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Pulmonary Medicine
What every physician needs to know:
Are you sure your patient has tuberculosis? What should you expect to find?
Beware: there are other diseases that can mimic tuberculosis.
How and/or why did the patient develop tuberculosis?
Which individuals are at greatest risk of developing tuberculosis?
What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
What imaging studies will be helpful in making or excluding the diagnosis of tuberculosis?
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of tuberculosis?
What diagnostic procedures will be helpful in making or excluding the diagnosis of tuberculosis?
What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of tuberculosis?
If you decide the patient has tuberculosis, how should the patient be managed?
What is the prognosis for patients managed in the recommended ways?
What other considerations exist for patients with tuberculosis?
What's the evidence?
What every physician needs to know:
Tuberculosis is an infection that primarily affects the lungs but that can also involve nearly every organ system in the body. It is caused by Mycobacterium tuberculosis, a slow-growing microorganism that is characteristically acid-fast; that is, it resists decolorization by acid after it has been stained. The microorganisms that cause the disease are transmitted from person to person almost exclusively by the airborne route; transmission through blood, bodily secretions, the oral/fecal route, sexual contact, casual contact, and fomites does not generally occur.
It is estimated that nearly a third of the world's population, or some two billion people, have latent infection with M. tuberculosis. Persons with the latent form of the infection are not sick in any way, nor are they contagious; they simply harbor living organisms that are contained by their bodies' immune systems. A person with latent infection has roughly a 5-10 percent lifetime risk of developing the active and contagious form of the disease. Treatment of latent tuberculosis, which is indicated for persons at highest risk for developing the active form of the disease, reduces the risk of progression by 60-80 percent.
Active tuberculosis, which is contagious and which can be fatal if untreated, is typically characterized by cardinal but somewhat non-specific signs and symptoms: fever, cough and weight loss. If diagnosed promptly, most cases of active tuberculosis can be cured using a combination of antibiotics taken for 6-9 months.
Tuberculosis exists in a latent form and an active form. Latent tuberculosis infection (LTBI) is a state of asymptomatic infection in which patients have no signs or symptoms of the disease and cannot transmit the organism to others. A small percentage of patients of patients with LTBI will go on to develop active tuberculosis, but most will remain healthy throughout their lives.
The most common form of active tuberculosis is pulmonary tuberculosis. Eighty-five percent of all cases of tuberculosis involve the lung. Based on the appearance of tuberculosis on a plain chest radiograph, pulmonary tuberculosis is often classified as cavitary (associated with cavities, or holes, visible in the lung parenchyma) or non-cavitary.
Extra-pulmonary (outside the lung) cases of tuberculosis occur in 15 percent of patients, most often in combination with lung disease, although they may occur without lung involvement. The most common forms of extra-pulmonary tuberculosis are tuberculosis of the lymph nodes, especially the lymph nodes of the neck; tuberculosis of the bones and joints (usually the large bones and joints, such as the spine and hips); tuberculous pleurisy; disseminated (miliary) tuberculosis; genitourinary tuberculosis; and tuberculosis of the central nervous system, including tuberculous meningitis.
Are you sure your patient has tuberculosis? What should you expect to find?
The principle symptoms and signs of pulmonary tuberculosis are common but somewhat non-specific. They begin slowly, so the presentation of tuberculosis is nearly always that of a sub-acute to chronic illness that develops over a period of weeks to months. The most important and common signs and symptoms are fever, cough, and weight loss. The fever is persistent and low-grade and has an insidious onset. The cough is generally productive, and in patients with the cavitary form of the disease, it may be accompanied by hemoptysis. Weight loss is responsible for the historical name for tuberculosis: consumption. Significant weight loss, to below 90 percent of ideal body weight is associated with advanced disease and a higher risk of mortality.
Patients with pulmonary tuberculosis may also complain of drenching night sweats that require a change of bed clothes or bedding, vague chest discomfort, or pleuritic-type pain if they have pleural involvement. Symptoms of extra-pulmonary tuberculosis are related to the organ involved: enlarged lymph nodes, back pain (from spine involvement), dysuria (in GU tuberculosis), prolonged and profound headache (with meningitis), and anemia (especially with disseminated or miliary tuberculosis).
Beware: there are other diseases that can mimic tuberculosis.
The differential diagnosis of pulmonary tuberculosis includes several other infectious diseases of the lung, as well as some non-infectious diseases. Several infections can present with the subacute to chronic illness that is typical of pulmonary tuberculosis. Overall, the differential diagnosis of tuberculosis includes infections like pneumonia, chronic lung abscess, fungal infections of the lung, non-tuberculosis mycobacterial infections, melioidosis, and paragonimiasis, as well as lymphoma, sarcoidosis, Wegener's granulomatosis, hypersensitivity pneumonitis, and bronchogenic carcinoma.
How and/or why did the patient develop tuberculosis?
Tuberculosis occurs throughout the world, although twenty-two countries (the "high burden: countries) account for more than 80 percent of all cases. There are 8-12 million new cases of tuberculosis in the world each year, the vast majority of which occur in East, Southeast, or South Asia--China and India alone account for 40 percent of all the cases in the world each year--Central Asia, and sub-Saharan Africa. In general, case rates are highest in countries that have lower levels of economic development, higher levels of malnutrition, and overcrowding. In many African countries, more than half of those with tuberculosis are also infected with HIV.
In the developed West, tuberculosis case rates are much lower. In the United States in 2010, for example, the incidence of tuberculosis was 3.6/100,000 persons. By contrast, in the high-burden countries, case rates ranged between 150 and1700 per 100,000 persons.
Tuberculosis is acquired almost exclusively by the airborne route. A person exposed to an infectious case of tuberculosis inhales organisms into the respiratory tract. In some cases, the body's innate immune system eliminates the mycobacterium immediately and completely, and no state of latent infection develops. In many other cases, an immune response ensues that results in a state of latent infection, in which living bacteria are contained in an area of granulomatous inflammation and the patient is completely asymptomatic and not contagious. In most instances, this latent state is maintained indefinitely, and no clinical illness will ever occur. However, in some cases (often if there is coincident immunosuppression), the well-formed granuloma breaks down, and the mycobacteria begin to grow and divide, causing clinical illness.
Which individuals are at greatest risk of developing tuberculosis?
Individuals at highest risk for contracting active tuberculosis include the following:
Persons with compromised immune systems, including HIV infection (even if the individual is on anti-retroviral medications), prolonged treatment with higher doses of prednisone (more than 15 mg/day for more than 30 days), treatment with other immunosuppressives (especially TNF-alpha antagonists), and organ transplant recipients who are receiving anti-rejection therapies
Persons who have been in close contact with someone who has active tuberculosis
Persons who have recent evidence (within two years) of having acquired latent tuberculosis infection (e.g., health care workers whose annual testing for latent tuberculosis infection is newly positive)
Recent (within five years) immigrants to the U.S. from high-burden countries, as more than half of all cases of tuberculosis in the U.S. occur in persons born outside the U.S.
Persons with evidence of latent tuberculosis infection, an old tuberculosis scar on chest radiograph (e.g., an upper-lobe fibrotic scar), and no prior history of treatment for tuberculosis
Persons with end-stage renal failure
Persons with poorly controlled diabetes mellitus
All persons in these categories should be tested for latent tuberculosis. However, there will still be patients who present with signs and symptoms of active tuberculosis who do not fall into any of these categories, and tuberculosis should be considered as a diagnostic possibility in those cases.
Although children and the elderly are at increased risk for tuberculosis, the mode of the age distribution for tuberculosis cases in the U.S. and around the world is in the 25-44 age group.
What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
The initial evaluation for most patients suspected of having tuberculosis should include a plain chest radiograph and a sputum smear examination. Sputum can be obtained through simple expectoration or by sputum induction if the patient is unable to produce an expectorated sample. Induction by inhaling nebulized hypertonic saline will often produce a satisfactory specimen. Samples may also be obtained by early-morning gastric aspiration, as organisms may migrate up the respiratory tree during sleep and be swallowed. Several studies have indicated that samples obtained via bronchoalveolar lavage are no more sensitive for diagnosis than samples obtained by sputum induction.
Sputum should be examined by microscopy for the presence of
M. tuberculosis organisms either after Ziehl-Neelsen or after auramine-rhodamine staining with fluorescent microscopy. (
Figure 1.
Ziehl-Neelsen and auramine stains showing M. tuberculosis organisms
When there is a reasonable clinical suspicion of tuberculosis, a negative sputum smear examination does not rule out the diagnosis. A sample should be sent to culture at the same time sputum is sent for smear examination. Culture has excellent sensitivity (90-95%), although positive results take 10-28 days to develop if broth-based systems like mycobacterial growth indicator tubes (MGIT) are used, and longer if a solid medium like Lowenstein-Jensen agar is used. Drug-susceptibility testing should be obtained for any specimens that are culture positive so the antibiotic regimen can be adjusted if necessary.
A useful adjunct to sputum smear examination is nucleic acid amplification testing (NAAT), which confirms the presence of mycobacteria by identifying nucleic acid sequences that are unique to M. tuberculosis in sputum samples. This technique detects nearly all smear-positive cases of tuberculosis and about half of the smear-negative cases, for an overall sensitivity of 80-85 percent, and results are usually available within twenty-four hours. In addition to improved sensitivity over smear alone, NAAT confirms whether a positive sputum smear is caused by M. tuberculosis and not another non-tuberculous mycobacteria species.
Recently, highly automated technologies for nucleic acid amplification have been developed that also have the capability of rapidly identifying mutations in M. tuberculosis that are associated with drug resistance, particularly resistance to rifampin.
Tests for prior exposure to M. tuberculosis, such as tuberculin skin tests (TST) and interferon gamma release assays (IGRA), are positive in 70-80 percent of patients with active tuberculosis, but a negative test result from a TST or IGRA does not exclude tuberculosis as a diagnostic possibility, so these tests have limited utility in the evaluation of a patient with suspected active disease. Similarly, serological tests for tuberculosis, which identify antibodies against cell wall components and other antigens of M. tuberculosis, lack good sensitivity and specificity for diagnosis of active disease and should not be used.
Routine blood tests, such as complete blood counts, electrolytes, liver function tests, and erythrocyte sedimentation rate, are often useful in monitoring patients who are being treated for tuberculosis, but they are not useful diagnostically, as abnormalities in all these parameters are common in but not specific to tuberculosis patients.
What imaging studies will be helpful in making or excluding the diagnosis of tuberculosis?
Although routine chest radiography is not available in many resource-limited settings, plain chest radiograph should be obtained in every patient suspected of having tuberculosis.
The radiographic findings in tuberculosis have been well-known and well-described for many years: The classic location for abnormalities in patients with tuberculosis is in the upper lobes (
Figure 2.
Upper lobe cavitary disease
Figure 3.
Pulmonary tuberculosis
Figure 4.
Extensive bilateral cavitary tuberculosis
A miliary pattern can be seen on plain chest radiographs in cases of disseminated tuberculosis. (
Figure 5.
Miliary tuberculosis
Other than parenchymal infiltrates, several other radiographic findings can represent tuberculosis. Pleural effusion is a common finding, and effusions in tuberculosis can be quite large. At times the effusions will accompany parenchymal infiltrates, but effusions often occur with no other changes.
Mediastinal or hilar adenopathy can also be the sole manifestation of tuberculosis, particularly in patients with compromised immune systems. (
Figure 6.
Chest radiographs showing typical upper lobe infiltrate (left image, arrow) and extensive mediastinal adenopathy (right image)
Figure 7.
CT scan showing extensive necrotic adenopathy caused by tuberculosis in a patient with HIV infection
CT scanning of the chest is usually not required in the evaluation of patients with suspected tuberculosis when the plain radiograph shows advanced or typical findings, but it can be a useful adjunct when the plain radiograph findings are subtle or confusing or when the differential diagnosis of the findings on plain radiography is long.
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of tuberculosis?
Other than the laboratory tests listed above, other non-invasive tests have little role in the diagnosis of tuberculosis. Pulmonary function testing is not only generally not helpful, but such tests should be avoided while patients are infectious. Cardiopulmonary exercise testing is not helpful.
What diagnostic procedures will be helpful in making or excluding the diagnosis of tuberculosis?
Several tests are useful in making the diagnosis of tuberculosis, including testing for tuberculosis infection with tuberculin skin testing (TST) or by interferon gamma release assays (IGRA). IGRA are more specific than TST, but neither is sensitive or specific enough to establish a diagnosis of active tuberculosis on its own.
Sputum smear examination and sputum culture are also useful. The sensitivity of sputum smear examination is 50-60 percent, while specificity depends on the background prevalence of non-tuberculous mycobacteria in the population. Sputum culture has high sensitivity and specificity, but there are cases of active tuberculosis in which sputum cultures will be negative. Therefore, if there is a high clinical suspicion based on clinical and radiographic findings, and the patient responds to treatment, a diagnosis of tuberculosis should be considered confirmed even if cultures are negative. Up to 10 percent of cases of tuberculosis will be culture-negative.
Chest radiography is extremely helpful in diagnosing tuberculosis, although radiographic findings are not specific, and radiography alone cannot establish a diagnosis.
Fiberoptic bronchoscopy and transbronchial biopsy have little role to play in the diagnosis of tuberculosis. These procedures are sometimes performed if there is significant diagnostic uncertainty and the clinician finds it necessary to rule out other diseases, such as sarcoidosis or lung cancer.
What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of tuberculosis?
If a tissue biopsy is performed, the typical finding of tuberculosis is necrotizing granulomas, which may also stain positive for acid-fast organisms. However, the causes of granulomatous inflammation are many, and this finding (without the presence of acid-fast organisms) in and of itself does not establish the diagnosis.
If you decide the patient has tuberculosis, how should the patient be managed?
Because of the disease's infectious nature, the treatment of a patient with tuberculosis requires both medical and public health approaches. In the United States, tuberculosis is a reportable condition; that is, a physician is obligated to report any case to the local health department. The health department will conduct a contact investigation so persons exposed to the patient prior to diagnosis and at the institution of treatment can have a proper medical evaluation.
Because of the infectious nature of the disease, consideration should be given to protecting the general public from infection. Hospitalization is not always required, but patients should not resume work or other activities until they are no longer infectious. Patients are usually considered non-infectious when they have been on therapy for at least two weeks AND their sputum smears are negative for acid-fast organisms.
Antibiotic therapy is the only treatment that can cure tuberculosis. In cases of drug-susceptible tuberculosis (still the vast majority of all tuberculosis cases in the world), treatment consists of a four-drug induction phase given for two months and a four-month continuation phase that usually consists of two drugs. The induction phase usually requires that the drugs isoniazid, rifampin, pyrazinamide, and ethambutol be given daily, while the continuation phase consists of isoniazid and rifampin.
During therapy, patients should be examined at least once a month to assess for treatment response and adverse drug effects, and they should have sputum samples collected monthly until cultures revert to negative for at least two consecutive months. Components of the routine visit should include a history, a physical exam, vision testing for patients who are taking ethambutol, and liver function testing.
As the therapy for tuberculosis is prolonged and is often accompanied by side effects, the treating physician should pay particular attention to ensuring adherence to the therapy. Directly observed therapy (DOT) is recommended for nearly all patients who are undergoing treatment. In addition to providing medications, the best DOT programs offer medical, social, and nursing supportive care to patients; DOT has been shown to be successful in the U.S. even in difficult-to-treat populations.
In cases of drug-resistance, particularly multi-drug resistance (MDR-TB, defined as tuberculosis that is resistant to isoniazid and rifampin), therapy is prolonged and individualized, and consultation with an expert in the treatment of drug-resistant tuberculosis is strongly advised. Treatment of MDR-TB relies on several drugs that are difficult to administer and/or that have significant side effects. The most useful of the second-line anti-tuberculosis drugs are the advanced quinolones (levofloxacin and moxifloxacin) and the injectable agents (streptomycin, amikacin, and kanamycin).
In some cases of MDR-TB, surgery may be a useful adjunct to antibiotics if the disease is relatively confined to a lobe or segment of the lung. Empiric therapy for MDR-TB is usually not warranted. Cases in which there should be a high index of suspicion for MDR-TB include those in which there is a prior history of self-administered treatment for tuberculosis or in which the patient is known to have been in contact with another person with active MDR-TB.
What is the prognosis for patients managed in the recommended ways?
Most patients with tuberculosis respond well to therapy and are completely cured of their disease. Cure rates for drug-susceptible tuberculosis approach 100 percent, and the relapse rate is only on the order of 3-5 percent. However, in certain cases of drug-susceptible tuberculosis, a higher relapse rate can be predicted and treatment should be prolonged to nine months. Predictors of a high relapse rate include extensive bilateral cavitary disease, persistent positive sputum culture beyond the first two months of therapy, and initial body weight that is less than 90 percent of predicted ideal body weight. Any two of these three risk factors raises the chance for relapse to 10-15 percent if treatment is discontinued after six months.
Special mention should be made of patients with HIV infection. In the era preceding the use of highly active antiretroviral therapy, mortality rates for HIV-infected patients with tuberculosis were in the range of 20 percent in the first year following diagnosis of tuberculosis. Several recent studies have shown that mortality rates can be reduced to well below 5 percent if antiretroviral therapy is instituted soon after therapy for tuberculosis is also instituted.
However, simultaneous treatment of tuberculosis and HIV infection is difficult for several reasons: the sheer number of medications (at least seven, in most cases) involved creates a difficult regimen for most patients to adhere to, a multiplicity of drugs leads to a multiplicity of side effects, drug-drug interactions that are due mostly to rifampin's potent activity as a cytochrome P450 inducer create problems in maintaining adequate blood levels for several of the drugs, and immune reconstitution inflammatory syndrome (IRIS) can occur. Therefore, treatment of simultaneous TB and HIV infection should be undertaken with the close guidance of someone knowledgeable and experienced in this area.
Therapy is much more complicated and outcomes may be poorer for patients with multi-drug-resistant tuberculosis than for those with drug-susceptible tuberculosis. If there is resistance to isoniazid and rifampin alone, the best medical therapy, sometimes combined with surgery, can achieve cure rates approaching 90 percent. For extensively drug-resistant tuberculosis (XDR-TB), which is often associated with HIV-infection, outcomes have been poor and mortality rates have been high.
Patients who present with advanced pulmonary tuberculosis may have considerable residual lung damage even after they are treated and cured. Scarring of the lungs, volume loss, and bronchiectasis are all common in patients who present with extensive disease at the time of diagnosis. As a result, loss of lung capacity and chronic respiratory disease may be seen in some patients who have been cured of their tuberculosis.
What other considerations exist for patients with tuberculosis?
Patients with tuberculosis are often faced with an unfortunate and unfair social stigma of which caregivers should be aware, as it has the potential to affect the patient adversely in many ways. Many patients with tuberculosis live at the margins of society, and caregivers should be sensitive to their economic and social circumstances. Patients may need referral to a range of social services, including those for housing, substance abuse counseling, legal services, and mental health.
All patients with tuberculosis should receive HIV testing.
What's the evidence?
LoBue, PA, Enarson, DA, Thoen, TC. "Tuberculosis in humans and its epidemiology, diagnosis and treatment in the United States". Int J Tuberc Lung Dis. vol. 14. 2010. pp. 1226-32.A good overview of basic concepts of the development of tuberculosis and clinical issues related to diagnosis and treatment.
Taylor, Z, Nolan, CM, Blumberg, HM. "American Thoracic Society; Centers for Disease Control and Prevention; Infectious Diseases Society of America. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America". MMWR Recomm Rep. vol. 54. 2005. pp. 1-81.Public health aspects of tuberculosis control that are also relevant to individual practitioners.
Bennett, DE, Courval, JM, Onorato, I, Agerton, T, Gibson, JD, Lambert, L. "Prevalence of tuberculosis infection in the United States population: the National Health and Nutrition Examination Survey, 1999-2000.". Am J Respir Crit Care Med. vol. 177. 2008. pp. 348-55.A comprehensive survey of the prevalence of latent tuberculosis infection in the United States.
Mazurek, GH, Jereb, J, Lobue, P, Iademarco, MF, Metchock, B, Vernon, A. "Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC). Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States". MMWR Recomm Rep. vol. 54. 2005. pp. 49-55.Recommendations from the Centers for Disease Control and Prevention (with input from an outside group of experts) on the use of interferon gamma release assays for the diagnosis of tuberculosis infection.
"American Thoracic Society, Infectious Disease Society of America, Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection". MMWR Recomm Rep. vol. 49. 2000. pp. 1-51.Recommendations from leading professional societies and the CDC regarding who should be tested and treated for latent tuberculosis infection in the U.S.
Brodie, D, Schluger, NW. "The diagnosis of tuberculosis". Clin Chest Med. vol. 26. 2005. pp. 247-71.A comprehensive review of diagnostic approaches for active tuberculosis.
Ellis, SM. "The spectrum of tuberculosis and non-tuberculous mycobacterial infection". Eur Radiol. vol. 14. 2004. pp. E34-42.A review of radiographic findings in tuberculosis.
Geng, E, Kreiswirth, B, Burzynski, J, Schluger, NW. "Clinical and radiographic correlates of primary and reactivation tuberculosis: a molecular epidemiology study". JAMA. vol. 293. 2005. pp. 2740-5.A study of the relationship between radiographic findings and characteristics of disease transmission in tuberculosis.
Yoo, SD, Cattamanchi, A, den Boon, S, Worodria, W, Kisembo, H, Huang, L. "Clinical significance of normal chest radiographs among HIV-seropositive patients with suspected tuberculosis in Uganda". Respirology. 2011 Apr 22.A recent study that demonstrates yet again that normal chest radiographs are common in HIV-infected patients with tuberculosis.
Morse, M, Kessler, J, Albrecht, S, Kim, R, Thakur, R, Nthobatsang, R. "Induced sputum improves the diagnosis of pulmonary tuberculosis in hospitalized patients in Gaborone, Botswana". Int J Tuberc Lung Dis. vol. 12. 2008. pp. 1279-85.A study that reviews the value of induced sputum in the diagnosis of pulmonary tuberculosis.
Brown, M, Varia, H, Bassett, P, Davidson, RN, Wall, R, Pasvol, G. "Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate". Clin Infect Dis. vol. 44. 2007. pp. 1415-20.A study that points out that fiberoptic bronchoscopy adds little to the diagnosis of tuberculosis in patients from whom an adequate induced sputum sample has been obtained.
"Centers for Disease Control and Prevention (CDC). Severe isoniazid-associated liver injuries among persons being treated for latent tuberculosis infection - United States, 2004-2008". MMWR Morb Mortal Wkly Rep. vol. 59. 2010. pp. 224-9.A description of the incidence and severity of isoniazid-induced liver injury in the U.S.
Cattamanchi, A, Dantes, RB, Metcalfe, JZ, Jarlsberg, LG, Grinsdale, J, Kawamura, LM. "Clinical characteristics and treatment outcomes of patients with isoniazid-monoresistant tuberculosis". Clin Infect Dis. vol. 48. 2009. pp. 179-85.A valuable study on the outcome of patients with the most common form of drug-resistance seen in the United States: INH mono-resistance.
Saukkonen, JJ, Cohn, DL, Jasmer, RM, Schenker, S, Jereb, JA, Nolan, CM. "ATS (American Thoracic Society) Hepatotoxicity of Antituberculosis Therapy Subcommittee. An official ATS statement: hepatotoxicity of antituberculosis therapy". Am J Respir Crit Care Med. vol. 174. 2006. pp. 935-52.
Caminero, JA. "World Health Organization; American Thoracic Society; British Thoracic Society. Treatment of multidrug-resistant tuberculosis: evidence and controversies". Int J Tuberc Lung Dis. vol. 10. 2006. pp. 829-37.A comprehensive overview of the issues related to treatment of multi-drug-resistant tuberculosis.
Blumberg, HM, Burman, WJ, Chaisson, RE, Daley, CL, Etkind, SC, Friedman, LN. "Fujiwara; American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis". Am J Respir Crit Care Med. vol. 167. 2003. pp. 603-62.Official guidelines for the treatment of tuberculosis, from the American Thoracic Society, the Infectious Disease Society of America, and the CDC.
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Shadow Kids - Laughing At Jazz
El Diablo's Social Club follow the ALFOS rocking MancTalian connection of 003, with some sonic waves beamed down from the furthest reaches of our galaxy. Shadow Kids (Mike Simonetti and Secret Circuit) took a peyote fuelled trip down to the cold and barren flats of Chile in a beat up VW Camper packed with analogue gear, energy drinks and as much of Radio Shack's dead stock as they could cram in, gripped by the obsessive desire to intercept the cosmic transmissions from the distant reaches of our galaxy and translate them into a sonic language we can all understand. 'Laughing Jazz' starts off proceedings with an infectious string arrangement that rides the wobbly baseline like a pro cosmic surfer before out of nowhere a Chicago tinged piano creeps into the mix to bring things back from space and onto the dance floor. 'Nightsun' plays out like a theatrical play of different sections and is intriguing from the first beat (although it is over 2 mins before the 4/4 kicks in!) and continues to surprise throughout its 8 minute playing time, with psyched out melodies, snappy percussion and a 'womp womp' bassline before entering a final stage that goes for an almost heads down vibe. Ruf Dug emerges from an interdimensional wormhole to turn in an excellent wobble boogie version of 'Laughing Jazz' that takes in disco elements whilst punchy piano chords keep it hooky. Ruffy gives the track a little extra panache by rerecording the vocals and drives us direct to the dancefloor with a killer bassline sampled from wherever Glimmers nicked 'You Rocked My World' from. Lastly, cosmic disco's branch of the David Icke appreciation society (or Seahawks as they're more commonly known) do the seemingly impossible and crank up the psych meter to full throttle making 'Nightsun' an even grander experience with a running time of just over 12 minutes! The listening equivalent of Lord Of The Rings, this is epic, beautiful & an absolutely stunning piece of work.
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Radiosurgery is a medical procedure that allows non-invasive treatment of benign and malignant tumors. The goal of Radiosurgery is to produce clinical outcomes on par (or better than) traditional surgery, using the best technology science has to offer.
Three common terms you might hear oncologists use are (click each for more info):
- Stereotactic Radiosurgery(SRS)
- Stereotactic Body Radiation Therapy (SBRT)
- Intensity-Modulated Radiation Therapy (IMRT)
Radiosurgery is very high-dose, focused radiation, delivered with extreme precision to target only the intended tumor volumes (or lesions) while avoiding surrounding healthy organs and tissues. SRS & SBRT are acronyms often used by medical professionals referring to Radiosurgery. Radiosurgery typically is employed to address discrete tumors or lesions the size of a golf-ball or smaller. SRS & SBRT can treat many of these lesions in one treatment plan or multiple treatment plans.
Some older definitions of SRS limit its course to one fraction or treatment which today is technically incorrect. Radiosurgery can be delivered in 1-5 treatments which typically are delivered at least 24 hours apart because of the radiobiology of the disease they are treating. For instance, most GammaKnife treatments are inherently limited to one large dose (or fraction) in the brain, whereas technologies such as the CyberKnife can be divided into up to 5 treatments for clinical purposes including mitigating edema or brain swelling.
SRS (Stereotactic Radiosurgery) refers to the treatment with high-dose, focused radiation of intracranial and spinal tumors such as meningiomas, acoustic neuroma, pituitary adenoma among others (click here for more info).
SBRT (Stereotactic Body Radio Therapy) refers to the treatment with high-dose, focused radiation of Breast, Lung, Prostate, Liver , Spine, Kidney, Adrenal, Pancreatic, Bone, Abdominal and Soft-Tissue Cancers, Tumors and Lesions. SBRT can also, like SRS, be delivered in up to 5 large high-dose fractions (click here for more info).
A Radiosurgeon can prescribe Radiosurgery with either the curative care intent (ablating the tumor over time) or palliative care intent (enhancing a patient's life by minimizing suffering) for their patients.
Radiosurgery may be employed as a first line, stand-alone modality to treat a patient or to supplement other modalities such as surgery, chemotherapy, and conventional radiation.
A specialized type of therapy called Stereotactic Radisurgery uses many focused beams, targeting a well-defined tumor aided by:
- Detailed Imaging
- Computerized 3D Treatment Planning and
- Experienced Medical Professionals
to deliver the radiation dose with extreme accuracy (i.e., stereotactically).
Is Radiation Therapy Safe?
Some patients worry about the safety of radiation therapy. Radiation has been used successfully to treat patients for more than 100 years (read about the history of radiation therapy). In that time, many advances have been made to ensure that radiation therapy is safe and effective. Before you begin receiving radiation therapy, your radiation oncology team will carefully design your plan to make sure that you receive safe and accurate treatment. The medical phycisist in the center works with the radiation oncologist to develop an extensive safety and quality assurance plan to ensure that every patient receives the right treatment in the safest possible way, each and every time.
Treatment will be carefully planned to focus on the cancer while avoiding healthy organs in the area. Throughout your treatment, members of your team check and recheck your plan. Special computers are also used to monitor and double-check the treatment machines to make sure that the proper treatment is given.
If you undergo external beam radiation therapy, you will not be radioactive after treatment ends because the radiation does not stay in your body. However, if you undergo brachytherapy, tiny radioactive seeds will be implanted into your body either temporarily or permanently.
Your radiation oncologist will explain any special precautions that you or your family may need to take for a short time following treatment.
If you are very interested in the technical aspects of radiation, here are some questions you may want to ask your radiation oncologist about the quality assurance at the clinic where you will be receiving therapy.
There are two major types of Stereotactic Radiation Treatment:
- Stereotactic Radiosurgery (SRS) refers to one or more treatments usually of the brain or spine.
- Stereotactic Body Radiation Therapy (SBRT) refers to one or more treatments with the body, most often excluding the brain or spine.
The advantage of SRS/SBRT is it delivers a focused beam of radiation, non-invasively, to the cancer in a shorter amount of time than traditional treatments. Plus the treatment is delivered with extreme accuracy, minimizing the effect on nearby organs. However, this treatment may not be suitable for all situations, so a Radiation Oncology Specialist should be consulted to discuss treatment options. Click here to contact a Colorado CyberKnife specialist today
Introduction to Radiation Oncology
Board Certified Radiation Oncologist Dr. Alan J Katz describes the history of radiation oncology, and specifically how it's used to treat prostate cancer.
Who is Radiosurgery Appropriate for?
Radiosurgery can treat many diagnoses as a first line therapy, precluding surgery altogether, e.g. prostate cancer, certain lung cancers, many brain and spinal tumors, primary kidney, liver and adrenal tumors among others.
- Patients who do not want or refuse invasive surgery
- Patients that are medically unstable (non-surgical candidates-those with comorbidities or other medical conditions that preclude surgery)
- Patients who fail surgery (disease cannot be resected because it's microscopic, residual, recurrent or too close to a critical structure)
- E.g. a prostate cancer patient whose PSA continues to rise after prostate surgery (prostatectomy) is a surgical failure
- E.g. a lung cancer patient whose PET scan or other medical image shows or presents recurrence 3 months after surgery (lobectomy)
- E.g. a brain cancer patient whose neurosurgeon was unable to resect or excise all of a patient's tumor in surgery will often require radiosurgery as an adjunct treatment to improve and enhance surgical outcomes
- E.g. a breast cancer patient following lumpectomy and mastectomy who requires high-dose radiation to improve and enhance the durability of their surgical procedures
What does Radiosurgery Treat?
Radiosurgery can be a safer alternative in the treatment of many ailments and cancers from Brain Tumors (primary, gliomas, metastases, meningiomas, acoustic neuromas, arteriovenous malformations…) to Brain, Breast, Lung, Prostate, Liver , Spine, Kidney, Adrenal, Pancreatic, Bone, Abdominal and Soft-Tissue Cancers, Tumors and Lesions.
Read more about cancers treated with Radiosurgery
What are my Radiosurgery treatment options?
Stereotactic radiation may be delivered by a number of different devices; brand name stereotactic treatment machines you may hear mentioned include: Accuray CyberKnife and Accuray TomoTherapy, Elekta Versa HD, Elekta Gamma Knife, Novalis Tx, Proton Particle Therapy, Varian Edge, Varian Trilogy and Varian TruBeam STX and Viewray.


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Thousands of people living around the Japanese nuclear power plant most seriously damaged by the earthquake evacuated Saturday as authorities detected radiation leaks from the crippled facility, began screening evacuees for radiation exposure and announced plans to distribute pills to protect against thyroid cancer.
Government officials stressed that the amount of radiation that had been released by the Fukushima Daiichi reactor after an explosion at the facility appeared to be relatively low, and international authorities said the situation had not yet become a major public health threat.
To try to assess the extent of the exposures, workers at evacuation centers – wearing white masks and protective clothing – used handheld scanners to check everyone for radiation exposure as an estimated 170,000 people fled an evacuation zone that had been doubled to a 12-mile radius around the plant. The number of people possibly exposed to radiation could reach 160, the Japanese nuclear safety agency said.
"They must be planning for a worst-case scenario, which would be the core partially melting down or melting down," said John Boice, scientific director of the International Epidemiology Institute in Rockville, Md.
Three of those known to have been exposed had been chosen for random testing from among 90 patients and staff members at a hospital two miles from the plant who were awaiting evacuation by helicopter and needed to be decontaminated, officials said. None had yet shown physical symptoms of radiation poisoning, officials said.
As authorities in Japan know better than those in any other nation, the extent of the risk from a nuclear power plant ultimately depends on how much and what kind of radioactive material is released, where it travels and how many people are exposed for how long, experts said.
Radiation from nuclear power plants poses a host of health risks, ranging from severe toxic effects in workers exposed to high doses to long-term increased rates of many cancers.
Most of what is known about the risks of radiation comes from studying survivors of the atomic bombings of Hiroshima and Nagasaki during World War II, the 1986 Chernobyl nuclear disaster in Ukraine and radiation exposures for medical purposes.
In Chernobyl, about 30 firefighters who were exposed to very high doses of radiation while trying to douse the blaze at the plant died within a month.
"They had huge exposures," Boice said. "These were the kind of doses that just knocked out the blood system, the gastrointestinal system."
One worker at the Daiichi plant had died from injuries after becoming trapped in the exhaust stack of the plant, according to the World Nuclear Association. At least four other workers were reportedly injured in the explosion and had been hospitalized.
Beyond the deaths of firefighters in Chernobyl, the most well-documented health effect was an increase in thyroid cancer, primarily among children, due to exposure to iodine-131. An estimated 6,000 to 7,000 excess cases of thyroid cancer have occurred because of Chernobyl, mostly among people who were children at the time.
Japanese officials announced plans to distribute potassium iodide pills, which block radioactive iodine from accumulating in the thyroid glands, causing thyroid cancer, to people living around the Fukushima Daiichi facility and the damaged Daini plant about seven miles away.
Of the radioactive elements released in a nuclear plant leak, radioactive iodine has a relatively short "half-life" of eight days, which means that it essentially disappears within about 80 days, said Fred Mettler, a radiation expert at the University of New Mexico. In comparison, another radioactive substance released by nuclear power plants, cesium-137, has a half-life of about 30 years, meaning it poses a much greater risk because it gets into the food chain.


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Aug. 21, 1997
Spartans Conduct First Preseason Scrimmage
|Nick Saban.
EAST LANSING, Mich. - Michigan State third-year head football coach Nick Saban sent his team through a two-hour scrimmage Thursday to open the second week of preseason camp.
Following a 60-play "controlled" scrimmage, Coach Saban dedicated five periods to special situations, including third down, red zone, goal line, coming out from the end zone and get the ball back.
"I thought the first units on both sides of the football showed improvement," Saban said. "I was impressed with the maturity level of the first-teamers and their ability to compete in certain situations.
"Some of our young players showed their inexperience today. We need those guys to grow up quickly and provide quality depth at some positions."
|Todd Schultz.
Veteran quarterback Todd Schultz, who sat out spring contact drills after undergoing successful ACL reconstruction surgery on his left knee, completed 14-of-18 passes for 188 yards. Gus Ornstein, who missed all of spring practice after dislocating his left kneecap in a baseball game, took all the snaps with the No. 2 offense and completed 12-of-20 pass attempts for 106 yards.
"Todd Schultz has made progress during the preseason," Saban said. "Todd threw the ball well today and looked very comfortable in the pocket. He moved around some and avoided the pass rush and that's encouraging.
"Gus Ornstein got off to a slow start today but played better as the scrimmage progressed. He has shown signs of improvement this preseason."
The No. 1 offense put together a seven-play, 65-yard drive on the first series with fifth-year senior running back Marc Renaud scoring on a 19-yard run. Schultz went 3-for-3 for 33 yards on the scoring drive. Spartans Conduct First Preseason Scrimmage -- 2
The No. 3 offense produced the only other touchdown of the scrimmage as true freshman Lorenzo Guess hooked up with freshman walk-on Chris Strayer for a 38-yard TD pass.
"We still have a long way to go before the season opener," Saban said. "We've been at it now for eight days and 14 practices so the players are tired. We have to work through the fatigue and continue to improve."
Michigan State opens the 1997 season Sept. 6 against Western Michigan at 12:30 p.m. in Spartan Stadium.


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Search Jim Cramer's "Mad Money" trading recommendations using our exclusive "Mad Money" Stock Screener.
NEW YORK (TheStreet) -- With the Dow Jones Industrial Average approaching another milestone, Jim Cramer told his Mad Money viewers Wednesday he can still make a case for the top five stocks that helped propel the average to these lofty heights.
Cramer said Caterpillar (CAT), Walt Disney (DIS), Intel (INTC), Merck (MRK) and even Cisco (CSCO) are still strong buys.
Cramer told viewers that it's only natural to think you missed the move in a stock that's already up big, but in the case of Caterpillar this stock still hasn't reached its 2011 highs and the world's economy will surely be stronger six months from now. At 15 times earnings, Cramer said investors have not missed Caterpillar.
Cramer said while Disney is not cheap at current levels, the company does have a lot going for it including several billion dollar sequels from its movie powerhouses including Marvell, Pixar and Lucasfilms.
Intel is another stock that helped power the Dow from 16,000 to 17,000, yet this stock is still cheapand has a 2.9% yield and a solid balance sheet with better than expected earnings, Cramer said. Also in the high-yield camp, Merck, which also sports a 3% yield but still trades at a discount to the rest of the market. Cramer said this company's animal health business alone makes Merck an attractive stock.
Finally, there's Cisco, which delivered an upside surprise with great visibility in its earnings. Cramer said Cisco also has a 3% yield, a terrific balance sheet and trades at just 12 times earnings.
Should You Own JPMorgan Chase?
Is JPMorgan Chase (JPM) a buy after announcing CEO Jamie Dimon has throat cancer? Cramer said he's been pondering that question because JPMorgan is a stock which he owns for his charitable trust, Action Alerts PLUS.
After careful analysis, Cramer said he's still a buyer of JPMorgan. He said the company's release included the phrase "curable" cancer, which means Dimon's doctors must have a lot of confidence that his condition is indeed curable.


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PRZOOM - /newswire/ -
Makati City, Philippines, 2011/11/22 - NetSuite now in college curriculum on both sides of the pacific, enables students to learn real-world business operation skills (NYSE: N) - NetSuite.com. NYSE: N; ORCL
NetSuite, Inc., the industry's leading provider of cloud-based financials / ERP software suites, today announced the details of SuiteAcademy, an educational program designed to bring cloud-based business management solutions to university classrooms worldwide. Driven by the growing global demand for teaching NetSuite cloud solutions in college classrooms,"SuiteAcademy" will put NetSuite software and professor developed curriculum in the hands of students, giving the next generation of business leaders a competitive advantage by having worked with the fastest growing financial management solution (according to Gartner). The adoption of cloud computing is accelerating among businesses worldwide and educational institutions are making sure they stay up-to-date with the latest technology to ensure that their students learn the most practical and relevant curricula.
Sixteen universities worldwide have already made the move to the cloud by adopting NetSuite as a key component of their accounting degree curricula. Purdue University; University of California, Los Angeles; University of Toronto; Mapúa Institute of Technology; De La Salle University and University of San Carlos in the Philippines are among some of the institutions that have embraced NetSuite, for many of the same reasons that thousands of companies worldwide have switched from on-premise software to the NetSuite cloudto keep pace with 21st century business and computing trends, avoid integration hassles, and escape the vicious cycle of software upgrade and the high maintenance costs caused by on-premise software such as SAP, Microsoft Dynamics Great Plains and QuickBooks. The NetSuite cloud business solution is predominantly introduced in the third and fourth year of degree programs, meaning that the next generation of managers, entrepreneurs, and business professionals can come to the job market with a stronger understanding of business operations and a clear understanding of the power of cloud computing. For more information about SuiteAcademy, please visit netsuite.com/suiteacademy.
NetSuite has been working with universities for years because higher education sales and accounting programs are increasingly recognizing that the same trends affecting the global business community are reflected in the classroom environment. As the demand for cloud-based business management solutions grow, tomorrow's business leaders must be ready to hit the ground running with an understanding of the cloud computing revolution.
"SuiteAcademy enables business and accounting programs to significantly improve the quality, flexibility and accessibility of their instruction by freeing students and instructors alike from the complexities and hassles of outdated, conventional on-premise software," said Marty Réaume, NetSuite Chief People Officer. "By adopting NetSuite into their curricula, institutions can free their students to work on real-world business programs any time and from anywhere, instead of tying them to outdated software in a computer lab."
"SuiteAcademy" works with academic institutes to ensure students are better prepared for life after school. SuiteAcademy gives students the same access to NetSuite software that companies have been benefiting from for years. Combined with professor developed curriculum, students can expect to learn the entire business process end to end, and learn how NetSuite customers are able to make better and faster business decisions. Faculty new to the program can have access to online training and downloadable material, allowing them to develop custom content for their courses. Faculty can also benefit from a community forum that allows them to share ideas with SuiteAcademy administrators and other program participants.
Feedback from universities that have already adopted NetSuite in their rubric indicate that the world's leading cloud ERP/financial suite has enhanced the learning experience for students by providing more practical experience and a better understanding of process flows and revenue cycles throughout an entire organization. Because NetSuite is delivered through the cloud, it can be accessed from anywhere on campus or anywhere in the world, and not just constrained to the confines of the universities computer lab.
"There is no substitute for hands-on experience. NetSuite is a great software service. Utilizing it for sharing with the higher education community provides a great opportunity for effective teaching and student learning," said Professor Robert Sorensen, Purdue University. "My students can now go to job interviews and say they have experience using NetSuite."
"With a continually evolving global business environment, it's critical that our students possess the relevant skill sets to succeed in business once they graduate," said Dr. Rey Vea, president and CEO of the Mapua Institute of Technology. "As cloud computing is on the cutting edge of the IT and business communities, and NetSuite is a leading cloud computing company located in Makati, we have developed courses using NetSuite's technology to help us prepare our graduates for today's and tomorrow's business environment."
Today, more than 10,000 companies and subsidiaries depend on NetSuite to run complex, mission-critical business processes globally in the cloud. Since its inception in 1998, NetSuite (netsuite.com) has established itself as the leading provider of enterprise-class cloud ERP suites for divisions of large enterprises and mid-sized organizations seeking to upgrade their antiquated client/server ERP systems. NetSuite excels at streamlining business operations, as demonstrated by the 2011 CODiE Award for Best Financial Management Solution, as well as a recent Gartner study naming NetSuite as the fastest growing financial management systems vendor in the world. NetSuite has continued its success in delivering the best cloud business suites to businesses around the world, enabling them to lower IT costs significantly while increasing productivity, as the global adoption of the cloud is accelerating.
Follow NetSuite's Cloud blog, NetSuite's Facebook page and @NetSuite and @NetSuiteAPAC Twitter handles for real-time updates.
NetSuite and the NetSuite logo and where business is going are service marks of NetSuite Inc.
Agency / Source: NetSuite, Inc.
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Acura TL 2009
Why being so mean to this guy? all he did was copy the comment of this article, TL SH-AWD (as sporty claimed as it's) is just so happened to be listed at #1. Camry at #10
Toyota Camry
Take rate: 3 percent
Odds of a manual Camry being sold: 1237 to 1
Odds of being dealt a full house: 694 to 1
My comments are regarding the article - seriously, it was about 50/50 interesting vs "so what?" in my opinion. Camry is one of the "so what?" vehicles on the list. Yes, they make a manual Camry. No, it isn't at all surprising that it doesn't sell well.
None of my comments had anything to do with the person who posted the article. Anyone who thinks that my comments were "mean" may need to seek medical attention for extreme sensitivity to internet-based comment exposure. I doubt that's the case with our OP!
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I did not take kirstie host comments as a direct hit-- I find it refreshing when they actually respond via blog and not delete my posts like in the past. For a "performance" sedan i found it funny that only 5% come in stick form--and so did MotorTREND .
BILLYPERKS my point is we all know whos buying these cars- people who have moved up from camry's (ES350's) and buicks-- or other cars that rarely sell manuals.. Sorry Kristie I thought the article was more then 50/50 interesting because they were about the car in question in this blog..
and Billy I have no idea how many infinti G's come standard--but if you look online at your local dealership they prob have atleast one on the lot --and those odds are better then 6305 to 1.
I'm a big fan of the previous generation TL & haven't warmed up to the current generation's "polarizing styling." I started to like how the SH-AWD models looked. Then yesterday I saw a black/black TL SH-AWD (sorry graphic guy, not your cup of tea) with the acessory Sport Grill and said to myself: "now that's sharp."
I've been reading up on the TL SH-AWD w/ 6 speed stick and am impressed by both what I read from the road tests as well as owner feedback.
Now I'm a huge BMW fan, but for me the 3er is too small and the 5 is way out of my price range. I'm going to give the TL SH-AWD 6MT a serious look when it comes time for me to purchase my next car, which won't be for at least a year.
My daily driver is a 2001 Honda Prelude Type SH - 5spd manual (122K miles & counting), My wife drives a 2010 TSX Tech - 5spd automatic (12K miles & counting). My wife also leases an '07 X3 that has to go back to BMW at the end of next month with 45K miles.
Performance wise, I think handling is the most important thing to me. My next car's gotta have some cajones too as my Prelude's 156 lb ft of torque isn't much in the age of mid- 6 second (0-60) Camrys, Altimas, Maximas...
Interior material quality and overall build quality are also VERY important to me. I'm more than willing to sacrifice some ride comfort for better handling.
Of course I have to drive it, but from the Prelude & my TSX, I'm very impressed with the way Honda builds a car.
Your thread has a new lurker/poster. Maybe I'll have 2 Black/Black Acuras in my driveway next year.
2001 Prelude Type SH, 2011 Pilot EX-L 4WD, 2015 Infiniti G37x Q40 AWD
I exempt any hot dog served at a sporting event from that description. Those are made only of tasty, meaty goodness - a fan-tastic, fan-pleasing delight.
Kirstie...you're killing me here, girl. You just gave me a grin. Actually, I agree with you regarding ball park "dogs". But, only if they've been cleansed with bacteria killing lotion.
I think manual trans cars in general are dying a slow death. Even Lambos and Ferraris are going the way of auto trans vehicles.
People who can afford to buy the likes of a TL, BMW, Benz, Audi, etc for the most part expect an automatic trans. Yeah, you'll hear of someone here and there who prefers a manual, but they're rarities.
Fact is, manumatic transmissions have become very, very good, for the most part. The TL's is one of those. If fewer and fewer people know how to drive a manual trans, the fewer people there are to teach someone else how to drive one, then even less folks bother to learn.
Even among muscle cars, I remember my former Chevy dealer telling me that automatic equipped Camaros were outselling manual trans Camaros 20-1. And, that's for a car with a dedicated manual trans fan base.
I'm pretty good with a manual trans having done autox and bracket racing in the distant past. There's no way I can shift faster than a good auto trans can shift. Recent auto trans cars have rev matching, quick shift paddles, no clutch take up worries. They've become very good which blunts the need for a manual trans.
I keep hearing that BMW, Infiniti, etc make manual trans cars, I just haven't seen any of them available. I have seen TL's with the 6 MT. They don't last long on the dealer's lots. That said, the market is miniscule for manual trans cars, period.
Even folks who are on a tight budget, who tend to buy base economy cars, will pay extra for an automatic transmission.2018 Acura TLX SH AWD ASpec
nyc....sorry, I posted the above before seeing your post.
Black interior is what I've decided to stay away from since it gets very steamy around the midwest. I think the Black (crystal black pearl) is very sharp....especially with the midnight chrome grill and tailpiece.
I did drive the manual trans TL SH AWD as my dealer had a couple available when I was shopping. They're great, great manual trans cars. Probably the most refined manual trans lux sports sedan I had ever driven, bar none. You should drive one and form your own opinion.
But, we're getting to the end of the model year for Acura (August? Sept?). If you want a 2010, and you can find a manual trans car, I think I might jump on one because I'd bet the initial shipments of '11s won't be manual trans cars.2018 Acura TLX SH AWD ASpec
I know the manumatic slushboxes are getting better & better. The 5 speed automatic in my wife's TSX is the best I've ever driven. For my own car, I really want to stick with a stick for no other reason than I enjoy shifting my own gears. Can modern day automatics shift faster than me? Yes. Can they shift smoother than me? Absolutely.
I'm not in the market for a car right now. We're in the middle of trying to buy ahouse right now & I want to get comfortable making mortgage payments for at least a year before I even start car shopping. Besides, my aforementioned 2001 Prelude Type SH is wonderful for now. 122K miles and still as tight as the day I picked it up.
2001 Prelude Type SH, 2011 Pilot EX-L 4WD, 2015 Infiniti G37x Q40 AWD
here is the link again
http://www.motortrend.com/features/consumer/1004_10_cars_you_didnt_know_you_coul- d_get_with_a_stick/index.html
no BMW, Infinitis, on this list== seems motor trend hit it on the head when they put a Camry and BUick on the same list as Acura. Your arguement should be look the A5 is on the list-- but my counter would be is the S4/S5 on the list? A True sports car?
And automatics will always out sell manuals-- always in america -but for BMW and infiniti you will get a number of people looking to get into manuals -those numbers are no where near 6300 to one. -- Acura well built safe car but its not a sports sedan-and does not live up to its comp in performance- please find me an article by a major publication that says otherwise.
There's no way I can shift faster than a good auto trans can shift. Recent auto trans cars have rev matching, quick shift paddles, no clutch take up worries. They've become very good which blunts the need for a manual trans.
IMHO, the real difference in driving a stick vs. automatic is that YOU -- not the car/computer -- get to decide WHEN to shift gears.
With your eyes on the road and dictated by your mood, your brain tells your right hand and left foot how to maneuver next. No automatic (or manumatic, steptronic, or whatever fancy name) can ever match that until engineers can connect the control of shifting mechanism to human mind. Paddle shifters may come close if only the time lag can be eliminated.
totally agree. its more control,ts reflexes, its totally different. I think the reason why acura continues with the stick is to try to differentiate itself from buick/lexus but performance enthusiasts have not been duped.
and anyone who speaks with such tone is fit to be a host?? never see this anywhere else, really...
Anyone who thinks that my comments were "mean" may need to seek medical attention for extreme sensitivity
Maybe I should have clarified that the "mean" feeling was after a series of "not-positive" collective responses to sween's post, and not directed to just one person or just kristie's comment.
but still, not sure who needs medical attention here... I can give one if anyone needs it
My comments are regarding the article - seriously, it was about 50/50 interesting vs "so what?" in my opinion. Camry is one of the "so what?" vehicles on the list. Yes, they make a manual Camry. No, it isn't at all surprising that it doesn't sell well.
None of my comments had anything to do with the person who posted the article. Anyone who thinks that my comments were "mean" may need to seek medical attention for extreme sensitivity to internet-based comment exposure. I doubt that's the case with our OP!
jt....I hear you.
But, the numbers of cars you can buy with manual transmissions (regardless of whether or not you can actually find them on dealer lots) seems to me to be dwindling every year. At some point, the manufacturers have to decide whether those numbers are enough to warrant continued production of them, at least in this country.
In the sports lux category, manual trans cars may be stipulated as being produced. Good luck finding them, though.
I know when I was shopping, the only manual trans Audi I found was an A5 (not the A4) in my entire state. I could have swung a helluva deal on it, too as the dealership was honest in saying Audi forced them to take a manual trans car. They know it would take a long time to sell it (it had been there 5 months when I looked at it 3 months ago....it's still there). It wasn't a weird color (it was black with black interior) or optioned strangely either. It was a pretty straight forward A5 that they couldn't move because of the manual trans. I could have made a great deal on it, if that's what I wanted.
Same when I looked at the Benz C300 lux sports sedan I looked at Sales person said they're available, as a special order from the factory. But, they hadn't stocked them as general inventory for 3 years.
Good luck finding a new BMW with a manual trans on the dealer's lot. I'm sure they're out there. They're just extremely hard to find and not big movers.
I love a good manual trans car. I've been eyeballing a pristine manual trans '98 Mustang Cobra Convertible with ~20K miles that one of my friends has for sale. He bought it new. Always garaged, never seen rain, nor snow. Totally optioned up. Just a real cream puff. Now, that's a perfect car that has a manual trans.
(if I could only get him to be realistic on the price).
In my lux sports sedans, I prefer manumatics (as it seems the vast majority do). I know the one in the TL is a very good one. I've become used to downshifting into corners with the paddle shifters on mine, then blasting out the other end of a sweeper.
ctl....kirstie doesn't need me to defend her. But, I disagree with your assessment of her as a host (she's witty, funny, likes to mix it up). I do believe somehow, there seems to be some very sensitive folks here regarding her post. I didn't find it condescending, nor mean spirited at all. Just sayin'!2018 Acura TLX SH AWD ASpec
billyperks2 Posts: 378In my lux sports sedans, I prefer manumatics (as it seems the vast majority do). I know the one in the TL is a very good one. I've become used to downshifting into corners with the paddle shifters on mine, then blasting out the other end of a sweeper.
I try to baby mines because I plan on keeping her for the long term but when going around corners or merging on to the freeways, the manumatic turns the car into a beast.
relax, hombre. Really. Relax. You're reading way too much into my comments, namely the one you picked out - t'was meant in a humorous manner.
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Numbers continue to dwindle, auto makers still see a small market for MT cars in the USA & continue to offer them. Finding them on a dealer's lot might be a whole other issue. I'm pretty sure every 4 door G37 in the ny/nj/ct area is of the X variety - auto only.
When I picked up my wife's TSX, there was ONE sitting on the lot - white/black/tech.
If it is out there, and I want one, I'll find it.
My problem with the paddle shifters is that I know there's a torque converter that doesn't like when I redline the car.
2001 Prelude Type SH, 2011 Pilot EX-L 4WD, 2015 Infiniti G37x Q40 AWD
Unfortunately, the number of MT buyers and the availability of MT cars is in a vicious cycle. There aren't enough MT buyer to warrant dealers to stock on MT cars; with the few cars on the lots there is virtually no selection (colors/options) for MT buyers. You almost always have to resort to special ordering one to get what you want -- if you can wait or plan ahead.
As to manumatic and paddle shifters, besides the time lag and the torque converter as nyccarguy mentioned, it drives me crazy that you have to go from gear 6 to 5-4-3-2 when cornering. Even though it may not actually shift through each gear, those tapping (and counting in head) just kills all the fun.
gbosil Posts: 88I agree about the paddle shifters. I have a 2007 TLS with Paddle Shifters basically as a compromise for my wife to drive it. I am a MT Guy all the way. The Paddle Shifters suck! There is a lag in between shifts up or down and they are just NOT FUN! Acura needs to improve the functionality of the Paddle Shifters. Nothing like a MT that ties the driver to the car! Paddle Shifters take out all the fun!
rlonn1 Posts: 106I drove a 4 speed 1965 Chevy Camaro, YELLOW, when I was in high school back in the 60's. Over the years since then and a lot of Big City stop and go driving , convinced me to go with a more relaxing Automatic. However you may want to try the SH-AWD and the paddle shifters. For me these are a BLAST and a lot of fun, as it takes me back to having that control. The Paddle Shifters and how they respond are totally new for 2009-10. I find them very fast on the shift... I took it down to Qualcomm Stadium here in San Diego (Chargers Football)... and put the TL through its paces.. When I was GOOD at using a manual I was Real Fast, and it is FUN for sure, but at 62, having the luxury of a super smooth Automatic, a "S" mode and also the Paddles, just is a sweet combination of all three! BTW, some may feel that the "S" mode means paddles, not true. In S mode it is still automatic but holds the gear a bit longer based on acceleration and torque. However once you hit the paddles in "S" it does not shift till you tell it to shift, but it will shift from 2 to 1 if you are coming to a stop for safety reason... It may also shift out at redline, but i always shift at 750 RPM BELOW red line! :blush: :blush:
manumatics are compromises without a doubt. However, as most point out, the market for manual trans cars is minute. Hell, even I wouldn't mind owning one again in the form of the TL SH AWD. Loved driving the one I test drove. Truth is, I the auto version and the manual version are so good, I would be happy to live with either (actually, I do )
I'm not so certain I'd be one to drive a manual trans on a day-to-day basis. I've had them in muscle cars, in the first BMW I owned, and in Japan based sports cars. Fun on weekends. Fun in good weather. Day-to-day? Not so much, especially in traffic, in bad weather, etc.
Just my opinion, of course.
I don't see availability ever getting better, and probably leaving the U.S. based luxury cars entirely at some point.
As an example of how good automatics have become, I remember reading one of the trade rags a little while ago where they tested an automatic 'vette vs a manual trans 'vette. The automatic 'vette was faster.2018 Acura TLX SH AWD ASpec
faster is not always better as pointed out by other TL owners --sport is about driving and not cruising, its about driver feel and not only how the car performs but how it looks and how it reacts - I find it funny when people talk about traffic and how it sucks to have a manual-- sure its more work but if you get a good car with a slick stick (like acura offers) its not bad at all to deal with--2nd gear and some clutch work all you need- no break needed if done right- and you have your daily driver.
I know the economy stinks but acura introduced this car as the 2009 model and they sold 33k cars --new model mind you --sure honda sales in 2009 were down 20% y/y -- but in 2004-06 (3 yrs) it sold 75k on avg.- its clear that most performance lux car buyers are not looking at the brand- even with the great lease rates and commercials about how safe they are. (do the math on manuals from my previous post-- they are rare in TL form almost as rare as finding a BP supporter outside tony haywards family) So i would conclude that acura might depart from manuals quicker then other U.S. based lux brands and concentrate on Lexus not BMW (or have they already done this and not told the owners??) I think lux makers that support the sport market will continue to offer manuals (in limited form).
here is the data from 09
http://www.prnewswire.com/news-releases/american-honda-december-sales-up-156-per- cent-80720207.html
It will take awhile to move in the direction Acura wants to move. My perception, as I've mentioned before, is that the TL is positioned as a "tweener". It's between a BMW 3 and 5 series (closer in 5 series size and performance, but closer to the 3 series in price), between an Audi A4 and A6 (same comparison to BMW).
You could probably make that same comparison between the Infiniti G and M, although the M is available in a V8 (where the Acura RL was going before the Honda cutbacks), and the G is moving down market with the G25. Given the announcement for the G25, I see it competing more in the Buick Regal sandbox.
Given that Acura revamped their entire lineup in the last 2-3 years, based on the interviews I've heard with their execs, they knew it was going to take a little while for the dramatic changes to be accepted. That being said, I see next year as being a nice one for them.
Regarding manual trans, good luck finding a manual trans BMW, Audi, Mercedes on a dealer's lot. You'd probably have better luck finding a manual trans Acura TL than any of those other brands.
A Lexus buyer is substantially different than those who'd buy any of the brands above. The Lexus buyer would not like the ride of any of those car brands, regardless of how well they handle.
Lexus' target was Buick (probably Cadillac, too). They hit a bulls-eye. Now, GM/Buick is hitting back. Again, I don't see much cross shopping with those and Acura/BMW/Mercedes/Audi/Infiniti and Buick/Lexus.2018 Acura TLX SH AWD ASpec
While I agree with you on almost all points graphic, I have always felt that of the 3 main German luxury companies, Mercedes as been pretty close to Lexus in regards to soft ride, less precise handling (compared to Audi and especially BMW) and more focused on luxury comfort then sport performance like Audi and BMW are!
if anything, I think the luxury cross shopping goes as follows:
with Cadillac and Acura kind of thrown in between all these depending on what model Acura or Cadillac people are considering!
just my two cents!
Why the new TSX wagon? Do they have another car in the pipeline that would "advance" the line ? Because if not those growing pains will continue.
Bring back the legend, integra, nsx - Acura has lost its vigor.
smarty .....I can see how your grouping may very well be how those brands perceive themselves.
No big disagreement, except that I could see a Mercedes buyer looking at a Cadillac....maybe a Buick....probably cross shop a Lexus, too.
BMW/Audi/Infiniti, more or less is where Acura plays. Again, the size and performance of a 5 series, A6, or M series, for the price of a 3 series, A4 or a G.2018 Acura TLX SH AWD ASpec
yeap, exactly what I was talking about! Cadillac and Acura are cross shopped among all the other luxury brands depending on what model your looking at! I know that because of how many comparisons, awards, etc the MDX gets, that is cross shopped with a lot of other luxury SUVs!
MDX is a nice rig- but its not the flagship to a brand. Whats acuras next move to make it stand out in the lux car market? Graphguy you said that the CEO was optimistic on the future, and said that next year will be a good year--but why? Buick (advertising on this very page) will undercut them on price and offer similar fwd performance on sedans. They will struggle to gain share but its a viable option if your looking to buy a car and not lease one. Lexus has its "brand", BMW has it on performance, Infiniti on its diverse line of cars, Audi on its performance/german heritage. whats the next move for acura?
My feel is they need a sports car-- a Viable flagship with a V8-- A coupe a convertible and a hybrid- bring back the legend (coupe and sedan). Stop recycling the same cars (accords) and put out something that puts it on the leader board and not a company like the atlanta braves- sure good competitive team but never wins the ring.
smarty...I think the MDX is actually the very definition of the luxury SUV segment more than any of the other lux SUVs on the market.
sween....Acura made it's bones with arguably the best 6 cyl engines on the market throughout their existence. They've either delayed or canceled the V8 they had planned for the RL. While another NSX would be exciting, it would be a very low volume car. Even the previous one came with a 6 cyl.
V8s are falling out of favor except in the muscle cars and the largest SUVs.
The Acura Prez wants to have the brand be viewed as leading edge compared to the competition of BMWs, Mercedes, etc. I had a video interview with him a couple of months ago, but can't remember where I saw it.
Again, seems like you like the Buick. Not my cup of tea, and haven't heard anyone except you who would cross shop the Acura with a Buick, but to each their own.2018 Acura TLX SH AWD ASpec
best 6cly engines in the market thats an interesting statement-- where can they prove that- or can you provide documentation that this is the case? They delayed the V8 prob because they could not sell a RL - while the NSX did prove to be a low volume car-the line did use its technology (like the Vtec) and incorporate it into other cars-they also cut back on indi racing- Lexus now has a supercar- at a stupid price - toyota has its nascar backing-- nissan has a supercar and a Z car-- BMW has the M line-- Audi the S line (plus racing)- and Benz has AMG.
I agree with you on V8's are now "falling out of favor" as the ford taurus sho commercials tell you, but to be a true lux car you need a standard V8 (atleast one). Each one of the flagships have one.. except the RL.
To say the acura prez wants to have a brand leading view - i would agree that the brand has great technology - the AWD is interesting but nothing its comp doesnt offer-- great nav i'm guessing hes talking about..none of which comes to power or performance-and its styling is one that only the CEO would love.
Standard TL shoppers are looking a buick dont kid yourself..
I'll be into Buick in maybe 10 years -and in my mid 40's..while i'm cross shopping it against Acura- the buick folks are noticing (look to your right, another laCrosse ad) i woundn't knock the car if i was you- its the same as the standard TL just better looking. :shades:
sweendogy, I got to agree with graphicguy that few people in the market for performance sedan would cross-shop Buick with Acura/Audi/BMW/Infiniti, maybe not even Lexus buyers.
You often mentioned Buick, but have you driven a LaCrosse or Regal yet? While Buick may have improved with these new models, it is hard to imagine that its cars suddenly are on par with those segment leaders in terms of quality and performance. Even if initial data looks good, the long term reliability and resale value are still big question marks.
You said that you will be into Buick in 10 years. Wondering why wait that long if you think so highly of it? I found it especially interesting because, like you, I also drive the Infiniti G. I just can't see how a G owner would want to move into a Buick. The only GM car I would consider is the Cadillac CTX -- a RWD sedan.
C&D just had a comparison test among Huyndai Genesis, Lexus ES350, Buick LaCrosse, and Ford Taurus Limited (not SHO), and they finished in that order. C&D did a good job in picking these contestants. IMO, that's the group Buick belongs to.
sween....no dice on the Vigor, Integra, etc. That's a step backwards for Acura. I can see perhaps bringing back the Legend name, as it has some name recognition. But in reality, it's still going to be the same engineering, same drivetrain, same car underneath as they're selling today. I remember all of those cars of yesteryear being way too conservatively styled for my tastes, though.
jt...I keep forgetting to put the Genesis as a Buick competitor. While I don't lend much credence to the trade rags as few of them drive the same way I do, they're fun to read.
While I did test drive the Genesis, I can see it as a competitor to the Lexus, Buick, probably a Cadillac, too.
Again, anyone looking for a lux sports sedan probably isn't going to like the Genesis. If they like the Lexus, or the Buick, then I can see looking at the Genesis, too. I have a business acquaintance who has an '09. He loves his.2018 Acura TLX SH AWD ASpec


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Applicants interested in applying to the Dental Hygiene and/or Dental Assisting Programs must attend one of the following sessions listed below before making an appointment and submitting a dental application with the Academic Counselor for Dental Programs.
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Upcoming Information Sessions
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If you have any questions, please contact the Dental Counselor, Kelly Diamond, at 910.938.6248 or by e-mail at email@example.com.
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Im getting ready to start selling at farmers markets. I am going to do cupcakes, cookies, quick breads, etc. I also want to do pies because everyone keeps asking for them. Here is my problem, I don't know what pies I can sell. Nothing can be perishable of course, but what pies are perishable? I know/assume no pumpkin, sweet potatoe, anything with eggs. But what about fruit pies? Apple is really the one I want to sell. Can anyone help? Thanks!
Apple pies are great sellers this time of year. Also pear, or a mixed fruit pie with cranberries. Smaller pies sell better than the large ones. Make pie in sheet cake size and sell by the square - that's a great way to have people buy their samples. Next week they might buy a whole pie. I suggest, of course, that you also call your health inspector and ask what they allow.
Generally, most baked pies would be allowed as they do not require refrigeration. (i.e. apple pie, pecan pie, blueberry pie, etc). Pies with custard and or pudding type fillings are generally not allowed as they do require refrigeration. But check with your local health department as each state is different and even with in a state the rules can vary from county to county or even town to town. Good luck!
Oops wrong forum!
Thanks everyone. I will call the health department and ask.


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EPoX 9NPA+ SLI
EPoX 9NPA+ SLI
Just a short post and a couple of pics of EPoX's nForce4 SLI board. It's got the same feature set as pretty much all the other high-end SLI mainboards, but being EPoX it shouldn't cost the earth. Enjoy.
by Ryszard Sommefeldt on 12 March 2005, 00:00
Quick Link: HEXUS.net/qabas
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Meet this week's Ag Kid: Samantha Coulson
Thu, 14 Jun 2012 17:34:30 GMT —
Meet 16-year-old Samantha Coulson of Green City. Her interest in agriculture began when she was 9 years old showing rabbits in 4-H. Then when she was a freshman at Green City R-1, her Ag advisor presented an opportunity to plant mums in the greenhouse. It was something new she wanted to learn and grow.
â??I did not know when I started that if my mums came in a seed. I just had no idea. I have been able to learn a tremendous amount over the years in how to grow them, market them, customer skills, how to mix the soil, look for bugs...things for that,â?? Coulson said.
Samantha is a member of the Green City FFA and the Green City 4-H Workers. During these past three years, she grows her mums in the summer and sells them in the fall. She has kept excellent records in her book and has received much recognition at the Missouri FFA State Convention. But it has required Samantha to put in a lot of time and responsibility.
â??The first major thing is ordering them then planting them when they arrive. Once you get them planted, then you water them and mix in the fertilizer in there," Coulson said. "With how hot it gets during the summer, youâ??ll have to water them every day.â??
Samantha said despite all the hard work, in the end it all pays off.
â??As a freshman, I agreed to take on a project that you have no idea what you are doing. Now going into my senior year, Iâ??ve learned and accomplished a lot such as winning two state awards and a bronze in nationals,â?? Coulson said.
Samantha said agriculture has helped shaped her into the person she is today and plans to keep it in her life.
â??Through years of classes and all the wonderful people I met through FFA, I have done so much. It just made me decide that I want to continue this for the rest of my life,â?? Coulson said.
When not in the greenhouse, Samantha is involved in FBLA, Student Council, and Prom Committee. She plans to go to Mizzou for college and study Ag education to become a teacher.
Congratulations Samantha on being this week's Ag Kid.


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Jun 22, 2016 · 5:30 PMCassandra Meetup at MyHeritageAgenda 5:30 PM Gathering and refreshments 6:00 PM Ran Peled - Harnessing Cassandra Power at MyHeritage 7:00 PM Daniel Chen - Planning a cluster deployment Harnessing... Learn more
Nov 10, 2015 · 10:00 AM2 Great Speakers, 2 Great Cassandra TopicsHi Everyone! We are very excited about this Meetup as we have 3 amazing speakers with great topics to cover!! Bio's, Abstracts and Agenda below! ----- Agenda: 10:00 – 10... Learn more
Sep 23, 2015 · 8:00 PMCassandra Summit 2015 Live StreamThis is the Link to the LiveStream (9/23/2015): http://www.datastax.com/ (It will be on the homepage) Keynote from: 20:00 to 22:00 Sessions from: 23:00 to 04:00 (24th) -... Learn more
Jun 29, 2015 · 6:30 PMSecuring Cassandra & DataStax EnterpriseWe are very happy to announce DataStax Solutions Architect Johnny Miller will be speaking at our next meetup hosted very kindly by our friends at Outbrain who are also... Learn more
May 10, 2015 · 6:00 PMPlanning the correct data path & Contributing Code to CassandraWe are very happy to have our next Cassandra meetup in Tel Aviv. Two great speakers are lined up for this and as always we will be offering drinks and snack. See you... Learn more
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The HIPAA security awareness training program covers all important healthcare points, topics, and issues.
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myhipaasecuritytraining.com, industry leaders in offering high-quality, cost-effective HIPAA consulting and security training services, is offering an in-depth HIPAA security awareness training program for immediate download. Researched by leading healthcare compliance experts, the HIPAA security awareness training program covers all essential topics and subject matter relating to the HIPAA Security and Privacy provisions. Covered Entities (CE), Business Associates (BA), and other applicable organizations must comply with HIPAA mandates requiring security awareness training for all employees, yet this can be a daunting, time-consuming, and expensive proposition. The HIPAA security awareness training program offered by myhipaasecuritytraining.com covers all important points, issues, and concerns for today's information security age, while also including numerous section pertaining to HIPAA Privacy, Security, Breach Notifications, and the Final Omnibus Ruling, and much more.
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So far, I have a program written that reads in binary files filled with floats, and then dynamically allocates space for a 2-dimensional array of those numbers (I'm programming matrix operations). This allows me to read in the numbers of the binary file, then convert them into a matrix and reference them in the convenient way of typing array[i][j].
I have a main function that calls two other functions, read and print (print is solely for checking if I am reading the correct values). My program usage is as follows:
So, my program reads and prints out the first binary file successfully, does not matter what file I choose to put first. The problem lies in reading the second file. My program will read and print out the first binary file into a matrix properly, but I always get a segmentation fault immediately after this (it should be clear that I read and print the first file successfully, the numbers are printed on the screen, then "Segmentation Fault" is printed below my first matrix), which I know is caused by the computer trying to access locations in memory it should not.Code:programname <address of first binary file> <address of second binary file>
I believe my problem most likely lies in my usage of malloc, which is why I'm posting here. Ive heard before you should free() whatever pointers you create by using malloc(), but I am confused about what exactly free() does. When I am allocating memory for the pointers, aren't I going to continue to need the pointers throughout the rest of my program to continue the reference the 2-d array I made? Ultimately, I would like to have two arrays so I may add, subtract, or multiply them.
And when I have repeated uses of malloc(), does that try to use the same portions of memory over and over? Or does it just find available memory anywhere in the computer? Sorry, I know this was quite a lot to read and it was probably confusing, if anything is unclear, please ask me. All help is appreciated. Thank you.


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Assassin's Creed III set during American Revolution confirm leaks
The setting and time period for this year's Assassin's Creed III has been accidently leaked online, with more than one source providing artwork of the game's new Native American hero.
Assassin's Creed III will take place during the American Revolution, if images leaked from both magazine Game Informer and US retail chain Best Buy are to be believed. The artwork shown so far seems to confirm an 18th century setting, with the new protagonist wielding a pistol, a bow and arrow, and a tomahawk.The above image allegedly comes from an email sent to Best Buy employees, and then forwarded onto website Kotaku , that indicates the official reveal of Assassin's Creed III will take place on March 5.
Careful study of the artwork seems to reveal that the main character is a Native American. Most of his weaponry certainly seems to be, as well as some of his clothing. His face is a little hard to make out be he doesn't seem to be Caucasian.No doubt more will be revealed on March 5 (next Monday) but confirmation that this is not some elaborate fake has come from American mag Game Informer, who have a long history of worldwide reveals for major new games.They jumped the gun last night though, with a banner appearing on their website for a short time, before being hastily taken down again. It seemed to be a fairly low tech Photoshop job, combining what looks like official Ubisoft artwork with a famous painting of George Washington crossing the Delaware.It's not impossible that Assassin's Creed III might feature more than one era and/or setting but it now seems certain that the majority of it will take place in North America during the 18th century.
Officially though the only thing Ubisoft has confirmed is that Assassin's Creed III will be out on October 30 for Xbox 360, PlayStation 3, and PC.
Update:Ubisoft has admitted the leaks are real and released the packshot art below to prove it. The official reveal though is still set to 5pm March 5.
Are you excited about the prospect or upset that the series has turned into yet another game in, and about, America? Let us know via the usual email address.
Video:Checkout the Assassin's Creed: Revelations trailer
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After Solheim Cup win, time for Wie, Americans to bring on the South Koreans
Before looking forward after a fantastic Solheim Cup, one that had me glued to the TV from practically start to finish and was more involved than any other women's golf event I can remember (except for those I've covered on the ground), lets give credit where credit is due: Undefeated Michelle Wie was the tournament MVP, and this appears to be a galvanizing moment for her moving forward.
When she lost her 3-up lead to Helen Alfredsson on the back nine today and her putter was wavering, I thought we were looking at the same ol' Wie. But she finished strong on the 18th with a birdie and now has her most significant win since she came onto the national scene.
Now, onwards…
Had the Solheim Cup been founded this year, the two best teams wouldn't have been Europe and the USA, it would be USA versus South Korea. The Solheim Cup is here to stay, but it's time for an off-year match between the U.S.A. and South Korea, which could be even bigger. I'm assuming there are some suits already drumming this up with potential sponsors, because frankly the idea seems so obvious by now, especially after large crowds this weekend and what seemed like a good amount of interest in Solheim Cup coverage.
I'm not sure the Americans and Europeans have much of a rivalry versus each other compared to the professional men and the Ryder Cup. With Annika Sorenstam out of the game and Laura Davies in the twilight of her career, there aren't that many serious threats from across the pond to take on Christie Kerr, Paula Creamer and now Wie, too.
South Korea is producing young talent at a much higher rate than Europe. Another issue is that many of the European players don't play much in America, where the competition is better.
South Korea on the other hand is dominating the American tour, and they've taken sort of a on a collective villain role for a lot of golf fans here. Rather than wish they'd go away or learn better English, it's time to showcase their best against ours, like the Soviets versus Canada in hockey back in the 1970s with the Super Series.
The South Koreans aren't going anywhere, and a match play event would help market and individualize the players far more in America than they are presently. Match play formats are great for learning a lot about a dozen players, rather than try and track 144 over four days.
The obvious thing to do would be a Presidents Cup style Americans vs. The World minus Europe. But just because that's the men's format, the LPGA shouldn't think they need to copycat. Instead, simply USA vs. South Korea (sorry, Lorena Ochoa) would be the best and most spirited golf product the women's game could put together, and would generate as good of a rivalry as there is in sports.
You can follow Brandon Tucker's golf blog and more on Twitter: http://twitter.com/brandontucker or follow WorldGolf.com at Twitter.com/worldgolf . Have a golf travel question for Brandon? Email him by clicking here
|« Best golf state in America? With accessible, diverse courses, it may just be Oregon
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Anyway, yes Michelle Wie at least doubled her following this week. She did great and had some clutch shots and putts. These crowds were not what these girls are use to either. They all handled everything well and did what they came to do.


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Dr. Prafull Maharishi
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