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Dr. Poonam Somai MD Patient Reviews
- Rheumatology Nashville, TN
Overall Rating
51 Patient Reviews
- Friendly Staff
- Promptness
- Wait Time 29.9 minutes
- Appropriate Followup
- Spends Time With Patients
- Bedside Manner
- Fair and Accurate Diagnosis
- Easy Appointments
Showing 1 - 12 reviews
1.0 of 5
October 8th, 2016
Terrible Provider-Waste of Time
Dr. Somai stood in the doorway of the exam room and looked like she was in a hurry and this was an initial visit! She came in the exam room for a minute to check my fingers and that was about it. Let's just say she missed the boat on my diagnosis and I had to see another rheumatologist to get to the bottom of my issues. Don't waste your time or $$$
1.0 of 5
July 1st, 2016
No bedside manner
Dr.Somai sat on the bench part of the table, typed on her laptop, squeezed my wrists to check for inflammation, then prescribed several medications and left the room. She doesn't spend quality time with her patients and she brushes off serious pain. She's rude and keeps patients waiting. Time to seek a new doctor!
5.0 of 5
May 15th, 2016
Dr. Somai is extremely thorough and has done more for me than my last rheumatologist who ignored my symptoms wanting me to see a psychiatrist because I wasn't "handling my diagnosis well". Dr. Somai has been wonderful and knows her field very well. I never have an issue with wait times and her staff is very attentive as well. If I call the office and leave a message, I get a call back from the receptionist almost immediately. I see how busy she is so I know how hard it is for her to take all of these calls plus call to remind me of my appointment and call me with my lab results. The physician assistant has been great as well. I drive almost an hour to see her every month and it's worth it!!!
1.0 of 5
March 27th, 2016
I would not recommend this doctor as she no idea what she is doing for her patients. I would not recommend her any way shape or form in treating any patient.
1.0 of 5
January 4th, 2016
dont waste time or money she does not care about her patients
5.0 of 5
December 22nd, 2015
Dr. Somai has been excellent. She is attentive and responsive to my symptoms and concerns. I am very much improved from my first office visit two years ago. I highly recommend her.
5.0 of 5
November 17th, 2015
Wonderful Rhumotoligist
Dr. Somai is very caring and has made great suggestions that have helped my fibromyalgia pain. I have always been seen on time and she has always been on top of thing concerning my condition. Would highly recommend her.
1.0 of 5
October 5th, 2015
Every time I have been here the wait is so long. Drug reps are in and out...food deliveries are in and out...friends from other offices are in and out. The patients should be the ones that are in and out!! This is only my 2nd visit and I won't be back. I'm sitting in the waiting room still WAITING for a 1230 appointment at 135...really?
1.0 of 5
June 19th, 2015
Go to someone else.
Spends about no more than 2-3 minutes with me each visit and is very rude when I try and tell her about joints that are bothering me.
1.0 of 5
February 25th, 2015
Could never make an appointment
I called the office several times. Each time the receptionist's voice mail would come along asking to leave a message. The calls are never returned so I was never able to make an appointment. I wish there was an option to give half star rating.
1.0 of 5
January 9th, 2014
Dr. Somai does not know her field at all. I have suffered with plaque psoriasis and psoriatic arthritis for 14 years. She did not believe that I was suffering enough to have Embrel prescribed for me. I have giant break outs all over my body and Embrel always clears it up. She does not know what she is doing . Do not let your PCP refer you to her. You not be taken care of or treated with rescpect.
1.0 of 5
November 23rd, 2013
Not recommended!!
My experience with Dr. Somai was very bad! She did not want to listen to my questions, she left the room before I could get answers and did not return. I was charged a no-show fee when she didn't make it clear that I had an appointment after seeing her in the hospital the first time. When I needed to contact her about the medicine she put me on, I had to go through her receptionist and the problems I was experiencing were never resolved. I suffered for weeks because she didn't care enough to contact me and change the medication she put me on or give me another appointment so I could see her before my next appointment was due. I was 15 minutes late for my last appointment with her, due to a vehicle stalled on the road entering the St. Thomas parking garage. When I arrived, I was told by the receptionist that Dr. Somai had already left (even though her office hours did not end for another 35 minutes). Just as I was leaving, Dr. Somai walked out and refused to speak to me when I announced that I was there. She returned to her office and left through the back door. I feel she's very immature,has a poor bedside manner, and really doesn't care about her patients.
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Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
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Dr. Robert Wadley MD Patient Reviews
- Pain Management Raleigh, NC
Overall Rating
36 Patient Reviews
- Friendly Staff
- Promptness
- Wait Time 34.3 minutes
- Appropriate Followup
- Spends Time With Patients
- Bedside Manner
- Fair and Accurate Diagnosis
- Easy Appointments
Showing 1 - 12 reviews
1.0 of 5
June 1st, 2017
Horrible experience, money driven
They make you come every two weeks, charging my insurance over $600 for a 15 minute visit, never discuss a treatment plan other then advising me they are lowering my meds every two weeks to an amount I won't even be able to get out of bed. Stay away, find a doctor who truly cares
1.0 of 5
April 28th, 2017
After being seen at this practice for 5 yrs, I have NEVER once seen or been seen by Robt Wadley who supposedly owns it, or any other doctor. In addition the facility does not appear to be clean.
1.0 of 5
September 30th, 2015
Ghost "doctor"
I am NEVER seen by the doctor. I am ALWAYS seen by a nurse. I am 70 years old. I have NEVER taken more medicine than I was told to take. . Every time I go for my visit my URINE IS TESTED. I have never seen or talked to this Doctor, but without my knowledge or consent, his clinic sent a letter to my psychiatrist stating that if she continued to write script for a benzodiazapine that I haqve been taking in conjunction with Delauded , they would not treat me with Dilauded. i NOW SUFFER WITH TYERRIBLE PAIN AND MY BODY HAS TERRIBLE SPASMS WHICH WERE SUCCESFULLY TREATED WITH XANAX! The FDA does not list these dtrugs together as contraindicated. Yet this Doctor who has never seen or talked to me has the nerve to mandate my meds be changed.
1.0 of 5
August 12th, 2015
never got to see him. saw a nurse who wasn't able to prescribe. she ran back & forth from me to him, but he never came into the room. He has never spoken to me
1.0 of 5
February 2nd, 2012
this docter gives this proffesion a bad image SHAME on YOU!!
I've gone to this office since 2009.I have been treated very badly by doctors and staff!i would never go back nor would i recommend this doctor or his facilities to anyone!!
5.0 of 5
January 19th, 2012
My overall experience with Brier Creek/ Dr. R. Wadley, is very idealistic, punctual and very demanding. I simply realize that people and if even the doctors with bed side manners carries alot of weight in the health world. The clinics themselves not only have experienced staff but also a well qualified team of people that care for each other and even "you" the patient. I would encourage everyone to try and visit this facility whenever you're in pain.
1.0 of 5
December 8th, 2011
sucks- big rip off
This practice is a complete scam. they rope you in for multiple appts. to bill insurance companies. The shots do not help.don't take the TENS unit, you will get beat over the head with payments, even for the "free" trial. Very impersonnal as well.you are just a number in his bank acct.
1.0 of 5
March 31st, 2011
Stay away! Report issues to the medical board!
If you have been to this practice and have received unethical treatment like me, you need to file a complaint with the medical board. This so-called professional doctor did injections from my neck to my lower back! He was wrong with his diagnosis, which cost me a year plus, of undescribable pain that could have been avoided! Now that I think back, when I was injured in my auto accident, I asked for a referral to a radiologist for a mri or ct-scan. Dr Wadley and Dr. Kim said it wasn't needed because they knew what was wrong with me already! They also told me I wasn't eligible for an mri because of a previous chest surgery! They did all of these radio frequency injection, and trigger point injections on me! When I told them that only my mid-back worked, instead of trying to figure out why the other 2 areas didn't work, they just pushed meds on me and said they wouldn't repeat the other areas. Come to find out, after my gen practitioner pulled me out of that practice, they were way off base! I walked around with a torn rotator cuff for a year dealing with them! They swore up and down that it was my neck, not my shoulder! I told them that I disagreed! They probably knew all along, but didn't want to send me to a surgeon, because then they wouldn't be able to attempt to rip me off the way they did! Oh and they misdiagnosed my lower back too! I had three bulging disc, not pinched nerves or torn ligaments like he tried to tell me! Stay away from this place! If it is too late and they have already screwed you over, then report it to the NC Medical Board!
1.0 of 5
August 3rd, 2010
Horrible year long experience
I would not recommend this practice to anyone. The office staff is lead by a unprofessional office manager and a unethical physician. The bedside manner is very poor, and the privacy protection of the patient is very poor. The do not give any type of careful consideration to patient concerns. I also feel as though he is very flaky when it comes to a proper diagnosis.
2.3 of 5
April 26th, 2010
ongoing pain issues and NO answers
Ive been a patient for more than six months. The problem or concern I have is that I never call the office between appts unless i really need some help. If you feel like your having an issue that needs a doctors knowledge, there is NEVER anyone available. No Dr Wadley, Dr Kim or this new Jeff guy thats buddy buddy with Dr Wadly. I knew from the beginning way back last summer that there were issues here but I really wanted to give them a chance. Its so so frustrating when they just throw me off to somebody to get me off the phone because of them always being understaffed or you are considered out of sight out of mind.
1.0 of 5
July 13th, 2009
Snake Oil Salesmen!!!!!
The worst medical experience I have ever had. I agree with a previous comment about the NP. I had PROBLEMS with my medication and they refused to have me come in to discuss and adjust, and one of them was a new drug out with no track record. Worst weekend I've had in some time, and I've had 4 surgeries for my problem. They are there for only one reason. To sell pain injection therapies. That's it. After long chat and a sales-pitch that rivalled a used car salesman's with the NP, the doc walks in, shakes my hand, looks at the area in question and starts in on the sales pitch all over again. No time to investigate, she didn't even write the name of the proc down after asking several times. They would not even let my spouse come back with me. The RECEPTIONIST'S first question when I called was to find out if I've scheduled the procedure yet. If you need an outpatient injection therapy thing, this is the place for you. If you don't, they don't want you for a patient. They have NO concern for their me. They prescribed twice the strength meds that I was on, just different ones. I felt all the junkie effects and non of the pain relief, had more fevers, jumpy heart/chest on this unproven crap and an additonal proven, but not on me med. Legitimate problems and I was summarily dismissed. Awful.
5.0 of 5
June 29th, 2009
amazing service
I love how Brier Creek Pain and Spine offers much more than just medication management. The massage therapist and pain psychologist are great. The injections are a little scary but they seriously work!
Health Guides
Get the facts about migraine headaches, including the different types of migraine and migraine triggers.
Nearby Doctors
Dr. Robert Wadley, MD is similar to these 3 Doctors near Raleigh, NC.
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Chilean Fresh Fruit Spots Entice Winter-Worn Shoppers
Despite the au courant topics of "food miles," "Slow Food" and "locavores" — that go hand in hand with the locally grown movement that's being largely driven by America's awakening green culture — the intricacies of our global produce supply chain are truly a thing of beauty.
Despite the au courant topics of "food miles," "Slow Food" and "locavores" — that go hand in hand with the locally grown movement that's being largely driven by America's awakening green culture — the intricacies of our global produce supply chain are truly a thing of beauty. Yet at no time during the calendar year is the magnificence of our global food chain more vividly displayed and appreciated than during the ongoing peak winter selling season, when supplies of nearly any locally grown item are appreciably nonexistent.
For that reason, U.S. retailers are certainly fortunate to be able to rely on an industry that knows very few national or regional boundaries; one that is able to transition from suppliers in one growing region or country in the summer months, and move relatively quickly onward to another supplier in a different part of the world — say, Chile, South Africa or Peru — in the winter, seemingly without a hitch.
To this end, the Sonoma, Calif.-based Chilean Fresh Fruit Association (CFFA) deserves hearty kudos for its captivating television campaign that's been airing once again this winter in select U.S. markets. The well-done spots, which entice consumers to enjoy "Summer in the Winter" with fresh Chilean fruits, not only emphasize the counter-season availability, but more important, their quality and freshness. CFFA has helped retailers move Chilean fruit by offering tagged TV commercials in some 30 major U.S. markets and four markets in Canada in conjunction with POS materials like price cards and recipe booklets for consumers, and care-and-handling brochures and merchandising ideas brochures for retailers.
After showcasing beautiful close-ups of vine-ripened fruits being carted carefully to baskets while next panning slowly across lush panoramas of mountaintops and tree fruit orchards, the key messages communicated in the captivating TV spots are highly effective on multiple fronts. In addition to giving consumers an up-close peek inside Chile's lush Central Valley — renowned for its long-standing stellar reputation for producing quality fruit — it's also commendable that the spots give winter-weary consumers a "firsthand" chance to see the place and the people that keep much of our nation's produce aisles stocked with fresh fruit throughout the winter and spring.
Perhaps the best part of all, the Chilean fruit industry's savvy media message is aptly reinforced in-store with the ultimate clincher: a fabulous array of attractive, great-tasting fruit that handily hits the sweet spot with often reluctant wintertime fruit-deprived consumers.
Parting thought: Since most observers believe strongly that the increasingly popular "locavore" consumer segment is primarily motivated by a basic consumer instinct to connect products with places and faces, traditional produce organizations seeking a way to do just that could easily take a page out of CFFA's effective playbook.


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Heightgoddess Deals. To make your purchase, please click on the banners or texts below and come in, We are open for business 24/7 with same day shipping and 30 to 60 days return policy. Born out of necessity and passion, HEIGHT GODDESS (HG) is a clothing line that acknowledges and celebrates tall women. Created by[More]
Tabargains is truly a great place to shop for almost anything that you need that is legal, of course and with such great bargains on prices, click here and try them for yourself, you will be glad you did.


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Guru and the Light Within by Swami Rama
Expand Messages
- Guru and the Light Within
by Swami Rama
An excerpt from:
If you prepare yourself to know the higher knowledge, then you will deserve. To
deserve means to increase your capacity. You want to put the entire ocean in a
bucket. The ocean is there. You can have it, but you do not have the capacity.
When you deserve, you will have the capacity. The Lord, the Reality, the Truth,
is always within you. You simply have to become aware. You can make sincere
efforts to work with yourself.
Don't be disappointed with failures. When you start to make sincere efforts and
start to practice, you will find light on the path. The light itself will guide
you. The light of consciousness is within you. If you ignore that light, the
guide outside you, the external teacher, will be of no use to you. He will make
you a slave. Every individual has certain notions. He also lives with his
notions. He creates a following and millions of people are swayed and misguided.
Do you know what a guide means? The word guru has been vulgarized. Such a pious
word is being misused. I call it guide. Do not depend much on guides. It is
better for you to prepare yourself and remain awake. The scriptures say to wake
up from the deep sleep of ignorance. Remain fully awake, remain conscious, and
go on learning. Never close the door of learning. The day you close the door of
learning you become ego, ego, ego.
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|This is a disambiguation page. A number of articles are associated with the title Soo.
NOTE: If an internal link referred you to this page, you may wish to change the link to point directly to the intended article.
Soo might refer to:
- Jin-Soo Kwon, a main character on the show
- Aunt Soo, a character that appears in Sun and Jin's flashbacks


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PRINCETON – Europe can choose its own musical accompaniment to its latest crisis. In Berlin, 50 Cent's "All Things Fall Apart" has just had its premiere, so that soundtrack might be appropriate. Or the continent can reach back to Giuseppe Verdi, born two hundred years ago, whose penultimate, and probably greatest, operatic achievement starts on the coast of Cyprus with a storm of fantastic violence and the opening words of its hero, Otello: Esultate, rejoice! The war has been won; but Otello's achievement is later destroyed by his jealousy.
Today, Cyprus appears to have been rescued. But the rescue has fueled a growing rift that jeopardizes the future of European integration, partly owing to the way that the upheaval of the early twentieth century – especially the Great Depression – has been reenacted in the debates about the post-2008 financial meltdown and the subsequent euro crisis.
The interwar economic slump became intractable because it was also a crisis of social stability, democracy, and the international political order. Widespread bankruptcy and unemployment increased social tension, ultimately making normal democratic politics impossible. In Germany, the epicenter of democracy's collapse, radicals on both the right and the left raged against the postwar peace settlement and the Versailles Treaty.
In the last years of the increasingly unstable Weimar Republic, as democracy was fraying, German governments started to use their opponents' radicalism in an effort to extract security concessions from the Western powers. Domestic political pressure became a source of heightened international tension.


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I cannot urge you enough to make sure you keep your baby's nails well-trimmed- not only for your baby's sake but for your own as well. Despite how paper-thin baby fingernails can be, they can at times seem like little kitty claws. Since your newborn will not have adequate motor control, he will often bat his arms about, scratching himself in the process. Always use clean nail clippers or trimmers to keep your baby's nails at a safe length.

Even on a newborn, you might be surprised how much lint, hair, and fuzz balls can become collected in his tight grasp, a common aspect of newborn development. I've heard more than once how a baby would start crying in pain, and after a thorough investigation of what might be the matter, a hair was found to be wrapped tightly around a wee finger or toe.

That is why it is a good idea to check your baby's hands and feet at every diaper change. After a good investigation for toe fuzzies and the like, I always use a baby wipe to clean hands and feet after changes.

Looking to save money? Read How to Make Your Own Baby Wipes.

Baby mittens (not the kind you where in the winter) are an excellent item to keep on hand (keep on hand, get it?... Nevermind) for newborns. Babies are so prone to scratching themselves, baby mittens are a simple way to prevent that problem.

A tip I would offer: when packing for the hospital, stow a pair of baby mittens to be used after delivery. When my first baby was born, she came back from getting a vaccination with her face scratched terribly. Consider sliding a pair on just before your baby has any procedures done that might be painful.

Whether you use baby lotions or not is pretty much up to you. If your baby doesn't seem to have any dry patches, it may not be necessary. However, many parents enjoy lubing up their baby in a gentle lotion. It is not uncommon for your baby's skin to peel in the weeks after birth (see photo.) Though it likely doesn't bother your baby, you may want to use a baby lotion.

Apply lotion within a few minutes following a bath to help lock in the moisture. Bear in mind, a little dab will do you. Little bodies do not require a great deal of lotion

Every now and then, your baby might develop an ingrown toenail. If you have ever had one, you know how painful they can be. Be sure to trim your baby's toenails regularly. Clip them straight across with nail clippers and do not round the edges down.

Depending on the climate, you may need to keep your baby's feet covered for warmth and protection. However, I'll be honest with you, I have found that newborn baby socks are positively pointless. My little ones, always, always manage to kick their socks off within minutes. I've found it far easier to have use baby coveralls with the feet built in.


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It happened before with Gossip Girl--so I guess it's going to happen again. :p
A TV series was recommended to me by a friend, and she was waxing about it--pretty much raving, actually. She was talking about The Royals, a TV series about the British royal family--no, NOT the royal family we know, but a different one. It premiered on E just recently. The cast includes William Moseley from the Narnia movies, Elizabeth Hurley, and newcomers (well, at least, to me) like Alexandra Park and Merritt Patterson.
Liz Hurley plays Queen Helena of England--in my opinion, she's a nasty piece of work. Her husband, King Simon (played by Vincent Regan) is the kind of King you would empathise--no, feel terrible for. His son, Prince Liam (wonderfully portrayed by William Moseley) was a partying playboy until his older brother Prince Robert was killed in an accident. Alexandra Park plays Princess Eleanor, Prince Liam's twin--and boy, she loves to party too. And she loves to do it hard. Oh, and Her Royal Highness does drugs too. Fine and dandy! No wonder King Simon isn't optimistic about the future of the monarchy. I wouldn't blame him. Add the fact that his wife and brother Cyrus, the Duke of York (played by Jake Maskall) are very much instrumental to the potential destruction of the monarchy--makes you wonder what they'll do next.
And there's the girl-next-door (like, almost literally) Ophelia Pryce, the daughter of the royal head of security. Liam's got his eye on her--thing is, his ex Gemma (played by Sophie Colquhoun), who, by the way, is a diamond heiress--stirs up trouble. (As much as I dislike her, I do like her line, "I can be you. But you can't be me." A comeback quip for haters is born!)
Eleanor (who is slowly becoming my favourite character in the show) isn't all sex, booze and drugs. She's got a heart, too! A former flame asks her to be the quiet, kind and gentle girl he knew--because he knows that she exists. And there's her bodyguard Jasper Frost, portrayed by Tom Austen who is pretty much delightful looking. There is tension, and yes, the love-hate vibe going on between them--believe it or not, it had me hanging at the edge of my seat (she actually bails Jasper out from jail because she needed his help about the death of Prince Robert). My favourite episodes where her character shone was the fourth (weirdly) and the eighth.
After reading stuff about The Royals, I was prepared to hate it. But I couldn't. Like with Gossip Girl, I was hooked. It wasn't just the clothes--or the location. It was also about the lines. I found a scene where this was pretty much evident. Thank you, Enstarz!
Queen Helena: My God, you wretched brats! Your brother, my first born son, and you can't find the decorum, the civility, to honor his memory. What is wrong with you?
Princess Eleanor: Is that scripted too?
Queen Helena: I scropt you because we can't trust either of you to come up with a reasonable coherent thought.
(Note: As I've read from the linked source, Prince Liam speaks up after the verbal sparring between Queen and Princess got nasty, and after she insists that she is inconsolable after her eldest son's death)
Liam: Really? Because our dad is out there genuinely grieving over the death of his son, while you're in here, worrying about the family's image and topping off on the botox!
(This gets him a slap in the face)
So far, I've found only one con: Dark eye shadow makes Princess Eleanor a younger Morticia Addams.
For the girls, if you want your mother to watch it too--tell her Joan Collins is there--a pretty good bait, especially if she's watched Dynasty, since Joan Collins play Grand Duchess of Oxford, Queen Helena's mother.


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In the market for a new pair of affordable boots because you just can't justify spending $1,435 on these gorgeous bad boys? We got you.
There's no denying this style of footwear can get expensive (point blank: There's a lot more fabric involved than your average ankle-strap heel), but chic, budget-friendly versions definitely do exist.
Click here for scroll through some of the best under-$100 fall boots online retailers have to offer. The prices are so good, you may want to buy multiples.
Happy hunting!


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The Crap We Missed – Tuesday 6.10.14
Welcome to Tuesday's The Crap We Missed, our daily wrap-up of the most important happenings in the celebrity world. This is where you come to discover the origin of Kim Kardashian's bag of curdled yogurt ass. This is where you get to pretend John Mayer is actually having that stroke we've all been praying for. It's our safe place. Our place where Howard Stern's wife whispering homophobic slurs hidden in Saved By The Bell references into Mario Lopez's ear are not only acceptable, but encouraged.
Welcome, brethren, and enjoy speculating about Hugh Grant's date hiding a penis. I know I have been. Speculating! I meant I've been speculating, not hiding a peni– I think you know what I was getting at,
- Photo Boy
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To determine the neurofunctional basis of verbal memory dysfunction in women with metastatic breast cancer. This objective was based on previous research suggesting memory and other cognitive deficits in this population. We attempted to determine if verbal memory impairments were related to the most commonly studied disease parameters including adjuvant chemotherapy and chronic stress-related disruption of limbic system structures.
We utilized functional magnetic resonance imaging (fMRI) to test our hypothesis that women with breast cancer would demonstrate significantly lower brain activation during a verbal declarative memory tasks compared to age and education-matched healthy female controls. We also assessed several stress-related variables including diurnal cortisol levels to test our hypothesis that women with breast cancer would demonstrate higher stress and this would contribute to brain activation deficits during memory tasks.
Women with breast cancer had significantly lower prefrontal cortex activation during the memory encoding condition compared to controls. However, the breast cancer group demonstrated significantly greater activation than controls during the recall condition in multiple, diffuse brain regions. There were no significant differences between the groups in stress-related variables. Women who were treated with CMF chemotherapy demonstrated lower prefrontal cortex activation during memory encoding.
These results suggest that women with metastatic breast cancer may be at risk for verbal memory impairments as a result of altered functional brain activation profiles. These findings may be associated with chemotherapy type and/or other aspects of the breast cancer disease process.
Women with breast cancer (BC) may have an increased risk for long-term cognitive-behavioral impairments including those of executive function and memory, likely due to neurotoxic side effects of chemotherapy (1–3). The incidence of these impairments is uncertain but has been reported to range from 28–75% among breast cancer patients receiving CMF (4). Cognitive-behavioral impairments significantly extend disease-related disability, affecting home, educational and occupational activities. Additionally, the high prevalence of BC and increasing survival rates contribute to a large and growing cohort of cognitively affected individuals (3). Currently, there are no specific treatments for these cognitive impairments and no preventive interventions are available.
Neuroimaging studies provide insight regarding the neurobiologic mechanisms underlying cognitive impairment in various populations. To date, there have been only four such studies conducted in BC to our knowledge. These reports indicate altered cerebral metabolism and decreased volume in executive function regions, including prefrontal cortex, basal ganglia and the cingulate gyrus in women with BC compared to controls (5, 6). Additionally, reduced corpus callosum genu white matter pathway integrity (i.e. fractional anisotropy) was noted in a small sample of women with BC compared to controls and was correlated with lower processing speed (7). A case study of monozygotic twins discordant for BC indicated increased white matter hyperintensities and altered frontal-parietal functional brain activation in the twin with BC (8). This case study represents the only functional MRI (fMRI) study conducted to date. FMRI allows in vivo assessment of brain function by detecting blood flow differences and is widely used to study brain-behavior relationships in children and adults (9–12). Group fMRI studies could significantly advance our understanding regarding the neurobiologic mechanisms underlying cognitive deficits in women with BC. Additionally, fMRI studies are being increasingly utilized to guide and provide potential targets for cognitive interventions (13). This study aimed to implement an fMRI paradigm to investigate verbal memory function in women with BC.
Some studies suggest that cognitive deficits in women with BC are associated, at least in part, with illness-related stress (3, 14). Abnormal diurnal cortisol patterns have been observed among women with breast cancer (15, 16) and cortisol is known to play a vital role in cognitive and emotional function. In the present study, we obtained both psychological and physiological measures of stress including self-rating questionnaires, vital statistics and salivary cortisol to use as covariates of nuisance in our analyses of brain activation.
Many studies of cognitive outcome in women with BC do not include chemotherapy in the analyses due to the significant variation among patients in terms of chemotherapy regimen. However, cognitive deficits in survivors of BC have been associated with cytotoxic chemotherapy such as methotrexate (17) and hormonal blockade with tamoxifen (5, 18–20). Animal studies have suggested that certain chemotherapeutic agents including methotrexate, carmustine, cisplatin, 5-fluorouracil, and cytarabine may be more toxic to white matter progenitor and hippocampal stem cells than they are to actual cancer cells (21–23). We collected chemotherapy and tamoxifen treatment information in order to conduct exploratory analyses regarding the effects of particular treatment variables on brain activation during verbal memory.
Fourteen women (mean age = 55.1 ± 8.0 years, range = 43–65) with metastatic (N = 8) or locally advanced (N = 6) breast cancer and 14 age and education-matched healthy female controls (mean age = 54.2 ± 8.0, range = 40–65, p = .78; mean education rank = 5 ± 2; p = .83) participated in this study. Education data were gathered using the following ranking system: 1 = Less than High School, 2 = Graduated from High School/GED, 3 = Completed Trade School, 4 = Some College, 5 = Bachelor's Degree, 6 = Some Graduate School, 7 = Master's Degree, 8 = Ph.D., M.D., and/or J.D.
All women with BC had a history of adjuvant chemotherapy treatment and 11 had a history of radiation therapy to the neck, affected breast, axilla and/or lumbar spine. Chemotherapy types included 6 cycles of cyclophosphamide, methotrexate and 5-fluorouracil (CMF, N = 5) or 4–8 cycles of adriamycin, cyclophosphamide, and taxol/taxotere (ACT, N = 9). All chemotherapy and radiation treatments had to be completed at least 6 months prior to enrollment to be eligible for the study (mean time since last chemotherapy/radiation = 3.3 ± 3.3 years, range = .5 – 10.3). Eleven of the patients also had taken tamoxifen during their course of BC treatment (mean time since tamoxifen = 5.3 ± 2.3 years, range = 2–9). Six of the 11 BC/tamoxifen patients took tamoxifen after chemotherapy/radiation, 3 took it concurrently with chemotherapy/radiation and 2 took tamoxifen before chemotherapy/radiation (these 2 were treated in 1991 and 1995, respectively). Information regarding anti-cancer treatments was obtained using both patient and physician report as well as medical records, when available.
Healthy female controls were recruited via community flyers and internet postings restricted to the same zip codes as the women with BC to reduce differences in socioeconomic status. There were no significant differences between the groups in terms of minority status (X2 =.003, p= .74).
All potential participants were excluded for MRI contraindications (e.g. metallic implants, biomedical devices) and were free from medications that affect cortisol (e.g. hydrocortisone, megestrol) and functional MRI (e.g. antipsychotics, sedatives, MAO inhibitors, tricyclic anti-depressants). Participants with BC were excluded for active cancers within the past 10 years other than breast cancer, basal cell or squamous cell carcinomas of the skin, in situ cancer of the cervix, positive supraclavicular lymph nodes as the only metastatic lesion at the time of initial diagnosis, history of neurologic conditions including metastases to the brain as well as history of learning or other developmental disability, preterm birth and psychiatric or chronic medical conditions not related to BC. Healthy controls were excluded for any history of learning or other developmental disability, preterm birth, psychiatric, neurologic or chronic medical condition. Their participation in the present study was approved by the Stanford University Institutional Review Board and all participants gave written informed consent before beginning the study.
As salivary cortisol has been found to be a reliable tool for investigations of HPA activity (24–26), saliva samples were collected on two consecutive baseline days, not including the day of the MRI. Samples were collected at awakening, 12PM, 5PM and 9PM on both days using cortisol-specific self-collection kits, according to a previously published protocol (15, 16). Participants were provided with both verbal and written collection instructions. Due to significant variance in the cortisol data, all cortisol variables were log transformed (see Table 1). Cortisol level could not be obtained for 3 women with BC and 2 controls.
is a 12-item self-rating measure designed to assess factors affecting stress and cortisol levels related to physical activity, stress level, sleep and subjective sense of health.
Heart and respiratory rate were measured during the entire MRI scan.
The WAI is an 84-item self-rating measure of typological stress coping strategy including anxiety, restraint and repression (27). Although the WAI yields multiple subscale and composite scores, we examined only the three composite scores: Repressive-Defensive/Restraint, Distress, and Restraint, as well as the two subscales that we have previously shown to differentiate women with BC and healthy female controls: Anxiety and Repressive-Defensiveness (15). This subset of WAI scores were used in order to reduce the number of comparisons and the amount of measurement error associated with multiple scales and to constrain this analysis to the WAI scales that are most consistent with our a priori hypothesis regarding the effects of stress on memory function.
The BDI is a 21-item self-rating inventory of depressive symptomology including sadness, suicidal ideation, fatigue, loss of interest and sleep disruption (28).
We acquired structural scans using a protocol that provides a high level of anatomic resolution and tissue contrast: 3D IR prepared FSPGR, TR: minimum, TE: minimum, flip: 15 degrees, TI: 300 ms, BW: +/−31.25 kHz, FOV: 22cm, Phase FOV: 0.80 FOV (22 × 15.4), slice thickness: 1.5mm, 128 slices (to get 124 slice locations), 256×256 @ 3 NEX.
Acquisition of functional MRI (fMRI) data was based on a spiral-in/out blood oxygenation level dependent (BOLD) protocol (29). This provides for improved BOLD signal in regions of interest such as the amygdala and hippocampus. Thirty-two axial slices (3 mm thick, 1 mm skip) parallel to the AC–PC line and covering the whole brain were imaged with a temporal resolution of 2 seconds using a T2* weighted gradient echo spiral pulse sequence (TR = 2000 msec, TE = 30msec, flip angle = 80° and 1 interleave). The field of view was 200 × 200 mm2, and the matrix size as 64 × 64, giving an in-plane spatial resolution of 3.125mm. An automated high-order shimming method based on spiral acquisitions was employed to reduce field heterogeneity.
All stimuli were presented using E-Prime software (Psychology Software Tools, Pittsburgh, PA), which also triggered the initiation of the scan. Stimuli were presented using a custom-adapted system that projects stimuli at high resolution (1024 × 768) onto a screen attached to the head coil. Subjects look directly upward at a mirror to view the stimuli. Behavioral responses were recorded using a 4-button fiber optic finger switch system. Task performance was acquired simultaneously while subjects performed the tasks in the scanner.
The encoding condition of the fMRI task required subjects to view visually presented nouns and make a semantic discrimination for each by pressing button 1 if the word represented something man-made and button 2 if the word represented something not man-made.
During the recall task condition, subjects were again presented with single nouns and were asked to press button 1 if they recognized the word from the previous task and button 2 if they did not.
The specific details of these tasks are described elsewhere (30).
Using Statistical Parametric Mapping 2 (SPM2) software1 images were realigned to correct for head movement using least square minimization, normalized to a standardized template in order to directly compare brain activation across subjects, stimulus types and experimental conditions; and smoothed to reduce the effects of noise. Images for each subject were then visually assessed for correct spatial normalization using in-house software that creates 3D renders and slice maps (axial, coronal, sagittal) of raw, normalized and statistical images for comparison with template examples of correctly aligned images. We also employed our automated in-house software program, "ArtRepair" (http://spnl.stanford.edu/tools/ArtRepair/ArtRepair.htm) to automatically detect and repair motion and signal intensity outliers as well as other artifacts at the volume, slice and voxel level (31).
Group differences in baseline 2-day cortisol slope, stress questionnaire, heart rate and respiration rate were conducted using independent t-tests and WAI scores were measured using MANOVA in SPSS 16.0. As there were no between group differences in distress measures, we did not include them as covariates in further analyses.
fMRI task performance data (percent correct, reaction time) were compared between groups using independent t-tests.
Statistical analyses were performed SPM2 (32). Any images that represented movement, signal and/or rotation outliers as indicated by the ArtDetect5 procedure were excluded from the statistical analyses. The number of outlier images excluded did not total greater than 1% of the total number of images for any scan.
A within-subjects procedure was used to model all the effects of interest for each participant. Confounding effects of fluctuations in global mean were removed by proportional scaling where, for each time point, each voxel was scaled by the global mean at that time point. Low-frequency noise was removed with a high-pass filter (0.5 cycles/min) applied to the fMRI time series at each voxel. A temporal smoothing function (Gaussian kernel corresponding to dispersion of 8 sec) was applied to the fMRI time series to enhance the temporal signal-to-noise ratio. For each participant, brain activation related to each fMRI task was determined by contrasting experimental and control conditions.
Group analysis was performed using a random-effects model that incorporated a two-stage hierarchical procedure. This model estimates the error variance for each condition of interest across participants, rather than across scans (33) and therefore provides a stronger generalization to the population from which data are acquired. Individual contrast images were analyzed using a general linear model to determine voxel-wise t-statistics. One contrast image was generated per participant, per effect of interest. A one-way t-test was then used to determine whole brain within-group activation for each task. Between group differences in brain activation for each task was determined using an analysis of variance model masked with the within-group SPM map to restrict these analyses to the regions of significant within-group brain activation and further reduce the number of statistical tests performed. The statistics for all analyses were normalized to Z scores, and significant clusters of activation were determined using height and extent thresholds of p < 0.05, controlling for multiple comparisons using false discovery rate. Activation foci were superimposed on high-resolution T1-weighted images and their locations interpreted using known neuroanatomical landmarks.
The MarsBaR2 region of interest (ROI) toolbox in SPM2 was used to create ROIs representing the regions of significant between group differences in activation. This is accomplished by creating a mask of the significant activation clusters from the between group contrasts. The ROI Toolbox3 in SPM2 was then used to extract the mean intensity value across all voxels in the ROIs for each subject. These ROI values were then used in SPSS 16 as dependent variables in general linear models (GLM) with group as a fixed factor and age as a covariate to confirm the whole brain between group SPM results while removing the effects of age. ROI activation was correlated (two-tailed Pearson) with task response data that were significantly different between the groups to explore the associations between brain activation and task performance differences.
For the BC group only, ROI values were also entered as dependent variables in a multiple regression with tamoxifen (1 = yes, 0 = no) and chemotherapy type (0 = ACT, 1 = CMF) as independent variables. ROI values were correlated (two-tailed Pearson) with time since the last chemotherapy/radiation treatment. These analyses were conducted to explore the effect of treatments on brain activation in the regions of between group difference.
There were no between group differences in any of the distress-related variables (Table 1).
The two groups performed the encoding condition similarly in terms of accuracy (p = .79) but there was a nonsignificant trend for the women with BC to show faster reaction times (p = .06). The BC group demonstrated significant brain activation in bilateral inferior occipital gyrus extending into the left fusiform gyrus, left cerebellum and right middle occipital gyrus and the left inferior frontal gyrus extending into the left insula (Table 2). The control group demonstrated significant activation in the left superior frontal gyrus extending into bilateral anterior cingulate, right superior frontal, bilateral middle frontal, left inferior frontal and bilateral superior temporal gyri as well as bilateral basal ganglia (Table 2).
The control group demonstrated significantly greater activation in the left superior frontal gyrus extending into the right superior frontal gyrus, bilateral middle frontal gyri and left postcentral gyrus, compared to the BC group (Table 2, Figure 1a). The BC group showed no regions of significantly greater activation compared to controls. These between group results were irrespective of age, confirmed by ROI GLM analysis (F = 9.25, p = .005, Table 1).
Chemotherapy type, but not tamoxifen, predicted activation in the between group difference ROI (i.e. the regions illustrated in Figure 1a; adjusted R2 = .52, F = 7.4, p = .01) in the BC group. Given the negative coefficient values for chemotherapy type (B = −.40, t = −3.2, p = .009), women with BC who received CMF chemotherapy demonstrated significantly lower activation in the ROI. A post hoc GLM examining encoding ROI activation between controls, CMF and ACT groups indicated significant differences between CMF and controls (p < .0001) as well as CMF and ACT (p = .001) but no significant difference between controls and ACT (p = .25). This finding is illustrated graphically in Figure 2. There were no significant differences between ACT and CMF groups in terms of age, ethnicity, education, stress variables, time since tamoxifen or fMRI task performance. Time since chemotherapy/radiation treatment was significantly greater in women treated with CMF compared to ACT (p = .006). However, the difference in encoding ROI activation between the CMF and ACT groups remained even after covarying for time since chemotherapy/radiation treatment (p < .0001).
Encoding ROI activation was significantly correlated with reaction time in controls (r = .58, p = .04) but not in the BC group (r = .04, p = .90). The difference in these correlations (Fisher r–z transformation) was nearly significant (z = −1.46, p = .07). Encoding ROI activation in the BC group was not correlated with time since treatment.
The two groups demonstrated similar accuracy on the recall task (p = .39) but the BC group showed significantly slower reaction time (p = .002). Women with BC demonstrated significant brain activation in the left inferior occipital gyrus extending into right inferior and bilateral middle and superior occipital gyri, bilateral cerebellum, bilateral cuneus and precuneus, bilateral inferior and superior parietal lobe, bilateral fusiform gyri, bilateral superior and inferior temporal gyri, left middle temporal gyrus, bilateral hippocampus, bilateral dorsolateral prefrontal cortex, bilateral cingulate, bilateral medial frontal gyri, bilateral basal ganglia and bilateral lateral orbital gyri (Table 3). Controls significantly activated bilateral inferior frontal gyri extending into right middle frontal gyrus, bilateral cingulate gyri extending into left superior frontal gyrus, left cuneus extending into left lingual and fusiform gyri, right middle occipital gyrus extending into right cuneus, right inferior parietal lobe extending into right superior parietal lobe and right precuneus, right cerebellum, and left superior parietal lobe (Table 3).
Compared to controls, the BC group demonstrated significantly greater activation in right superior temporal gyrus extending into bilateral fusiform, bilateral lingual gyri, left hippocampus, bilateral basal ganglia, right precentral gyrus, right superior and inferior frontal gyri, right middle frontal gyrus, bilateral inferior frontal gyrus, right cingulate gyrus, bilateral insula, bilateral parahippocampal gyrus, bilateral cuneus, bilateral precuneus, bilateral superior parietal lobe and cerebellum (Table 3, Figure 1b). Controls did not show any regions of greater activation compared to women with BC during the recall task. These between group results were irrespective of age as confirmed by ROI GLM analysis (F = 4.93, p = .04, Table 1).
Treatment variables were not associated with activation in the between group difference ROI for the recall task in the BC group. Recall ROI activation was not correlated with reaction time in either group.
Women with metastatic disease were significantly older than women with locally advanced breast cancer (t = 2.9, p = .01). However, there were no significant differences between women with metastatic or locally advanced breast cancer in terms of ethnicity, education, stress variables, time since tamoxifen, time since chemotherapy/radiation, fMRI task performance or fMRI ROI activation, even when controlling for age.
To our knowledge, this is the first cohort study of functional brain activation in women with breast cancer (BC). We demonstrated reduced prefrontal cortex activation in women with BC compared to controls during the semantic encoding phase of a verbal declarative memory task. During the recall condition of the task, women with BC showed significantly increased spatial extent of cortical activation compared to controls. Regions of increased activation included those less commonly involved in declarative verbal memory retrieval (e.g. orbital prefrontal, right superior temporal gyrus, inferior temporal gyrus, occipital gyri) as indicated by studies utilizing a similar fMRI task (34). These findings suggest overactivation of brain regions during this memory task. These results were irrespective of age and therefore not likely explained by aging or menopause. Women with BC were similar to controls in performance accuracy during both task conditions but showed a tendency to respond more quickly during encoding and significantly more slowly during recall.
Previous studies have demonstrated abnormalities of the prefrontal cortex (5, 6) in women with BC who have undergone adjuvant chemotherapy. The prefrontal cortex is known to play a critical role in declarative memory (35). Our present results offer increased insight into and more specific neural correlates of verbal memory difficulties in certain women with BC. Specifically, during memory encoding, women with BC showed lower prefrontal activation as well as quicker, perhaps more impulsive, response time compared to controls. Reduced prefrontal resources may indicate lower attention and/or organizational skills associated with learning and memory. For example, women treated with CMF chemotherapy for BC may have more difficulty attending to stimuli and/or engaging in organizational or mnemonic strategies for memorization. Increased prefrontal activation was associated with increased reaction time in controls but not in the BC group. It appears that the controls were able to utilize more prefrontal resources and took more time to encode the stimuli. Because the stimuli were not properly encoded, the recall condition required a significant increase in neural effort in the BC group. These findings have implications for potential treatments for verbal memory impairments in women with BC. For example, focusing cognitive interventions on executive, prefrontal skills could provide rehabilitation that will improve encoding efficiency and reduce recall effort.
Cognitive difficulties in chemotherapy-treated BC have been somewhat controversial because neuropsychological testing scores are often within normal limits (2) or not different from controls (18). There may be significant discrepancies between subjective and objective measures of cognitive ability as well as associations between subject cognitive complaints and psychological distress (18) leading some to conclude that treatment-related cognitive deficits in BC are merely based on anxiety about performance. Our results show that, although some women with BC might perform as accurately as controls on certain memory tasks, they have brain-based deficits related to memory encoding and thus require a great deal more neural effort when attempting to recall information. This likely results in increased cognitive fatigue and frustration, resulting in negative subjective evaluation of cognitive ability.
Some studies suggest cognitive deficits associated with BC and its treatment tend to resolve over time, at least in some patients (36–38). However, our sample of women with BC were, on average, 3.3 years post-treatment and we showed no relationship between increased time since treatment and improved brain function during memory tasks. Some women with BC may be able to compensate for neurofunctional changes associated with chemotherapy while others cannot. For example, one study suggested that women with BC who have the E4 variant of the APOE gene, which is believed to affect memory function and elevate risk for Alzheimer's dementia (39), might be at higher risk for cognitive difficulties than women with BC who carry other APOE alleles (40). Further studies are required to determine if there are other variables that predict cognitive outcome in women with BC.
Contrary to our hypotheses, we did not find that our sample of women with BC was more distressed than controls. It is possible that only those women who do not have significant distress agreed to an MRI, which can be a stressful and intimidating procedure. Sampling bias may thus influence our findings. However, our results show that neurofunctional deficits exist even in seemingly non-distressed women with BC during memory tasks. Therefore verbal memory impairments in some women with BC cannot be explained by illness-related stress.
In fact, verbal memory impairments might be related to the type of chemotherapy regimen. Our results suggested that women with BC who underwent adjuvant CMF chemotherapy showed significantly lower prefrontal cortex activation during memory encoding than women treated with ACT chemotherapy. As shown in Figure 2, women with BC who received ACT chemotherapy were more similar to controls in terms of prefrontal activation. Additionally, 3 of the 5 women treated with CMF actually showed deactivation of the prefrontal cortex (negative mean ROI value) during encoding. CMF rather than ACT was associated with greater brain activation impairment likely because of methotrexate. Previous studies implicate an association between cognitive deficits and methotrexate in women with BC (17), an animal model suggested negative effects of methotrexate on the frontal lobe functions in rats (23), and one study showed abnormal prefrontal cortex morphology in children with leukemia treated with methotrexate (41). However, our results should be considered preliminary given the small sample size, particularly of the CMF group. Additionally, CMF is an older chemotherapy regimen that is no longer as commonly utilized as other regimens (women in our sample treated with CMF underwent chemotherapy in the late 1990's). Therefore, this finding may have clinical relevance only for women who underwent chemotherapy in the more remote past.
It is unclear why CMF chemotherapy was associated with brain activation during encoding but not recall. Between-group activation differences during recall were much more diffuse than during encoding, which may have reduced the power of the recall ROI analysis. As indicated above, methotrexate has been associated with prefrontal cortex abnormalities. Although both encoding and recall tasks were associated with significant between-group differences in prefrontal cortex, encoding differences were more in the left hemisphere while recall differences were more in the right. This is consistent with previous studies demonstrating a left-sided bias for encoding and a right-sided bias for retrieval (42). Children with leukemia who received methotrexate demonstrated more significant left prefrontal abnormalities (40). Thus, left prefrontal cortex regions may have increased vulnerability to methotrexate-related toxicity. This potential leftward vulnerability may stem from the numerous well-documented left-right asymmetries of the prefrontal cortex including lower white matter volume (43) and coherence (44) of the left frontal hemisphere. Additionally, the left frontal cortex has significantly lower N-acetylaspartate (NAA) levels than the right. NAA is believed to play a role in glial cell-specific signaling and myelination (45). Methotrexate is known to cause white matter abnormalities (46, 47). The left frontal cortex may have less white matter "reserves" to deal with neurotoxic injury than the right due to the asymmetries described above.
Tamoxifen did not predict brain activation in regions of between-group difference but there was not enough variance to truly explore this relationship given that only 3 women out of 14 did not receive tamoxifen. Future studies should include a second comparison group of women with BC treated only with surgery as many of these receive tamoxifen or other similar hormonal therapies, but not chemotherapy. The addition of this "no chemotherapy" group would also help address the weakness of the present study inherent in cross-sectional designs. Specifically, based on the present results, it is difficult to determine if the altered brain activation profiles in the BC group stem from chemotherapy effects, additional aspects of BC (e.g. immunosuppression, inflammatory responses), or a combination of these factors. In fact, some studies have suggested that a percentage of women with BC may have cognitive impairments - including verbal memory deficits - prior to beginning adjuvant chemotherapy (14).
In conclusion, our present findings provide preliminary but compelling evidence of neurofunctional deficits associated with verbal declarative memory in women with metastatic breast cancer, potentially specific to those treated with CMF chemotherapy. Our results have important implications not only for chemotherapy treatments in BC but also for potential cognitive interventions in women with BC who demonstrate verbal memory deficits. However, small sample sizes and a cross-sectional design limit the interpretation of findings. Larger studies utilizing neuroimaging techniques with appropriate comparison groups and/or longitudinal designs are necessary to further elucidate the neurobiologic status associated with cognitive deficits in women with BC.
These findings provide neuroanatomically specific evidence of neurofunctional deficits associated with memory storage and retrieval in women with metastatic breast cancer, potentially specific to those treated with CMF chemotherapy. These results suggest that certain types of chemotherapy may induce verbal memory impairment as demonstrated by altered functional brain activation profiles. They provide evidence regarding the oft-cited but poorly understand syndrome of 'chemobrain' among women with breast cancer, explaining their primary neurocognitive problem as difficulty in performing cognitive tasks rather than deficits in the outcome of their performance per se. They also indicate that one type of chemotherapy, CMF, was most strongly associated with these deficits, suggesting opportunities for adjusting chemotherapy to minimize neurocognitive impairment and/or targeting women who received this older regimen for cognitive interventions. These results have important implications not only for chemotherapy treatments in breast cancer, but also for the design of cognitive intervention programs for women with BC who demonstrate verbal memory deficits.
This study was supported by NIA/NCI Program Project grant AG18784 (D.S.), the Randolph H. Chase, M.D., Fund II (D.S.), The Jay and Rose Phillips Family Foundation (D.S.) and the NIH Director's New Innovator Award 1DP2OD004445-01 (S.K.). The authors would like to thank Bita Nouriani for helping with recruitment coordination, Eric Neri for his assistance with cortisol and psychosocial data, and Nancy Adleman for her help with fMRI task programming and testing.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Product code: 25912
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$295,000 70 acres 4 Beds | 2 Baths | 1709 sqft 880 N Hwy 69, Arcadia, KS 66711 - Crawford County
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Tobago's coastline may not be huge, but traveling along it, past bays and coves, forests and cliffs, is like working your way through an encyclopedia of beaches. There is the classic, white-sand Caribbean option at Pigeon Point, the seafood stalls at Store Bay, the nest-dotted stretch of Turtle Beach, and the fishing village feel of Castara. There really are beaches in Tobago for everyone.
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I tend to put others ahead of me which is both good and bad. I'll do anything to help my friends and family. Just don't burn me, burn me and I'll not budge an inch.
I'm looking for someone who doesn't mind me traveling and wants to better themselves as I make my changes. I soon plan on getting a bicycle and plan to use it.
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- Friends
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- BATSMENRB4s6sSR641107058.1832.3 that's a peach, Anderson has produced a most beautiful away-seamer, fantastic seam position, pitches on off, straightens a shade and kisses the edge of the bat, How pokes tentatively but has no answer to that one, Ambrose completes an easy catch and England are on top. That was the best ball of the day so far. 102/328644043.7523.6 Now then. There you go, he's been trying to shape that one away from the right hander and just let that one go straight, poor, poor judgement from Redmond, that's what happens when all you're thinking off his leaving the ball, angles in and rattles the top of off, Sidebottom appeals for lbw but the furniture is disturbed there 80/106000.0025.6 Oh yes, he's got his man, angles in from way outside off, coming in and strikes Marshall in line, that's a huge appeal and Simon Taufel takes a bit of time and raises his finger, that was going on to hit middle and leg, he's foxed Marshall with his angles here and exploited the fact that the new batsman never really got his feet moving. Fine bowling. 86/2not out15417617587.50111011110.0035.5 Got 'em, tossed up and he's nailed a big wicket, he has just been hammered for six but he keeps at the flight, McCullum tries to pelt that through the off side but only gets a thick edge. Paul Collingwood takes a sharp catch at first slip. That appeared to have deflected off the keeper's gloves there. Panesar is over the moon. 123/44131030.7640.3 he's missed that and there's blood on the pitch, he tries to pull a short one but that's too quick for him, struck full on on the face and that seems to have gone through the grill, he's taken off his helmet and is spewing blood on the ground 136/438765050.0064.4 Direct hit! Bowls it full and slower, he glides it gently towards Cook at backward point and sets off for a risky run, Oram is struggling to make his ground and finds himself just a couple of inches short of the crease, the third umpire takes a look and Oram has to go 249/564.6 disaster this time, Vettori tucks it towards square leg and they go for two, he's quick enough to get back but doesn't ground his bat, he's not even watching the ball as Monty's throw comes in, he tries to run into the crease but his front foot is in the air as Ambrose takes off the bails, it's just a few inches over but he has to go. What reckless running this. New Zealand are throwing this away. 250/657787173.0784.5 got 'em, too close to cut and he's played on, 80mph and he's got his second wicket, Mills tries to get on his toes and cut but that's rattled the stumps, fine innings from Mills but he's disappointed with that shot 339/7560083.3388.1 Bell takes a catch. He is angry with himself for dropping the previous one and flings the ball down to the ground after taking it. It was a bouncer, O'Brien couldn't get away from it, fended it off with an ungainly pull and it lobbed towards square leg and Bell ran few paces back from his position at short leg 368/803000.0090.3 And it's all over. Taylor stranded on a brutal 154. Anderson cleaned up Martin with a full and fast delivery, the bat was again inside the line and the off stump was pegged back. Another duck in martin's illustrious batting career. The crowd give a standing applause for Taylor. what a knock it has been. Yes, Flynn has not come out to bat and so New Zealand's innings has come to an end 381/9Extras19 (b 4, lb 11, nb 1, w 3)TOTAL381 all out (90.3 Overs, 401 minutes)
Bowling O M R W Econ WD NB RJ Sidebottom 27.0 6 86 2 3.18 1 1 JM Anderson 20.3 0 118 4 5.75 2 0 MS Panesar 22.0 1 101 1 4.59 0 0 SCJ Broad 20.0 3 60 0 3.00 0 0 PD Collingwood 1.0 0 1 0 1.00 0 0 Fall of wickets:1-80 (AJ Redmond, 23.6 ov), 2-86 (JAH Marshall, 25.6 ov), 3-102 (JM How, 32.3 ov), 4-123 (BB McCullum, 35.5 ov), 4-136 (DR Flynn, ), 5-249 (JDP Oram, 64.4 ov), 6-250 (DL Vettori, 64.6 ov), 7-339 (KD Mills, 84.5 ov), 8-368 (IE O'Brien, 88.1 ov), 9-381 (CS Martin, 90.3 ov)
- BATSMENRB4s6sSR601405042.8543.5 what a sensational catch! Brendon McCullum you beauty, that's the magic that was needed to make a game of this, full and moving away, O'Brien has put it in the corridor, the edge is taken and McCullum takes off, gymnastic dive to his left and pulling off a low, one-handed catch inches from the ground. O'Brien is so stunned that he could as well have opened a dinner invite from Julia Roberts. That was a McCullum special 111/219263073.079.3 what a ball! He's nipped one out, pitching on off and jagging back in alarmingly, that's almost like a legbreak that Warne would have been proud of, his bat is facing the covers and the ball strikes into the pads, huge appeal and Taufel gives that after a bit of consideration, that probably did too much but such balls usually stun umpires into giving it, it was simply too good 33/1301333022.5554.1 what a big wicket! just as stumps approach, Vettori slips in the arm-ball, starts on off and drifts in, strikes him in line and that was quite plumb, Hair raises the finger and Vaughan has to go, that's just tilted the scales 141/326802032.5066.4 big big wicket, Vettori strikes and he's got the edge this time, tossed up outside off, that was turning away, Pietersen pokes away from his body (as he's been doing all morning) and the ball kisses the outside edge on its way to Taylor at slip, that's a wonderful way to cap off what's been a super spell of left-arm spin 160/5471057.1456.2 tossed up and another edge, that was into Jamie How's lap, one edge too many here, England are losing their way here, Vettori is turning it on. Sidebottom begins the long walk 145/48290027.5869.3 same length, another half-hearted shot from Bell, and edges it to Taylor who juggles once and hangs on to it while falling down himself 164/62100020.0070.2 sucker punch there, another wicket and England are reeling, wonderful arm-ball, pushed through quicker, Collingwood plays back and he's dead for all money there, the moment he missed the ball he was in deep trouble, strikes his back pad and the appeal is more of a formality, Hair has no trouble in giving that 164/73180016.6676.2 Taylor's shades are working perfectly in this gloom, tossed up full, bit of turn, Ambrose drives and falls into the trap, outside edge goes straight to first slip, five wickets for Vettori and England are teetering on the brink, can they avoid the ignominy of the follow-on? 179/830504060.0083.3 soft dismissal, the ball doesn't come onto the bat and Broad lashes hard at it, not much timing there and it pops up to wide mid-off, Jeetan Patel takes the catch and it's all over 202/10130033.3377.1 another sensational catch from McCullum! Whatever New Zealand touch is turning to gold here, short of a length, angling away from the left-hander, pokes and the edge is taken, flies towards first slip but McCullum is there, full length acrobatic dive to his left and pulls off a marvellous one-handed take, the ball settles in the webbing and he's plucked a beauty 180/9not out3120025.00Extras16 (b 2, lb 7, nb 7)TOTAL202 all out (83.3 Overs, 329 minutes)
Bowling O M R W Econ WD NB CS Martin 10.0 3 31 0 3.10 0 1 KD Mills 9.3 1 38 2 4.00 0 2 IE O'Brien 23.0 9 49 3 2.13 0 0 DL Vettori 31.0 5 66 5 2.12 0 4 JDP Oram 8.0 3 5 0 0.62 0 0 AJ Redmond 2.0 1 4 0 2.00 0 0 Fall of wickets:1-33 (AN Cook, 9.3 ov), 2-111 (AJ Strauss, 43.5 ov), 3-141 (MP Vaughan, 54.1 ov), 4-145 (RJ Sidebottom, 56.2 ov), 5-160 (KP Pietersen, 66.4 ov), 6-164 (IR Bell, 69.3 ov), 7-164 (PD Collingwood, 70.2 ov), 8-179 (TR Ambrose, 76.2 ov), 9-180 (MS Panesar, 77.1 ov), 10-202 (SCJ Broad, 83.3 ov)
- BATSMENRB4s6sSR29395074.3512.6 flighted on middle stump, the ball holds its line after pitching and comes on straight, How gets forward to defend but the ball hits him in front of middle, Taufel is convinced. How doesn't look too happy, perhaps he was disappointed with himself rather than the decision 50/26251024.009.3 that's the breakthrough, bit of extra bounce from a length and moving in, Redmond pushes hard but the thick edge flies to Collingwood at gully, he's taken a neat catch and Anderson lets out a leap 28/128484058.3324.1 quick one, flatter too, hurries onto Marshall, he walks across and doesn't make contact, struck on the pads and he's well in front, big appeal and Taufel gives that straight away, Panesar gets the breakthrough 85/315481031.2530.3 and that's a fiver! Monty gets his 100th wicket, that's huge, Taylor has to go, pitching on middle and turning away, beats his bat, exactly like the ball that beat him a few moments back, Taufel gives it this time and England are on a high, Taylor was the real danger-man here 91/603000.0024.4 he's got another! not that much turn this time, almost a straighter one, he's tried to sweep that but missed it completely, struck on the hips and that's plumb, Taufel gives that one straight away, Monty is leading a fightback here 85/44140028.5728.5 another for Monty! full ball on middle and leg, Vettori goes for the sweep but can only get a top-edge, Broad is waiting at backward square leg and that's straight to him, Monty takes off on his celebrations and England are cock-a-hoop 91/58301026.6640.4 That's six for Monty! full and spinning away, he goes for the big sweep but is done in by the bounce, top-edge soars high in the air and Ambrose is waiting under it to complete the catch on the leg side. Now then, now then 114/87170041.1735.1 A loose shot, just after he started to look comfortable. Plays away from the body, edges, and Ambrose takes a nice catch diving to his left. this could have been tricky for the slip fielder as it was landing mid-way between Ambrose and first slip 106/76220027.2741.2 and it's all over, tries to loft over mid-off but there's only a tame scoop there, thick outside edge and Anderson pockets a simple catch at mid-on 114/10not out02000.00absent hurt-Extras11 (lb 11)TOTAL114 all out (41.2 Overs, 166 minutes)
Bowling O M R W Econ WD NB RJ Sidebottom 12.2 5 26 2 2.10 0 0 JM Anderson 8.0 1 21 1 2.62 0 0 MS Panesar 17.0 5 37 6 2.17 0 0 SCJ Broad 4.0 0 19 0 4.75 0 0 Fall of wickets:1-28 (AJ Redmond, 9.3 ov), 2-50 (JM How, 12.6 ov), 3-85 (JAH Marshall, 24.1 ov), 4-85 (BB McCullum, 24.4 ov), 5-91 (DL Vettori, 28.5 ov), 6-91 (LRPL Taylor, 30.3 ov), 7-106 (JDP Oram, 35.1 ov), 8-114 (KD Mills, 40.4 ov), 9-114 (IE O'Brien, 41.2 ov)
- BATSMENRB4s6sSR10618612056.9869.4 that's a stunner at first slip, Taylor with his shades again, angling away from him, expansive drive from Strauss, edge taken and Taylor pulls off a low catch to his left, he's moved quick and latched on, fine innings from Strauss but is there a twist in the tale? 235/328692040.5720.5 and that's the breakthrough. Vettori strikes! Is that the opening NZ were looking for? Slightly short again but he's extracted good bounce here, inside edge onto the thigh pad, bobs up to Marshall at short leg and he's lapped it up, that's No.1 for NZ 60/1481035046.6050.2 Now then! Now then! full and outside off, probing line that and Martin gets his reward, late swing there, Vaughan goes for the full-blooded drive but snicks through to the keeper, that's a comfortable catch for McCullum and New Zealand are ecstatic, they so desperately needed that 150/242785153.8472.2 Have they got him? Worked to the leg side and they think of two, Martin rips in another accurate through to the keeper and he's short this time, it's referred to the third umpire but he has to go, now then, now then, is the cat among the pigeons? 248/4not out21424050.00not out24562042.85Extras25 (b 9, lb 10, nb 6)TOTAL294/4 (88 Overs, 347 minutes)
Bowling O M R W Econ WD NB CS Martin 13.0 1 45 1 3.46 0 2 KD Mills 6.0 0 17 0 2.83 0 2 DL Vettori 35.0 7 111 1 3.17 0 2 IE O'Brien 20.0 2 62 1 3.10 0 0 JM How 1.0 0 4 0 4.00 0 0 JDP Oram 13.0 1 36 0 2.76 0 0 Fall of wickets:1-60 (AN Cook, 20.5 ov), 2-150 (MP Vaughan, 50.2 ov), 3-235 (AJ Strauss, 69.4 ov), 4-248 (KP Pietersen, 72.2 ov)
Match Details
Old Trafford, Manchester
11am start, Lunch 13.00-13.40, Tea 15.40-16.00, Close 18.00
- Old Trafford Cricket Ground, Talbot Road, Manchester, M16 0PX (Phone: 0161 282 4000)
New Zealand , elected to bat first
Series result
England led the 3-match series 1-0
Player of the match
TV Umpires
Reserve Umpire
Match Referee
Match Notes
- England: 100 runs in 33.2 overs (204 balls), Extras 10
- 2nd Wicket: 50 runs in 94 balls (AJ Strauss 21, MP Vaughan 29, Ex 2)
- AJ Strauss: 50 off 105 balls (4 x 4)
- Drinks: England - 129/1 in 44.0 overs (AJ Strauss 55, MP Vaughan 35)
- England: 150 runs in 49.3 overs (302 balls), Extras 11
- Lunch: England - 171/2 in 56.0 overs (AJ Strauss 73, KP Pietersen 5)
- England: 200 runs in 63.4 overs (388 balls), Extras 18
- 3rd Wicket: 50 runs in 81 balls (AJ Strauss 25, KP Pietersen 19, Ex 7)
- AJ Strauss: 100 off 178 balls (11 x 4)
- England: 250 runs in 72.5 overs (443 balls), Extras 24
- Match Scorer: Binoy George
- Drinks: England - 177/7 in 75.0 overs (TR Ambrose 3, SCJ Broad 10)
- England: 200 runs in 82.5 overs (504 balls), Extras 16
- Innings Break: England - 202/10 in 83.3 overs (JM Anderson 3)
- New Zealand 2nd innings
- Lunch: New Zealand - 1/0 in 3.0 overs (JM How 0, AJ Redmond 1)
- New Zealand: 50 runs in 12.5 overs (77 balls), Extras 4
- Drinks: New Zealand - 65/2 in 18.0 overs (JAH Marshall 21, LRPL Taylor 5)
- Tea: New Zealand - 99/6 in 32.0 overs (KD Mills 4, JDP Oram 2)
- New Zealand: 100 runs in 32.6 overs (198 balls), Extras 11
- Innings Break: New Zealand - 114/10 in 41.2 overs (CS Martin 0)
- England 2nd innings
- Drinks: England - 48/0 in 16.0 overs (AJ Strauss 18, AN Cook 22)
- England: 50 runs in 16.2 overs (101 balls), Extras 8
- 1st Wicket: 50 runs in 101 balls (AJ Strauss 19, AN Cook 23, Ex 8)
- End Of Day: England - 76/1 in 27.0 overs (AJ Strauss 27, MP Vaughan 12)
- 5th Wicket: 100 runs in 137 balls (LRPL Taylor 58, JDP Oram 34, Ex 8)
- New Zealand: 250 runs in 64.6 overs (392 balls), Extras 14
- LRPL Taylor: 100 off 130 balls (13 x 4, 1 x 6)
- New Zealand: 300 runs in 76.6 overs (464 balls), Extras 14
- 7th Wicket: 50 runs in 72 balls (LRPL Taylor 15, KD Mills 38, Ex 0)
- New Ball Taken: New Zealand 315/6 after 80.1 overs (LRPL Taylor 111, KD Mills 43)
- Lunch: New Zealand - 322/6 in 81.0 overs (LRPL Taylor 115, KD Mills 46)
- KD Mills: 50 off 74 balls (7 x 4, 1 x 6)
- New Zealand: 350 runs in 86.2 overs (521 balls), Extras 17
- LRPL Taylor: 150 off 172 balls (17 x 4, 5 x 6)
- Innings Break: New Zealand - 381/9 in 90.3 overs (LRPL Taylor 154)
- England 1st innings
- Tea: England - 42/1 in 15.0 overs (AJ Strauss 17, MP Vaughan 4)
- England: 50 runs in 20.1 overs (122 balls), Extras 2
- Drinks: England - 76/1 in 31.0 overs (AJ Strauss 33, MP Vaughan 20)
- 2nd Wicket: 50 runs in 143 balls (AJ Strauss 27, MP Vaughan 21, Ex 2)
- AJ Strauss: 50 off 125 balls (5 x 4)
- England: 100 runs in 39.4 overs (240 balls), Extras 4
- England: 150 runs in 57.2 overs (349 balls), Extras 12
- End Of Day: England - 152/4 in 59.0 overs (KP Pietersen 22, IR Bell 4)
- New Zealand 1st innings
- New Zealand: 50 runs in 12.2 overs (74 balls), Extras 1
- 1st Wicket: 50 runs in 74 balls (JM How 31, AJ Redmond 20, Ex 1)
- Drinks: New Zealand - 61/0 in 15.0 overs (JM How 40, AJ Redmond 20)
- JM How: 50 off 75 balls (5 x 4)
- Lunch: New Zealand - 92/2 in 29.0 overs (JM How 58, LRPL Taylor 4)
- New Zealand: 100 runs in 31.3 overs (189 balls), Extras 2
- DR Flynn retired hurt at 136/4 (4, 40.3 overs)
- New Zealand: 150 runs in 42.1 overs (253 balls), Extras 6
- Drinks: New Zealand - 163/4 in 43.0 overs (LRPL Taylor 45, JDP Oram 5)
- LRPL Taylor: 50 off 52 balls (7 x 4, 1 x 6)
- Rain: New Zealand - 180/4 in 50.0 overs (LRPL Taylor 57, JDP Oram 10)
- Tea: New Zealand - 180/4 in 50.0 overs (LRPL Taylor 57, JDP Oram 10)
- Wet Ground: New Zealand - 180/4 in 50.0 overs (LRPL Taylor 57, JDP Oram 10)
- 5th Wicket: 50 runs in 74 balls (LRPL Taylor 34, JDP Oram 13, Ex 4)
- New Zealand: 200 runs in 53.5 overs (323 balls), Extras 6
- Bad Light: New Zealand - 202/4 in 54.0 overs (LRPL Taylor 67, JDP Oram 22)
- End Of Day: New Zealand - 202/4 in 54.0 overs (LRPL Taylor 67, JDP Oram 22)
Sponsored Headlines
|England INNINGS
|AJ Strauss
|AN Cook
|MP Vaughan
|caught wk
|KP Pietersen
|run out
|IR Bell
|not out
|PD Collingwood
|not out
|TR Ambrose
|SCJ Broad
|RJ Sidebottom
|MS Panesar
|JM Anderson
|(b 9, lb 10, nb 6)
|294 (4 wkts; 88 ovs)


text:
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American Street, Belmullet, Co. Mayo,
Tel: 097 81476 / 087 0979744
PSRA Licence No. 001261


text:
Maha opposition leader`s son commits suicide
Maharashtra leader of opposition Eaknath Khadse`s son on Wednesday shot himself in Jalgaon.
Zee Media Bureau
New Delhi: The son of Eknath Khadse, leader of opposition in Maharashtra, reportedly succumbed to his injuries on Wednesday after he shot himself in Jalgaon.
Nikhil Khadse had sustained bullet injuries in the head and his condition was reported to be critical.
He was admitted to the hospital by family members. The doctors later declared him dead, as per news reports.
The motive behind the drastic step is not known, though it is rumoured that Nikhil was not keeping well for over a year.
Nikhil, in his mid-30s, is a member of the Jalgaon Zilla Parishad, around 415 km to the east of Mumbai, and had contested the 2009 Maharashtra Assembly elections.
(With IANS Inputs)