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From the NorthShore HealthSystem (Dr Howington), University of Chicago Pritzker School of Medicine, Evanston, IL; Penrose Cardiothoracic Surgery (Dr Blum), Memorial Hospital, University of Colorado Health, Colorado Springs, CO; University of Michigan Medical School (Dr Chang), Ann Arbor, MI; Division of Pulmonary, Critical Care, and Sleep Medicine (Dr Balekian), Keck School of Medicine of University of Southern California, Los Angeles, CA; and the Department of Thoracic and Cardiovascular Surgery (Dr Murthy), Cleveland Clinic, Cleveland, OH.
Correspondence to: John A. Howington, MD, FCCP, NorthShore University Health System, 2650 Ridge Ave, 3507 Walgreen Bldg, Evanston, IL 60201; e-mail: email@example.com
COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.
Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.
The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.
Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
2.1.1. For patients with clinical stage I and II non-small cell lung cancer (NSCLC) and no medical contraindications to operative intervention, surgical resection is recommended (Grade 1B).
2.1.2. For patients with clinical stage I and II NSCLC, it is suggested that they be evaluated by a thoracic surgical oncologist or a multidisciplinary team even if the patients are considered for nonsurgical therapies such as percutaneous ablation or stereotactic body radiation therapy (Grade 2C).
Remark: At a minimum, we suggest that multidisciplinary teams have representatives from pulmonary medicine, thoracic surgery, medical oncology, radiation oncology, radiology, and pathology.
22.214.171.124. For patients with clinical stage I or II NSCLC and who are medically fit, it is recommended that they be treated by a board certified thoracic surgeon with a focus on lung cancer (Grade 1B).
Remark: Ideally general thoracic surgical procedures would constitute > 75% of the thoracic surgeon's clinical practice, and involve an average of ≥ 4 anatomic surgical resections performed per month at the center to maintain the experience and smooth function of the care teams.
3.2.1. For patients with clinical stage I NSCLC, a minimally invasive approach such as video-assisted thoracic surgery (thoracoscopy) is preferred over a thoracotomy for anatomic pulmonary resection and is suggested in experienced centers (Grade 2C).
184.108.40.206. For patients with clinical stage I and II NSCLC, systematic mediastinal lymph node sampling or dissection at the time of anatomic resection is recommended over selective or no sampling for accurate pathologic staging (Grade 1B).
220.127.116.11. For patients with clinical stage I NSCLC undergoing anatomic resection who have undergone systematic hilar and mediastinal lymph node staging showing intraoperative N0 status, the addition of a mediastinal lymph node dissection does not provide a survival benefit and is not suggested (Grade 2A).
188.8.131.52. For patients with clinical stage II NSCLC undergoing anatomic resection, mediastinal lymph node dissection may provide additional survival benefit over mediastinal lymph node sampling and is suggested (Grade 2B).
3.5.1. For patients with clinical stage I or II central NSCLC in whom a complete resection can be achieved, a sleeve or bronchoplastic resection is suggested over a pneumonectomy (Grade 2C).
4.3.1. For patients with clinical stage I and II NSCLC who are medically fit for surgical resection, a lobectomy rather than sublobar resection is recommended (Grade1B).
4.8.1. For patients with clinical stage I NSCLC who may tolerate operative intervention but not a lobar resection due to decreased pulmonary function or comorbid disease, sublobar resection is recommended over nonsurgical therapy (Grade 1B).
Remark: Regardless of whether patients undergo wedge or segmentectomy, adequate margins should be achieved.
Remark: Sublobar resection should involve an anatomic segmentectomy whenever possible.
4.8.2. During sublobar resection of solid tumors in compromised patients, it is recommended that margins greater than the maximal tumor diameter for lesions less than 2 cm should be achieved; for tumors larger than 2 cm at least 2 cm gross margins should be sought to minimize the likelihood of a positive margin and/or local recurrence (Grade 1C).
Remark: The data regarding the appropriate gross margin necessary to achieve a pathologically negative margin or minimize local recurrence in larger tumors (> 2 cm) is less well established. It may be that larger margins for larger tumors are required.
Remark: In patients undergoing resection of solid stage cI NSCLC in whom the ability to achieve an adequate margin is compromised, the addition of brachytherapy mesh to sublobar resection may improve local control.
4.10.1. In patients with major increased risk of perioperative mortality or competing causes of death (due to age related or other co-morbidities), an anatomic sublobar resection (segmentectomy) over a lobectomy is suggested (Grade 2C).
4.12.1. For patients with a clinical stage I predominantly ground glass opacity (GGO) lesion ≤ 2 cm, a sublobar resection with negative margins is suggested over lobectomy (Grade 2C).
5.3.1. For patients with clinical stage I NSCLC who cannot tolerate a lobectomy or segmentectomy, stereotactic body radiation therapy (SBRT) and surgical wedge resection are suggested over no therapy (Grade 2C).
Remark: Surgical resection has the potential benefit of definitive histologic analysis (eg, adenocarcinoma subtype) and pathologic nodal information. In compromised patients for whom such information would not change management SBRT is a preferred option. Also, SBRT is favored in patients for whom an adequate margin in unlikely with a surgical wedge resection.
Remark: Radiofrequency ablation may also be considered for peripheral tumors < 3 cm in inoperable patients.
18.104.22.168. For patients with completely resected pathologic stage IA,B NSCLC, it is recommended that postoperative chemotherapy not be used (outside of a clinical trial) (Grade 1B).
18.104.22.168. For patients with completely resected pathologic stage IIA,B(N1) NSCLC and good performance status, postoperative platinum-based chemotherapy is recommended (Grade 1A).
Remark: No clear recommendation is possible regarding adjuvant chemotherapy for larger tumors without lymph node involvement.
22.214.171.124. For patients with completely resected pathologic stage I NSCLC, it is recommended that postoperative radiation therapy should not be used (Grade 1A).
126.96.36.199. For patients with completely resected pathologic stage II NSCLC, it is suggested that postoperative radiation therapy should not be used (Grade 2A).
22.214.171.124. For patients with stage I and II NSCLC and a positive bronchial margin (R1 resection), postoperative radiation therapy is suggested (Grade 2C).
Patients with stage I and II non-small cell lung cancer (NSCLC) have early-stage disease and are typically approached with curative intent therapy. Although no patient can be guaranteed a cure, the chance of cure is sufficiently high that no patient with clinical stage I or II NSCLC should be denied treatment until evaluated by a physician or preferably a multidisciplinary team of physicians experienced in the care of patients with lung cancer.
Unfortunately, stage I and II NSCLC combined account for only 25% to 30% of all patients presenting with lung cancer in the United States today. Since the last edition of the lung cancer guidelines was published, the seventh edition of TNM staging in Lung Cancer was published by the International Union Against Cancer and the American Joint Committee on Cancer (AJCC).2 The present staging system is based on analyses of the 67,725 cases of NSCLC within the database. The analysis of this database allowed a detailed study of the impact of tumor size on prognosis. The seventh edition staging system is now recommended for the classification of carcinoid tumors and small cell lung cancer as well as NSCLC. This review and recommendations are focused on the treatment of stage I and II NSCLC only, in a way that is relevant to the current (seventh edition) stage classification system.
Changes in the seventh edition of the lung cancer stage classification system that impacted stage I and II NSCLC are T related and include new size cuts for a refined T stage classification. T1a tumors are ≤ 2 cm, T1b tumors are > 2 to 3 cm in size. T2a tumors are > 3 to 5 cm in size, and T2b tumors are > 5 to 7 cm in size. Tumors > 7 cm in size or tumors with satellite lesions in the same lobe are now classified as T3 tumors. In the new staging system, patients with T2b (> 5-7 cm) with negative nodes and no distant disease are stage IIA. Patients with T2a tumors and N1 lymph nodes are also stage IIA. Patients with N1 lymph nodes are classified as stage IIa if they involve a T2a tumor and stage IIB with a T2b tumor. Patients with T3N0M0 tumors are also classified as stage IIB. In this article we discuss T3 tumors either due to size (> 7 cm) or invasion; T3 tumors due to the presence of same-lobe additional nodules are discussed in the article by Kozower et al,3 "Special Treatment Issues in Non-small Cell Lung Cancer," in the American College of Chest Physicians (ACCP) Lung Cancer Guidelines. A more detailed discussion of the current stage classification system is provided in the article by Detterbeck et al,4 "The Stage Classification of Lung Cancer," in the ACCP Lung Cancer Guidelines.
A multidisciplinary writing committee composed of a pulmonologist, a methodologist, and four thoracic surgeons was assembled and approved according to the process for the ACCP Lung Cancer Guidelines as described by Lewis et al,1 "Methodology for Development of Guidelines for Lung Cancer," in the ACCP Lung Cancer Guidelines.1 To update previous recommendations on the treatment of stages I and II NSCLC, a series of population, intervention, comparator, outcome (PICO) questions (Table S1) were developed and used to structure a literature search of computerized databases (MEDLINE, COCHRANE, Google Scholar, and Embase in some cases). The search included papers published through the end of 2011, overlapping with the previous ACCP lung cancer guidelines. Search terms were chosen according to the questions being addressed (details of the search strategy and results are available on request). Only papers published in English were included in the reviews. Articles were selected if they reported on the outcomes in question in patients with stage I or II NSCLC and included randomized controlled trials (RCTs) as well as cohort and outcomes studies.
A multidisciplinary writing committee reviewed and summarized the available literature and assessed the quality of the supporting evidence using a standardized method (see Lewis et al1 in the ACCP Lung Cancer Guidelines). The writing committee used this to develop recommendations and graded the strength of the recommendations. The evidence and the recommendations were then discussed and refined and finally approved by the entire lung cancer guidelines panel as described elsewhere.1 In accordance with the ACCP Lung Cancer Guidelines (third edition) process, the resulting guideline was reviewed and approved by the ACCP Guidelines Oversight Committee as well as external reviewers.
Surgical resection is widely accepted as the optimal treatment of stage I and II NSCLC over no treatment. There are no RCTs comparing surgery alone to radiotherapy alone, chemotherapy alone, or ablative therapies in otherwise healthy patients with stage I and II NSCLC. The argument for surgery comes primarily from consistent data from retrospective surgical series and databases and registries showing higher survival rates after surgery than after other treatment modalities. Based on such retrospective series of resected stage I and stage II NSCLC, the prognoses for stage I and II NSCLC, expressed in terms of 5-year survival rates, are commonly accepted to be 60% to 80% for stage I and 30% to 50% for stage II NSCLC.5 In contrast, data on the natural history of untreated clinical stage I or II NSCLC consistently shows poor survival (2-year survival of approximately 20% and 15% 5-year survival).6 Although these patients are not comparable, the natural history data are consistent with data from tumor doubling times of NSCLC that were observed for a period of time before resection.6 Although indirect and stemming from uncontrolled comparisons, the large amount of data and the consistency thereof makes a strong argument for surgical resection over no treatment.5,6 This also underscores that surgery should be considered carefully before alternative approaches or no treatment is chosen.
2.1 Recommendation
2.1.1. For patients with clinical stage I and II NSCLC and no medical contraindications to operative intervention, surgical resection is recommended (Grade 1B).
There is a growing body of knowledge showing improved perioperative surgical outcomes and better long-term survival in patients with cancer when they are treated by specialists in cancer surgery and at higher-volume centers. It is certainly plausible that a specific focus, specialized training, and higher volume lead to organization of the process of care in ways that result in better outcomes. Thoracic surgeons have had increased exposure in terms of broader experience and greater operative volume of lung resections during their resident education, particularly in the recent era of a separate pathway focused on general thoracic surgery for certification in thoracic surgery. For the noncardiac thoracic surgeon, thoracic procedures represent a greater proportion of their practice compared with general surgeons or cardiac surgeons. In the United States, general thoracic surgeons are typically defined as American Board of Thoracic Surgery certified surgeons for whom at least 50%, and for most individuals 75%, of their clinical practice is composed of thoracic procedures.
Our systematic literature search identified a number of papers reporting both short-term (perioperative mortality) and long-term outcomes (4- or 5-year survival) outcomes relative to surgeon specialty. In the United States, about 30% of pulmonary resections are performed by general surgeons, 45% by board-certified (BC) cardiothoracic surgeons who practice primarily cardiac surgery, and 25% by BC cardiothoracic surgeons who practice primarily thoracic surgery.7 We selected papers reporting an adjusted OR, summarized in Figure 1.8‐11 We report the OR relative to a consistent denominator of the general surgeon as the reference (or the cardiac surgeon when comparing only among cardiac and thoracic surgeons).
Inclusion criteria: multicenter database studies reporting adjusted outcomes for thoracic surgery relative to specialization up to 2012. Lobe = lobectomy; MC = Medicare; NIS = Nationwide Inpatient Sample; NS = not significant; Pneum = pneumonectomy; S = Surgeon; SEER = Surveillance Epidemiology and End Results.
aFor long-term survival, rates are an adjusted hazard ratio.
Figure 1 illustrates the consistent finding in every study of lower mortality in patients treated by thoracic or cardiac surgeons compared with general surgeons. However, the differences were sometimes not statistically significant. Only a few studies have reported a comparison between cardiac and thoracic surgeons, with some showing no difference and others showing lower perioperative mortality for thoracic surgeons. This is corroborated by a recent high-quality meta-analysis, with a pooled OR for perioperative mortality of 0.78 (95% CI, 0.7-0.88; P < .0001) for thoracic surgeons vs general surgeons, and an OR of 0.82 (95% CI, 0.69-0.96; P = .016) for cardiothoracic surgeons vs general surgeons.12 Furthermore, the rate of complications (or a surrogate for complications, eg, prolonged length of stay [LOS]) was lower for thoracic and cardiac surgeons as compared with the general surgeons in most studies.7‐9 This lower incidence of complications occurred despite the finding that the patients treated by thoracic surgeons had more comorbidities.13
The studies have also consistently noted better long-term survival after surgery performed by a thoracic or cardiac surgeon vs a general surgeon. The rate of mediastinal node dissection is twofold to threefold higher among specialty-trained surgeons. Other measures, such as the use of PET scanning and video-assisted thoracic surgery (VATS) resections, are more commonly done by thoracic and cardiac surgeons, whereas the use of neoadjuvant or adjuvant therapy is not different.7
The data shown in Figure 1 are OR that are adjusted for other factors, such as patient characteristics or facility characteristics (eg, high or low volume). However, which factors and how many were considered in the adjustment is inconsistent.12 Different databases were used for these analyses, each of which has strengths and weaknesses. Furthermore, although the definition of a general surgeon vs one who is BC in cardiothoracic surgery is clear, the criteria used to differentiate a cardiac from a thoracic surgeon are somewhat varied. The studies in Figure 1 all come from the United States with the exception of one from The Netherlands.11
The two largest studies used the National Inpatient Sample (NIS) database, which is specifically designed to represent a US cross-section of hospitals, involving about 20% of all hospital discharges regardless of insurance type.8,9 Schipper et al8 observed a raw mortality of 11.5%, 10.1%, and 6.4% for pneumonectomy and 4.1%, 3.0%, and 2.3% for lobectomy among general surgeons, cardiac surgeons, and thoracic surgeons, respectively. After adjustment for age, sex, type of hospital, case volume, insurance type, and 24 comorbidities, there was little difference between general and cardiac surgeons, but there remained a strong trend, albeit not statistically significant, for thoracic surgeons vs general surgeons (OR, 0.70; 95% CI, 0.47-1.06; P = .093). In this study, surgeons were not defined by board certification but by caseload in their practice. In a similar study involving largely overlapping cohorts from the NIS database, Ellis et al9 found statistically significant differences between thoracic and cardiac surgeons vs general surgeons. Exploratory sensitivity analyses suggested that the threshold for defining a surgeon as one or another type affected the results, with the best results seen in those very specifically focused on thoracic surgery (95% thoracic surgical cases).9
The search identified a large number of studies investigating whether outcomes are affected by the case-volume of centers performing surgery for lung cancer; we selected studies reporting on adjusted ORs, taking into account other potential factors. These are summarized in Figure 2.14‐33 The studies have demonstrated lower hospital mortality rates in higher-volume centers, with only one exception. The difference in perioperative mortality was statistically significant in most of the studies. This is corroborated by a recent good-quality meta-analysis (Fig 3A), which found a pooled OR of 0.71 (95% CI, 0.62-0.81; P < .0001).12 The few studies addressing individual surgeon volumes for lung cancer resections have found lower perioperative mortality is associated with high-volume surgeons.29,30
Inclusion Criteria: Multicenter database studies reporting adjusted outcomes for thoracic surgery relative to case volume up to 2012. CA = California database; CI = 95% confidence interval; FL = Florida database; High-vol = high volume; Low-Vol = low volume; JACS = Japanese Association of Chest Surgery; JATS = Japanese Association of Thoracic Surgery; NCDB = National Cancer Database; NSQIP = National Surgical Quality Improvement Program; NY = New York database; Reg = registry; Seg = segmentectomy; Surg-Vol = surgeon volume. See Figure 1 legend for expansion of other abbreviations.
aFor long-term survival rates are an adjusted hazard ratio.
bN is total number of patients.
cRelative to high volume teaching hospital.
A large number of studies have also found a benefit to long-term survival in patients having undergone resection at a higher-volume institution (Fig 2), although two smaller studies found the opposite effect. The recent meta-analysis found a pooled OR of 0.93 (95% CI, 0.84-1.03; P = .16) (Fig 3B).12
These studies have involved adjusted ORs, taking into account other factors that might have an impact. However, which factors and how many were included is variable. The thresholds for volume that were used were also quite variable. Although most of the studies were conducted in the United States, the results are consistent with studies from Asia and Europe. The types of databases used also varied.
The largest study examined 90,088 patients undergoing pneumonectomy. The unadjusted perioperative (in-hospital) mortality was 2.7% vs 4.9% in the highest-volume vs the lowest-volume deciles of hospitals, and a rate of prolonged LOS, respectively, was 14% vs 8%.14 A large US National Cancer Database study estimated that if perioperative mortality and survival rates equal to that in the best-performing quintile of hospitals could be realized across the board, > 500 perioperative deaths and nearly 1,500 subsequent deaths annually could be avoided in the United States among patients undergoing lung cancer surgery.15
The search also identified several studies addressing the impact of teaching hospitals (those with a training program or university medical center) that met the inclusion criteria. Most of these have also found better outcomes (both short term and long term) at teaching hospitals, even after adjustment for other factors such as case-volume (Fig 4).34 A significant benefit was found for surgery performed at a thoracic surgery teaching hospital vs a non-thoracic surgery teaching hospital (perioperative mortality of 2.7% vs 3.7%, P < .05).34
Inclusion criteria: multicenter database studies reporting adjusted outcomes for thoracic surgery relative to teaching facility status up to 2012. See Figure 1 and 2 legends for expansion of abbreviations.
bRelative to medium-sized nonteaching hospital.
The data in aggregate (Figs 1, 2, 4) present a strong body of evidence for referring patients with known or suspected early-stage NSCLC to physicians and centers with a focus on lung cancer care. In general, the benefit amounts to an approximately 15% to 20% improvement in surgical outcomes, which is far greater that attributable to interventions such as adjuvant therapy or newer chemotherapy drugs. A focus on high-quality care is necessary to improve the outcomes of patients with lung cancer, a disease that requires a multidisciplinary approach, in which approximately 30% of patients with early-stage disease receive no definitive treatment and which carries an overall cure rate < 20%.
It is difficult, however, to define exactly which factors account for the improved outcomes. Although the relationship between volume and outcomes may be fairly consistent within a large database, it is less consistent as a predictor of outcomes when applied to individual institutions. Furthermore, low perioperative mortality in a given year is a poor predictor of overall good outcomes.35 Furthermore, at least a portion of the impression that low-volume centers have worse outcomes may be attributed to the way the data are analyzed and portrayed36,37; and the contribution of volume to the variation in perioperative mortality rates is relatively low.37
Furthermore, there are difficulties with implementation of case volume as a tool to improve outcomes. A sophisticated meta-analysis was unable to identify a potential threshold as a target.12 Travel distance to an appropriate hospital is probably less important: studies have found that 75% of patients could reach a high-volume hospital by traveling < 25 additional miles, and 25% actually travel farther to a more distant low-volume hospital.38 However, if patients were redirected to the centers currently in the upper 2 quintiles of volume (top 40%), their volume would increase by 250%, and 91% of hospitals would stop providing thoracic surgery.17 The wisdom and practicality of such redirection needs thoughtful consideration.
Furthermore, there are data that having effective systems of care may be a key factor, and volume may merely be associated with this aspect. One large study has demonstrated that the incidence of complications was not correlated with perioperative mortality and appears to be attributable to patient-related factors and not to surgical quality. Instead, decreased perioperative mortality correlates primarily with a better response once complications occur.39 It appears that a shift to higher-volume institutions alone is not adequate,25 and that organization of care plays an important role.40
In summary, the setting in which pulmonary resection is accomplished has a major impact on short-term and long-term outcomes. Treatment at a center with higher volume, specialty trained individuals, and an organized system of care is likely to result in significant benefits. However, the relationship of these factors to outcomes is complex and requires further study.
2.2.4 Recommendation
Several recent single-institution retrospective series have demonstrated that VATS lobectomy is associated with fewer complications,41‐47 lower estimated blood loss or transfusion rate,42,48 and shorter hospital LOS,41,44‐48 even for older patients (Figs 5A, 5B).41,42,47,49‐51 Two meta-analyses50,52 (quality assessed as fair and good) and two systematic reviews53,54 (both poor quality) of VATS vs open lobectomy have been reported. These studies all found VATS is associated with a short-term benefit (reduced complications, perioperative mortality, pain) and long-term recurrence and survival rates that are at least as high as after thoracotomy. In addition, outcomes studies using US databases55‐57 confirmed lower complications, mortality, and length of hospital stay, even when hospital volume is taken into account, as well as equivalent long-term survival. Nevertheless, most of the data come from nonrandomized comparisons; only three small RCTs have been conducted,58‐60 which demonstrated equivalent outcomes but were too small to demonstrate this in a statistically robust manner. Most of these studies involved a mixture of stages, but the large majority of patients were stage I and II.
Although our search identified many papers comparing VATS to open lobectomy, few of them specifically addressed stage I or II NSCLC. Analyzing data obtained from the Society of Thoracic Surgeons General Thoracic Database, a prospective surgical specialty-specific registry, Paul et al56 identified subjects undergoing lobectomy from 2002 to 2007. Two matched cohorts of 1,281 patients each were defined by surgical approach: VATS or thoracotomy. Subjects were matched by propensity score using baseline preoperative variables, including patient demographics, comorbidities, and pulmonary function; however, data were missing for clinical stage in nearly 40% (1,021 of 2,562) and pathologic stage in 21% (546 of 2,562). Patients undergoing VATS were more likely to have clinical stage IA/IB disease, although the final (pathologic) staging distribution was not significantly different between the two groups. Patients undergoing VATS lobectomy experienced fewer postoperative complications overall: (26% vs 35%, P < .0001), fewer pulmonary complications (8% vs 12%, P < .0001), less atrial fibrillation requiring medical treatment (7% vs 12%, P < .0004), and fewer blood transfusions (2% vs 5%, P < .003). In addition, VATS lobectomy was associated with earlier chest tu


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Each year, emergency departments see an estimated six million people who come in with chest pain. At St. Anthony's, a seamless fast track system immediately identifies patients undergoing an active heart emergency. For patients with blocked arteries, St. Anthony's team of cardiac specialists moves fast. Where the national standard to clear a blockage is 90 minutes or less, St. Anthony's team, available 24/7, has cleared them in as little as 12 minutes.
In a cardiac emergency, St. Anthony's uses two web-based programs that transmit electrocardiograms directly from an ambulance to the Emergency Department physicians for quick detection of heart attacks. This allows the emergency team to better prepare for the patient and contact the cardiac cath lab team before the patient even arrives, and in some cases, patients may skip the emergency department and make it from home to our catheterization lab for treatment in less than an hour.
In keeping with the fast track process, there is no "waiting room" — patients are immediately moved into a private room for additional laboratory tests and continuous EKG monitoring. Depending upon a patient's condition, we also can arrange for a heart stress test that day. Some patients could be headed home in as little as four hours, versus a traditional overnight stay in the hospital.
The American Heart Association endorses the use of rapid treatment outpatient units, stating the "approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain."
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subset: commoncrawl


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David G. Larson posted a link to this article on Google+ which got me thinking about what should Google+ really implement. After some thought, here are my thoughts at the moment.
I'd agree that Twitter #hashtags are not highly aesthetically pleasing. As many people know, placing a hash sign (#) in front of a word on Twitter turns that word into a searchable link when your tweet gets posted. Is that important? Can't you search for any word without having to add the #sign. Yes, #hashtags are not strictly necessary for a basic search. However, the #hashtag on twitter has been elevated by the users as an important convention. It signals a start or continuation of a conversation about a certain topic.Twitter itself shows what #hashtags are trending at the moment. You can also go to http://whatthetrend.com/ for more info.
Twitter #hashtags are used even more extensively by certain groups of people. It's called Twitter chat. There's even a Google Docs list you can find via http://bit.ly/chatlist. There are sites to make it easier to start/find twitter chats (tweetchat.com, twubs.com, twebevent, and many more).
To me, this feels very reminiscent of Ward's Wiki (c2.com) back in the days when the Wiki concept was new and c2.com was a vibrant, active community. You would go to the RecentChanges page to get a list of what was trending/changing/being discussed at the moment.
Like #hashtags, WikiMarkup is simple, powerful, and effective. You just smash two words together to create a link. Clink on the link and you are now editing a new page. Other people are encouraged to contribute to that page. Often the page would start out as something resembling a chat (ThreadMode). Sometimes the conversational page would be Refactored/Converted to Document Mode. Also like #hashtags, WikiMarkup is not necessarily particularly aesthetically pleasing. And, no, I'm not recommending the use of WikiMarkup as the tool of choice here.
Twitter #hashtags also feel similar to OpenSpace conversations. The conversation lasts as long as it needs to. It's important that these conversations are easy to set up. And that it is easy to leave the conversation when you are no longer gaining from it or have nothing more to add.
#Hashtags are probably not the best choice for Google+. But it does feel like Google+ needs something to help facilitate temporal discussions around topics that a user is interested in. A tool that facilitates self-organization. Self-organization like often happens in Open Spaces, WikiPages, and Twitter #hashtags.
So, should Google+ use duplicate Twitter #hashtags? Google+ should at least co-exist nicely with #hashtags. There should probably be some Google+-centric way to facilitate these temporal topic-based conversations. Perhaps something like virtual topic-based public circles. Perhaps Sparks could be used instead. I admit that I don't fully grasp the Sparks concept. It seems like there's something more than just a saved search, but I'm not sure what.
Edited to add: Google seems to be adding some better searching functionality if you use them. To me, that is a good thing.
I'm new to the Google+ community. Folks who've been there longer have probably organized their own conventions already for these temporal topic-based conversations. If so, what are they?
Better yet, what other topics do you want to discuss on Google+?
Feedback, comments, questions, etc. are of course welcomed.
Jason Nocks


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Tuesday August 6th, 2013 1:18am
As we enter the quarterfinals this coming weekend, a look ahead at a very intriguing set of matchups.
Coming up: First game of the weekend pits No. 3 seed Ohio State vs. unseeded Cornell
Forecast: A little odd to see these teams seeded they way they are. Ohio State used an ECAC run to propel them to the No. 3 seed. Cornell's loss to Princeton in the Ivy League Tournament semifinals proved to be costly and cost them a seeded spot. Both were dominant in first-round wins, with the Buckeyes pasting Towson, 16-6, and the Big Red dismantling Maryland, 16-8. Ohio State features a number of dynamic scorers in Logan Schuss, Jesse King, and Carter Brown. Cornell counters with Rob Pannell, Steve Mock, and Connor English. Ohio State seems bent on showing people they belong at No. 3 and can handle the expectations; Cornell played lights out against the Terps and demonstrated why they were in the Top 5 for most of the season.
Tasty Nuggets: The last time these two tangled in the postseason was 2008, a first-round game Ohio State won handily 15-7. That was the last time the Buckeyes were in the quarterfinals as well as the tournament. Cornell was last in the quarterfinals in 2011, and they were defeated by Virginia. They missed the Big Dance in 2012.
Where the game will be won: Defense and goaltending will be huge in this one. Both offensive units have been playing at a very high level but in different forms. Ohio State is a bit more methodical with body punches, then all of the sudden you look up and they are on a four-goal run. Cornell is flashier, knockout artists that can hit you with dizzying flurries. Will the Buckeyes run the zone that was so effective against Towson? Can Cornell provide a second consecutive stout defensive effort? Ohio State needs to contain Rob Pannell-led offense as much as possible, taking him out of his game to the point that other people need to beat them. I look for Buckeye Joe Meurer to draw the cover on RP3. The Big Red hopes to slow down a team that has scored in double digits in their last seven games. Goaltenders Greg Dutton (OSU) and AJ Fiore (Cornell) will need to make saves in what could be an offensive display.
Coming up: Top-seeded Syracuse takes on unseeded Yale
Forecast: It's like looking in the mirror with these two teams. Both have depth of scoring; both feature stingy, physical defenses; and both will push transition when given the opening. Where they differ is at the face-off, where Yale has a decisive advantage. The Orange survived an early blitz by Bryant last weekend to win going away, 12-7. Yale erased a 5-1 halftime deficit to Penn State and rallied for a 10-7 win. With the victory, the Bulldogs became the first team in tourney history in 53 games to score 0-1 goals in a half and come back to win.
Tasty Nuggets: Syracuse last made the quarterfinals in 2011 but has not won in this round since 2009. This Orange senior class is looking to avoid being the first class not to advance to the national semifinals since 1979. Yale last advanced to the quarterfinals in 1992, where they were beaten by Syracuse 17-8.
Where the game will be won: Half field offensive sets. Yale figures to get the majority of face-offs with Dylan Levings at the square. The good news for Syracuse is they are 8-1 in games where they lose the face-off battle, including getting dominated by Bryant's Kevin Massa last weekend. Yale will need to convert the anticipated extra possessions into goals from the likes of Brandon Mangan and Conrad Oberbeck. Easier said than done against a very good Syracuse defense that has allowed only 14 goals in their last three games. Syracuse needs to get defensive stops and execute against a tough Yale D led by Mike McCormack and Peter Johnson. JoJo Marasco and his midfield linemates pose a unique challenge to this Eli defensive unit.
Coming up: No. 4 Denver to tangle with No. 5 North Carolina
Forecast: A lot of goals. Denver dropped 19 scores on Albany in the first round while the Tar Heels tickled the twine on 16 occasions vs. Lehigh. Quite simply two of the most prolific offenses will be on display at Lucas Oil Stadium. Pioneer Wesley Berg is on fire after his eight-goal performance against the Danes, while UNC attackman Marcus Holman is playing his best lacrosse of his career.
Tasty Nuggets: The last time the two schools met in the NCAAs was last season, a high-octane 16-14 win by the Pioneers in the first round. Denver is in the Quarterfinals for the third-straight season and look to advance to their second Championship Weekend in three seasons. North Carolina last made the quarterfinals in 2010. The Tar Heels are seeking their first appearance in the national semifinals since 1993.
Where the game will be won: What "second" line player will step up in this one? Wesley Berg, Eric Law, Cam Flint. Marcus Holman, Jimmy Bitter, Joey Sankey. These are the players we expect to do the most damage. The X-factor for each club could be the difference in this one. Maybe Eric Adamson for Denver. Perhaps Chad Tutton for UNC. Or will a goalie step up with that big late save? This game has all the makings of a fan friendly, high-scoring contest.
Coming up: No. 2 seed Notre Dame vs. No. 7 seed Duke
Forecast: Two teams seemingly going in different directions. Notre Dame needed a furious fourth quarter to subdue a spirited Detroit squad in the first round. In the span of a few hours we had a second team that scored a single goal in a half of NCAA tournament lacrosse come back to claim victory. Duke had a come-from-behind win of its own in double overtime against Loyola but looked more dangerous offensively than the Irish. Does Notre Dame have anyone who will be able to create space offensively and run by the Blue Devil defense?
Tasty Nuggets: This is the only rematch from the regular season in this round. The Irish defeated the Blue Devils, 13-5, on Feb. 16 in Durham. Notre Dame is in the quarterfinals for the fifth time in six years and looks to advance to its third Championship Weekend in four seasons. John Danowski has not lost in the Quarters since arriving in Durham, as Duke looks to clinch its eighth consecutive berth (not including 2006 suspended season) in Championship Weekend. The last two times these programs have met in the NCAA Tournament, Duke has prevailed — the 2010 National Championship game and the 2011 Quarterfinals.
Where the game will be won: Strength on strength matchups, and not so strong units. Notre Dame's defense against the Blue Devil O. Irish goalie John Kemp stepped up last week against Detroit with several key saves in the second half. Duke figures to get the majority of possessions with Brendan Fowler at the face-off, so Kemp's close unit led by Matt Miller and Stephen O'Hara will have to play a good deal of defense and needs to be strong against Jordan Wolf and company. On the other end Notre Dame will need to pressure what can be a vulnerable Blue Devil defense and find their offensive touch early.
Mark Dixon covers lacrosse for the ESPN Networks and Inside Lacrosse. He welcomes you to follow him on Twitter @DixonLacrosse and provide any feedback at firstname.lastname@example.com.


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Canadian Liberals set to bust deficit pledge as oil tumbles
By David Ljunggren and Randall Palmer
OTTAWA (Reuters) - Canada's Liberal government looks certain to break its promise to keep budget deficits to C$10 billion ($7 billion) a year but a deteriorating economy makes it hard to determine how large the shortfall will be, according to sources familiar with the party's plans.
The Liberals, elected last year on a promise to boost infrastructure spending, are likely to unveil their first budget by the end of March as decade-low oil prices slam economic growth and government revenues.
Finance Minister Bill Morneau has consistently sidestepped questions about the deficit cap, placing more emphasis on another pledge, to ensure the ratio of debt to gross domestic product (GDP) continues to fall.
"Let's be real here: the minister has already fundamentally said that the C$10 billion limit is out of the window," said one Liberal source, who declined to be identified because of the sensitivity of the subject.
Morneau said on Wednesday that now was the time to make promised investments in infrastructure, especially given very low interest rates.
Another source familiar with Liberal thinking said the party would find it hard to row back on its spending promises.
"It's going to be a bigger deficit than we expected. They've really committed themselves to the infrastructure spending," the source said. "The challenge right now is no one really knows where the economy is heading."
The government's fiscal update in November called for West Texas Intermediate crude oil at $50 a barrel in the first quarter of 2016, about $20 above where it is now. [O/R] Continued...


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This book is getting a bit dated. You should consider the latest version of Smashing WordPress: Beyond the Blog instead. You'll find it here.
Smashing WordPress Themes: Making WordPress Beautiful is my second book on WordPress published by Wiley in the Smashing series (yes, of Smashing Magazine fame). The first one was Smashing WordPress: Beyond the Blog which will get a 2nd Edition later in 2011.
In Smashing WordPress Themes: Making WordPress Beautiful I'll teach you how to create great WordPress themes and get the most out of the wonderful publishing platform that is WordPress.
You can expect 368 pages of WordPress theming in full color, written in a way far from boring tech books of the olden days. WordPress is fun, and so the tone of Smashing WordPress Themes is light and conversational, just as in my previous book, without thinking that the dear reader is a dimwitted moron. Read an excerpt or just order the thing and you'll see what I mean.
11 chapters of theming galore
So what's in the book then? Lots and lot on WordPress theming of course. We'll not only learn what makes themes work, but also put our knowledge to good use by building a magazine theme, giving an existing WordPress site community features with the BuddyPress plugin, creating a semi-static website, and so on.
Here's the contents at a glance:
Part I: What are WordPress themes?
- Chapter 1:
Gettings Started with WordPress
- Chapter 2:
This is a Theme
- Chapter 3:
Digging Into the Twenty Ten Theme
Part II: Hacking a theme
- Chapter 4:
Using Child Themes
- Chapter 5:
Choosing a Theme
Part III: Building your own theme
- Chapter 6:
Planning the Theme
- Chapter 7:
A Semi-Static Theme
- Chapter 8:
A Media Theme
- Chapter 9:
A Magazine Theme
Part IV: Taking themes further
- Chapter 10:
The BuddyPress Community
- Chapter 11:
Extending with Plugins
Who should buy Smashing WordPress Themes?
We'll cover the basics, but you should know that some rudimentary knowledge of HTML, CSS and PHP will help, although you don't need to be an expert nor know all three. If you've dabble with scripting languages, web publishing, or something similar then I'm sure you can use this book to learn to do WordPress themes.
If HTML, CSS and PHP sounds like Greek (or any language you don't know, should you know Greek), then you should get acquainted with these things first.
Want to buy the book? Then get it from Amazon, either in in dead treees format (paperback), or for your Kindle platform of choice (digital).
Finally, a nice big cover
You may nab that cover if you want to cover (pun intended) the book in any way. I appreciate a link back here should you do so. Thanks!


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Web site development can be an intimidating process to nonprogrammers. And collaboration with others can also be daunting, requiring expensive server-based applications. But it doesn't have to be that way. A technology with the strange-sounding name WikiWikiWeb (or just WikiWeb) simplifies both processes.
Created in 1994 by Ward Cunningham, WikiWeb was loosely derived from HyperCard principles and is written in a language called HyperPerl. The guiding principle behind the original Web site of Kansas City, Mo.-based WikiWeb Inc. (www.wikiweb.com) is that anyone can change or add to anything on a Wiki site at any time via an ordinary browser interface, making it an ideal collaborative environment.
Wiki provides an easy way to navigate files in a database. The technology is a stable platform that allows for adaptation or cloning to suit individual requirements. Wiki sites have been created using several development tools and languages. The www.Kehei.com WikiWeb is Perl-based; a clone written by Patrick Mueller was created in Rexx; and there are also Wiki engines in Python, Java, Smalltalk, Active Server Pages, Ruby, PHP and Visual Basic. Many clones have been created to support corporate or departmental intranets.
Why Wiki?
The main benefit of using Wiki is that it's not necessary for all changes to be submitted to a single intranet manager or webmaster. Those who use the site can keep it up-to-date on the fly. One implementation involves a customer support site for IBM's Component Broker product. Because pages are generated dynamically, the most current version of the file is always being served and links are automatically updated. Dynamic page-loading increases server load, but the Apache Web server with the mod_perl programming module can simultaneously support up to several hundred users.
Wiki Sites
LilyPond, a music software site, is using Wiki for its online documentation.
For Tcl enthusiasts, there's The Tcl'ers Wiki. This is a collaboratively edited area on the Web dedicated to the Tcl programming language and its extensions.
The JOS Project is a collaborative undertaking by an international group of Java programmers and enthusiasts that's aimed at the creation of a free and open Java-based operating system (JOS). This site's goal is to support the creation of membership lists, hold brainstorming sessions and provide requirement documents, detailed specifications, sample code and other documents essential to the JOS Project.
Also check out the WikiWeb hosting site to see the variety of Wiki sites being used on the Web, from Java information to vegetarian recipes.
The original Wiki site stores all pages together in one file using the Unix dbm hashed-access method. The Wiki translator accesses the database as it formats each hyperlink, which -- according to the dbm documentation -- can be done in two disk reads or fewer. The flexibility of this technology lets it sit on top of other databases such as Oracle, Access, Mini SQL and Revision Control System.
Wiki's formatting procedures aren't WYSIWYG, nor are they particularly intuitive. But the editing and creation commands are easy enough to master with minimal study, and they're brief enough to keep open in a second browser window for quick reference.
The basic text-formatting rules are simple:
- Don't indent paragraphs.
- Words wrap and fill spaces as needed.
- Use blank lines as separators.
- Four or more hyphens at the beginning of a line make a horizontal rule.
You'd never guess some commands: Use doubled single quotes ('') for emphasis (usually italics), tripled single quotes (''') for strong emphasis (usually bold) and six single quotes ('''''') to separate names that would otherwise appear to Wiki as page names but aren't. For example, QuickStudy, the name of this tutorial, would be input as Quick''''''Study to avoid being coded as a hyperlink.
Linking Made Easy
Creating hyperlinks to local pages is as simple as joining capitalized words together; if there were a page on the topic, its name would appear as JoinCapitalizedWords. Since page names are the hyperlinks between documents, it's important to assign names that clearly inndicate a page's content.
Creating new pages is simple. Following the Wiki naming convention (using joined capitalized words as page names), include a link to your new page in any other page. When you save the page, a link will be generated that ends in a question mark. Clicking on the question mark opens the link's edit window. Type or paste in text, save, and you're done.
I was able to easily add my own test file to the Wiki Wiki Sand Box, which is an area of the site where users are free to experiment.
In the piece I added, there are two hyperlinks to local pages: WikiWikiSandBox and TextFormattingRules. The word test was italicized by using the emphasis rule, while WikiWikiSandBox uses both the strong emphasis rule and the local hyperlink rule. The most-used-pages links were created with the list rules. For these, I had to use the Alt key plus 0-0-9 in place of the Tab key, which didn't work in the edit window.
The original Wiki markup language doesn't incorporate an HTML subset, although some clones have included one. The logic behind its omission is that using raw HTML would mean losing too much control over the content presentation. Since HTML hard-wires the syntax and features, a single small error can break an entire page; also, full HTML allows users to exploit browser security holes.
Because pages are automatically indexed by their assigned category (a term used interchangeably with "topic" in the Wiki world), site maintenance is considerably reduced.
As a former intranet manager, I would have loved to have been able to delegate site updates through such an easy-to-use tool. Anyone responsible for maintaining a Web site or who has manually updated hard-coded links in flat HTML pages would appreciate Wiki.
Blake is a freelance writer in Dover, N.H.
This story, "WikiWikiWeb" was originally published by Computerworld.


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The Castle is currently home to the largest private collection of motor vehicles in Britain which is housed in a purpose built museum and includes many fine and rare veteran, vintage, classic, sports and touring automobiles and motorcycles.
Caister Castle was built in 1432 by Sir John Fastolf. The 90 foot tower remains intact and visitors can climb to the top for a magnificent view of the castle ruins and the surrounding area. The castle is of historical interest both because it is one of earliest buildings in England of importance to be built of brick and because of its connection with Fastolf and later the Paston family.


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Da Ponte became the first professor of Italian literature at Columbia University.
Confiding in the favour and discernment of the Emperor, Da Ponte declined this offer.
Such is the flattering testimony given by Algarotti to the style of Jacopo Da Ponte.
It does not seem to have occurred to Da Ponte to develop his plot by means of an artistic arrangement of ensemble pieces.
Mozart, when he wrote the score to Da Ponte's libretto, was excited to production by the situations.
Da Ponte, however, hoped to overcome this difficulty; he agreed with Mozart to keep.the undertaking a secret.
The words of our excellent Da Ponte were a scaffolding to introduce his musical creations to the public.
Casanova threatened to have him hanged, but according to Da Ponte, was dissuaded from this by counter accusations made by Costa.
In the winter of 1792-3 Da Ponte found himself in great distress in Holland.
An actual wager laid in Vienna is said to have furnished the basis for Da Ponte's libretto.


text:
Community Board 7/ Manhattan is your part of local government. Like all other community boards, we are mandated by the Charter of the City of New York. The Board plays an important advisory role in dealing with land use and zoning matters, the City budget, municipal service delivery, and multiple community concerns of the Upper West Side.
The Board is headed by Roberta Semer, Chair. The chair is elected by the Board Members for a one year term, with a maximum three terms. There is also an Executive Committee comprised of the Chair, the First Vice Chair, Second Vice Chair, and two Co-Secretaries. CB7's staff is headed by its District Manager, Penny Ryan. Staff members include John P. Martinez, Assistant District Manager, and Jessie Nieves, Community Associate.
The Board consists of fifty volunteer members appointed by the Manhattan Borough President, twenty-five of whom are selected by the three Council Members representing the District. All of CB7's Board Members live, work, or have a significant interest in the district and are appointed based on their qualifications and the needs of the current Board.
CB7 has several standing committees that work with the community to address the concerns of the Upper West Side. Board members are required to serve in one or more of these committees during their appointment. For further information about CB7 rules and policies, please read the CB7 Bylaws.
For in-depth information about community boards and their role in City government see the details at About Community Boards.


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|Topic Review (Newest First)
Hi everyone,
Sorry for the gap between this post and my last.
We went to the vet first thing on Monday morning. The vet didn't seem overly concerned either at the idea of kennel cough (he didn't ask us to use a side entrance etc.) or, when we arrived, at our actual presentation. He said that since she wasn't off her food then he wouldn't diagnose kennel cough at all, or even the after-effects of the kennel cough vaccine. He put it all down to the stress of kennelling instead (it was her first time). All he gave us was some paste to help with the diarrhoea.
It's not the response that I was expecting, and I'm not 100% convinced that his explanation matched up with the symptoms...but he's the expert, right? On the plus side she's stopped coughing. The diarrhoea is still bad, but it's also improving. She's still quite miserable and lethargic...but fingers crossed it'll all improve quite quickly.
All I can say is: for whatever caused this, I won't be rushing to put her back into a kennel anytime soon. We obviously need a back-up plan for if we both need to be away again, so I'd say that it's time to look for a trusty person to come to the house twice a day and walk her in that situation. That should reduce her stress levels and cut out most transmittable diseases... (Perhaps they'll also feed the cat? Although he's never had a problem with catteries when that's been essential).
Thank you all for your lightning-fast contributions when I was at my most worried... I really appreciate the support!!
|The vax needs to be given a bit before so that the immune system can react and start mounting a response. Given the day of kenneling, combined with the stress of kenneling, probably made the dog more susceptible
Huntergreen...I might be wrong but this is what the Data Sheet says
Nobivac KC Data Sheet
Qualitative and quantitative composition
Per dose of 0.4 ml vaccine reconstituted with diluent (water for injections):
Active substances:
≥108.0 and ≤109.7 cfu1 of live Bordetella bronchiseptica bacteria strain B-C2
≥103.0 and ≤105.8 TCID502 of live canine parainfluenza virus strain Cornell
Nobivac KC
Vaccination against infectious tracheobronchitis (kennel cough) is recommended if dogs go into a high risk situation such as a boarding kennel. All dogs should be protected against the unpleasant effects of this whooping cough-like disease. It can be spread whenever dogs get together, and a single dog can cause an outbreak of infection. Intervet/Schering-Plough recommends that if possible dogs are vaccinated at least two weeks before entering the kennels
The problem with the shot is that it requires a booster if it was never given before. I'm not sure just one shot on the same day would work at all. Once diagnosed the kennel needs to be notified because all dogs are at risk, especially the ones that were given the shot for the first time on the day they arrived.
|i don't believe the vaccine consists of live virus/bacteria and there fore cannot cause the illness.
My guess would be your dog has picked it up from the actual vaccination. I don't know why they would give it to your dog the day they admitted her into the kennel, the dog is not instantly immune the moment it gets the vaccine, it takes several days to take effect.
As far as the actual KC, a dog can still get it even if vaccinated, there are so many strains the vaccine does not guard against. I would be more pissed about the fact they gave my dog a vaccine without my consent, which in my opinion is what led to your dog displaying the symptoms she has.
The vaccine-on-entry also seems a crazy choice because of this (from BahCan's fact sheet):
Unvaccinated dogs should receive one dose at least 3 weeks prior to the period of anticipated risk, e.g. temporary kennelling, in order to get protection for both vaccine agents. In order to get protection for Bordetella bronchiseptica unvaccinated dogs should receive one dose atleast 72 hours prior to the period ofanticipated risk.
But what on earth can I say to them?
I guess they'll just say that it was one of their 'preconditions.' I didn't actually take her to the kennels; they picked her up and drove her to the kennels about an hour away. We live in centre of the capital city, so I suppose it's cheaper for them to be based further out. But they have a good reputation, and at $70+ per night I was expecting something good for my princess. I didn't sign anything that gave them permission to vaccinate, but I suppose they simply enforce a policy that every dog is vaccinated on entry. We were also charged for a 'veterinary examination on admission'.
I don't really have a problem with the vaccination for the vaccination's sake; I'm not anti-immunisation per se, and if that was what they needed to allow her to stay, then so be it. But I wasn't expecting to pick up an ill dog, and I certainly wasn't expecting to pick up a dog with an illness that they'd immunised against.
So I guess my questions are:
i. If she picked it up from the kennels, is this any reflection on their cleanliness/policies etc.? I'll be letting loose on Facebook etc. and involving my legal insurance if it's a case of negligence.
ii. If she picked it up from them/it's a side effect of their enforced vaccine, would you expect them to pay for the bill? My heart says absolutely yes to this; I paid top-dollar to leave my dog in their care and she came back with an illness that I'll have to pay even more to put right (even if only to be on the safe side). But this is the first time that I've kennelled, so I don't know what the 'protocol' is in these situations...
I'll let you all know what the vet says tomorrow....
I would be asking the kennel why they gave your dog a vaccination.
Here is a link about that vaccine that gives some of the listed side effects
Nobivac KC - Product Data Sheet
If you scroll down it will list adverse reactions, it says wheezing, coughing and sneezing amongst other things
I've just pressed her neck to diagnose - she didn't cough, but she did wheeze. I'd like to use antibiotics to be on the safe side, but I'll obviously see what the vet says. I've found a vet relatively close by that's open on Sundays on a regular basis, so hopefully that will cut down some of the supplemental weekend charges.
They vaccinated her when she went in (I've just checked her vaccination record book as well). They used 'Nobivac KC', which is apparently against 'Bordetella bronchiseptica and canine parainfluenza virus'. Perhaps she picked up a different strain then...
Is this any reflection on the kennel, by the way? I realise that it's highly contagious, but is it any reflection on their policies/cleanliness? She was isolated for her stay because she was just coming off heat (I feel bad for her having to face this straight after!). At $70+ per night, I hadn't expected to bring home a sick dog, to be honest...
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Ask The Expert
Chiropractic and fitness
Getting Fit
Q: I'm due to go skiing in 4 weeks, but just pulled a hamstring and am told it will take 2 or 3 weeks before I can do any training. Am I likely to be fit to ski and what can I do to improve my chances please? View answer
Q: I skied recently and I started to get the usual leg burn towards the end of day one and by day 4 it was there within an hour of skiing. What do you recommend for lessening the burn in the first place and post recovery? View answer
Q: I'm trying to get to a good standard of fittness for my Easter Skiing break. I'm gradually building up my stamina, but would welcome your suggestions for strength exercises? View answer
Leg Pain
Q: I had an operation for a herniated disc. After extensive re-hab I can ski but the worst after-effect is stiffness in my leg and particularly foot, which is partly relieved by exercise. Any comments and are there any exercise you think will help? View answer
Back pain
Q: I've got sciatica, should I avoid a ski holiday this winter? View answer
Q: Skiing moguls or hitting that unexpected bump on a flat light day really kills my low back area. Why is this? View answer
Q: I really struggle with low back pain after my second or third day skiing, it ruins the rest of my ski week and I feel like I don't get value for money from my ski holiday. What can I do? View answer
Q: I wrenched my neck skiing last week in a fall and suffered whiplash. My neck has not felt right ever since and I find it hard to turn my head in one direction - now I'm back in the UK what should I do? View answer


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ENTouch Photography Photographer
ClassieChic101Model Female Nashville, Tennessee, US
My MM URL: http://www.modelmayhem.com/classiechic101
Mayhem # 1553141
About MeI would like to network through this site , as well as find a photographer whom is willing to work with me and help be to perfect my poses and facial expressions..
However I am good enough in the business to know rather to make a decision or not so please do not contact me if you think you have found another young female that does not know about the business..I know a scam or a snake when I come across one.
I am a full time college student Monday- Thursday, with a part time job that I work in throughout the week and weekend.. Right now I have a very busy schedule so I like to know things in advance so I could fit it in... Two days notice of a shoot is not enough time for me to prepare..
Shoot in summer 2008 for Profectiv Hair Products in Atlanta Georgia with Reggie Anderson, look out for my face in their hair line!!!
Recently did a shoot with my relative Myka Drake for Heels and Handbags in Nashville,TN.
A Little More About Me:
So I have only been in two live photo shoots..I am looking for those of you who are seeking to help models with little experience on a TFCD basis only!!! Unless you have a scheduled shoot that you are looking to hire models for. I am just getting started so I do not want to work with anyone who is just looking for money. I would like you to help me, as I give you what you need to expand your images as well.
***I am interested in:
I do not do nudity.
Have you worked with ClassieChic101? Add Credits for ClassieChic101! >>
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I,______________, accept the appointment as a Community Assistant (CA) at Ball State University Apartments for the academic year 2016-2017, and I understand that the following conditions are a part of this acceptance:
1. This agreement is for the academic year 2016-2017. Employment is contingent upon approval of the Resident Manager and the Office of Housing and Residence Life. Reapplication is necessary for each subsequent year of employment, and employment is contingent upon approval of the Resident Manager and the Office of Housing and Residence Life.
2. Employment is contingent upon signing a University Apartment lease for the 2016-2017 academic year.
3. A Community Assistant will receive a salary equal to $3000 for 10 months, paid bi-weekly.
4. A Community Assistant must maintain a minimum cumulative GPA of 2.5 during the period of employment. A Community Assistant who falls below a 2.5 or whose semester GPA falls below a 1.00 may be terminated. A CA must be in good academic and disciplinary standing with the University.
5. The Community Assistant is required to participate in an orientation program that is held each semester. The Fall Orientation is scheduled for the eight to ten day period prior to the beginning of classes. The Spring Orientation is scheduled for the weekend prior to the beginning of classes. The Community Assistant is required to attend at least two of the monthly staff development sessions provided each semester.
6. The Community Assistant shall present a positive, friendly, and concerned attitude toward apartment residents, and support the polices of Housing and Residence Life, serving as a resource person and positive role model for student, campus and community services. He/She is expected to refrain from behaviors or language that may be offensive to individuals or groups.
7. A CA shall be responsible for coordinating (at minimum) a fall and spring semester community program designed to promote community development within your assigned area, in addition to other community-promoting activities.
8. A CA shall be responsible for coordinating and implementing events for their assigned area throughout each semester. A CA shall be responsible for coordinating (at minimum) a University Apartment-wide activity each semester with an assigned CA programming group.
9. A Community Assistant shall attend Community Association for Scheidler and Anthony (CASA) meetings and assist with programs planned by CASA and the Resident Managers.
10. A CA shall attend weekly staff meetings as scheduled by the Resident Manager team and weekly one-on-one with assigned Resident Manager.
11. A Community Assistant is expected to meet with and know the residents in the assigned living area.
12. A Community Assistant shall assist with communication and administrative duties, including greeting new residents, submitting articles for the monthly newsletter, delivering newsletters and fliers, relaying complaints, gathering needed information, and conducting maintenance and safety inspections.
13. A Community Assistant must confront residents of policies and procedures and report lease violations and behavioral problems to the supervising Resident Manager. The Community Assistant is expected to observe University Apartments' policies and procedures.
14. A CA shall participate in an on-call duty rotation with fellow CA staff members. While on duty may be asked to assist with policy violations, crisis intervention, lock-outs, and immediate maintenance concerns.
15. Should outside activities or employment interfere with the performance of the required duties, the Community Assistant may be notified that employment is terminated.
16. A Community Assistant is required to have a valid driver's license.
17. A Community Assistant will perform other reasonable duties as assigned.
18. I, as a Community Assistant, for the Office of Housing and Residence Life, may terminate this agreement by written notice at any time during the contract period.


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OKLAHOMA CITY (AP) -- The Sonic drive-in restaurant chain named James O'Reilly as senior vice president and chief marketing officer Friday.
O'Reilly worked most recently as chief concept officer at bagel company Einstein Noah Restaurant Group Inc., where he managed the company's marketing, information technology, research and development. Prior to his time three years there, he worked for Yum Brands, which owns the KFC, Taco Bell and Pizza Hut chains.
Sonic Corp., based in Oklahoma City, operates more than 3,500 restaurants nationwide.


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"The quality of these super cute, modern cards is superb. Go with the pearl paper, you won't regret. Fun size! I like to be a little different; these pleased! Shipped fast."
"Just moved to a new city and wanted calling cards to share new information. Also added a list of my 12 favorite books to the back of the card being a bibliophile and often meeting with other book lovers. Lots of compliments on these sweet and fun cards!"
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Copyright © 2004-2017 Shutterfly, Inc | Tiny Prints | Terms of Use. Designated trademarks and brands are the property of their respective owners.


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Bmw z3 for sale by owner for sale on US's largest classifieds sites (832 results)
2001 BMW Z3 2.5i
1998 BMW Z3 2.8 2dr Convertible
2001 BMW Z3 2.5i
1996 BMW Z3 Convertible in Montgomery
*CLEAN CARFAX* *HEATED FRONT SEATS/HEATED MIRRORS, LEATHER TRIM, CONVERTIBLE SOFT TOP, Power Door Locks, Power Windows, Cruise Control, A/C, Cell Phone Hookup * Come in today to test drive this 1996 BMW 3-Series Z3. This is a Certified Clean Carfax vehicle. Stop by our dealers
78,379 Miles
Year: 1996, Make: Bmw, Model: Z3
2001 BMW Z3 2.5i Convertible Rear-wheel Drive
2001 BMW Z3 2.5i Black Sapphire Metallic **Local One Owner Trade**, **Clean CarFax**, Passed Dealer Inspection, **Extra Clean**, **Recent Oil Change**, **Non-Smoker**, **Leather Seats**, 2D Convertible, 5-Speed Manual, Black Top. Don't miss this! Not many available especial
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2000 BMW Z3 2.8 Convertible
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51,940 Miles
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Spotless, GREAT MILES 59,811! 3.2L trim, Cosmos Black Metallic exterior and GRAY LEATHER interior. Leather Interior, Premium Sound System, Aluminum Wheels, IN-DASH COMPACT DISC PLAYER. READ MORE!KEY FEATURES INCLUDELeather Seats, Premium Sound System, Aluminum Wheels Ro
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For all London-based fashion fans the wonderful b Store will be hosting a preview sale in less than an hour's time. With mulled wine, mince pies and up to 50% off this isn't an opportunity to be missed!
B Store 24a Saville Row, London, W1S 3PR, 0207 7346846
By admin | December 11th, 2008


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Toccoa, Stephens Co. Both Set to Release Proposed Budgets Today
Both the city of Toccoa and Stephens County are scheduled to unveil their proposed Fiscal Year 2015 budgets during meetings today.
Stephens County will go first, releasing its proposed budget during its 8:30 a.m. commission meeting in the second-floor courtroom of the historic Stephens County Courthouse.
Last week, Stephens County Administrator Phyllis Ayers said that following two days of budget discussions among county commissioners, the county's proposed Fiscal Year 2015 budget was being built on the premise of an increase of 3.19 mills in the millage rate.
Later today, the city of Toccoa will release its proposed Fiscal Year 2015 budget during its regular commission meeting at 5 p.m. at Toccoa City Hall.
After a budget retreat with city commissioners last month, Toccoa City Manager Billy Morse said at that time that the city's millage and utility rates were proposed to remain unchanged for the upcoming fiscal year.
Both this morning's Stephens County Commission meeting and this afternoon's Toccoa City Commission meeting are open to the public.
Both the city and county commissions must approve a budget for Fiscal Year 2015 on or before June 30 since the new fiscal year starts on July 1.


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11/24/2007 / Devotionals
Go therefore and make disciples of all nations, baptizing them in the name of the Father and of the Son and of the Holy Spirit, teaching them to observe all that I have commanded you. And behold, I am with you always, to the end of the age." Matthew 28:19-20 (WEB)
Do you remember the story of King Hezekiah? He was very sick, and Isaiah told him he would die. Isaiah left and Hezekiah immediately turned to God in prayer. God sent Isaiah back to the king with the message that God would add 15 years to the king's life. That was a unique situation. King Hezekiah knew he had 15 years to live.
God knows how many years I will live, also. I cannot add one minute to that time. However, I can make the most of every minute I have. Jesus said the harvest is plentiful but there are not many laborers. He also said to pray that the Lord of the harvest would send workers to the field. Where is that field? It is everywhere. It is the whole world. The world is filled with people who are dying in their sinspeople who need to know that they need a savior, and Jesus is the only one who can save them.
Whom will God send to that field? Anyone who is willing to go. Jesus told his first disciples to go and make disciples of every nation, baptizing them, and teaching them to obey everything he commanded the disciples. I am a spiritual descendent of those first disciples. Therefore, I, too, must obey everything he commanded them. I must do my part to make, baptize, and teach disciples.
God has given each of us certain talents. Most of us have learned numerous skills from our parents, our teachers, our co-workers, or through trial-and-error. If we are willing, God will combine our talents and skills with the gifts the Holy Spirit has given us to create a unique laborer he can send into the fields. Remember, the entire world is the field. Your neighborhood is part of the field. We do not all need to go to other countries to participate in the harvest. We can do so every day, right in our own neighborhoods, workplaces, and schools.
I cannot add one minute to my earthly lifespan. However, I can point someone to eternal life with Jesus. There is no better way to spend my earthly life.
What about you? Will you follow the Lord of the harvest into the field?
O, God, please send more workers to the field. Here I am; send me. You gave me life. I now give you my life to do with as you see fit. Make my life pleasing to you, God. Use me to bring others to you through your Son, Jesus the Christ. In his name I pray. Amen.
Copyright 2007, Star Ferdinand. All Rights Reserved.
Star Ferdinand is the author of The Prayerful Bible Study Series of study guides, numerous devotionals, and other Christian writings. You can read more of her writings at starferdinand.wordpress.com.
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Fantasy Football Playoffs Starting Advice (12/08/10) Russ Bliss gives his fantasy football tips on how to make your starting lineup decisions during the all too critical fantasy playoffsFun Reading-Fantasy Football & the male Ego (posted 7/1/09) Mr. IDP himself (Robert) shares with our members the pain of not sticking to your fantasy football draft strategy.
Injury Reports for each week of the Playoffs. We've got the NFL Injury Report for each round of the playoffs thru Super Bowl 46
REVISED Power Analyzer Playoffs Predictions (1/13/12): The Wild Card weekend didn't go exactly as predicted and each week
along with updating the player statistical predictions, the game
predictions are also updated. See the revised Power Analyzer NFL playoffs predictions and see the changes in who it now projects going to the Super Bowl.
Playoffs and Super Bowl 46 Predictions by Russ Bliss (1/6/12): After going thru the Power Analyzer predictions for the playoffs and
Super Bowl, our NFL/Fantasy Analyst Russ Bliss went over it in his own
mind and came up with a lsightly different version of how things will
go. Check out Russ's playoffs and Super Bowl 46 predictions now!
Power Analyzer Playoffs Predictions (1/5/12): Our fantasy football Power Analyzer software program turns it's
algorithm towards the NFL playoffs and has projected all the stats for
every player and come up with the winners of each playoff game all the
way thru Super Bowl 46. Russ Bliss provides commentary on our Analyzer software's playoffs predictions and what it sees happening in each game
Fantasy Playoffs Passing/Receiving Matchups! (11/9/11) Just like with the RB's, Russ has broken it down again for you in 2011. Which QB's, WR's, and TE's have the best passing/receiving matchups during your fantasy playoffs weeks? Looking at weeks 14-16 (and again showing weeks 13 and 17 too)
Russ has posted the information you need to know to put yourself in
position to bring home the Championship!
Fantasy Playoffs Rushing Matchups! (11/9/11) Looking for what players and teams have the best rushing matchups during your fantasy playoffs weeks? Russ Bliss has broken it down again this season and puts you in
the know of each team's rankings weeks 14-16 (plus showing the matchups
for weeks 13 and 17 as well).
2011 Fantasy Points Allowed per Game Defensive Rankings: starting in week 3 and updated each week thereafter all the way thru the end of the 2011 regular season, we'll have the updated fantasy points allowed per game rankings for both rushing and receiving for all 32 NFL defenses.
Fantasy Football News and Notes! Updated every
Tuesday, Wednesday, and Thursday, this where you'll find the news and
notes Russ reads on his fantasy football radio show. So if you miss the
radio program, you can at least always check out the written version of
Russ's fantasy football news and notes.
2011 NFL Season and Playoff Predictions! (9/8/11): Russ is back at it with how he sees each division shake out, who the
playoff teams will this season, and who will eventually come away as the
2011 season's Super Bowl champion. It's all in his 2011 NFL Season Predictions
AFC West Team by Team Positional Preview (9/1/11): Wondering what's up with Ryan Mathews and Mike Tolbert? How about
Knowshon Moreno and Brandon Lloyd? Do any of the QB's besides Phillip
Rivers have any fantasy upside? Russ Bliss looks at the AFC West in his 2011 Divisional Preview.
Fantasy Football Strength of Schedule Matchups (8/30/11): Using the Fantasy Points allowed Per Game formula, you can see how each team's defense ranked against the run at the end of the 2010 season. We also have the chart for figuring QB, WR, and TE matchups in the receiving fantasy points allowed per game totals from 2010. Bonus! The Fantasy Points allowed Per Game formula explained
AFC South Team by Team Positional Preview (8/26/11): There's a lot of fantasy talent in the AFC South as Russ noticed going thru his 2011 AFC South Division preview. Check out his thoughts on each team and each position.
AFC North Team by Team Positional Preview (8/19/11): Next up is Russ's look at the 2011 AFC North Division preview going team by team and position by position with an eye on fantasy football analysis.
AFC East Team by Team Positional Preview (8/16/11): In the first installment of a series of divisional previews, Russ previews each team in the AFC East for 2011 and gives a position by position breakdown for what to look for and expect with an eye on fantasy relevance.
Fantasy Football IDP Rankings! (8/8/11) Our IDP Guru Robert Kirlin has completed his IDP positional rankings. Check out his
2011 IDP Rankings for Defensive Linemen
2011 IDP Rankings for Linebackers
2011 IDP Rankings for Defensive Backs
5 Quarterback Situations to Avoid in 2011 Fantasy Drafts (8/5/11): Every year there are teams whose QB sitaution is awful for fantasy prospects. Russ looks at the 5 worst QB situations for 2011 owners should avoid in fantasy football drafts.
NFL Free Agency and Trades Impact on Fantasy Football (8/1/11): Thanks to the lockout months of free agent and trade activity is being
condensed into a couple of weeks. Russ Bliss looks at the impact these trades and free agent moves are having on fantasy football in 2011.
The Latest on the NFL Lockout (7/12/11): It's looking like July 15th will come and go without a deal, but there is renewed optimism that a deal is near and a new timeline for an expected agreement takes shape.
2011 Rookie Sleepers (7/4/11): There are some rookies everyone has already designated for fantasy greatness, but in his 2011 Rookie Fantasy Football Sleepers article,
Russ identifies 3 players, 1 each at QB, RB, and WR who aren't getting
as much publicity for their potential both in 2011 and beyond.
2011 Top 10 Tight End Rankings! (7/1/11): Antonio Gates at #1 on Russ list of the 2011 top 10 fantasy TE's will surprise no one, but who he has at #2 might! Check it out along
with Russ's explanation of the rankings and his initial tiers for the
top 10 TE's.
2011 Top 10 WR Rankings! (6/22/11): Russ lists his top 10 fantasy football WR's for 2011 in his latest article. You may surprised at a couple of the names on it, and a couple he left off.
2011 Top 10 RB Rankings! (6/10/11): Russ unveils his top 10 fantasy football running back rankings for 2011 and you might be surprised who is on, and who is not on the list. A MUST read.
Fantasy Experts Mock Draft Complete! (6/3/11): The draft is over and Russ goes pick by pick over his selections and what his thinking was. Good stuff for those wanting to know what to expect in their upcoming fantasy football drafts!
Fantasy Football Experts Mock Draft Update (5-31-11): Russ
is taking part in a fantasy experts mock draft consisting of 12 teams,
16 rounds, and the results have been illuminating. You can check out
rounds 1-4 in his fantasy football blog, but rounds 5-12 are all in Russ's latest article about the fantasy experts mock draft.
LeGarrette Blount vs. Shonn Greene (5/17/11): Russ Bliss looks at these 2 RB's and answers the question of which one you will have the better season in 2011.
*SPECIAL* Arizona Cardinals Draft Thoughts (5/15/11): FFS Fantasy Football Analyst Dana Valentine is as big a Cardinals fan as you will find anywhere. He breaks down the Arizona Cardinals 2011 NFL Draft and says they possibly got the steal of the draft with one of their picks.
*SPECIAL* St. Louis Rams Draft Thoughts (5/13/11): Russ Bliss is our token Rams fan here at FFS and he vents his disbelief and frustration at what he thinks was a draft filled with lost opportunities by his favorite NFL team.
*SPECIAL* San Diego Chargers Draft Thoughts (5/13/11): Our Chief Marketing Officer, Brady Chatfield, lives and breaths the Chargers, so what did he think about his team's NFL draft? Brady expresses his doubts about some of the picks and proves that even the CMO of FFS is well versed as a NFL analyst.
*SPECIAL* San Francisco 49ers Draft Thoughts (5/12/11): FFS President and CEO Jeff Coruccini is a big time 49ers fan and shares his thoughts on why he liked his favorite team's 2011 NFL Draft selections
2011 Quarterback Situations (5/8/11): There are 10 teams with significant questions about their QB situation heading into 2011 and the lockout is helping no one figure it out. Russ
Bliss examines these 10 teams and what they're thinking is and whether
their starter is currently on the roster
2011 NFL Draft Preview: Tight Ends (4/26/11): It's a weak TE class according to Russ Bliss in his last positional preview heading into the 2011 NFL Draft. Russ lists his top 5 prospects at the TE position with only 2 guys likely to be taken in the first 2 rounds this year.
2011 NFL Draft Preview: Wide Receivers (4/25/11): No one disputes who the top 2 WR's are in this draft class, but who
else could become stars in the NFL? Russ likes North Carolina's Greg
Little as the 3rd best and lists his other top 10 WR prospects in the 2011 NFL Draft.
2011 NFL Draft Preview: Running Backs (4/19/11): In a year without a true dominant player at the position, Russ looks at the top 10 RB prospects for the 2011 NFL Draft and says Illinois' Mikel Leshoure is the best of the bunch.
2011 NFL Draft Preview: Quarterbacks (4/18/11): Russ Bliss looks at the top 7 rookie QB's in this draft class and finds no "can't miss" prospect although many project to be taken in the first 2 rounds.
2011 Fantasy Football Rankings: Top 10 Quarterbacks (3/22/11): It may be early, but Russ says it's time to start creating initial fantasy rankings at each position and he starts with his top 10 Fantasy Quarterbacks in 2011.
Tampa Bay's Mike Williams vs. Philadelphia's Jeremy Maclin (3/19/11): Russ posted his thoughts on these two WR's in his blog. Now he looks at what the other fantasy analysts thought about which WR each would rather have.
Fantasy Analysts Sleeper RB Picks for 2011 (3/15/11): The latest from the roundtable discussion between several fantasy football analysts focused on sleeper RB's not currently in the top 25 RB's in average draft position. Not everyone could stay within this parameter, but Russ looks at each pick and gives his thoughts on the choices.
Sam Bradford vs. Josh Freeman (3/9/11): Russ recently took part in a roundtable discussion between several
fantasy analysts giving their opinions on these two QB's looking at both
Dynasty and Re-draft values of both. Check out what the other experts said and Russ's comments on each choice.
2011 Fantasy Football Sleeper Quarterbacks (3/3/11): Josh Freeman tops the list according to Russ Bliss. But he's not the only guy Russ has pegged as an early fantasy football sleeper QB.
2011 Fantasy Football Sleeper Running Backs (2/15/11):
Wondering about which RB's not drafted in the first 3 rounds are the
guys you should be paying attention to and targetting? Russ has 5 fantasy football sleeper RB's you need to know about
2011 Fantasy Football Sleeper Wide Receivers (2/1/11): Russ breaks out the crystal ball and looks at some of the early 2011 fantasy football sleeper wide receivers he's keeping an eye on already for the 2011 season.
Bounceback Player of the Year (2/28/11): Russ
was invited to take part in a roundtable series of discussions with
several fantasy websites and this was their first topic. Russ gave Shonn Greene as his pick for 2011, but who did the other analysts pick? Russ lists their choices and gives his thoughts on each.
2011 NFL Scouting Combine Preview: Quarterbacks (2/22/11): The combine is ready to rock and with an eye on the all-important Quarterback position, Russ looks at 5 future NFL rookie QB's looking to solidify their draft stock and what they need to accomplish in Indianapolis.
2011 NFL Scouting Combine: What to Watch For (2/11/11). 40
yard dashes, height and weight measurements, Wonderlic Tests and more
are what to expect, but Russ explains what he's looking for when he
watches the Scouting Combine.
Fantasy Focus: Head Coaching Changes. Russ Bliss gives his opinion on the fantasy football impact of the NFL Head Coaching changes that have happened this off-season heading into 2011.
All I Want For Christmas is a Fantasy Championship. Russ Bliss writes to Santa Claus and asks for a fantasy championship for Christmas. He also adds some wishes for his partners here at FantasyFootballStarters.com