypass grafts for iliac disease have been established. Meta-analysis has demonstrated 5-year limb-based patency rates of 90% in claudicants and 87% in patients with CLI. Two recent studies comparing surgical aortofemoral bypass to aortoiliac angioplasty and stenting have demonstrated similar results. Surgical bypass yielded higher 3-year primary patency rates and greater improvement in ABIs, but at the cost of increased surgical complication rates, including need for emergent surgery, infection, transfusion, and lymph leak. Importantly, neither study demonstrated any significant difference in secondary patency rates, limb salvage, or long-term survival. The durability of endovascular recanalization of the iliac arteries has been established, although primary patency is generally less than that of surgery. A recent study involving iliac recanalization demonstrated 1-, 2-, and 3-year primary patency rates of 86%, 76%, and 68%, respectively. Secondary patency rates were 94%, 92% and 80%, respectively. Another study has reported 3-, 5-, 7-, and 10-year primary patency rates of 90%, 85%, 80%, and 68%, respectively. Despite substantial variation between these studies, the long-term patency of recanalized iliac segments has proven satisfactory. Surgical intervention incurs higher morbidity, including risk of impotence and retrograde ejaculation; endovascular therapies allow greater ease of reintervention. The TASC authors have noted that when choosing between endovascular or open-surgical/bypass therapies with equivalent short-term and long-term outcomes, endovascular techniques should be used first.
Percutaneous Transluminal Angioplasty Versus Stent
The Dutch iliac stent trial concluded that percutaneous transluminal angioplasty (PTA) with selective stent placement yielded patency rates similar to those occurring with primary stenting. More recent stratified studies have documented that primary angioplasty with selective stenting is effective for TASC A and B lesions. However, stenting has demonstrated significant benefits over angioplasty alone in TASC C and D lesions. Other authors have found patency rates for primary stenting of TASC C and D lesions to be similar to those for TASC A and B lesions. Finally, a recent study found no significant difference in the patency rates of iliac artery stents among all TASC categories, questioning the utility of the TASC classification and associated endovascular and surgical recommendations in iliac disease.
Bare Metal versus Covered Stent
Literature is developing with respect to the role of stents covered with polytetrafluoroethylene (PTFE) in treating iliac occlusive disease. Two studies have confirmed its technical feasibility, and both demonstrated 1-year primary patency rates of 91%. A recent report described significant benefit to using covered balloon-expandable stents in type C and D lesions as compared to bare metal stents at 18 months follow-up with respect to binary restenosis (95.4% vs 82.2%), amputation rate (1.2% vs 3.6%), and clinical improvement (94.2% vs 76.7%). Another study demonstrated significantly higher 5-year primary patency rates with use of stent grafts as compared to bare metal stents (87% vs 53%) in patients undergoing simultaneous CFA endarterectomy and iliac revascularization Additional information regarding patency rates of covered stents will also be provided by long-term review of aortic endograft experience.
Endovascular Adjunct to Other Procedures
Endovascular therapy may be an adjunct to a separate surgical or endovascular procedure. It has been demonstrated that an ipsilateral stenotic, but not occluded, superficial femoral artery (SFA) is a predictor of iliac intervention failure and that SFA stenoses should be addressed at the time of iliac intervention. When iliac intervention is being performed in conjunction with infrainguinal surgical bypass, graft patency is significantly greater with stenting as compared to angioplasty alone and is similar to that of aortofemoral bypass at 5 years. For external iliac artery disease that extends into the CFA, external iliac artery stent placement with CFA endarterectomy and patch angioplasty has produced durable results with less extensive surgery than conventional bypass. A more recent study evaluating the combined CFA endarterectomy with stenting of the common or external iliac artery demonstrated a 5-year primary patency rate of 60% and a secondary patency rate of 98%. Endovascular repair and femoral-femoral bypass may be useful in patients with a stenotic segment <5 cm in the inflow limb and contralateral iliac occlusion, but not in patients with stenoses >5 cm (primary patency rates at 3 years = 85% and 31%, respectively).
Predictors of Success and Failure
Multivariate analysis of independent predictors for iliac intervention failure has been described in multiple studies. An untreated stenotic (>50%) SFA in the setting of iliac artery angioplasty or stent had a 3-year primary patency rate of the iliac intervention of 36%. SFAs that are occluded, patent, or receiving concomitant angioplasty at the time of iliac intervention demonstrated 3-year primary patency rates of 84%, 81%, and 75%, respectively. Occluded SFAs can be observed, but stenotic SFAs should be repaired at the time of iliac intervention. Hypertension, hypercholesterolemia, chronic renal insufficiency, poor tibial runoff, external iliac artery disease, female gender, smoking, gangrene or ulcer, diabetes mellitus or presence of a distal bypass, and hormone replacement therapy in females have all been described as independent predictors of failure. Immediate hemodynamic improvement and the presence of two-vessel femoral or two-vessel tibial runoff have been described as predictors of favorable outcome.
- Endovascular thrombolytic therapy and endovascular mechanical embolectomy are preferred therapies for in-situ native iliac artery thrombosis.
- Isolated iliac artery emboli are preferentially treated by surgical embolectomy; if significant associated distal emboli are also present, endovascular thrombolytic therapy is preferred.
- Endovascular repair is recommended for TASC A and B lesions.
- Primary iliac artery angioplasty with selective stenting has patency rates similar to those of primary stenting in TASC A and B lesions.
- A stenotic SFA is a predictor of failure for iliac artery intervention, and it should be repaired at the time of iliac intervention.
- Surgical repair of TASC C and D lesions is generally indicated; however, endovascular repair has demonstrated good results from a much less invasive procedure and may be indicated in some patients.
- ABIs, ankle-brachial indices
- CTA, computed tomography angiography
- MRA, magnetic resonance angiography
- TASC, Trans-Atlantic Inter-Society Consensus
Clinical Algorithm(s)
Algorithms were not developed from criteria guidelines.
Iliac artery occlusive disease
Guideline Category
Clinical Specialty
Emergency Medicine
Internal Medicine
Intended Users
Health Plans
Managed Care Organizations
Utilization Management
Guideline Objective(s)
To evaluate the appropriateness of radiologic and other procedures for evaluation and treatment of iliac artery occlusive disease
Target Population
Patients with iliac artery occlusive disease
Interventions and Practices Considered
- Computed tomography angiography (CTA), pelvis, with runoff
- Magnetic resonance angiography (MRA), pelvis, with runoff
- Anticoagulation adjunctive therapy
- Antiplatelet adjunctive therapy
- Catheter-directed thrombolytic therapy
- Catheter-directed angiography
- Catheter-directed angioplasty (aortoiliac only)
- Catheter-directed stent placement (aortoiliac only)
- Catheter-directed stent placement (aortoiliac plus femoral angioplasty)
- Bilateral angioplasty only
- Bilateral stent placement
- Surgical revascularization
- Best medical management including supervised exercise program only
- Risk factor analysis, lipid profile and ankle-brachial indices (ABIs)
- No further treatment or evaluation
Major Outcomes Considered
- Mortality rate
- Rate of recurrent ischemia
- Rate of amputation
- Primary and secondary patency rates
- Limb salvage rates
Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Literature Search Procedure
The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).
The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.
The following criteria/limits are used in the searches.
- Articles that have abstracts available and are concerned with humans.
- Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
- May restrict the search to Adults only or Pediatrics only.
- Articles consisting of only summaries or case reports are often excluded from final results.
The search strategy may be revised to improve the output as needed.
Number of Source Documents
The total number of source documents identified as the result of the literature search is not known.
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Strength of Evidence Key
Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis, and results.
Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.
Category 3 - The conclusions of the study may be valid, but the evidence supporting the conclusions is inconclusive or equivocal.
Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.
The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.
More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the "Availability of Companion Documents" field).
Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Description of Methods Used to Formulate the Recommendations
Modified Delphi Technique
The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.
Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.
If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The recommendations are based on analysis of the current literature and expert panel consensus.
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Selection of appropriate radiologic and other procedures for evaluation and treatment of iliac artery occlusive disease
Potential Harms
Surgical intervention incurs higher morbidity, including risk of impotence and retrograde ejaculation.
Anticoagulation is potentially contraindicated in the setting of recent spinal surgery.
Qualifying Statements
Qualifying Statements
The American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.
Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Identifying Information and Availability
Bibliographic Source(s)
|Kostelic JK, Ray CE Jr, Lorenz JM, Burke CT, Darcy MD, Fidelman N, Hohenwalter EJ, Kinney TB, Kolbeck KJ, Kouri BE, Mansour MA, Nair AV, Owens CA, Rochon PJ, Vatakencherry G, Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® radiologic management of iliac artery occlusive disease. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 8 p. [33 references]
Not applicable: The guideline was not adapted from another source.
Date Released
1996 (revised 2012)
Guideline Developer(s)
American College of Radiology - Medical Specialty Society
Source(s) of Funding
The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.
Guideline Committee
Committee on Appropriateness Criteria, Expert Panel on Interventional Radiology
Composition of Group That Authored the Guideline
Panel Members: Jon K. Kostelic, MD (Principal Author); Charles E. Ray, Jr, MD, PhD (Panel Chair); Jonathan M. Lorenz, MD (Panel Vice-chair); Charles T. Burke, MD; Michael D. Darcy, MD; Nicholas Fidelman, MD; Eric J. Hohenwalter, MD; Thomas B. Kinney, MD; Kenneth J. Kolbeck, MD; Brian E. Kouri, MD; M. Ashraf Mansour, MD; Ajit V. Nair, MD; Charles A. Owens, MD; Paul J. Rochon, MD; George Vatakencherry, MD
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Kostelic JK, Funaki BS, Ray CE Jr, Brown DB, Burke CT, Gemery JM, Kinney TB, Lorenz JM, Mansour MA, Millward SF, Nemcek AA Jr, Owens CA, Reinhart RD, Silberzweig JE, Vatakencherry G, Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® iliac artery occlusive disease. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 7 p.
Guideline Availability
Electronic copies: Available from the American College of Radiology (ACR) Web site .
Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.
Availability of Companion Documents
The following are available:
- ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site .
- ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in PDF from the ACR Web site .
- ACR Appropriateness Criteria®. Evidence table development – diagnostic studies. Reston (VA): American College of Radiology; 2013 Nov. 3 p. Electronic copies: Available in PDF from the ACR Web site .
- ACR Appropriateness Criteria®. Evidence table development – therapeutic studies. Reston (VA): American College of Radiology; 2013 Nov. 4 p. Electronic copies: Available in PDF from the ACR Web site .
- ACR Appropriateness Criteria® radiologic management of iliac artery occlusive disease. Evidence table. Reston (VA): American College of Radiology; 9 p. Electronic copies: Available from the ACR Web site .
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on May 12, 2010. This summary was updated by ECRI Institute on July 27, 2010 following the FDA drug safety communication on Heparin. This NGC summary was updated by ECRI Institute on September ??, 2012. This summary was updated by ECRI Institute on March 10, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.
Copyright Statement
Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site .
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.


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- - 2012 champ Fernando Vieira mini-documentary (http://www.mmaforum.com/grappling-technique/103423-2012-champ-fernando-vieira-mini-documentary.html)
2012 champ Fernando Vieira mini-documentary
Fernando Vieira is a Cristiano Carioca black belt from Manaus. He is a 3-time world champion and the 2012 World Pro champion. He recently moved to Toronto, Canada to train and teach at Evolucao Thai, which is owned by Andre "Dida" Amade and his brother Mauricio Veio.
Here he talks about taking his BJJ and MMA career to the next level.
World champion and World Pro champion, Fernando Vieira, shows how to pass one of the more complicated and annoying guards, the shin-on-shin.
Part 1 of 3.
Part 2 of 3:
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- In the ending of adventure mode, the player finds Maxwell trapped in a demonic throne, with a phonograph playing ragtime nearby. Turning it off makes him thank you, because he's been listening to that one song for eternity. And turning it back on...
Maxwell: I suppose I deserved that.
- Generally, the baying of the Hounds, which appear every few days, tends to invoke trepidation in the characters. When Wolfgang hears them, however...
Wolfgang: I hear puppies!
- Willow's reaction to a Deerclops is basically what any rational person would say if they met such a monstrous creature.
Willow: Holy crap!
- One of the possible traps is a simple chest. If you open it, the season immediately changes to the unforgiving Winter or Summer. The only thing a character can say when they fall for the trap is "Whoops".
- Wickerbottom is normally a no-nonsense woman. In the presence of a baby beefalo, she momentarily gushes over its cuteness before catching herself.
Wickerbottom: Look at its widdle face! *Ahem*.
- Wilson's comment on the pitchfork is pure hilarity:
Wilson: Maxwell might be looking for this.
- WX-78 refers to the statue of a Glommer as "stone insect". Literal, but logical. But when he meets the real Glommer:
- Several concept art pieces for Don't Starve Together alternate character costumes have been released. Most of them are wearing the trademark frown, but Willow's "Burnt" skin has a tiny smile, as if she's thinking, "totally worth it".
- The Shadow skin sets all give the characters suitably threatening and cool Evil Makeovers, especially in the official artwork for the sets... with the exception of Maxwell, who instead gets the ridiculously dorky-looking Unshadowed set, complete with Nerd Glasses. William Carter really has has come a long way since 1901.
- Krampus is a Hawaiian-Shirted Tourist in Shipwrecked.
- The Beefalo song. It is something quite special.
- Wendy's quote for the Moon Stone once the Star Caller's Staff has been placed:
Wendy: Perhaps it thirsts for a sacrifice. Where's Webber...


text:
Alex Bond
4-H Center Director
999 Fortson Road
Hampton, GA 30228
Phone: (770) 946-3276
Fax: (770) 946-4494
Email: firstname.lastname@example.com
Other Georgia 4-H Centers & Links:
- Burton 4-H Center
- Jekyll Island 4-H Center
- Rock Eagle 4-H Center
- Wahsega 4-H Center
- 4-H Tidelands Nature Center
UGA Extension: Georgia 4-H
Fortson 4-H Center
Atlanta's Outdoor Classroom
Right around the corner in Hampton, Georgia, lies Fortson
4-H Center. There are 75 acres of forest, field, pond, and wetlands just waiting for your kids to explore the wonders of nature and get dirty!
Fortson 4-H Center is Hiring
Interested in working for 4-H at Fortson 4-H Center. Check out our Employment Opertunities for full and part time employment.
Environmental Education Program
We offer engaging and hands-on classes to immerse students in the natural environment to actively apply concepts learned in the classroom. All groups are welcome including public, private, home-based, religious and Montessori schools, as well as clubs and scouting groups. Our calendar open for reservations! We hope to see you at Fortson 4-H Center very soon.
Contact: Alex Bond email@example.com
Spring 2017 Homeschool Club
We are taking reservations for our Spring 2017 homeschool club, please find more information here.
Contact: Jessica Simoneaux (firstname.lastname@example.com)
Renting our Facilities
Fortson 4-H Center offers a variety of facilities to suit the needs of many types of groups. Fortson's seven cabins, all with central heat and air and modern restroom facilities, can sleep up to 174 people.
Find out more information here.
Making the Best Better
Georgia 4-H is the largest youth organization in the world, please check-out our public value statements: Public Value Statements as well as the eight year study conducted by Tufts University on the value of the 4-H Program: The 4-H Study of Positive Youth Development.


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As I mentioned in last week's post, I didn't quite make my monetary goal for the year, but I learned an incredible amount that was far more valuable. Here, I'll share a few things I've learned by trying to reduce "stuff" and obligations this year.
#1 – Marie Kondo can help you get organized
If you really want to reduce clutter and get your life organized, the KonMari method, which Marie Kondo outlines in her book, The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing, is, by far, the best method to use.
Her method is simple.
- Discard "stuff" by considering things by category (clothing, books, papers, etc), NOT by room. Ask yourself if each item sparks joy. If it doesn't, get rid of it. You're left with a household of things you truly love. I was surprised by how many things I used to have that I rather disliked.
- Organize completely. Don't buy anything fancy, just organize using the storage room you have and maybe a couple of shoeboxes.
I have yet to make it to the "organize completely" phase, but I have been floored by how well the "discard" phase works. Of all of the methods I tried this year, I found Marie Kondo's to be the most useful. Her book is a quick read and I highly recommend it.
#2 – Clean 10 minutes a day
Set a timer and see how much you can clean in just 10 minutes. Do it every day. This is the only way I can keep my house reasonably clean and it's really painless. I can get a lot done in 10 minutes and when that timer goes off, I'm done. No guilt for anything left out, I can get that tomorrow because I know I'll have another 10-minute opportunity then. Some days I get so much done that I'm motivated to continue – not because I have to – but because I want to. This habit gives me a fresh start to every day and it's really easy.
#3 – Wait 30 days before you buy something
I'm not talking about cereal or deodorant. Go ahead and buy those when you need them. However, for items that you'll use over and over again (that will persist long after you purchase them) give yourself a chance to think twice about them. The 30-day rule lets you consider other options or do some research. It also shows you how much you want an item. If you can't stop thinking about it for 30 days, then it'll probably be something you enjoy for a long time, so buy it.
#4 – Increase automatic savings when you get a promotion
If you get a 3% raise and you're already sending 8% of your paycheck to your 401(k), increase the amount you save to 9-11% right away when you get a raise. You'll still feel like you got a raise (unless you're very disciplined and save the entire thing – kudos to you), but you'll also painlessly increase your savings, which could mean an extra six figures or more when you retire.
#5 – Experience gifts are awesome
It turns out that wine, chocolate, trips, and my personal favorite, massages, have become my favorite things to give and receive. Experience gifts are consumable; things that people use up, so they don't stay around the house. They make the best presents because they build memories instead of a stockpile of "stuff". The Minimalist Mom has a great list of 90 clutter-free gifts for any occasion.
#6 – Don't throw away anything that doesn't belong to you
Even kids notice when something is missing. If anyone catches you in the act of discarding something that's not yours, the hit to his or her trust is massive. It's not worth it and eventually #7 happens.
#7 – Your family will start de-owning stuff on their own
I think my husband jumped on board shortly after I'd cleared off my side of the dresser for the first time since we bought it. It looked like the border between Haiti & the Dominican Republic.
Our closet also became easier to use. Eventually I noticed that he'd gone through his massive T-shirt collection and had thrown a bunch away. He didn't tell me he did it, but he did. Finally, we sat down and considered the family DVD collection together.
When you first start to de-own, it can be really hard to do it alone, knowing that the dent you're making is only a fraction of the total family "stuff". We've still got a ways to go, but I've noticed my family jumping on board, slowly but surely. Nathan has even mentioned (with a hint of gratitude that he may never admit to) how much cleaner certain rooms are now.
#8 – Time is your most precious resource
Seriously. Assuming you have basic necessities covered, nothing else matters (well, except your health). My new goal is focused on carving out more time for the things that matter (including health) because time debt is no longer something I'm willing to live with.
#9 – Shopping for groceries online is the best lifehack ever
I save 1-1.5 hours each week by shopping for groceries online and then picking them up at the store. I also save loads of money because I can easily see my total and kick things out of my cart. There are just so many very cool ways that shopping for groceries online makes my life easier. The link above to my online grocery-shopping manifesto is worth checking out if you'd like to try it. I lay out all the pros and cons.
#10 – Minimalism ruins the fun of shopping
I can't just make an impulse purchase anymore. For example, if I'm shopping for clothes, I can't just buy the first shirt I like. No, now there's a little voice inside my head asking annoying questions like, "Is this well-made?" "Is this versatile?" "Does it look amazing on me?" It's a great voice, but sometimes I wish I hadn't swallowed the red pill and changed my life forever.
#11 – It is impossible to get kids to get rid of stuff
Many will tell you they've succeeded in getting their kids to give away their toys. I'll believe it when I figure out a way that works with my kids.
#12 – One extracurricular activity per week per family member is more than enough
This rule helps us all minimize the craziness that comes with too many obligations. It keeps us (the parents) from turning into a shuttle service and it helps us all prioritize what activities we really want to be involved in. I've also found that constricting activities to weekdays is helpful. That leaves our weekends freed up to explore and go on Family Adventure Days. Alison has soccer, Maddie is in gymnastics, and I stay late at work one night a week for yoga. Perhaps this only works because our kids are so young, but the rule works for us right now.
#13 – Minimalism is a journey
At first, I naively thought I could organize my entire life and then sit back and reap the rewards. Then the junk mail showed up and our kids had birthdays and received a bunch of presents. Freeing yourself from your stuff only works as well as your system for ensuring new stuff doesn't catch you offhand. Figure out how you'll defend yourself before you get started and you'll have an easier time sticking to your wonderful new excess-free world.
One Year of Minimalism
I find it funny that my list naturally came out to an "unlucky" 13 items because I feel so lucky to have stumbled upon this project for the last year. It's changed how I think about the world and how I make decisions daily. I am, without a doubt, living a life closer to my dream life. I am excited to continue it with a new goal and I'm glad that you've been reading.
Share this post if you know someone who could benefit from it!


text: Divxturka.net is using Redbunker! Because Redbunker is better than Hotfile, Netload and Rapidshare ! Click here and buy REDBUNKER premium account! Plot: In this sequel to Sharktopus, two Piranhacondas hunt down their stolen egg. The scientist who stole the egg hitchikes the island and meets up with a movie crew on-set of filming. The star, the scientist, and some crew-members get kidnapped by some money-craving people who put them on ransom for some dough. Meanwhile, a Piranhaconda roams the island, along the way eating an island-goer, and some scientists searching for a rare flower. The snake comes to the kidnappers' hideout and attacks. The crew and the scientist escape. The lead kidnapper finds a camera and realizes that the scientist stole the egg, which caused the snake to attack, and he decides to kill the snake, and the crew. The snake follows the crew, who are in a truck, but is wounded by a grenade. The second Piranhaconda arrives and, sensing blood, attacks its wounded mate. It then decides to track down the crew. The scientist reveals that he had the egg, so they try to escape via boat. But the Piranhaconda stalls their . Genre: Horror | Sci-Fi IMDB rating: 3.1/10 from 996 users Directed by: Jim Wynorski Starring: Michael Madsen, Rachel Hunter, Rib Hillis Release Name: Piranhaconda.2012.1080p.BluRay.x264-MELiTELiViDiTY Size: 5.44 GiB Video: MKV | 1920×1080 | 8317 kbps Audio: English | DTS | 768 kbps Runtime: 1h 26mn Information: Code: http://www.imdb.com/title/tt1886644/ Download: Code: Single Link No Extraction http://www.redbunker.net/u98dwihjwrb4/m-piranhaconda-1080p.mkv.html Screens:


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-- Chesapeake recently announced that it had entered into a $3.0 billion unsecured loan facility, maturing on 2017, with proceeds to be used to repay borrowings under the company's existing corporate revolving credit facility. Borrowings may be repaid at any time this year without penalty, and Chesapeake has stated it intends to do so, out of asset sale proceeds. This transaction was costly for Chesapeake: it carries an initial variable annual interest rate through Dec. 31, 2012, of LIBOR plus 7.0%, which is currently 8.5%, given the 1.5% LIBOR floor in the loan agreement. Subject to certain limitations, the interest rate would step up to a fixed rate of 11.5% if the loan is not repaid by May 11, 2013.
-- Although this $3 billion debt issuance enhances near-term financial flexibility, we believe there is a risk of constraints on Chesapeake's ability to draw on its corporate credit facility. Among other maintenance financial covenants under the facility, there is a reported total debt to lagging-12-month EBITDA limit of 4.0X. We believe that if EBITDA remains at the weak level of the first quarter ($838 million) or worse, as we anticipate, without a significant reduction in reported total debt from the level at March 31, 2012 ($13.1 billion), Chesapeake could breach this covenant within the next three quarters.
"Based on our estimates and price deck assumptions (including natural gas price of $2.00 per British Thermal Unit in 2012, $2.75 in 2013, and $3.50 thereafter), we expect Chesapeake's negative free cash flow to total over $16 billion during 2012 and 2013."
As a result of this news, or a desperate need for downside protection, I saw that CHK June Puts were very active over open interest. These strikes stood out the most. OptionMonster saw a put spread in there. Look at the option chain below.
June 7 puts traded 61,441 times with 1,082 contracts open.
June 12 puts traded 41,734 times with 8,164 contracts open.
June 15 puts traded 23,146 times with 14,249 contracts open.
June 11 puts traded 13,569 times with 4,125 contracts open.
Source: Google Finance
These were mostly out of the money puts. Here was the range of activity on the stock chart.
Source: StockCharts.com


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STEVE INSKEEP, host:
It's MORNING EDITION from NPR News. Good morning. I'm Steve Inskeep.
One of the few aid agencies with people working in Myanmar offers a few hints at the devastation. The agency World Vision describes piles of bodies and a massive rice-growing region devastated. The nation formerly known as Burma might have suffered more from a cyclone than it did from the tsunami a few years ago - that's according to people at this aid agency.
We're going to get the latest this morning from NPR's Michael Sullivan, who's covering the story from Bangkok, and Michael, what have you learned?
MICHAEL SULLIVAN: Hi, Steve. I think what we can say right now is that what's going on is we're still trying to figure out just how widespread the destruction is that was caused by this thing and how many people were actually killed, and I think we're still trying to find out just how many people were left homeless by this thing.
I mean, there are some estimates that as many as several hundred thousand people were affected by this thing, but there's no firm estimates yet because these assessment teams that the few aid agencies operating in the country have on the ground are still out doing those assessments, and we just don't have any clear indication yet about what the real situation is. But we know, of course, that it's dire for many people.
INSKEEP: What is the terrain like that was struck by this cyclone?
SULLIVAN: It's very, very low-lying area, and that really complicated things here. Because the Burmese officials that were speaking today about this in the former capital, Yangon, were saying that there was basically this 12-foot-high wall of water that was generated by this storm, and it basically just inundated many, many villages near or along the ocean.
And that's basically where most of the casualties came from - not from the storm itself but from the wave that followed.
INSKEEP: We're talking with NPR's Michael Sullivan, who's reported on Myanmar and surrounding countries for years. He's reporting from Bangkok today. And Michael, I want to mention that like many other journalists, you're not in the country yet, not allowed in the country yet. And that raises another important question: Is this military government, this isolated government, going to let aid agencies in when they arrive offering help?
SULLIVAN: Aid agencies have already offered help, and some people say that the Myanmar government has accepted these offers, but I think it's not really clear yet. I mean, there are no reports as of now of international aid agencies actually getting new people into the country, people who weren't there already, and there's no reports of them getting, you know, plane-loads of food or water-purification tablets or, you know, plastic sheeting, any kind of portable shelter, into the country yet.
All they're doing now is distributing what they've already had in country on hand before this thing happened. So in theory, at least, from what I understand from yesterday in New York, that some people were saying that the aid agencies would be allowed in. But in practice, so far, it hasn't happened. There are many here who - in Bangkok - who have applied for visas for their people and they haven't gotten those visas yet. But they say they're optimistic that they'll get them probably tomorrow.
INSKEEP: Is that different than the pace of assistance that arrived after the tsunami, which I know you covered? Two or three days after was there actually aid arriving in other countries after the tsunami?
SULLIVAN: Yes. I mean, I think the countries involved there, particularly Indonesia and Thailand, they responded, you know, very openly. When this happened, they immediately recognized the consequences and they said, look, we need help. The government of Myanmar is a secretive government. It doesn't accept that much outside help, even in the best of times, and they're naturally suspicious of the international community in general and the West in particular.
And you know, they just don't like asking for help, and they don't really like the presence of international people on the ground, especially when it comes to this referendum that was planned for this coming weekend, this referendum on a new constitution the military is trying to get passed that many opposition groups say is, you know, just a sham, just a way for the military to stay in power.
They didn't want people around for this thing, and they certainly don't want journalists in to cover this thing, although the referendum in some of these affected areas now is said to be postponed.
INSKEEP: NPR's Michael Sullivan is covering the latest that we can learn about a tropical cyclone that struck Myanmar, killing thousands. He's in Bangkok. Michael, thanks very much.
SULLIVAN: You're welcome, Steve.
INSKEEP: And we'll bring you more as we learn more.
Copyright © 2008 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR's programming is the audio record.


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I'm going to give it a try reading these. :) It'd be interesting to hear what you think the challenges are, and what the right decisions need to be made on?
On digital experiences, Open Source, startups & the future
Ray Ozzie, who took over the role of Chief Software Architect at Microsoft when from Bill Gates retired about five years ago, announced recently that he will be retiring soon. When Ozzie first became Chief Software Architect, he wrote a famous 5000-word internal memorandum titled, The Internet Services Disruption. The memo outlined the transformative and disruptive potential of web services.
Ozzie wrote, "The ubiquity of broadband and wireless networking has changed the nature of how people interact, and they're increasingly drawn toward the simplicity of services and service-enabled software that 'just works'. Businesses are increasingly considering what services-based economics of scale might do to help them reduce infrastructure costs or deploy solutions as-needed and on subscription basis.". Ozzie was spot on as this is what today's Software as a Service (SaaS) and Cloud Computer are all about.
Now, five years later, just before he is about to retire, Ozzie wrote another 5000-word memo entitled Dawn of a New Day. In this memo, Ozzie reflects on how Microsoft has been transformed over the past five years with regards to so-called 'services'. Despite many successes, Ozzie acknowledges that for the most part, Microsoft missed the boat on mobile and social software.
More importantly, he also lays out his vision of where things are going in a post-PC world: "To cope with the inherent complexity of a world of devices, a world of websites, and a world of apps and personal data that is spread across myriad devices and websites, a simple conceptual model is taking shape that brings it all together. We're moving toward a world of 1) cloud-based continuous services that connect us all and do our bidding, and 2) appliance-like connected devices enabling us to interact with those cloud-based services."
I spent most of my evening reading both memos. It provides some unique insight about what it means to be Chief Software Architect at one of the largest software companies in the world, as well as how they see the future. In general, I agree with Ozzie's vision of the future as he explains it in his latest memo. The part on complexity also resonated with me. I think the points he makes are very relevant for most of us that make a living with Drupal. Like Ozzie, I think development of this new service-connected world will be neither fast nor easy. However, I think Drupal is uniquely qualified to play a prominent role in such a world. It requires us to make the right decisions, to manage complexity, and to stay on top of our game. Whether you like Microsoft or not, the memo is worth reading.
I'm going to give it a try reading these. :) It'd be interesting to hear what you think the challenges are, and what the right decisions need to be made on?
Fantastic read, very open, I particularly enjoyed reaching this point "...the power and responsibility to truly effect transformation exists in no small part at the edge. Within those who, led or inspired, feel personally and collectively motivated to make; to act; to do."
It's funny, I was reading the same documents on the same night Dries. I came across this quote when I was googlin' for more:
"Complexity kills. It sucks the life out of developers, it makes products difficult to plan, build and test, it introduces security challenges, and it causes end-user and administrator frustration."
Yep, it was Ray. Good thing so much work has gone on in the d7 UX project, eh?
Drupal is based on content management.
While this "new dawn" is based on managment of person. The new web is person-centric. Drupal has not been built that way and Drupal 7, with all its stress on overlay, missed the boat. Compare the user interface, user to user relationship, and easy posting-sharing of media between individuals in Facebook. Drupal with all its might should have those functionalities long before. This is not to say that Drupal would have mimicked FB or by installing Drupal I will have beaten FB. Neither its a question of FB clone. But the functionalities available to the end-user, the way users can rediscover known persons, meet new persons, and share stuffs. Surely you can do lot of those with Drupal but thats not exactly as easy. Like Microsoft after few years, after no more White House is left that will have its "CMS", Drupal will be posting similarly how it missed the bus of social stuff.
Updates from Dries straight to your mailbox


text:
Career Center
Welcome to Aging Services Career Center
Associate Director Standards and Survey Methods
The Joint Commission
The Associate Director, Standards and Survey Methods plans, manages and evaluates activities and projects related to the development and refinement of accreditation and certification standards and survey methods. Supervises professional and administrative support personnel.
Internal Number: 1
About The Joint Commission
The Joint Commission is dedicated to helping health care organizations help patients. We realize our mission through the work our employees do every day to help health care organizations aspire to provide safer, higher quality care. We are committed to providing products and services that are relevant, and to working collaboratively with our fellow employees, health care organizations and other st...akeholders. Everything we do, every survey or review we conduct, every interaction with the public, and every standard we set is done with the aim of helping our customers better serve their patients, residents and clients. We invite you to join our team of dedicated partners committed to creating a better experience for the patient.
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Filed To: Women's
Amanda Beard
- Beard dives into the pool.
- The Olympian trains.
- A much needed rest between workouts in Los Angeles.
- The swimmer steps out for a break.
- Beard rests after exiting the pool.
- Relaxing in the bleachers between sets.
- The Olympian swimming underwater.
- Start over


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We are very proud that the US magazine Runner's World has put our Katadyn BeFree water filter on their Gear of the Year wish list.
The ultralight, super soft and flexible water flask with integrated filter weighs only 59 grams (2 ounces) and fits in (almost) every pant or shirt pocket. Such convenience makes the BeFree your ideal trail companion for longer adventures or trail runs. Using it couldn't be more uncomplicated: Simply fill the flask and tighten down the mouthpiece. While you drink, water feeds through a 0.1 micron hollow fiber filter that reliably filters microorganisms such as protozoa and bacteria. The ingenious system is composed of a tough BPA- and PVC-free 0.6L Hydrapak SoftFlask™ with a 0.1 micron hollow fiber filter that can treat up to 1,000 liters of water. The flask is easily filled with its wide 42mm opening. Free Flow Channels™ ensure fast water flow when drinking. Plus, the hollow fiber filter can be cleaned simply by shaking or swishing in water -- without the need for backflushing. The nozzle also has a protective cap to keep it clean along the way. Other notable advantages of the BeFree: It is the only hollow fiber filter on the market today for which replacements are available. In addition, the nozzle cap can be replaced.


text:
Sydney is a lively and exciting city. Once you arrive, it isn't hard to see why this is one of the most popular tourist destinations in Australia. It is the capital city of New South Wales and is home to over 5 million people, making it the most populous city in Australia. The city's size is reflected in its road network, which includes the Sydney Harbour Bridge, Sydney Harbour Tunnel and a number of motorways in and around the capital.
As well as a thriving CBD, there are also a number of districts in Sydney. Each boasts their own unique style and attractions. Parramatta is a western district of Sydney. A city within its own right, but still located within 25 kilometres of the city centre and less than 10 kilometres from the iconic Sydney Olympic Park.
Alpha Car Hire has recently opened in Parramatta and is offering great prices on a range of cars. But before you hop in your rental car and get going, you may want to do a little research about driving around the area. Luckily, the team here at Alpha has put together some tips for driving around Parramatta and Sydney to save you any unnecessary drama or stress.
Interstate visitors and overseas travellers driving around Parramatta and the wider Sydney area can sometimes find themselves lost or confused by the city's extensive road network. Navigating this city can be a daunting task for those unfamiliar with its geography.
The Sydney Orbital Network has ten motorways that move traffic in and out of the city center, all of which are now owned by private operators. Using Sydney's motorways is typically the fastest and most efficient way to drive around the city. Just make sure you have gotten yourself an E-Toll pass as most toll roads no longer accept cash payments.
Be alert as to what roads have tolls, as it might not be immediately obvious due to the lack of tollgates for cash payments. You can download a comprehensive guide to Sydney's motorways here. It may help if you take a look at the network before getting behind the wheel.
If you are visiting from another country, remember that Australian road rules dictate that you drive on the left hand side of the road. Because of this you also need to keep in mind that, when crossing the road as a pedestrian, you need to look to the right first. Then, after checking both directions, you can walk across the road.
Like most large cities, traffic in Parramatta and Sydney can be pretty bad sometimes. You can cut down on your driving time by avoiding major roads during peak hour. There is also a Live Traffic NSW App that you can download.
Traffic is usually worst heading into the middle of the working week, with the Eastern Distributor, Old South Head and Pacific Highway most commonly affected by congestion.
Make sure that you stick to the speed limits when driving and be wary of traffic lights. There are plenty of cameras and police around the city, ready to catch drivers breaking the law.
Car rental in Sydney is relatively easy to find. Alpha Car Hire in Sydney offers visitors and locals the best prices for a rental car. Just make sure you have your current drivers license and credit card available when booking.
Once you are in the car and ready to hit the road, there are a number of great places within driving distance of the city.


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Integrating the 2030 Agenda into Finland's Domestic Policy Framework
The main challenge in implementing the 2030 Agenda in Finland will be integrating the principles and targets of sustainable development into all of the country's domestic policies, including those policies related to developing countries. At the outset, it is especially important to pay attention to choosing suitable indicators and monitoring and following up on them. Coherence will not be possible without concrete targets and indicators by which to measure them. The 17 Sustainable Development Goals (SDGs) can be achieved only in co-operation with all stakeholders including civil society, the private sector, scientific institutions and the media. Implementation of the 2030 Agenda is also broadly supported by Finnish civil society, which is currently in the process of building a systematic internal co-operation structure to create new kinds of partnerships in line with the universal spirit of the SDGs.
Published on Fri, 2016-08-12 18:59
The main challenge in implementing the 2030 Agenda in Finland will be integrating the principles and targets of sustainable development into all of the country's domestic policies, including those policies related to developing countries. Genuine political commitment is a prerequisite for implementing the 2030 Agenda broadly and coherently throughout the public administration. Different stakeholders have to be engaged and also take responsibility for implementing the goals. Implementation has to be monitored not only globally but also regionally.
This requires sufficient planning, coordination and allocation of resources, which in turn requires political commitment to implementing the universal goals but also prioritizing policy actions in order to get a serious and efficient start. Committing to the goals means that attaining them is mainstreamed into all decision-making, and not just considered in a separate action plan. It is important to understand the 2030 Agenda in a holistic way, so that for example gender equality is not only a separate goal but also a cross-cutting theme.
Published on Thu, 2013-02-14 21:22
The Finnish government wants to be an accountable member of the international community, but its political will to be so does not always transpire. Finland has not, for example, been able to reach the 0.7 % target for its development funding.
Published on Mon, 2012-10-29 14:25
"Land grabs" in the Global South have caused much debate and concern during the last couple of years, especially since the global food price crisis of 2008. Kepa, a platform for Finnish NGOs interested in development issues and focal point of Social Watch in that European country, held a discussion on the issue this month. Tuomo Alhojärvi wrote a report on the debate for Kepa's website.
Published on Thu, 2012-09-06 09:05
Finland has certain problems: many people numb themselves with antidepressant drugs and alcohol, people bully and harass each other at work, a young man will fire into a crowd of people, a father kills his family. Finnish people should learn something from developing countries, wrote Johana Pohjola in an article published by Helsingin Sanomat daily newspaper.
Published on Fri, 2011-08-05 07:43
Source: Helsingin Sanomat
Concerns about climate change and about the future of the planet were given the most weight by the readers of Helsingin Sanomat (HS), a Finnish newspaper, when they voted on what they considered to be the most unethical product in the world.


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Read a Name
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Read a Name
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OnomasticoYesterday : s. Emilio Today : s. Massimo di Verona Tomorrow : s. Felice I


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TOMORROW! Testify at the EPA
Remember a couple of months ago, when the EPA announced new carbon regulations? Remember how excited we were, because these regulations effectively outlaw new coal plants?
To recap David's post:
- The proposed regulations will only affect new plants, BUT
- the EPA may be legally obligated to regulate existing coal plants soon.
- Most importantly, the regulations will effectively outlaw new coal plants.
Now is your opportunity to speak up and show your support. If you live in D.C. or Chicago, stop by one of the hearings to join in rallies and more throughout the day. The public comment period has also been extended to June 25.
Washington, DC
Ariel Rios East Building
Room 1153
1301 Constitution Avenue
Washington, DC 20460
Chicago, Ill.
Ralph H. Metcalfe Federal Building
Lake Michigan Room (12th floor)
77 West Jackson
Chicago, Ill. 60604
Need more information? Check out the EPA's website.
The hearings and the public comments are important because it's our opportunity to show how much support there is beyond the EPA's proposed regulations. We can be sure that polluters are lobbying hard behind the scenes.
*image from Wikipedia.


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Denias' BeautyMature
I woke up and smiled as I saw Denias' figure beside me. He looked so calm when he was asleep. I snuggled closer up to him, having somehow rolled slightly away in the night (which caused me to think that my body was crazy). I closed my eyes as I put an arm around him and whispered "Oh I love you."
I jumped at his voice. Then relaxed back into him.
"No," I teased. "I'm just saying that because I'm a sucker for kittens."
Denias smiled and kissed me. He then heard a noise and shifted into kitten form.
I covered him up with the blanket and waited, eyes and ears strained for the slightest movement or noise. It turned out just to be my sister, going downstairs to watch TV.
"Coast clear," I whispered.
Denias shifted back with a sigh. Then he smiled at me. "We should go to mine."
"We should," I agreed. I grinned. "You should kidnap me."
Denias chuckled and picked me up, carrying me out of the window. I think I stopped breathing as we fell but he landed on his feet easily.
"Wow, you can jump out of high buildings?" I asked, quite stupidly actually.
Denias chuckled. "Wolf power" he mocked and lowered me down onto my feet.
I leant up to kiss him. "Well, now be a pony."
Denias shifted into a horse. A stunning horse which was dark, dark black. I climbed onto the beautiful creature. I had been about to say 'Giddy up horsey,' but I found I couldn't now, so inspired by the magnificent body beneath me and the velvet softness of its mane. My fingers twined in it and I leant down to kiss Denias' head.
"You're always this beautiful," I told him. "Always this special." I hugged his neck, resting my face against him. "And I meant what I said this morning. I truly love you."
Denias neighed and began to trot.
I lay against him as he moved, hyper aware of every muscle that contracted and relaxed underneath me. "It's like your body melts," I thought aloud. "This is what people mean when they talk about fluid motion."
Soon, we arrive beneath his bedroom window. He neighed and gestured with his head for me to jump off.
I reluctantly slid off, sighing discontentedly.
"I wish that could have lasted forever," I murmured. I walked around and looked into his liquid, gorgeous eyes. I kissed him on the nose. "I love you," I said. I leant up towards his ear. "I love you," I repeated.
He shifted back to human. "I love you too," he said, pulling me into his arms and kissing me sweetly.
I returned the kiss, caressing him lovingly. I then drew back to look intently into his eyes and tell him "I recognised the beauty of your equine form. Do you want to know why?"
"Why?" Denias whispered.
"Because," I said, in a low and intense voice, "it was the beauty I've felt every time we've kissed, caressed and shown our love for each other. I most especially felt it last night when we shared the best moment of my life. It's the beauty you've so gratifyingly let me be part of. The beauty of your soul."
Denias face turned soft and he stroked my cheek. "...Want to feel that beauty again?"
I felt my heartbeat quicken. "I would love to feel that beauty again."
Denias smiled and turned around. "Piggy back. I need my arms."
My brow furrowed slightly, but I smiled and released him. I pretended to wince. "Ouch, the lack of contact is causing my heart to tear."
Denias helped me onto his back then climbed to his room. When we got in, he put me down and quickly locked the door.
I giggled. "I feel like a criminal."
"Then let me teach you a lesson," Denias says, smiling as he pushed me down onto the bed.
My heart is now pounding. I gaze up into his eyes and lose myself there.
"Okay," I said, my voice barely above a whisper.
He kissed me and started to unbutton my shirt...


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I maneuvered around Mak so that my pert ass cheeks were on the edge of the pool table. Leaning back and opening my legs slightly I breathed 'I can be nice Mak. See anything you like?
I used to be rich, I used to be able to buy whatever I wanted, whenever I wanted. Now? Now I am working a bar in the middle of the desert. It's not so much the terrible wages, it's the boredom. I wish something exciting could happen to me. The day Mak and his biker gang strode into the joint, it did!
Now I make love under the stars, feeling a thick cock inside me while my nostrils fill with the smell of gas, oil and desire!
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Mak pushed up close to me and gently parted my legs. He pushed my back onto the pool table and started to undo my blouse. He was so tender, not at all what I was expecting. His strong, rough hands were all over my tits and stomach. He could appreciate a thin tight body. It used to be gym fit, now I was slim because I didn't get to eat much.
My body shivered as he worked his fingers down to my Daisy Duke's. He undid one button. I wanted him to open me up, slide his finger deep inside me and let me squirm. I wanted it right in front of all his men...
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Doctor Bloom's Story, a wry and subtle novel, is a Knopf Canada New Face of Fiction selection for 2004 and already a popular and critical favourite. What starts off sounding like a charming, bittersweet memoir develops rapidly into a complex and moving book centred on a pressing moral dilemma.
In the first few pages, Dr. Nicolaas Bloom, cardiologist and would-be writer, describes his life's trajectory: from medical and literary studies in Leiden, Holland, through practice and research in Cambridge to, following the death of his wife, a new life in uptown Toronto. Dr. Bloom's story proper begins in a writing workshop, taught by his tough-talking neighbour Larry Logan: Bloom finds himself entranced by one of his young classmates, a quiet, self-possessed young woman named Sophie Fuhr.
The novel quickly establishes the rhythm it will pursue throughout, its present-day action in counterpoint with Bloom's memories and reflections. Bloom works in a downtown medical clinic; he remembers his late wife and stillborn daughter; he considers his literary masters, most of all Chekhov; importantly, he meets Larry Logan's estranged wife Marianne. Then, out for a run in a local ravine, he sees a woman being beaten up; he has reason to believe it is his classmate, Sophie.
As Bloom and Marianne Logan fall for one another, and Bloom tentatively pursues his long postponed writing, Sophie's situation becomes more and more of a concern; soon it has drawn in Larry, Marianne and others, none of whom are able to step in and help her. This is in part because, complicating matters, Sophie does not appear to want to be rescued. As she puts it, speaking of herself in a coded, charged conversation in the writing workshop:
She has a belief. She believes that there are circumstances which, although they may not appear happy, are part of a the deeper life . it would be a mistake, she thinks, to leave these circumstances.
Sophie's husband, Walter Rollo Maggione, comes to Bloom for cardiac treatment. Abrasive and arrogant, some twenty-five years older than Sophie, he is a Swiss psychologist pursuing a doctorate at the University of Toronto, specializing in Jung. Meanwhile Marianne, a psychoanalytic psychotherapist, has come to care about Sophie as deeply as Bloom has.
Bloom and Marianne return from a brief Caribbean vacation to discover Sophie in the emergency room of Sunnybrook hospital, bruised and battered, claiming to have fallen down the stairs. Her husband has also been admitted, after an attack of angina. Attempts to intervene prove fruitless, but Bloom sees a way he could help Sophie: as Maggione's physician, he is aware of the subtleties of his condition, aware that were Maggione to not have the right medication to hand at the right moment, his life could be in danger.
The novel's central moral question gains shape: given all he knows about Sophie's situation about the violence and suffering she experiences, and her view of it as a kind of religious task can Bloom justify altering the odds ? Can he make it less likely that Maggione will pull through his next cardiac malfunction? Bloom's dilemma, carefully examined and disentangled, will haunt readers of this supple and moving novel long after its resolution.
About the Author
Don Coles is one of Canada s most successful and respected poets. He studied history at the University of Toronto and took a second degree at Cambridge University, then spent more than a decade on the continent in France, Germany, Switzerland and Scandinavia. Coles and his wife, Heidi, returned to Canada after the birth of his first child, and he was invited to join the faculty of York University s humanities department. It turned out, after a worrisome few days, that I liked it very much, and I was there for more than thirty years, he told the Globe and Mail in an interview. He was also, for ten years, Senior Poetry Editor at the Banff Centre for the Arts. Coles recently turned to fiction, in part out of a desire to work in a more generous and pliant space than my usual genre, he told the National Post. He described the process of writing Doctor Bloom's Story as: A sheer joy. . . . And I lived in it for eight or nine hours a day for at least four of the seven days in every week for three years. Not bad for a person generally considered to be, as I'm belatedly realizing, past it. Don Coles has published ten books of poetry. He is the recipient of a Governor General s Award, a Trillium Award and the John Glassco Prize for Translation. He lives in Toronto."
Praise For…
"Part crisp thriller, part meditation on writing, Doctor Bloom's Story is wholly marvellous."
"A straight-ahead, spryly imagined, tightly written tale of suspense. . . This is fabulous stuff. Doctor Bloom's Story has countless. . .moments that, in their combination of gaiety and sadness, fix themselves in your imagination. . . . Doctor Bloom is surely one of the most memorable and triumphantly conceived characters in recent Canadian fiction."
—The Globe and Mail
"Coles writes so elegantly and so convincingly that we would follow him anywhere."
—The Literary Review of Canada
"Coles, who has won many awards for collections of poetry, tells Dr. Bloom's story with an ear attuned to the rhythms of speech and an admirable eye for detail."
—Quill & Quire
"Doctor Bloom's Story is, by turns, witty, contemplative, and spirited story telling. One of our finest poets now proves himself to be an accomplished novelist."
—Guy Vanderhaeghe
"Any fan of Coles' poetry will instantly recognize the distinctive, casually sophisticated voice of this novel, the almost off-hand way it gathers a whole range of interests into a compelling whole. Doctor Bloom's Story is at once a medical mystery tale, an exploration of the limits of love and friendship, and a tribute to the art of writing — all rolled into an effortlessly seductive narrative. I couldn't put it down."
—John Bemrose, author of The Island Walkers
"Doctor Bloom's Story is utterly compelling, a novel both wise and wonderful."
—Richard B. Wright, author of Clara Callan
"How wonderful to find this trusted voice again, the poet transformed into the worldly late-bloomer Bloom! Reading Don Coles is like listening to an erudite, judicious friend tell the story of a life of the mind that doesn't for a moment neglect the delights of the flesh."
—Katherine Govier
"Doctor Bloom's Story is a complex, mellifluous novel that, while not tediously or pretentiously poetic, certainly puts language foremost — with commanding surefootedness and subtlety."
—New Brunswick Reader
"A masterful, taut and unusual book."
—Calgary Herald
"Coles has devised something odd, lovely and exceptional: a plot-driven novel of ideas in which ideas are integral to characterization. He captures Bloom's intelligence as it listens to itself unfolding, and it's both fascinating and entertaining to listen with him…. A book that buries a thought-poem on every page."
—The Vancouver Sun


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