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Doctor Who: The Creature from the Pit (UK - DVD R2)
Is this story really the pits? The Wilson Bros take a deep breath and find out...
Please allow us a few moments of your time in order to speak to those who are generally unfamiliar with our writing style: We have been writing reviews and articles for various websites for many years now and have developed a distinctive style that has been described as informative and humorous.
With these Doctor Who titles now making up the bulk of our reviewing, more Doctor Who fans are reading our work. Sadly, there are a few very vocal amongst the legion of Who fans who are not enamoured of our writing style and have openly accused us of misogyny.
We must stress that we are not misogynistic in the slightest (our respective other halves would kill us if we were!) and anything that could be mistaken for misogyny is merely humour and no offence is intended in the slightest.
Now we've cleared that up, on with the review…
Hot on the heels of the release of The Horns of Nimon in the Myths and Legends set, 2Entertain are releasing another story from Doctor Who's seventeenth season. Aside from the never-completed Shada (which we hope the Powers That Be will do something special with eventually), the release of The Creature From The Pit means that the only unreleased story from this season is Nightmare of Eden.
The activation of an emergency transceiver causes the TARDIS to materialise on the planet of Choris, a jungle planet that is teeming with life. The Doctor (Tom Baker) and Romana (Lalla Ward) discover that metal is in short supply on Chloris and has become a precious commodity. The tyrannical Lady Adastra (Myra Frances), head of a gynarchy that controls the only metal mine left on the planet, is determined to hold onto her power, despite being the target of scavengers and bandits. Adastra has wolfweeds to enforce her tyranny, balls of green weeds that can attack on command; Adastra also has a nasty habit of throwing anyone who crosses her into a pit that contains a fearsome creature.
The Doctor is captured by Lady Adastra, whilst Romana falls in with a group of scavengers who are determined to get their grubby paws on Adastra's stash of precious metal. When the Doctor is eventually cast into the pit, he meets the creature and suddenly events become much clearer and the true nature of the creature is revealed.
Though this was still deep in the Graham Williams era of Doctor Who, the unseen hand of Douglas Adams was still leaving its visible fingerprints over the script, with the sort of amusing dialogue that could only really come from the mind of a half-crazed genius with a cavalier attitude toward deadlines. The Creature from the Pit is buoyed by some of these touches that were inserted during the script editing stage, as it allows a story that would have seemed a little too pompous to breathe.
The story opens with a sacrifice being thrown into the titular hole in the ground to meet a grisly fate at the hands of the eponymous monster. There are some who would say that the actor concerned should have considered himself lucky, as he did not have to suffer the indignity of appearing the rest of the story.
When we mentioned to a Who-obsessed friend of ours that we were going to be reviewing The Creature from the Pit, he exclaimed 'oh, it's the one where Tom Baker meets the giant green phallus!', to which we replied 'yup, that's the one'. Whilst watching this story for the purposes of writing this review, one of us had one of our nephews present for the first couple of episodes; he's seven years old and fanatical about New-Who, but we introduced him to the classic series and he's been enjoying them. When the distinctly phallus-like creature appeared onscreen for the first time and bobbed its way toward the Doctor, the one of us watching it with our nephew started to snigger slightly (probably because a couple of pints of ale had been consumed beforehand) and our nephew turned and said 'I know what this looks like', which he was given the reply 'so do I' and we spent the rest of the episodes both suppressing giggles at Doctor Who's most penis-shaped adversary. It's amusing to note that at one point Baker appears to try and fellate the thing in order to communicate with it—well, that's certainly one way of trying to elicit a response…
Speaking of anatomically reminiscent baddies, one could only wonder if the Tythonians and the Vervoids ever decided to join up Warriors of the Deep-style and invade Earth—whatever the outcome would be, the planet will be fucked.
The Creature from the Pit has something of a bad reputation and is generally not well-liked amongst Doctor Who fans. We certainly watched this story when it was originally broadcast (as we mentioned in previous reviews, this season was the first one that we consciously remember being exposed to), and we caught it again a few years ago on satellite television. We were too young to fully absorb the different levels the story operated on originally, but when we saw it again, it was during a period when we were catching up with the Doctor Who stories that we had missed, and the result was that we quickly became jaded and The Creature from the Pit was one of those casualties.
Speaking of Douglas Adams (as we were a few paragraphs back), one of his unmistakable traits is evident here—the throwaway gag that would later cause a continuity headache; the Doctor makes a reference to Time Lords having ninety lives and that he had already used up one hundred and thirty—this is very reminiscent of casually mentioning in the radio series of The Hitchhiker's Guide to the Galaxy that Zaphod Beeblebrox had two heads, which became something of a nightmare when translating the show to a visual medium.
The Doctor states that he was born over the sign of crossed computers—would these computers be the same ones that he and Romana had the TARDIS materialise in Australia 1980 to gratuitously plug…?
One thing that does stick in the throat about this story is the way that the scavengers are depicted; they come across as the sort of stereotypical Jewish caricatures that were prevalent in the fifties and sixties; primarily interested in the acquisition of material wealth and little else. It could be argued that writer David Fisher was simply taking a classical character (Shylock or Fagin are the closest examples) and transplanting them into science-fiction, which is what some of the best sci-fi has always done. This is all well and good, but what is depicted on-screen still leaves something of a nasty taste in the mouth and would be questionable if attempted in this day and age.
Baker is still on great form as the Doctor—this was before he got bored and spent his final two seasons being firstly way over the top, and then eventually looking bored to tears. His portrayal of the Doctor in this story is particularly good, as he embodies all the best elements of the character; being open-minded and welcoming of an alien life-form he hadn't previously encountered, being disgusted by tyranny and the abuse of other life-forms, not to mention exercising his dry wit on the tyrants concerned and most importantly, finding an amicable solution to a conflict that would result in minimal loss of life for both sides.
It's pretty interesting to bear in mind that this was Lalla Ward's first story as Romana— Destiny of the Daleks would be the first to be broadcast, but the shooting schedule was such that The Creature From the Pit was the first to be filmed. You can see that Ward was still trying to get a handle on her take on Romana (she had some pretty big shoes to fill considering how much of an impact her predecessor, Mary Tamm, had on the show)—Ward still hasn't quite gotten her sparky banter between herself and Baker as polished as it would eventually become and the outfit she is wearing seems to be completely at odds with the rest of her wardrobe during her time on the show. And as for that maternity smock she wears at the start of episode one—yeesh! Had the Doctor gotten Romana up the poke? We're sure that K-9 could have run a test to find out—doubtless the Doctor was hoping that K-9's reply was 'negative, Master'…
Speaking of K-9, this was the first story (in transmission order) where the new voice of the tin dog was heard properly—in the season opener, Destiny of the Daleks, K-9 was unceremoniously written out of the story by saying that he had contracted laryngitis. This was seemingly cunning way of prolonging the amount of time between John Leeson leaving and David Brierley replacing him, so viewers would be more accepting of him due to the general absence of home video recorders at the time. Though K-9 would be primarily written out of episode one of The Creature from the Pit in a very 'go guard the door, Shemp' manner, he would eventually play quite a major part in the rest of the story, more so than many of the others we can remember. Ward is required to carry K-9 around for part of the story and it she was given the lightweight version to work with—it's a pity that Ward didn't spend some time at the Marcel Marceau acting school and picked up tips on how to make something seem heavy.
The supporting cast are fine, with Geoffrey Bayldon as great as always as Organon, the astrologer who was cast into the pit; Bayldon has always known how to mix humour and drama well and is a good match for Baker when he shares the screen with him. Myra Frances is great as Lady Adastra, bringing a steely determination and sneering nastiness to her role, showing that a female despot can be every bit as stupid and as pig-headed as the male ones in Doctor Who.
It's moderately fascinating to mentioned that there are similar story elements between this story and season fourteen's The Masque of Mandragora in that both involve mystics and astrologers, both set in times that could be looked upon as medieval-esque and in both stories the character whom the audience believe is the principle antagonist is dispatched early into the third act, only to by a character who comes to the fore as an even bigger threat.
The Restoration Team have done their stuff once again and The Creature from the Pit looks better now than it has ever looked before. In the absence of the original elements, they have cleaned up the film sequences and the results are most impressive, displaying a certain vibrancy that has been absent from the video release all those years ago. Colour Doctor Who stories always seemed to take on a more cinematic feel when there were extended scenes shot on film and this is augmented by the work that the RT have performed; maybe it's the blueness of his eyes or the yellowness of his nicotine-stained teeth, but there is an almost luminescent quality to Tom Baker during film sequences here. The videotape scenes look wonderfully clear, as the original tapes survive—the pulsating greens of Erato are particularly pleasing on the eye—and generally this is another fine restoration job from that dedicated bunch of Doctor Who obsessives.
What is there to say? Dialogue is clear and Dudley Simpson's music sounds fine, with a surprising amount of dynamic range when played through half-decent amplification. Good stuff.
Audio Commentary: This sonic reminiscing of times past includes the participation of actresses Myra Frances, along with director Christopher Barry and special effects maestro Matt Irvine. It's the usual routine with Ward—she bitches about aspects of the production, takes verbal jabs at Tom Baker and sings the praises of Douglas Adams on numerous occasions. Ward makes it perfectly clear that when the story was filmed, she was basically required to impersonate Mary Tamm and the wardrobe she wore in this story reflected this. Barry and Frances don't really get much of a look-in when Ward is in full-flight—to misquote her idol, Ward could talk all four legs off an Arcturan Mega-Donkey—but Irvine really is the star here, chipping in with some very down-to-earth (not to mention very funny) anecdotes about the production.
Christopher Barry – Director: This nineteen minute featurette focuses upon the contribution of this particular director; it's quite a poignant affair as Barry speaks about his life and professional career. Shot on location in the quiet little village of Albourne in Wiltshire, which was the setting for the classic Jon Pertwee story, The Daemons, Barry is a genial and thoughtful subject and could quite possibly be the final in-depth interview that he will give on his life, so watch and treasure it.
Team Erato: Erato, indeed! This year has seen several comedy extras on Doctor Who releases; the results have been decidedly mixed— 'Beneath the Masque' was fitfully amusing and the less said about 'A Holiday for the Doctor' the better—but this featurette trumps both of these because it's not only hysterically funny, but because the humour comes simply from the interviewees themselves and is edited in a way to maximise the laughs. The principle members of the effects team face the cameras to explain the chain of events that led to the creation of the most phallic-looking creature in the history of the show. Matt Irvine's earthy sense of humour works wonderfully here and the others interview all flesh out the events. We defy you not to at least giggle when everyone recalls the reaction of the cast and crew when the Erato was wheeled onto the set for the first time. This truly is first-rate stuff and it's great how many different terms for a penis are employed by the interviewees–did someone have a thesaurus on-hand to avoid repetition?
Animal Magic: This truly is a bizarre little offering, with Tom Baker in costume and on the set of The Creature From the Pit, doing a piece to camera whilst incarcerated in the stocks talking directly to the fans, recalling some of the creatures that he has encountered on his more recent travels. This is strange to say the least, but it's wonderful to have the opening titles of Animal Magic, along with the old 'wah-wah' guitar music. It would appear that the original elements were used for this, as it looks remarkably fresh, vivid and film-like—the biggest indication of this being obtained from the unedited master comes when Baker walks off at the end and is heard to exclaim 'Oh God, forgive me!'
Extended Scene: This very short sequence shows the hairy mob attacking some poor sod in the palace and killing him in a manner that was deemed too bloodthirsty for a Saturday teatime audience. It's a pity that they didn't put this piece back into the story itself.
Photo Gallery: A series of stills from this story is presented with sound effects playing over the top of them. It also includes a picture of Erato at its most phallic.
Production Subtitles: As always, you will be bombarded with more information that the human mind can comfortably absorb when you select this option—a whirlwind of dates, times and interesting bits of production trivia will appear before your very eyes, so much so that by the time you have finished, you will almost have assimilated the knowledge of the late producer Graham Williams.
PDF Materials: Pop this baby into your PC and you will have access to the original Radio Times listings for all four episodes of The Creature From The Pit. Oh, at the bottom of each listing is a gratuitous plug for the release of the theme to Doctor Who on vinyl.
Coming Soon Trailer: This gives you a little taster of the Kamelion box-set that was delayed from earlier this year, which contains The King's Demons and Planet of Fire.
We might have misjudged this story somewhat—though there are some holes in the plot that you could pilot a neutron star through, it's still very entertaining and the cast give it their all. Though the somewhat questionable portrayal of the scavengers is a little dubious, there is much to like here, especially seeing Baker genuinely enjoying himself and what's not to like about a story involving a pulsating green monster with a giant phallus…?
Review by Wilson Bros
Existing Posts
We have to admit that we were slightly charmed by it when reviewing this, having previously loathed with a passion.
As for what Romana's doing with that ball of string (if you hover over the pic, you will see our thoughts) - given the catty comments that Lalla Ward has made during commentary tracks, playing with such an object seems perfectly natural...
Kevin & Nick W
As for what Romana's doing with that ball of string (if you hover over the pic, you will see our thoughts) - given the catty comments that Lalla Ward has made during commentary tracks, playing with such an object seems perfectly natural...
Kevin & Nick W
I wonder what she is planning to do with that ball of yarn.
The story is silly, but I adore Creature From The Pit.
The story is silly, but I adore Creature From The Pit.
Thanks for the kind words.
With regard to the apparent trend of releasing below-par stories this year, the plan is to release all of them on DVD within the next couple of years or so, and this means that there are going to be periods within the schedule that will contain groups of stories that aren't THAT highly regarded.
The Kamelion box-set that comes out next is going to have a "special edition" edit of Planet of Fire, similiar to the one of Enlightenment, with new effects, a newlt created 5.1 surround-mix and a much leaner running time (66 mins).
Kevin & Nick W
With regard to the apparent trend of releasing below-par stories this year, the plan is to release all of them on DVD within the next couple of years or so, and this means that there are going to be periods within the schedule that will contain groups of stories that aren't THAT highly regarded.
The Kamelion box-set that comes out next is going to have a "special edition" edit of Planet of Fire, similiar to the one of Enlightenment, with new effects, a newlt created 5.1 surround-mix and a much leaner running time (66 mins).
Kevin & Nick W
Another great review Wilson Brothers and another mediocre Doctor Who release. After the excitement of the first releases in 2010 it seems to be a bit of a lull in generally decent stories. Next months release doesn't really do a great deal for me either.
Thanks - we couldn't resist getting one of the creature at it's most phallic...
The Wilson Bros
The Wilson Bros
Those screen shots are looking better!
General viewing, but some scenes may be unsuitable for young children
Disc Details
Release Date: 3rd May 2010
Discs: 1
Disc Type: Single side, dual layer
RCE: Yes
Video: PAL
Aspect: 1.33:1
Anamorphic: No
Colour: Yes
Audio: Dolby Digital 2.0 Mono English
Subtitles: English
Extras: Christopher Barry - Director, Team Erato, Animal Magic, Deleted Scene, Production Subtitles, PDF Materials, Photo Gallery, Coming Soon trailer
Easter Egg: No
Feature Details
Director: Christopher Barry
Cast: Tom Baker, Lalla Ward, David Brierley, Geoffrey Bayldon
Genre: Sci-Fi
Length: 94 minutes
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LOS ANGELES (AP) - The timing of Shirley Temple's death has forced a change in the tradition of placing flowers at a Hollywood Walk of Fame star when an honoree dies.
Hollywood Chamber of Commerce spokeswoman Ana Martinez says Temple's star is in storage while repairs are being made to the Vine Street location where it would normally be embedded in the sidewalk.
Instead, the chamber will place flowers Tuesday morning on the center divider of Hollywood Boulevard at La Brea Avenue, which is considered a gateway to the Walk of Fame.
As a child star, Temple was America's top box-office draw from 1935 to 1938 and she was inducted into the Walk of Fame on Feb. 8, 1960.
Temple died Monday night at her home near San Francisco at age 85.
(Copyright 2014 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.)


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The Seahawks need one win in their final three games to avoid the fifth 20-loss season since 2006, and second in a row.
NORFOLK, VA. | At some point next season, as the Old Dominion men's basketball team meanders across the nation competing in Conference USA, it might pause for a wistful reflection on the annual visits from old CAA punching bag UNCW.
Because the way the Monarchs beat the Seahawks on Wednesday night was similar to seven of the eight previous Ted Constant Center meetings between the two. Only this whipping was unexpected. These Monarchs aren't steaming toward the postseason. No, they're playing for an interim coach while scuffling toward the worst season in program history, yet still unleashed the horsepower to humiliate UNCW 84-61 and leave coach Buzz Peterson again searching for answers and leaders.
"As I told our guys in the huddle, not until they listen and be coachable are you going to win a game on the road," Peterson said. "I called 'em independent contractors, just doing what they wanted to do."
UNCW (10-17, 5-10) fell to 1-14 on the road this season, with 10 losses by double-digit margins. The Seahawks need one win in their final three games to avoid the fifth 20-loss season since 2006, and second in a row.
"I don't think there's a person in that locker room right now that's going to get on somebody else," Peterson said. "And that's one of our biggest issues we have. Somebody is not going to step up and challenge somebody else. I went into the locker room when we were down at halftime. It was quiet."
So was the Seahawks basket.
Just three days after stunning first-place Northeastern in Trask, the Seahawks trailed by at least nine points for the final 23 minutes against an ODU team that had not won at home since Veterans Day.
The Monarchs looked sharp though against the Seahawks in winning for only the second time in 2013. They followed the formula established by the rest of the CAA in runaway home victories: Pound the Seahawks inside, attack their halfhearted transition defense and coast to a confidence-builder.
"We don't play it," UNCW guard Tanner Milson said of the team's transition defense. "We don't handle defensive transition very well. We work on it in practice, but for some reason, I guess we don't work on it enough. Teams are seeing they can run on us and as long as we don't stop it they just keep going. We really don't do a good job on it at all. The first couple of times they do it they just get more confidence."
ODU (4-24, 2-13) scored 50 points in the paint, making the Seahawks' transition defense look like the clown car in a layup parade. It shot 58.9 percent from the field in its best offensive game of the season.
Keith Rendleman recorded his 17th double-double of the season (15 points, 11 rebounds) and broke Brian Rowsom's career UNCW rebounding record. But even that bright spot was sullied by a turnover. He collected a long offensive carom 30 feet from the basket on the left wing with 13:38 remaining. When he turned to pass to a teammate, ODU guard Keenan Palmore stole the ball, drove to the other end and dunked it to push the lead back to 16 points.
Rendleman has 1,022 career rebounds. He also moved into fifth on the school's career scoring chart with 1,442 points. He can't explain why the team's performance varies depending on the venue.
"They keep building momentum," Rendleman said. "It's like them stepping on you, and that's where your toughness comes in and you have to counter back and slow it down yourself."
UNCW shot 35.6 percent and committed 15 turnovers. Craig Ponder led four players in double figures with 16 points.
Brian Mull: 343-2034
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King upends GFA behind Sawyer's 33 points
STAMFORD -- In terms of motivational tools, revenge is one of the best.
Unfortunately for Greens Farms Academy, the King School had a piece of revenge that was just as good, if not better, than its opponent.
The two FAA schools met Thursday for the first time since heavily-favored GFA was stunned by King in last season's FAA playoff opener. So, the revenge factor was obvious for the league-leading Dragons. The host Vikings, however, also had some serious incentive.
"We wanted to show that last year was not a fluke," said King guard Drew Sawyer after King's almost equally surprising 65-57 victory over the Dragons on Thursday. "The team really met the challenge."
Led by Sawyer's 33 points, King (8-4, 3-2 FAA) handed GFA (6-2, 3-1) its first league loss.
"Nobody goes undefeated in this league," GFA head coach Doug Scott said. "But the key was we couldn't make a shot. And that Sawyer, he's just brilliant."
Sawyer was brilliant last February, too, when he scored 31 points to fuel the seventh-seeded Vikings' upset of the No. 2 Dragons 64-62 in the FAA quarterfinals. GFA was 18-5 last season (11-3 FAA) while King was 8-15, 3-12. This season the teams are a bit closer in ability, but the result was still a surprise.
"GFA is awesome, the best team in the league, and sometimes talent can just take over," King head coach Greg Dobbs said. "But I knew my boys were ready. We really executed the game plan on defense."
Not many teams can do that against GFA, a team that features a prolific scorer in guard Hunter Eggers (22.3 points per game), as well as Rice University-bound forward Sean Obi (18 ppg, 15.3 rebounds). And then there is Pat Ryan (14 ppg), Zach Baines (seven rebounds per game) and point guard Matt Tate, who leads the FAA in assists and steals.
"You can't just hold down one player," Dobbs said.
Eggers had 17 points for GFA, while the 6-foot-8 Obi added 17 points to go with 24 rebounds. Ryan added 10 boards
"Obi is a beast," Scott said. "But we saw two great players out there tonight."
Indeed, there was no denying Sawyer.
"My dad always said that when you play a real tough team you have to show them who you are," Sawyer said.
Connor Harris added 16 points for King and Guilbert Francois (nine rebounds, four blocks) did a good job against Obi, adding two big hoops with King nursing a six-point lead in the final three minutes.
King took an 11-2 lead as GFA missed 15 of its first 16 field goal attempts. And after the Dragons tied it at 11, the Vikings went up 14 before settling for a 31-20 halftime lead.
In the second half, GFA got within one point. But led by Sawyer and Francois, the Vikings showed they had more to prove on Thursday.
GFA was 24 for 78 from the field while King made 23 of 53 shots. GFA, which out-rebounded the Vikings 48-27, had 18 turnovers and forced 15.
Emery Filmer is a freelance writer
Matt Tate 2 2-2 8; Hunter Eggers 8 0-0 17; Pat Ryan 3 1-1 7; Zach Baines 0 0-0 0; Sean Obi 8 1-4 17; Andrew Chase 3 0-0 8; Brendan Bieder 0 0-0 0; Van Barnet 0 0-0 0. Totals: 24-78 4-7 57
Connor Harris 4 3-4 16; Drew Sawyer 10 13-20 33; Nick Della Jacona 3 0-0 6; Guilbert Francois 3 0-0 6; Chris Massucco 1 0-0 2; Desmond Hague 0 0-0 0; Eddie Meizer 1 0-0 2. Totals: 23-53 16-24 65
3-pointers: GFA--Tate 2, Chase 2, Eggers; K--Harris 3.


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7:00 pm
The Red Green Show "DNA All The Way" A rich eccentric passes away and everyone tries to prove a relationship. Red uses an electric fan to start a lawn mower.G
7:30 pm
Keeping Up Appearances - The Memoirs of Hyacinth Bucket "A Job for Richard" Hyacinth determines Richard should secure a high executive position with a local firm, which has a vacancy in its ranks. Richard fancies neither the prospect of the job nor the plan Hyacinth has for him to meet The Big Boss.G
8:00 pm
Mr. Bean "Hair By Mr. Bean of London" On a trip to the hairdresser, Bean is able to pocket some money and make a mess of other people's hair.G
8:30 pm
Outnumbered Ben's frequent visits to the emergency room are beginning to arouse suspicions. Karen is writing an angry letter to the prime minister asking him to fire her teacher. Jake is providing alibis for his girlfriend. A thunderstorm, distressing news and dreadful noises coming from next door keep the family up late.G
9:00 pm
My Family "Life Begins at Fifty" Susan is suffering from severe mood swings and forgetfulness. She is arrested for stealing a pair of sunglasses because she refuses to admit she is a "woman of a certain age." Ben is convinced he can handle Susan's defense in court.G
9:30 pm
My Hero "Big" Ollie's half-human, half Utronian physiology causes him to grow at an accelerated rate from nine-month-old to 19-year-old in 24 hours.G
10:00 pm
Are You Being Served? "Happy Returns" A free lunch in the canteen in honor of young Mr. Grace's birthday inspires the staff to organize a cabaret for his party.G
10:30 pm
As Time Goes By "Animal Magnetism" Lionel finds a dog that the women immediately want to keep. Sandy's ex-boyfriend harry (a policeman) becomes involved.G
11:00 pm
Ladies of Letters The series continues with Vera in England and Irene in Australia busy bringing up their granddaughters.Irene's daughter Lesley is mysteriously out at work all hours of the day and night and Vera's daughter Karen has taken up with Damon, the trailer park heavy.G
11:30 pm
The Red Green Show "DNA All The Way" A rich eccentric passes away and everyone tries to prove a relationship. Red uses an electric fan to start a lawn mower.G


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|Summary of Presentations
|Public Health and Medical Perspectives on Population-Based Carrier Screening
|Lessons Learned from Carrier Screening for TSD
|Lessons Learned from Carrier Screening for Sickle Cell Disease
|Lessons Learned from Carrier Screening for CF
|An Update on Technologies Relevant to Carrier Screening
|Current Challenges in SMA Carrier Screening
|Current Challenges in FXS Carrier Screening in the Prenatal Population
|Carrier Screening: Populations, Stigmatization, and Eugenics
|Reports from Small Group Sessions
|What to screen for and when to screen?
|How should we balance the screening interests of individuals, communities and society?
|Should services be targeted to subpopulations?
|How is informed consent defined and obtained?
|How can we measure the success of carrier screening programs?
|What will be the "next generation" screening methods?
|Concluding Comments
Population-based carrier screening for single gene disorders has been occurring since the 1960s, with each decade bringing new opportunities and challenges. In February 2008, approximately 125 scientists, clinicians, public health officials and patient representatives gathered to consider population-based carrier screening in light of lessons learned and emerging technologies. The following document summarizes the content presented by the speakers, as well as the output of six breakout sessions designed to address particular challenges facing carrier screening in the decades to come.
Topics discussed were: experiences of large-scale carrier screening programs for cystic fibrosis (CF), sickle cell disease, and Tay-Sachs disease (TSD); the impact of emerging technologies on the ability to screen for disorders such as spinal muscular atrophy (SMA) and fragile-X syndrome (FXS); the ethical, legal, and social challenges raised by carrier screening; and public health perspectives on screening for genetic disorders in the setting of expanding technical capabilities.
The meeting was co-sponsored by the National Human Genome Research Institute (NHGRI), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the Office of Rare Diseases at the National Institutes of Health (NIH), the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), the Genetic Alliance and the American College of Medical Genetics (ACMG).
In opening remarks, Co-Chair Duane Alexander, M.D., Director, NICHD noted that several factors have converged in recent years, warranting renewed discussion about population-based carrier screening, including efforts to expand newborn screening (NBS) programs (which will identify more carriers), increasing use of pre-implantation genetic diagnosis and prenatal testing and the prospect of the $1,000 genome. Alan Guttmacher, M.D., Deputy Director, NHGRI, noted that a decade has passed since the last major review of a population-based carrier screening program (CF). As more tests become available for such programs, it is important to be mindful of the tensions that exist with regard to research priorities, the need for protections and the push of technology. Further there are challenges in integrating any new technology in health care given current realities of the health care system which is in crisis. As technological advances provide the opportunities for expanded screening programs, several issues must be considered before moving forward.
Dr. Calonge provided a public health perspective on current applications of genomics, including:
Each of these applications provides opportunities for improved public health, for example, population-based epidemiology can take advantage of screening data and genomic registries to plan for services and design research. On the other hand, tensions between individual care and public health can become heightened in such applications as personalized medicine, where the high cost of a service that will only benefit a few might stand in conflict with the traditional goals of public health. Concerns that arise in the context of private healthcare and genomics (e.g., cost to consumers, privacy, choice) are not always consonant with the concerns of public health (e.g., public resources, population health). Nonetheless, public health practice can play a significant role by assuring the availability of services, follow up and treatment and protection from unwarranted use of tests and test results. Meeting these challenges will require resources, accurate tests, and protections against harm. Variability in policies and practice must be addressed: for example, there are significant differences in state public health involvement in genomic application, and — with the exception of NBS — most carrier screening is conducted within the context of reproductive healthcare delivery and implemented through a medical standard of care. This means consumers are dependent on the knowledge of healthcare providers and access to care. Other applications of screening are unlikely to find a place in public health (e.g., diagnostic testing). However, an expanded public health perspective on carrier screening — beyond just the reproductive focus — could contribute to reduction of the prevalence of disease. Learning how to provide complex genetic information on a population basis will be critical to the success of any carrier screening program. Evaluating the health value of genomic applications and prioritizing these within the larger context of health care services is essential, and will be challenging.
Dr. Elsas provided a medical perspective of issues facing carrier screening in large populations. He noted that carrier tests remain relatively expensive, thus they generally are not appropriate as a public health strategy. A critical clinical consideration is whether therapies or interventions are available for the condition for which screening is being done — that is, what is the benefit of knowing? He added that the following criteria should be met before proceeding with carrier screening programs:
He noted that TSD carrier screening has been successful in the Ashkenazi community because many of these criteria were met. However, the population being screened was educated, motivated, and relatively homogenous. Several factors combine to caution against expanding TSD carrier screening to additional ethnic groups, including "admixture," residual risks, and the need for functional (enzyme assay for HexA) as well as DNA-based screening tests.
CF carrier screening provides another type success story, in part because of data derived from pilot studies in the earliest stages of introduction. However, most infants with CF continue to be born to couples that do not know they are carriers, i.e., they were not offered carrier testing. Parental and professional acceptance of screening prior to pregnancy has been low in this group (parents of CF children) despite the obvious benefit of having more reproductive choices with preconception screening.
The well documented failures of the early sickle cell carrier screening programs highlighted the need for appropriate pre- and post-test counseling and greater attention to the social and clinical needs of the community and of screen-positive heterozygotes.
Dr. Elsas closed by saying that the widespread adoption of SMA carrier screening should be preceded by pilot research studies to determine community acceptance and allele frequency and to estimate the economics of testing methodology. In addition, to date, population-based carrier screening has not been recommended for FXS because of limited knowledge about intermediate expansions, inability to predict phenotype in females, lack of community and physician knowledge, limited counseling resources, lack of knowledge about community acceptance, and the costs of methods. These issues would need to be addressed prior to the adoption of a widespread screening program.
Presentation Slides
Dr. Desnick stated that prenatal carrier screening is currently available in the Ashkenazi Jewish population for as many as 16 recessively inherited diseases which to be at higher frequency in that group, including TSD. TSD is a fatal degenerative disorder of the central nervous system with onset of symptoms in infancy and death by age 2 to 5 years. There is no treatment available for this autosomal recessive disorder. Dr. Michael Kaback at Johns Hopkins began the first screening program in 1971, following the identification of the enzymatic defect. Education of the at-risk population and religious leaders led to wide acceptance of carrier screening. As of 2007, almost 2 million individuals had been tested, with over 65,000 carriers identified and over 1,500 at-risk couples found. Of these couples, nearly 4,000 pregnancies have been monitored and notably, over 3,200 unaffected children have been born. The screening program has been so effective that more TSD cases occur in the non-Jewish population than in the Jewish population. In 1997, the acceptance among Ashkenazi Jews of triple disease screening (for TSD, CF, and Gaucher disease) was evaluated and found to be high, which paved the way for incremental increases to the current screening panel of 16 diseases. (Individuals in the he Ashkenazi Jewish community have a 1 in 4 chance of being a carrier for 1 of the 16 disorders.)
Dr. Desnick noted that despite these successes, several challenges remain. TSD screening using an enzyme assay detects all carriers whereas DNA assays detect only specific mutations. Nearly all Ashkenazi carriers can be detected by screening for only three mutations; thus, DNA assays are preferred for screening in this population. However, as individuals increasingly marry outside the community, the detection rate will decrease. Increasing intermarriage rates nationwide also poses new challenges for counseling, as a priori and residual risks change. A second challenge is the clinical variability of Gaucher disease, an autosomal recessive disorder. Carrier screening for this disease is considered controversial, because the more common Type 1 Gaucher disease is often asymptomatic and effective treatment exists. This raises the question of whether population-based programs should screen for carriers of low penetrance diseases. However, recent studies revealed this not to be the case as the prenatal carrier programs identify younger affected individuals who have disease manifestations. Finally, prenatal screening is not acceptable for Orthodox and Chassidic Jews because abortion, artificial insemination and birth control are not options. In 1982, Chevra Dor Yeshorim was established to provide compatibility testing, i.e., genetic screening prior to "matches." As of 2006, over 200,000 individuals were tested and over 800 proposed matches of carriers were averted. This model has already been transferred to the Saudi Arabian population where matches are made and certain recessive disorders are frequent.
Ms. Ross described the development of carrier screening options and guidelines and their acceptance in the Ashkenazi population, starting with the American College of Obstetricians and Gynecologists' (ACOG's) recommendations in 1976 and progressing to their 2008 technical standards and guidelines for screening. With each new issuance of guidance or standards, the number of diseases included in screening panels has expanded, often at the urging of affected families. Still, carrier screening programs vary by hospital, even in New York City, with some populations benefitting from expanded screening panels and robust education and counseling opportunities. These disparities raise issues for families who want expanded disease menus so that they can choose screening options.
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Sickle cell disease and sickle cell trait were first described in 1933 and recognized as a molecular genetic disease in 1949. Early morphology tests could differentiate normal, disease, and trait status. Carrier frequency in the Black population was estimated at 8.1 percent, with normal life expectancy and no medical implications. The National Sickle Cell Anemia Control Act of 1972 aimed to reduce morbidity and mortality from sickle cell disease through increased awareness and education and through development of new modes of therapy. NIH Comprehensive Centers focused on research and treatment and HRSA (then HSA) funded sickle cell screening and education clinics focused on screening, education, information, counseling and referral of disease. CDC was tasked with training, proficiency testing and development of a reference laboratory. On the surface, this seemed to be a responsible public health strategy. However, misguided efforts resulted in mass screening programs conducted with inadequate training, poor methodology and lack of counseling. In addition, legislators pushed for policies mandating premarital and preschool testing. These early programs did not decrease the incidence of sickle cell disease. Several factors were at play in addition to poorly implemented programs, including distrust in the Black community, lack of access to selective abortion following prenatal diagnosis, and other pressing social and economic problems.
NBS for sickle cell disease and other hemoglobinopathies was recommended in 1987. Treatment of the disease had improved and the death rate in the early years of life had dropped from 20-25 percent to 2-3 percent. As of 2005, nearly 4.2 million newborns had been screened, with 3,419 infants found to have the disease and 72,111 found to be a carrier of one of the three mutations (HbFAS, HbFAC, or HbFAE). Most states do not report carrier status.
The identification of carriers through NBS programs raises several issues regarding notification of the carrier's parents, provision of education and counseling, and follow-up when the carrier reaches reproductive age, not to mention issues related to testing extended family, nonpaternity, and risk of stigmatization or discrimination. In the early stages of screening, carriers often were followed as individuals with disease and vice versa. More recently, it is becoming evident that carrier status might not be medically neutral for all individuals. The literature has included reports of clinical manifestation of carrier status, including: decreased urinary concentrating ability; recurrent hematuria; increased incidence of sudden death at extremes of human endurance; pain, splenic infarction, and sequestration at altitude; increased incidence of pulmonary emboli; and occurrence of a rare renal medullary carcinoma. Conversely, common diseases erroneously have been linked with sickle cell trait. Clearly, challenges remain with regard to understanding the medical consequences of carrier status for this disease as well as meeting educational and counseling needs.
Ms. Ohene-Frempong presented a consumer perspective as a parent of a child with the disease and a child with the trait and, also, as a plain language and cross cultural communications consultant. She emphasized the importance of making complex information accessible when results of sickle cell status are communicated through NBS programs. Ms. Ohene-Frempong is working on a HRSA-funded program to create materials and methods of information delivery that will increase health literacy, particularly about sickle cell disease and genetics. Methodology includes reliance on a series of surveys and focus groups to identify the best use of medical terminology and messages to ensure an accurate and readable product. For example, the term "trait" is not very descriptive, and the term "carrier" implies contagion or burden, so the use of "AS" to describe carrier status might be more obvious, and highlights the importance of the "S" gene. In addition, she stressed that the message has to be sensitive not just to the genetic aspects of the information, but also to the life impact of the information. Other considerations are whether, and how, to talk about other hemoglobinopathies (e.g., AC, AD, AE, A beta-plus thalassemia, A beta-zero thalassemia). Adequately and accurately simplifying complicated and probabilistic information in the context of population-based screening programs requires many formats and approaches to account for literacy levels, context, and venues for delivery.
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A 1997 NIH consensus conference resulted in the first public recommendation for population-based CF carrier screening. The process, which brought together experts from many areas of medicine, as well as patient advocates, is a model for how to approach mass screening programs, said Dr. Howell. The goal of the conferees was to address the following central questions:
Among several recommendations, the group suggested that carrier screening for CF should be offered to adults with a positive family history, partners of people with CF, couples currently planning a pregnancy, and couples seeking prenatal testing.
In 2001, ACOG and ACMG issued clinical and laboratory guidelines stating that carrier testing should be offered to Caucasians and Ashkenazi Jews using a universal pan-ethnic core mutation panel. The guidelines addressed the specifics of the panel, reporting of residual risks, and quality assurance standards.
In the early stages of widespread screening concerns emerged about the mutation panel because mutation frequencies differ in the general population. In addition, a survey of OB/GYN practice patterns revealed that while many practitioners were familiar with the recommendations, they were not always offering carrier testing, although they were more likely to do so during, rather than before, pregnancy (i.e., they were not using the recommended selection criteria). This highlighted the importance of continuing education and the need for simple and clear language in guidance.
Dr. Kharrazi provided a parent's perspective as well as the results of two California obstetrical provider surveys. The percentage of obstetrical providers offering prenatal CF carrier screening increased from 17 percent in the one-year period before the ACOG/ACMG guidelines to 53 percent 1-2 years after the release of the guidelines. In the second survey in 2003, inadequate provider knowledge and time, lack of patient knowledge, lack of CF screening educational materials, and high cost of the test were the most common reasons for not offering CF carrier screening.
Since 2001, many developments have changed the context of CF carrier screening in 2008. CF NBS has increased from 8 state programs in 2001 to over 40 in 2008. Because CF case detection rates (sensitivity) are lower for prenatal carrier screening than for NBS there are more parents being told that they are test negative for CF carrier status but who later find out that they have a newborn with CF according to NBS. This is causing parental confusion, denial about their child's CF status, and distrust of the medical profession. CF clinical care has improved and predicted median age of survival has risen from 32 years in 2001 to 37 years in 2006. As such, CF is being perceived more as a manageable chronic disease than a fatal genetic disease, but this perception varies by medical specialty so different messages are a source of confusion for parents. Knowledge about CFTR mutation frequencies and genotype-phenotype correlations has improved and this has revealed that the widely-used ACMG-23 CFTR mutation testing panel includes mutations with varying degrees of severity, is not equitable across geographic subgroups, and is not comprehensive for the non-White population. Together, these factors place even greater demands on limited educational and counseling resources, particularly preconception counseling and testing. In addition, they highlight the need to revisit the composition of the mutations on the panels used for carrier screening to achieve higher test sensitivity, specificity and equitability, to improve interpretability of the test results, to reduce current levels of provider and patient confusion, to the lower the cost of the test, and to reduce the time for genetic counseling.
Presentation Slides
In general, the technology for gene variant screening used in NBS programs can be used in population-based carrier screening. Several factors are critical in distinguishing which technology or technique is most relevant, including whether the screening is for a monogenic versus polygenic disorder, whether or not a high de novo mutation rate exists for the disorder and to what extent copy number variation plays in the disorder. Available technologies include genotyping assays, sequencing, and comparative genomic hybridization (CGH). Each has its advantages and disadvantages. Genotyping assays are most appropriate for allele discrimination, sequencing is best suited when dealing with a high mutation rate that is widely distributed, and high copy number variations call for CGH.
Genotyping assays include TaqMan ® - based assays as well as molecular diagnostic microarrays (SNP chips containing panels of mutations). Although costs are coming down for these assays, especially for SNP chips, it doesn't make sense to genotype 1 million SNPs for population-based carrier screening, said Dr. Hoffman. Current SNP chips do not sequence disease genes and do not contain common disease gene mutations. Custom chips could be constructed, however, that target mutations of interest. Cost and pragmatism are key considerations.
Sequencing is best for testing for dominant disorders and disorders for which there is a high new mutation rate. Duchenne Muscular Dystrophy is an X-linked recessive disorder with a high de novo mutation rate and could be the first X-linked disorder placed into population-based screening. However, because of the high mutation rate and the size of the gene, high-throughput screening will be difficult. Targeted sequencing using a shotgun method, and sequencing by hybridization are the most promising approaches in the near term. Advances in whole genome sequencing do not necessarily advance targeted sequencing.
CGH is best used when there is copy number variation. There are numerous examples of disease-associated copy number variations, but most are not reflective of carrier status. Thus, CGH is best suited for patient diagnosis.
Hybrid chip-based assays are likely to emerge as the best tool for population-based carrier screening because they can detect all common mutations in recessive disease and provide quantitative assays (CGH-type information) for common copy number variations.
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SMA is the most common autosomal recessive genetic disorder lethal to infants. It is caused by a homozygous absence of the survival motor neuron gene (SMN1). SMA has a carrier frequency of approximately 1 in 40 individuals; this prevalence shows neither racial nor gender preference. The disorder manifests itself through anterior horn cell degeneration resulting in progressive weakness and muscle atrophy. Only supportive treatment is available currently.
There are three types of childhood SMA: Type I (the most prevalent and most severe form, also known as Werdnig Hoffmann disease) - 50-70% of all SMA children suffer from Type I - these infants have severe generalized muscle weakness, can never sit unaided, over time become unable to swallow or control their own secretions, and generally die from respiratory failure within the first two years; Type II, the next most prevalent form, in which children cannot walk or stand unassisted, are generally very frail, and survivability is variable; and the mildest and least common form, Type III (also known as Kugelberg-Welander), in which children are ambulatory and typically walk unassisted for a period of time before needing a wheelchair for mobility. There is also an adult onset form, Type IV, in which symptoms appear after age 35; this form is very rare.
Humans possess a nearly identical SMN2 gene that provides insufficient amounts of fully functional SMN protein that is necessary to maintain survival of motor neurons throughout development. There is a genotype/phenotype correlation in SMA; milder phenotype has been associated with increased copy number of SMN2.
Carrier testing was first offered in 1997, and to date over 1,500 test have been conducted, the majority on family members of previously affected individuals. Widespread carrier screening is possible, though there are two limitations: 2% of SMA cases arise as a result of de novo mutation events, and the copy number of SMN1 can vary on a chromosome, about 5% of the normal population possesses three copies of SMN1 - thus, it is possible for a carrier to possess two copies of SMN1 on one chromosome and no copies on the second chromosome. However, carrier testing can detect 90 to 95 percent of carriers since 95-98% of all cases result from a common single deletion event.
Education is the key missing component to implementing a successful pan-ethnic carrier screening program for SMA. The Claire Altman Heine Foundation Pilot Program for Population SMA Carrier aims to improve education, estimate carrier frequencies, determine allele frequencies, and assess technical and cost feasibility.
Ms. Heine explained that the Claire Altman Heine Foundation was founded in 2005 in memory of her daughter, who died as a result of SMA Type I. The Foundation uses its funding to advocate for the implementation of pan-ethnic, population-based SMA carrier screening, to raise awareness of SMA, and to educate the public and professional communities. Ms. Heine emphasized that the need for pan-ethnic SMA carrier screening recommendations and/or guidelines by governmental and professional communities is compelling.
The impact of SMA is severe and clinically significant; Type I is fatal in early childhood; and currently there is no treatment or cure available. Carrier screening would provide options to couples where both partners are carriers of the SMA gene mutation. Since SMA is present in all populations, carrier testing should be offered to all couples regardless of race or ethnicity. Ideally, the testing should be offered before conception or early in pregnancy. The primary goal is to reduce the prevalence of SMA by allowing carriers to make informed reproductive choices.
FXS is the most common cause of inherited mental retardation, with an incidence of approximately 1 in 4,000 males and 1 in 8,000 females, in which it is less severe. It is found among all ethnic groups and occurs in families with no history of mental retardation. There is a spectrum of clinical involvement and FXS-associated conditions are found among carriers, including premature ovarian failure, and tremor and ataxias. One in 259 women is a carrier of the FXS premutation; however, most will have a negative family history. Only the mother has to be a carrier for the fetus to be at risk. The fragile X mutation is an unstable CGG repeat that can expand dramatically when a premutation allele is passed from mother to offspring. The risk of expansion of the repeat is influenced by the gender of the carrier and the number of repeats in the premutation; the higher the repeat number the greater chance of expansion to a full mutation .
ACOG/ACMG has recommended carrier testing only for individuals with: a family history of FXS or undiagnosed mental retardation, developmental delay, or autism; and prenatal diagnosis when the mother is a known carrier (of either the premutation or full mutation). However, risk factors based on screening alone are not effective in detecting carriers. For example, based on one published model, the maximal rate of detection of female premutation carriers by active cascade screening is 6 percent, compared with prenatal screening (60 percent). Moreover, the largest proportion of FXS births occurs in families without index cases. In addition, 50 percent of women have more children after having a child with FXS, but before that child has been diagnosed.
Thus, a case can be made for population-based carrier screening as FXS appears to meet the criteria applied to other common screening programs, i.e., the disorder is considered a significant health problem or carries a burden of disease, screening could be accomplished in a simple manner, and screening could be cost-effective. Pilot studies have shown that participants are in favor of testing or screening. Arguments against population-based screening are: 1) the genetics are too complex; 2) current education and counseling resources are inadequate; 3) the phenotype for female fetuses with full mutations cannot be predicted; and 4) time and costs.
Dr. Bailey described a study to assess the benefit of including FXS in NBS programs. Benefit to the infant is a fundamental tenet of NBS-historically this has been a necessary condition for screening. Although there is no cure for FXS, children with the full mutation are likely to experience a range of impairments that could be reduced, delayed, or prevented through early intervention. What should the policy be if there was a relatively inexpensive test that could accurately screen newborns for FXS? What if the test was DNA based and accurately reported CGG repeat length, thereby differentiating children with a full mutation from those with a premutation? A critical question is how carrier status would be reported. Because there are some phenotypic characteristics found in the carrier population, could early identification reduce or prevent risks?
Key questions to be answered include:
In sum, screening for full mutation FXS would likely benefit children and families. However, screening for carriers evokes important questions about benefit-for whom? and how? FXS is a good prototype to use in a prospective study of screening benefits. However, rather than thinking strictly in terms of cost-benefit, said, Dr. Bailey, we might need to assess family adaptation to information gained through screening.
Presentation Slides
Previous population-based screening efforts have illustrated the importance of balancing the interests of individuals, communities, and society, and the need to recognize historical sensitivity and cultural competence among health practitioners who engage in screening. Deciding which populations to target and the potential emergence of "hidden" subpopulations (e.g., sickle cell carriers) warrants focused attention. Moreover, one-size does not fit all-screening must be considered in light of group values and concerns. We also have learned the importance of competent screening programs among populations whose group identities are invested in the maintenance of values that are distinctively different than that of the majority culture, said Dr. Wailoo. Importantly, despite the many similarities in the evolution of carrier screening programs for sickle cell disease, CF, and TSD, each disease is linked to a specific racial/ethnic group, thus the term "genetic disease" does not do full justice to their complexities. Lurking in the background has always been the ultimate goal of developing therapies, so that the emphasis on prevention can be alleviated. In fact, treatment has improved for CF and sickle cell patients and life expectancy has improved. Behind the curtain of prevention lie the more challenging ethical dilemmas of prenatal diagnosis and selective abortion, artificial insemination by donor, adoption, or childlessness.
Clearly, each genetic disease and each population follows a unique trajectory: shaped by complex interactions among science, technology, medicine, values, subculture, and society. Histories of therapeutic advancement reveal that they solve some problems while creating others in their wake. For each of these three diseases, different interests and social, political, economic investments in screening resulted in different kinds of stigma and different meanings for each population. Thus, each carrier screening program comes to have different political, social, and cultural meanings.
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Criteria for screening should be established before generating a list of disorders to consider. A framework for criteria development already exists through the ACMG Report on Newborn Screening, which included: test accuracy; financial burden of testing; prevalence and carrier frequency; the natural history of the disease, including its severity, burden, and course; homozygous and heterozygote phenotypes; and whether an intervention is available for those identified as carriers. The top three considerations should be carrier frequency, disease burden, and cost of screening.
What to screen for depends on the rational for screening, i.e., what actions can be taken and when would screening occur across the life spectrum? Screening to date has been large ethnocentric; thus, one obvious criterion is ethnicity as well as personal and family history. When to screen depends on several factors, including cost, and the meaning of the information to the individual being screened. Consent/assent issues differ across the prenatal, neonatal, child, and adult populations. There can be risks with screening too early, either in the life of the individual, or the life of the technology. Benefit to the individual should be paramount, but the "family" nature of genetics blurs that requirement.
An expert panel should be convened to develop a scoring system for selection, based on review of data collected from stake holders, economists, patients, and providers, as well as surveys of potential target populations. Guidelines should be developed as soon as possible and revisited and revised as more data become available.
The first order principle is to engage the relevant communities. While consumer-driven special interest might be major force, the medical model is an equally significant force; thus, identifying the rightful gatekeeper is challenging. In any case, the gatekeeper should be trusted by the community, which can be difficult to define. State public health programs are not surrogates for the community, and in some cases communities are self-defined rather than neatly categorized along clinical or demographic lines. Some communities are more tightly knit and organized than others (e.g., Amish, Ashkenazi Jews). Many are proactive, wanting to be actively involved in research designs, development of registries, and development of public policy.
There are different screening models along the spectrum of community involvement, from the loosely defined newborn community for which screening is mandatory to communities requesting screening before it is technically or economically feasible.
In considering the interests of individuals, communities, and society we must consider the disorder being screened for, the time of screening (preconception, prenatal, newborn, adult), who will pay, who has access, and post-test consequences (e.g., counseling, planning, elective termination).
Other screening models to consider in developing criteria are imaging, cholesterol, blood pressure, and obesity, as indicators of future disease. Immunization policy and seatbelt laws are public heath models that bypass individual interest in favor of public health and societal interests. It is important to recognize that sometimes genetics will be overshadowed by behaviors; thus, education efforts and community involvement will vary depending on where they occur (e.g., school, clinic), when they occur (e.g., newborn, during pregnancy), and who leads them (e.g., consumers, health care providers, researchers).
"Market" pressures come from technology (e.g., $1,000 genome), special interest consumer/advocacy organizations, professional society guidelines, and specific community concerns.
Can we devise a set of criteria to determine when something rises to the level of available, optional, or mandated carrier screening? We need a framework for making these determinations. We need to be clear about the incentives for screening, determine the appropriate intervention, and establish who pays. There was a strong consensus for voluntary programs with education to make informed choices. Screening programs must be balanced, ensure access, account for health disparities and cultural differences, accommodate technology advances, recognize market pressures, address public health needs, respect individual autonomy, be economical, and address potential for discrimination. Education is essential as is community consultation.
Important considerations are discerning the difference between offering screening versus making it available, planning for the long-term, and developing registries and mechanisms for surveillance and risk assessment. A significant challenge is developing strategies for interventions for carriers identified through NBS programs, as this is not a well-defined or well-understood community.
Decision making regarding population-based screening must balance science, ethics, and clinical utility. A key consideration is when to address targeting issues-at the time when screening is offered or when interpreting the results of screening. If you cannot categorize people on the front end of screening, you can at least customize the interpretation on the back end. There is always the need to balance the desire for equitability with constraints. Should it be a public health activity or a clinical program, and how will that constrain or facilitate delivery?
The community should drive what is offered, but defining community is difficult-is it ethnicity, self-identity, or based on scientific markers? Another way of defining community is through point of service (e.g., newborn, prenatal). Carrier screening made available only through the prenatal settings favors those with access to prenatal care. However, education limitations and the priorities of primary care limit the ability to make screening widely available.
Subpopulations should be targeted only if population characteristics (e.g., reproductive isolates, specific geographic origin of ancestors) justify such an approach. Over time, DNA markers integrated with screening markers might change the targeting strategy by modifying the a priori risk and clinical validity.
Carrier screening resulting from NBS is a by-product that produces another subpopulation.
It will be important to assess the long-term effects of carrier detection, e.g., the outcomes of cascade carrier detection versus screening on the basis of increased risk versus offering screening to all. The intended use is the first limitation to a programmatic approach and lack of clinical validity data in larger populations will limit our understanding of the most effective approach.
The informed consent process provides information to the recipient, including risks and potential benefits of either being tested or not being tested, and the anticipated outcomes of testing. The information provided should be appropriate to the literacy level of the patient and culturally sensitive. Information can take many forms: multimedia, personal instructions, and written materials. There need not be a signature on a consent form for informed consent to occur. Consent should be obtained and discussed by personnel knowledgeable about the issues involved. All methods and approaches used for informed consent should be evaluated for effectiveness.
Informed consent for testing is the standard of care and perhaps even a statutory requirement in some states. Consent to diagnosis is distinct from consent to research.
When a carrier is identified during the course of NBS, "accidental detection of a carrier" occurs. Such incidental findings can also reveal nonpaternity. There is wide variation in policies in this area, which are made more complex because there was no prior consent for such screening, during which the potential for such results could be disclosed. Some programs provide specific information about the carrier state with verbal or written materials. One program advises the family that there is additional information available that might be of value should they want it-about half of families follow through. The group expressed general concern about the level of effort required for follow-up and counseling for infants being screened for FXS if the premutation were identified rather than the full-mutation. A California laboratory has been mandated to reduce the number of carriers identified in order to reduce the burden on follow-up. To accomplish this it has modified its mutation panel and cut-off values.
Key elements of informed consent for carrier screening include: the meaning of the term carrier, its meaning to you and your family, risks and potential benefits of the information, where to get follow-up information, levels of uncertainty about the test, and the future of the disease. These elements become more complex with the use of multiplex tests. It is not practical to discuss and describe each disease for which carrier screening might be done in multiplex panels. Templates should be developed that describe that carrier screening will be done for a group of conditions that might adversely affect your offspring. In the event that one of the carrier tests is positive, then detailed counseling about that condition should be carried out.
With regard to research, a national or central IRB could be created for carrier screening studies.
Do we define success in terms of public health or individual benefit? Should we measure net health benefit (i.e., balance between positive and negative outcomes)? Is one goal to reduce disease frequency in the population for lethal conditions? Key variables in answering these questions are clinical severity, longevity, and quality of life for treatable conditions. Other factors to consider are reproductive options and maximizing therapeutic approaches. One measure of success is participation by the target population when choice is an element. Another measure of success is adequate understanding by participants. At the systems level, a measure of success is appropriate follow-up by health care providers and the grass roots community as well as fair access to screening and counseling.
Major issues to consider in adopting a new screening program include: development of well-defined positive and negative outcomes; demonstrated ability of providers to educate consumers about screening; the burden of disease in the population; genotype-phenotype correlations; long-term follow-up from screening (longitudinal outcomes); insurance coverage and implications for carriers; and measures of quality of life for carriers who do not have children with conditions.
Methods for measuring success include: evaluations of pre- and post-testing education; surveys to determine whether tests are being appropriately offered; assessment of opt-in and opt-out rates; costs per net health benefit measurements; qualitative measures of "choice" in carriers and the general population (individuals who are screen negative); evaluations of enhanced genetics competency of health professionals; cohort studies (follow-up of screened populations) for rare diseases; population-based studies for other conditions; community-based research (e.g., public consultation).
New methodologies must be robust enough to qualify for population-based use; i.e., high analytic validity, replicable in many settings, high-throughput, cost-effective (including sample acquisition and preparation). If the near-term answer is hybrid chip-based assays, what approaches should be pursued in the long-term? DNA-based testing may not always be the best or complete answer. Analyte-based testing may play a role. Ideally, a two-stage approach should be used-DNA-based screening followed by analyte-based (or other) confirmatory testing.
Who develops a test and their motivations (e.g., economic and/or public health) might influence how evaluations of clinical validity and utility are performed and who will pay for such assessments. Addressing issues of specificity and false positives are complex when hundreds to thousands of tests are being run simultaneously. Who will decide which tests to read out, especially when a test has no incremental cost but the information it provides may not (yet) be clinically useful (e.g. CF tandem mass spectrometry experience in newborn screening)? How and when should such information be "released" and might there be staged release that is partially dependent on individual preferences, life stage, and clinical need.
Is the "$1,000" in the $1,000 genome the cost of the test to the tester or the person being tested? Does it account for counseling and other health care provider costs? Does the focus on cost over emphasize the technology rather than the need for clinical validity/utility, provision of relevant clinical services, and potential for genetic discrimination? The $1,000 genome might not be the answer for population-based carrier screening-will it be population based or population targeted? It might be more useful to consider an assortment of $1,000 (or, $100) genetics-based assays, each of which has clinical utility for differently defined populations, or, one "test" (potentially, whole genome sequencing) with an assortment of "subpanels" that are read out in various specific situations.
Clearly, new technologies will blur the distinctions between single-gene and common disease testing. If, that is the case, defining the needs of a "population" will become more difficult, requiring more of a focus on primary care. In moving forward with screening programs, it is critical to recognize the distinctions between predisposition screening, carrier screening, and diagnostic testing, and screening adults versus children. In addition, because carrier status is not always clinically neutral, the clarity between carrier status and unaffected is diminished.
Finally, is technology driving too much of the conversation and research agenda? New technologies may require new safeguards, or at least reinforce the need for ones we already are aware of (e.g., GINA).
In closing remarks, Dr. Alexander reiterated the numerous factors pushing for a more coherent and systematic approach to introducing new tests into population-based carrier screening programs. The history of current programs informs these discussions by highlighting the need for better techniques, more education, and access to counseling. He expressed concern that the largest screening program to date-NBS-has no consistent policy across programs, especially with regard to "incidental" identification of carriers. At some point this incidental identification might become intentional, and we should be better prepared than we are. And, as NBS panels are expanded, the issue becomes more critical. Dr. Alexander noted that several federal bodies are already reviewing screening programs, such as the Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children (ACHDGDNC). This group was chartered to advise the Secretary regarding the most appropriate application of universal NBS tests, technologies, policies, guidelines and standards for effectively reducing morbidity and mortality in newborns and children having, or at risk for, heritable disorders. In addition, new legislation requires the Secretary to assess the impact of NBS screening for FXS.
Dr. Francis Collins, Director, NHGRI, closed the conference by also emphasizing the importance of developing more uniform policies with regard to carriers detected through NBS programs. He also stressed that the environment is likely to become even more complicated as technology advances and the market places more pressures on the healthcare system and consumers. In moving forward we must recognize that criteria for screening programs rightfully should differ depending on the context within which a program is offered. As a next step, discussions should focus on what additional conditions are now appropriate for population-based carrier screening? These discussions should involve the public, perhaps under the guidance of an expert panel tasked to identify research needs and define the criteria for screening.
There was some discussion as to whether CDC's Evaluation of Genomic Applications in Practice and Prevention (EGAPP) project could undertake reviews of screening for specific disorders (e.g., SMA, FXS), or whether the Secretary's Advisory Committee on Genetics, Health, and Society might be asked to review issues surrounding expanded carrier screening programs.
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Trendy Tel Aviv contends with rockets for first time
For the first time since the 1991 Gulf War against Iraq, a siren blared Wednesday in Tel Aviv warning of a possible incoming rocket that may have been an improved, longer-range missile.
TEL AVIV, Israel — On this early Saturday evening, the streets were unusually quiet for a warm, breezy night in Tel Aviv, a city known for its raucous nightlife.
Shaked Shalom, 27, an Israeli who is originally from a small settlement near the Gaza border was among the few sitting in a cafe and drinking coffee with friends.
"My life hasn't really changed, as I'm used to this reality," he said.
He said he hoped Tel Aviv residents were tough enough to handle what could be a barrage of missile attacks.
"It worries me that people are scared already only after three missile attacks," he said. "They say that Tel Aviv has lived in a bubble and now that the bubble has burst."
A cosmopolitan city on the shores of the Mediterranean, Tel Aviv is full of restaurants, exclusive seaside apartments, gorgeous beachfront and fashionable stores and had never seen a rocket attack from Gaza.
Until this week.
For the first time since the 1991 Gulf War against Iraq, a siren blared Wednesday in Tel Aviv warning of a possible incoming rocket that may have been an improved, longer-range missile.
People ran for cover while others seemed bemused by the wail. An explosion was heard by some on the outskirts of the city.
The villages and towns in southern Israel have been hit for years with rockets fired by terrorists in nearby Gaza, and the people there are on a constant war-footing, constructing safe rooms and watching for text alerts that give a 15-second warning of an incoming rocket.
But Tel Aviv has mostly experienced rocket attacks via television broadcast..
Alfred Bracha, 55, owner of a supermarket on Florentine Street in south Tel Aviv, a haven for artists and the young and hip, said business since the missile attacks has been better because more people did not want to go far, given the threat of rockets. Instead they are shopping close to home at his corner store.
"The streets are more empty since the first alarm, the cafes are empty. But I think the situation can only get better," he said.
Bracha and others feel that the West would not let hostilities grow into a full-fledged war. He believed the United States would prevent Egypt's Muslim Brotherhood-backed government from making the conflict worse .
"Hamas is weakening, and I believe that Egypt has no money to go to war, especially as America financially supports Egypt and I believe they will not let them attack us," he said.
Still, he said that he couldn't bring himself to go out and party in typical Tel Aviv fashion knowing that his countrymen were in the field fighting.
"I feel solidarity with our military," he said.
Yam Umi, a 30-year-old artist, was walking her dog in the street and said she was irritated with the aggression of both sides.
"I'm more afraid of indifference of the people. The war has become an integral part of our life," she said.
"People think that Tel Aviv is a bubble, that everything here is fun and easy, but I feel an integral part of Israel," she said. "If rockets fall in the south, there is nothing strange about them falling here too."
Mahmoud Salim, 43, an Arab construction worker from the Palestinian territories who lives and works in Tel Aviv, worried that the situation would worsen.
"I feel fear, feel like there is no safe place," he said, his voice quivering. "Life has changed since the attacks on Israel, the streets are empty.
"Usually, in this weather, street life is bustling, but these days they are empty," he said. "The atmosphere is grim. It does not matter that I'm coming from the territories, I'm against the aggression of all kinds."


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E-mail: email@example.com
Phone: 707-664-2350
Office: Stevenson Hall 2013-A
Dr. Charles A. Elster
Professor, Department of Early Childhood Studies
"You are not required to complete the work, but neither are you at liberty to abstain from it." -- Ethics of the Fathers
Courses Taught
- [EDMS 463] Teaching Reading and Language Arts to Younger Students
- [EDRL 524] Literature and Literacy
- [EDMS 482F/S] Student Teaching Supervision & Seminar
- [EDRL 523] Curriculum Development Language/Literature
- [EDEC 420] Child Development, Family, School & Community
I am a professor in the Sonoma State School of Education, where I teach courses in the Multiple Subjects, advanced Reading-Language, and undergraduate programs. I also supervise student teachers a McNear Elementary School in Petaluma. My interests include early childhood and elementary education, the teaching of literacy and the study of literature. I am especially interested in the importance of poetry in language arts education.
- PhD, University of California, Berkeley
- MA, University of California, Berkeley, 1982
- BA, Yale University, 1976
Research Interests
- Teacher education in the language arts
- Language & literacy development in young children
- Literature, children's literature, genre theory, poetry
- Children's literature in the classroom
- Classroom interactions & linguistic diversity
- New literacies
Academic & Professional Experience
- Sonoma State University, 2005-present.
- Purdue University, 1989-2005.
- College of San Mateo, 1988-89.
- University of California at Berkeley, 1983-84, 1988-89.
- Hebrew Academy of San Francisco, 1980-1982.
Recent Scholarship and Publications
- Elster, C. (2010). "Snow on my eyelashes:" Language awareness through age-appropriate poetry experiences. Young Children, 65, 47-55.
- Elster, C. (2009). Seven types of hybrids to delight and challenge readers. The California Reader, 42, 19-26.
- Elster, C. (2003). Authority, performance and interpretation in religious reading: Critical issues of cross-cultural communication and multiple literacies. Journal of Literacy Research, 35, 663-692.
- Elster, C., & Hanauer, D. (2002). Voicing texts, voices around texts: Reading poems in elementary school classrooms. Research in the Teaching of English, 37, 89-134.
- Elster, C. (2000, September). Entering and opening the world of a poem. Language Arts, 78, 71-77.


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Crowds Gather for Michael Brown's Funeral
Family of Black Teen Calls for Peace on the Day of His Burial
ST. LOUIS—Thousands of people filled a church here Monday to remember Michael Brown, whose shooting by a police officer in a nearby suburb sparked days of protests and drew national attention to the often tense relationship between police and young blacks.
As a choir sang gospel songs, and mourners raised their hands in unison, the mood among the mostly African-American crowd that gathered for the teenager's funeral was celebratory rather than somber. Much of the unrest in Ferguson, Mo., has eased in recent days, and the...


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|I seriously had the hardest time trying to put together an image for this post.
In the end I gave up and just posted the most literal pic possible :)
Earlier this week I was in DC heading to an interview. Naturally, I was dressed up and as a finishing touch, I had a Kate Spade bag slung over my shoulder.
Since I'd gotten lost earlier, I was in a rush with only 15 minutes left to get there. As I scrambled to beat the timed crosswalk, I accidentally eye contact with one of the "Green Peacers," you know, the classic "save the whales" type that stand at street corners holding pamphlets armed with an overly friendly smile. This one was a young guy who looked like a lumberjack with his plaid sweater, scruffy hat, and wild beard. There was a large pair of "librarian glasses" perched on his nose. He headed towards me, pamphlets in hand, "Hey, do you have a second to talk about sea turtles?" Usually, I'll take a minute to listen to their little elevator speech, but today I had no time for chatting.


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The Rainier Falcon Club is a diverse group of people dedicated to the restoration and preservation of the Ford Falcon automobile. Our home base is located in Seattle, Washington with a new satelite group forming in the Spokane Washington area. Both groups have meetings and tech days regularly throughout the year and invite all who are interested to participate.
Our goal is to create new friendships around our mutual interest in the Falcon -- and have a good time doing it. The accumulated knowledge of our membership is an invaluable resource if you are interested in buying a Falcon or keeping the one you have on the road.
We are an official chapter of the Falcon Club of America and welcome all who would like to be a part of our organization. We invite you to attend a meeting or event and hope you will find it worthwhile to join.
If you have any questions or comments, please contact us via email.
Current Board Members:
Eastern Washington Contact and Events Coodinator:
View a PDF document of our current chapter bylaws.


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One Dozen Pies for Pi Day
Tomorrow is 3/14, which is known among math lovers—and now bakers, too—as pi/pie day (get it? 3.14 is pi, which rhymes with...).
Since we covered this day last year, our pie archives have gotten quite a bit fatter. We had 29 entries in our Best Pie Bakeoff in November—so many beautiful, creative projects from our readers. And we've made some of our own, too. Here are 12 of our favorites.
1. Meyer Lemon Shaker Pie. The pictures of this pie always stop us in our tracks. So beautiful and sunny- and a perfect pie for this time of year.
2. Apple Blackberry Pie with Ginger. This is practically a template for any sort of fruit pie. Easy, rustic, and quick.
3. Persimmon Tart. Another one where the filling shines without a lot of added ingredients. If you can wait for your persimmons to get mushy, this is a pretty way to use them.
4. End of Summer Prune Plum Pie. "End of summer" for Sara Kate, who lives in New York. But maybe you have these little Italian plums growing in your area?
5. Bean Brulee Tart. Definitely one of the most unique pies from our Best Pie Bakeoff- creamy beans blended into a sweet filling. We still haven't tried this recipe yet, but it's on our list.
6. Candy Apple Pie. Bold and beautiful, with a graham cracker crust, layers of apples and custard, and caramel drizzled on top. Oh goodness.
7. Cherry Berry Pie. We love the decorative cutouts on the top, and cherry pie is one of those classics that we don't see as often as we'd like.
8. Rustic Pear Custard Pie. A nice departure from apples! Pear seems like such a natural ingredient for pie, especially with a custard filling.
9. Pecan and Date Pie. This was based on a Cooking Light recipe, so maybe it's less guilt-inducing? Hmm. We love the idea of dates for sweetness.
10. Nearly Instant Apple Cinnamon Mini-Tarts These make use of those little lumps of leftover dough, and they take almost no time. You can have a taste of pie without the trouble.
11. Blueberry Lavender Cream Pie. Remember this one from last year? A spectacular purple color and a fancy secret ingredient.
12. Apple apple pie. Too cool. If only we had the pastry skills for this one...
• The Cook's Illustrated Vodka Pie Crust
• Three Basic Pie Crust Recipes
(Images: See linked posts for individual photo credits; top image by Faith Durand)


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Team Fortress is a revolutionary class-based mod supporting from 2 to 4 teams in various gameplay modes of capture the flag, capture and hold, and hunted. I will try to fill this profile with as much OFFICIAL TF (no variants/mods) files I can fill.
Only registered members can share their thoughts. So come on! Join the community today (totally free - or sign in with your social account on the right) and join in the conversation.


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Follow RFF News on your cell phone. Text follow rff to 40404 you will receive txt messages with RFF News
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Guys! I'm BACK!Sorry about my sudden disappearance, you know And, I read some of your comments!
This seems unnecessarily mean. It's fine to not like a racer, but to say he let his mom down when she herself didn't think so?
I think a hero is an ordinary individual who finds strength to persevere and endure in spite of overwhelming obstacles.
Quote from: DeafRacer on March 28, 2011, 02:20:48 PMGuys! I'm BACK!Sorry about my sudden disappearance, you know And, I read some of your comments! I have a lot of respect for Georgiapeach, as such I will keep my negative comments to aminimum.you were not my favorite racer. Also, you let your mom down, twice.
Was the Race harder this time?Luke: Yes! It was much physically harder this time around. It's like pushing ourselves to the limits!Margie: It was for me, the legs were longer, the distances we had to run were farther and challenges physically harder. Why do you think you had such a hard time in the Tea Challenge?L: There were over 1,500 teacups! So it was like literally impossible to find the right one! Completely pure luck. No skills involved.Luke, what is happening psychologically during your "breakdowns" on these challenges when you get so frustrated and want to give up?L: I really hoped that we might get saved or something like that. It was hard to hear that we got eliminated.How do you respond to fans of the show who accuse your team of being unsportsmanlike?L: It probably would have been different reactions if they get to experience fatigue, hunger and paranoia. It's not easy to run the race around the world, it can be very draining.M: Everyone is entitled to their opinion, Jen, Kesha, Luke and I have all accepted our share of the responsibility for the "incident in China." We have all apologized and moved on. When you have been on the road for 20-plus days, sleep deprived, hungry all the time, fuses are short, that is all it was. We are all great friends now.What was it like competing against Kesha and Jen again?L: It was nice to bond with them again after our "push" incident and now we are friends.M: We talked to them at the airport before leaving for Australia and no one was holding a grudge. We actually helped Jen and Kesha in China. They were looking in the wrong place for the clue box, and Luke and I found it so we called to them to tell them where the box was. There are no hard feelings.Do you think Kent and Vyxsin should have faced a stiffer penalty (four hours) for missing the mandatory flight from Japan?L: I adore Kent and Vyxsin. It was the rule that we had to take a required flight and they did not follow the rule so yeah, I think they should have faced a stiffer penalty. They were only 20 minutes ahead of us when we left the pit stop in Japan so they could have made it on the required flight. I just feel bad for Jaime and Cara for getting screwed over with Kent and Vyxsin's U-Turn, that is not fair for the girls.M: That is not a decision we get to make, rules are rules and they were very lucky!Luke, in what ways has the Race been more challenging for you as a deaf person?L: To be honest, I'm navigator-challenged! That's why I drove this time since my Mom's a better navigator but it was little scary with me driving and having to look back at my Mom for the directions! It was definitely the challenge for me!
THE DEADBOLT: Luke, when you first started the leg and opened the clue, why were you disappointed to still be racing in China?LUKE ADAMS: Are you kidding me? I was ready for a new country! We ran three legs in China on our original Race and I didn't want to run a third leg again in China! I was ready to fly out to somewhere. But really, I love China. It's a beautiful country!THE DEADBOLT: How long were you at the tea table?LUKE: Four Hours! That's the longest day ever of my entire life!THE DEADBOLT: How many bowls of tea did you drink?LUKE: I have no idea! There were fifteen-hundred. So, maybe three-hundred or four-hundred? I don't know.THE DEADBOLT: Can you talk about how it became so hard and what you were feeling as it got worse?LUKE: I am not a big avid tea drinker. Well, now I am not going to drink it again ever! Actually, drinking tea for four hours was just so draining.THE DEADBOLT: Margie, how hard was it to watch Luke go through that? What were you feeling?MARGIE ADAMS: It was so painful to watch. He is always so concerned that he is letting me or the deaf community down but that couldn't be further from the truth. He was drinking tea for four hours and I am sure he felt like quitting but he wouldn't because he didn't want to let me down.THE DEADBOLT: How are you able to stay so calm for your son?MARGIE: What choice did I have? Getting upset would not have helped the situation.THE DEADBOLT: What did Herb's hug mean to both of you after such a difficult experience?LUKE: It was really sweet of him! That means a lot to me. I wasn't having an easy day so a hug from him helped a lot.MARGIE: I think Flight Time and Big Easy are the only other people on this earth that understand what Luke went through because Flight Time experienced it too. He hugged me and said he was very proud of Luke and he was surprised by his strength and he really admired him. That was one of the best moments of the race for me, he is such a great guy.THE DEADBOLT: How was this race different for both of you as compared to Season 14?LUKE: A lot of flights delays and a heart attack this season! Where did they come from? Season 14 was definitely a fast paced race. We just kept go, go going. It was much easier the first time to keep our energy going. It was tough a second time around. The fact that we had to deal with so many flight delays and long travel made it harder.MARGIE: This race was harder for me. The legs were longer, the distances we had to run were farther, and challenges physically harder.
I just feel bad for Jaime & Cara for being U-Turned by Kent & Vyxsin the girls didn't deserve that.
Hi Luke, thanks for joining us and posting here! I have a question for you.Quote I just feel bad for Jaime & Cara for being U-Turned by Kent & Vyxsin the girls didn't deserve that. You've said this in a few interviews. Given that you famously U-Turned Amanda & Kris in S14 with no regret or remorse saying that is was part of the game and fair (smart even) to use it, how can you say that your friends the Cheerleaders "didnt deserve that"?
Exclusive: Margie Adams and Luke Adams talk 'The Amazing Race'By Reality TV World staffReality TV World: Out of the 10 other teams that were there, were there any that you were surprised to see?Luke Adams: The only team that I was surprised to see was [Justin Kanew] and [Zev Glassenberg]. They didn't go that far in their season. There were few teams that lost passports!Interesting take by Luke. I guess he is a tad jealous because the new special kid Zev stole his thunder all season.
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Livingdeath wrote:Hey all
Anyone interested in signing up for Arena Pass too? Playing 50 games (win or loss) earns you the Murkimus pet and achievement. Signup starts April 10th!!
I am interested in doing it with my Warlock.
Reply here if you are interested!!
Gaijin wrote:I have some interest, but I need to know how much the arena pass will cost.
Stoddart wrote:Only reason why i am buying the Pass is for the pet
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