text:
- Research article
- Open Access
- Open Peer Review
A systematic review of methods to diagnose oral dryness and salivary gland function
© Löfgren et al.; licensee BioMed Central Ltd. 2012
- Received: 19 September 2011
- Accepted: 16 July 2012
- Published: 8 August 2012
The most advocated clinical method for diagnosing salivary dysfunction is to quantitate unstimulated and stimulated whole saliva (sialometry). Since there is an expected and wide variation in salivary flow rates among individuals, the assessment of dysfunction can be difficult. The aim of this systematic review is to evaluate the quality of the evidence for the efficacy of diagnostic methods used to identify oral dryness.
A literature search, with specific indexing terms and a hand search, was conducted for publications that described a method to diagnose oral dryness. The electronic databases of PubMed, Cochrane Library, and Web of Science were used as data sources. Four reviewers selected publications on the basis of predetermined inclusion and exclusion criteria. Data were extracted from the selected publications using a protocol. Original studies were interpreted with the aid of Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.
The database searches resulted in 224 titles and abstracts. Of these abstracts, 80 publications were judged to meet the inclusion criteria and read in full. A total of 18 original studies were judged relevant and interpreted for this review. In all studies, the results of the test method were compared to those of a reference method.
Based on the interpretation (with the aid of the QUADAS tool) it can be reported that the patient selection criteria were not clearly described and the test or reference methods were not described in sufficient detail for it to be reproduced. None of the included studies reported information on uninterpretable/intermediate results nor data on observer or instrument variation. Seven of the studies presented their results as a percentage of correct diagnoses.
The evidence for the efficacy of clinical methods to assess oral dryness is sparse and it can be stated that improved standards for the reporting of diagnostic accuracy are needed in order to assure the methodological quality of studies. There is need for effective diagnostic criteria and functional tests in order to detect those individuals with oral dryness who may require oral treatment, such as alleviation of discomfort and/or prevention of diseases.
- Salivary Gland
- Pilocarpine
- Salivary Flow
- Salivary Flow Rate
- Diagnostic Accuracy Study
Oral dryness is a complex condition, expressed as a physiological deficiency with or without perceived dysfunction. Clinically, oral dryness may vary from a slight reduction in salivary flow with transient inconvenience to severe impairment of oral health and concomitant psychological indisposition. Salivary dysfunction has mainly been related to a decrease in salivary flow rate, but the molecular composition of saliva has gained more attention in understanding the complexity of the condition. Saliva has been shown to have multi- functional characteristics as expressed by several families of salivary molecules, each comprising multiple members that are multifunctional and overlapping [1]. This explains the presence of a compensatory mechanism in saliva and that the expression of salivary dysfunction is most likely to be multi-facetted.
The prevalence of oral dryness reported in the literature varies from 10% to 80% [2–12].
Part of this variation might be explained by the fact that there is no global consensus regarding the terminology associated with oral dryness, although many authors distinguish between xerostomia, denoting the subjective feeling and hyposalivation, denoting a decreased salivary flow rate [13–17].
Oral dryness may be caused by many factors. One factor of importance is pharmacotherapy. Decreased salivary flow rate has been reported as a consequence of treatment with various types of drugs but as for the subjective feeling of oral dryness the total number of drugs taken seems to be more important [18]. No age-dependent decrease in salivary flow rate has been established [19, 20] although a higher prevalence of perceived oral dryness has been reported with increased age [18]. This might be explained by an increased intake of medication with increasing age.
Several systemic disorders such as Sjögren's syndrome, diabetes mellitus, rheumatoid arthritis, and systemic lupus erythematosus are also known to cause oral dryness. In addition, radiotherapy to the head and neck region is a factor of importance.
With regard to an increasingly elderly population and its dependent use of medication, a multitude of negative side effects associated with disturbed salivary function will present a medico-socio-economic problem not only for the individual per se but also for society in the near future.
The most advocated clinical method for diagnosing salivary gland dysfunction is to quantitate unstimulated and stimulated whole saliva flow rates (sialometry). The cut-off value for a very low unstimulated and stimulated whole saliva flow rate is claimed to be ≤ 0.1 ml/min and ≤ 0.7 ml/min, respectively which is generally referred in the literature to studies by Ericsson and Hardwick [21] and Sreebny and Valdini [4]. Attempts have also been made to correlate perceived oral dryness to salivary output with varying results. However, reports where the patients describe their oral comfort/discomfort levels, suggest weak to no correlation between measures of salivary flow rates and an individual's own subjective description [4, 22–24]. Symptoms of dry mouth often occur when the salivary flow rate is reduced by about 50%, but can also be experienced within what is regarded as the normal salivary flow rate range [25]. Unless the mouth is almost dry, without proper individual baseline information it is almost impossible to ascertain if the level of a patient's salivary flow rate is actually below 'normal'. Since there is a great variability in individual salivary flow rate and a wide range of flow rate is accepted, the accurate assessment of dysfunction can be difficult. With this in mind, it can be argued if measurements of salivary flow rates can be used as a discriminating diagnostic tool.
Ghezzi et al. [26] studied the variation of stimulated parotid and submandibular flow rates in a healthy population of adults over a six-hour period. In accordance with other investigators [25, 27], they demonstrated that salivary flow rates are not constant and that there exists a broad range of stimulated parotid and submandibular flow rates among healthy individuals. These findings were confirmed in the study by Burlage et al. [28]. They determined the variation in stimulated parotid flow rate for repeated collections. They also found a large degree of similarity between the flow rates of the left and right parotid glands in healthy subjects as well as in patients with Sjögren's syndrome.
Responses to standardized questions have been compared to objective measures of major salivary gland output in order to identify certain questions that with a high degree of reliability predict true salivary gland dysfunction [22]. The results showed that questions focusing on perceived oral dryness associated with eating were highly indicative of salivary performance whilst the most commonly heard complaints such as perceived oral dryness at night and during the day had no significant correlation with reduced salivary flow rate.
Furthermore, the individuals' assessment of the quantity of saliva as "too little" was highly predictive of decreased salivary output.
The aim of this systematic review is to evaluate the quality of the evidence for the efficacy of diagnostic methods used to identify oral dryness.
The systematic approach of the literature review was adapted according to Goodman [29] and consisted of the following steps: specification of the problem, formulation of a plan to conduct the literature search with specified indexing terms, retrieval of publications and interpretation of the evidence from the literature studied.
Specification of the problem
The following question was developed to articulate the problem: What methods are used to diagnose oral dryness and what is the efficacy of these methods?
Formulation of a plan, literature search, and retrieval
The first step of the search was to use Medical Subject Headings (MeSH) and free text words to search the electronic databases PubMed (including MeSH Subheadings and [All fields]), Cochrane Library, and Web of Science."
The following search terms were identified on the basis of Medical Subject Headings (MeSH) and within the MeSH database these terms are defined as:
Saliva: the clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth and containing mucins, water, organic salts, and ptylin.
Xerostomia: decreased salivary flow.
Diagnostic techniques and procedures: methods, procedures, and tests performed to diagnose disease, disordered function, or disability. Year introduced: 1998.
Pilocarpine: a slowly hydrolyzed muscarinic agonist with no nicotinic effects. Pilocarpine is used as a miotic and in the treatment of glaucoma.
The above mentioned MeSH terms were combined by using the Boolean operator 'OR' with free text words within a search facet.
Since this review focused on diagnostic methods and an initial search resulted in a number of publications on intervention with pilocarpine, the decision was made to confine the search by excluding those studies.
Exclusion of studies on intervention with pilocarpine was obtained by using the Boolean operator 'NOT' in the search.
Inclusion and exclusion criteria
Inclusion criteria
Exclusion criteria
Human studies
Review articles and abstracts
Oral dryness primary condition
Studies on pharmacologic intervention with sialogogues (e.g. pilocarpine)
Study population presenting symptoms and/or findings of oral dryness
Studies on the effect of radiation therapy No control group
Standardized conditions for donors
Studies where oral dryness is a secondary outcome variable
Articles written in English
The search was limited to publications with an Entrez date in the period from January 1, 1966 to February 22, 2011.
The decision to include the article was made by reading the title and the abstract. Four authors (CDL, CW, MS and CC) screened all titles and abstracts independently for possible inclusion. When an abstract was considered by at least one author to be relevant, the full text was obtained for independent assessment against the stated inclusion criteria (Table 1) with the aid of a protocol (Additional file 1: Table S1). Any disagreement was resolved by discussion among the reviewers.
The protocol used in the assessment against the stated inclusion criteria.
Will the study be included in the systematic review? Yes No.
The second step was to search by hand the reference lists of the original studies that had been found relevant in the first step. Reference lists of reviews were also searched. Titles containing words suggesting diagnostic measures and techniques of oral dryness were sought.
Inclusion and exclusion criteria were also considered in the hand search. The abstracts of the selected references were obtained and when considered relevant by at least one author, the publication was ordered in full text. Book chapters and reviews were excluded, since the search focused on original studies.
Data extraction
Data were extracted on the following items: year of publication; study objectives; study design; study population; control group; test method; reference method; and authors' conclusion.
Original studies that presented a method for diagnosing oral dryness were interpreted according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool [30].
Protocol based on the Quadas tool for interpretation of relevant original studies
Was the spectrum of patients representative of the patients who will receive the test in practice?
Were the selection criteria clearly described?
Is there a diagnostic reference standard?
If so, is the reference standard likely to correctly classify the target condition?
Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?
Did the whole sample or a random selection of sample, receive verification using a reference standard of diagnosis?
Was the execution of the index test described in sufficient detail to permit replication of the test?
Was the execution of the reference standard described in sufficient detail to permit replication of the test?
Were the index test results interpreted without knowledge of the results of the reference standard?
Were the reference standard results interpreted without knowledge of the results of the index test?
Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?
Were uninterpretable/intermediate results reported?
Were withdrawals from the study explained?
Are data presented on observer or instrument variation that could affect the estimates of test performance?
Were appropriate results presented (percentage of correct diagnoses, sensitivity, specificity, predictive values, measures of ROC, likelihood ratios, or other relevant measures) and were these calculated appropriately?
The same reviewers assessed the articles separately. Any interexaminer disagreements were resolved by discussion on each article to reach a consensus.
The database searches resulted in 224 titles and abstracts. Of these abstracts, 80 publications were judged to meet the inclusion criteria and read in full. Data were extracted according to the pre-established protocol. Animal studies and publications in a language other than English were excluded. Publications using a sialogogue (not only pilocarpine) as intervention were excluded. Furthermore, studies where oral dryness was not described as a primary condition, studies where the conditions for the donors were not standardised and studies that did not include a control group were excluded. Studies were oral dryness was a secondary outcome variable, i.e. studies reporting oral dryness as a secondary finding to e.g. treatment or medication, but not to general diseases e.g. Sjögren's syndrome, were also excluded.
This resulted in 11 original studies being considered relevant for the review. The hand search of the reference lists of 11 original studies and 20 reviews resulted in an additional 60 abstracts. After these abstracts had been read, 24 publications were selected and read in full and data were extracted. After the publications had been read in detail, seven were selected.
A total of 18 original studies were interpreted for this review [4, 31–47].
Preliminary evaluation of the included studies revealed heterogeneity with respect to inclusion criteria, test method and reference method. Consequently, it was not possible to conduct a quantitative data synthesis leading to a meta-analysis.
Study objectives and study design
Seven of the included studies [31, 33, 34, 36, 37, 43, 44] aimed at examining the potential use of different tests or a combination of tests for the diagnosis of Sjögren's syndrome. The remaining 11 studies [4, 32, 35, 38–42, 45–47] described different methods for determining salivary hypofunction.
Sixteen of the studies [31–34, 36–47] were case control studies, and two [4, 35] were cross sectional studies.
Five studies were performed in the USA [4, 31, 39, 42, 46], two in The Netherlands [36, 37], two in Sweden [32, 34], one in Egypt [33], one in Great Britain [35], one in Japan [38], one in South Korea [40], one in Spain [41], one in Denmark [43], one in France [44], one in Mexico [45] and one in Israel [47].
Study populations and control groups
Data of study populations and control groups in the studies included in the review
First author, year of publication
Study population
Control group
Al-Hashimi 1998 [31]
43 subjects:
39 age/gender/race matched healthy control subjects
−38 with pSSa
−5 with sSSb
Age and gender not stated
Almståhl 2003 [32]
39 subjects:
12 control subjects
−9 subjects with history of head and neck radiation
(10 females/2 males) with normal salivary secretion rates Mean age 54 yrs
(2 females/8 malesc)
Mean age 55 yrs
−10 subjects with pSS
(10 females)
Mean age 57 yrs
−10 subjects treated with neuroleptic injections
(4 females/6 males)
Mean age 44 yrs
–10 subjects with hyposalivation due to medication or unknown origin
(9 females/1 male)
Mean age 54 yrs
El-Miedany 1999 [33]
25 subjects:
15 healthy age-matched controls
−15 with pSS
Mean age 50 yrs
−10 with sSS
10 younger controls
(20 females/5 males)
Mean age 26.2 yrs
Mean age 48 yrs
Gender not stated
Håkansson 1994 [34]
17 subjects with pSS (15 females/2 males)
30 subjects with symptoms of dry mouth and/or eyes
Mean age 63 yrs
(21 females/9 males)
Mean age 69 yrs
12 subjects without symptoms of dry mouth and/or eyes
(6 females/6 males)
Mean age 68 yrs
Hay 1998 [35]
341 subjects:
−189 females
Age (median) 49 yrs
−152 males
Age (median) 46 yrs
First author, year of publication
Study population
Control group
Kalk 2001 [36]
100 consecutive subjects:
36 healthy subjects
−33 with pSS
(20 females/16 males)
(30 females/3 males)
Mean age 39 yrs
Mean age 51 yrs
−25 with sSS
(21 females/4 males)
Mean age 54 yrs
−42 tested negative for SS
(40 females/2 males)
Mean age 55 yrs
Kalk 2002 [37]
20 subjects:
100 subjects (from previous study reported above-see study population)
−2 with pSS
−5 with sSS
(6 females/1 male)
Mean age 62 yrs
−13 non-SS
(13 females)
Mean age 55 yrs
Kanehira 2009 [38]
9 subjects with complaints of decreased salivary flow rate
31 healthy subjects
Age and gender reported for all included subjects
(22 females/19 males)
Mean age 48.8 yrs
Kohn 1992 [39]
22 subjects:
33 healthy volunteers
−19 with pSS
(20 females/13 males)
−1 with sSS
Mean age 54.4 yrs
−2 with idiopathic xerostomia
(17 females/5 males)
Mean age 52.2 yrs
Lee 2002 [40]
20 subjects with dry mouth
20 age/gender matched healthy control subjects
(unstimulated whole saliva flow rate <0.15 ml/min)
(18 females/2 males)
(18 females/2 males)
Mean age 42.6 yrs
Mean age 43.6 yrs
First author, year of publication
Study population
Control group
López-Jornet 2006 [41]
92 subjects:
70 healthy volunteers
−61 with pSS or sSS
(35 females/35 males)
(50 females/11 males)
Mean age 40.53 yrs
Mean age 57.08 yrs
−31 displaying symptoms of oral dryness from different causes
(29 females/2 males)
Mean age 52.52 yrs
Navazesh 1992 [42]
A total of 71 subjects were included.
Approx. half with salivary gland hypofunction, defined as unstimulated whole salivary flow rate ≤0.20 ml/min
Approx. half of the total number of included subjects. Individuals with normal salivary flow rates.
(48 females/23 males)
Mean age 52 yrs
Pedersen 1999 [43]
16 subjects:
14 healthy volunteers
(14 females/2 males) meeting the 1993 European classification for pSS.
(13 females/1 male)
Mean age unclear
Mean age 50 yrs
13 healthy volunteers
(12 females/1 male)
Mean age 24 yrs
Pennec 1993 [44]
72 consecutive subjects:
14 healthy subjects
- 40 subjects with pSS
Mean age 64.7 yrs
−16 subjects with sSS
Gender not stated
−16 subjects with connective tissue disease but no evidence of sSS
(70 females/2males)
Mean age 59.4 yrs
Sánchez-Guerrero 2002 [45]
90 subjects:
152 healthy subjects
−30 subjects with pSS
(106 females/46 males)
(29 females/1 male)
Mean age 35.2 yrs
Mean age 50.6 yrs
−60 subjects with CTDs without SS
(50 females/10 males)
Mean age 37.4 yrs
First author, year of publication
Study population
Control group
Sreebny 1988 [4]
151 subjects with reported dry mouth
372 subjects without reported dry mouth
(109 females/42 males)
(219 females/159 males)
Age range 18–55+
Age range 18–55+
Wolff 1998 [46]
50 subjects:
25 subjects with no perception of dry mouth and no medication with resting salivary flow rates > 1.0 ml/min
−25 subjects with complaints of 'dry mouth' due to medication, with resting salivary flow rates ≤0.1 ml/min
(15 females/10 males) Mean age 44
(20 females/5 males)
Mean age 48.5
−25 subjects with complaints of 'dry mouth' due to medication, with resting salivary flow rates > 0.1 ml/min
(18/females/7 males)
Mean age 49.2
Wolff 2002 [47]
27 subjects with complaints of dry mouth
32 healthy subjects
Age and gender not stated
Age and gender not stated
The control groups consisted mainly of age- and gender-matched healthy individuals. In two studies, the control group consisted of individuals with normal salivary secretion rates [32, 42]. One study [34] included individuals with symptoms of dry mouth in the control group, and in one study [37] the control group consisted of individuals with Sjögren's syndrome.
The number of included individuals in the study populations varied between 16 and 341 and in the control groups between 12 and 372.
Two studies did not report age and gender [31, 47] for individuals included in the study populations or control groups. Two studies [33, 44] did not state gender for individuals included in the control groups. Two studies [38, 42] reported age and gender for all included subjects.
The female/male ratio in the study populations 783/273 [4, 32–37, 39–41, 43–45, 47] and control groups were and 586/309 [4, 32, 34, 36, 37, 39–41, 43, 45, 46], respectively.
Index test methods and reference methods
Data of index test methods and reference methods in the studies included in the review
First author, year of publication
Test method
Reference method
Authors' conclusion
Al-Hashimi 1998 [31]
3 different gel electrophoresis systems
European Community criteria for the diagnosis of Sjögren's syndrome [42]
Salivary electrophoresis is a potentially useful test for the diagnosing of Sjögren's syndrome
▪immobilized pH gradient (IPG)
Almståhl 2003 [32]
The Copenhagen criteria for Sjögren's syndrome [47]
The concentrations of electrolytes in stimulated whole saliva, in individuals with hyposalivation, seem to be more related to the reason for the hyposalivation than to the salivary secretion rate.
El-Miedany 1999 [33]
Salivary smears
Criteria of Fox et al. for Sjögren's syndrome [48]
The saliva ferning test is a useful diagnostic aid in autoimmune xerostomia, approx equivalent to Shrimer's test in xeropthalmia
Håkansson 1994 [34]
▪Copenhagen criteria for pSS [47]
Salivary gland scintigraphy is a sensitive and valid method to measure salivary gland function and abnormalities
▪Shrimer-1 test
▪van Bijsterveld score
▪Tear-film break-up time
Hay 1998 [35]
Only weak associations were found between self-reported symptoms of dry eyes and dry mouth and objective measures said to define Sjögren's syndrome in the general population
▪Shrimer-1 test
▪Measurement of antibodies (ELISA, indirect immunofluorescence, Latex test)
Kalk 2001 [36]
Glandular sialometry and sialochemistry are not useful tools for differentiating SS from other salivary gland disease.
Parotid sialography was used to fulfill the criteria on the oral component.
Kalk 2002 [37]
Gland-specific sialometry and sialochemistry may eventually replace other, more invasive, diagnostic techniques for diagnosing SS.
Parotid sialography was used to fulfill the criteria on the oral component.
Kanehira 2009 [38]
Filter paper comprising 3 spots containing 30 μg starch and 49.6 μg potassium iodide per spot.
Sialometry (unstimulated whole saliva < 0.1 ml/min)a
This screening technique might be effective for estimation of salivary flow.
Kohn 1992 [39]
Sialometry (Unstimulated parotid and SM/SL < 0.1 ml/min Stimulated parotid and SM/SL < 0.6 ml/min)*
Salivary gland scintigraphy is a useful method in assessing salivary gland flow rates
Lee 2002 [40]
▪Oral mucosal wetness
Sialometry (unstimulated whole saliva <0.15 ml/min) a
Measurements of oral mucosal wetness could be thought of as one of the diagnostic methods for assessing dry mouth.
(SialopaperTM Periotron 8000®)
López-Jornet 2006 [41]
Oral Schirmer's test
Revised European classification criteria for SS [46]
Oral Shrimer's test can be used as a simple, objective test to diagnose salivary gland hypofunction.
Navazesh 1992 [42]
▪Lip dryness
Sialometry (unstimulated whole saliva ≤0.20 ml/min) a
Four clinical measures that together predict the presence of or absence of salivary gland hypofunction were identified: dryness of lips, dryness of buccal mucosa, absence of saliva produced by gland palpation, and total DMFT.
▪Buccal mucosal dryness
▪Salivary pool
▪Major salivary gland palpation
▪Tongue mucosa
▪Total DMFT
Pedersen 1999 [43]
European classification for pSS [42]
Rating of oral dryness by visual analogue scales or categorised questionnaires are valuable for the evaluation of oral involvement in pSS.
▪Labial salivary gland biopsy
▪Serological examination
▪Categorised questionnaire
Pennec 1993 [44]
European classification for pSS [42]
The most efficient combination of tests for the oral component of SS appears to be salivary gland scintigraphy plus saliva flow rate or salivary lactoferrin.
▪Salivary lysozyme
▪Salivary lactofferin
▪Parotic sialography
▪Salivary gland scintigraphy (99mTc)
▪Labial salivary gland biopsy
Sánchez-Guerrero 2002 [45]
Wafer test
For the oral component parotid secretion rate according to Fox et al. [48]
The wafer test is valid and reliable for identifying subjects with xerostomia
▪European questionnaire for sicca syndrome
▪Schirmer-1 test
Sreebny 1988 [4]
Sialometry (unstimulated whole saliva ≤ 0.1 ml/min) a
Dry mouth and several other symptoms are common in an outpatient population and they are a valid indicator of salivary gland hypofunction
Wolff 1998 [46]
Oral mucosal wetness(SialopaperTM Periotron 6000®)
Sialometry (unstimulated whole saliva ≤ 0.1 ml/min) a Salivary pH
Measurement of palatal mucosal wetness might be useful in assessing medication compliance and may serve as a guide to medication administration.
Wolff 2002 [47]
3-g-all-sucrose candy
Sialometry (unstimulated SM/SL < 0.1 ml/min + either stimulated parotid <0.25 ml/min or stimulated SM/SL < 0.15 ml/min) a
The candy weight-loss test is a measure of salivary hypofunction, which correlates with saliva output and reports of subjective dry mouth
- (1)
Secretion tests; including sialometry and sialochemistry,Oral Schirmer's test, secretion composition using protein separation techniques, total protein content, electrolyte content and specific protein content with immunological tests or iodine starch reactions (amylase) [31, 32, 36–38, 41]
- (2)
Mucosal/surface tests; including mucosal dryness/residual wetness tests, salivary smears and biopsies [33, 46]
- (3)
- (4)
- (5)
Salivary secretions used as reference method in the included studies
First author, year of publication
Al-Hashimi 1998 [31]
Stimulated parotid saliva (2%citric acid)
Almståhl 2003 [32]
Unstimulated whole saliva
El-Miedany 1999 [33]
Unstimulated whole saliva
Håkansson 1994 [34]
Unstimulated whole saliva
Hay 1998 [35]
Unstimulated whole saliva
Kalk 2001 [36]
Unstimulated and stimulated (2% citric acid) parotid and SM/SL saliva
Kalk 2002 [37]
Unstimulated and stimulated (2% citric acid)parotid and SM/SL saliva
Kanehira 2009 [38]
Unstimulated whole saliva
Kohn 1992 [39]
Unstimulated and stimulated (2% citric acid) parotid and SM/SL saliva
Lee 2002 [40]
Unstimulated whole saliva
López-Jornet 2006 [41]
Unstimulated and stimulated (4% citric acid) whole saliva
Navazesh 1992 [42]
Unstimulated and stimulated (inert gum base) whole saliva and stimulated (candy-stimulated and acid-stimulated 0.15 mol/L citric acid) parotid saliva.
Pedersen 1999 [43]
Unstimulated whole saliva
Pennec 1993 [44]
Unstimulated whole saliva
Sánchez-Guerrero 2002 [45]
Unstimulated whole saliva
Sreebny 1988 [4]
Unstimulated and stimulated (paraffin) whole saliva
Wolff 1998 [46]
Unstimulated whole saliva
Wolff 2002 [47]
Unstimulated and stimulated (2% citric acid) parotid and SM/SL saliva
Eleven of the included studies [31–37, 41, 43–45] used established criteria for the classification of Sjögren's syndrome as reference methods. Seven of these studies [31, 35–37, 41, 43, 44] used the European Community Study Group on diagnostic criteria for Sjögren's syndrome as reference method [48–52]. Two studies [32, 34] used the Copenhagen Criteria for the classification of Sjögren's syndrome [53] as reference method and two studies [33, 45] used the proposed criteria for Sjögren's syndrome according to Fox et al. [54] as a reference method. The cut-off values defining salivary gland hypofunction in the studies not using the above mentioned reference methods are presented in Table 4.
Diagnostic accuracy
In all studies, the results of the test method were compared to those of a reference method [4, 31–47]. These studies were interpreted according to the protocol based on the QUADAS tool [30].
Seven of the included studies [4, 31, 37, 41, 44, 45, 47] presented their results as a percentage of correct diagnoses.
Secretion tests
One study [31] examined the application of three different gel electrophoresis systems (SDS-PAGE, anionic-PAGE, immobilized pH gradient (IPG)) in the diagnosis of Sjögren's syndrome. Tests of accuracy revealed that the immobilized pH grading system had a specificity of 97%, sensitivity of 95%, positive predictive value of 97% and negative predictive value of 95% in the diagnosis of Sjögren's syndrome.
In the study by Kalk et al. [37], reference values of several salivary variables, i.e. sodium, chloride and phosphate concentration in stimulated parotid and submandibular/sublingual saliva, unstimulated and stimulated submandibular/sublingual flow rates and lag phase of parotid secretion were defined in order to diagnose Sjögren's syndrome. The most accurate test, with a sensitivity of 85% and specificity of 96%, combined stimulated submandibular/sublingual flow rate and parotid sodium and chloride concentration.
Oral Schirmer's test was used as test method in one study [41] for detecting salivary gland hypofunction. Cut-off values for the unstimulated test (≤ 30 mm/5 min, ≤ 40 mm/5 min, ≤ 50 mm/5 min, ≤ 60 mm/5 min), and for the stimulated test (≤ 50 mm/5 min, ≤ 60 mm/5 min, ≤ 70 mm/5 min, ≤ 80 mm/5 min) were examined and sensitivity, specificity, positive predictive values and negative predictive values were calculated. A cut-off value of ≤30 mm/5 min for the unstimulated sialometric test using Oral Shirmer's test provided a sensitivity of 67.9% and a specificity of 62.8%. A cut-off value of ≤ 80 mm/5 min for the stimulated test showed a sensitivity of 87.6%, specificity of 67.5%, positive predictive value of 55.7% and a negative predictive value of 7.8%.
Functional tests
A wafer test was used as a test method in one study [45] to predict early salivary gland dysfunction and xerostomia. Different cut-off values (3–7 min) were examined and the best balance between sensitivity and specificity was seen with a cut-off value of 4 min (wafer 4). This cut-off value exhibited a sensitivity of 92.9%, specificity of 71.7%, positive predictive value of 31.7%, negative predictive value of 98.6% and accuracy of 74.3%. With increasing time, the specificity for reduced salivary flow increased. Wafer 4 was compared with the European questionnaire [48] in order to validate the test as a screening instrument for low salivary flow and xerostomia. For low salivary flow, the European questionnaire [48] and the wafer 4 showed identical sensitivity. However, wafer 4 showed higher specificity, positive predictive value, negative predictive value, and accuracy. For xerostomia, wafer 4 showed higher sensitivity and negative predictive value when compared to the European questionnaire [48].
An indirect method (candy weight loss) was used as a test method in one study [47] to determine salivary output level. Significant associations were found when comparing candy weight loss with stimulated parotid and submandibular and sublingual saliva. When using a cut-off value of 0.23 g candy loss, the sensitivity was 92%, specificity 85% and the positive predictive value 82%.
Sreebny and Valdini [4] determined the validity of using symptoms related to dry mouth by using a questionnaire, to screen patients for salivary gland hypofunction. The study population was classified into three groups according to their ability to produce unstimulated whole saliva. Flow rates of ≤ 0.1 ml/min were characterised as "abnormal", between 0.11 and 0.2 ml/min as "low normal", and > 0.2 ml/min as "normal". Determinations of sensitivity, specificity and negative and positive predictive values were made for xerostomia alone and for xerostomia in combination with three symptoms that were closely associated with it. A positive answer to the question "Does your mouth usually feel dry" showed a sensitivity of 93%, specificity of 68%, positive predictive value of 54% and negative predictive value of 98%. When an additional three symptoms were taken into account (difficulty with speech, trying to keep mouth moist and getting out of bed to drink), the specificity increased to 91% and the positive predictive value increased to 75%.
Secretion/glandular morphology
A combination of tests for the classification of the oral component of Sjögren's syndrome was examined in the study by Pennec et al. [44]. The tests examined were salivary flow rate (unstimulated whole saliva), salivary lysozyme, salivary lactoferrin, sialography, salivary gland scintigraphy and labial salivary gland biopsy. The authors concluded that the most efficient combination of test for the oral component of Sjögren's syndrome was salivary gland biopsy (sensitivity 95%, specificity 75%, positive predictive value 90%, negative predictive value 14%) plus salivary flow rate (sensitivity 68%, specificity 81%, positive predictive value 90%, negative predictive value 50%) or salivary lactoferrin (sensitivity 58%, specificity 75%, positive predictive value 82%, negative predictive value 53%).
The aim of systematic reviews is to identify and evaluate all available research evidence relating to a particular objective. An essential part of any systematic review is the quality assessment of individual studies. Aspects such as study design, methods of sample recruitment, the execution of the tests and the completeness of the study report relate to the overall quality. The results of a systematic review will be biased if the results of individual studies are synthesised without any consideration of quality in terms of potential for bias, lack of applicability and the quality of reporting.
QUADAS [30] was the first systematically developed, evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. The QUADAS tool [30] contains a detailed explanation of the intention of each item, situations when the item does not apply and how to score items. This allows for minor adaptations in specific areas. The QUADAS tool [30] does not incorporate quality scores to assess the level of evidence. Since the importance of individual items and their potential biases may vary according to the context in which they are applied, incorporation of quality scores into the results of a review may generate different magnitudes of bias and lead to different conclusions regarding the effect of study quality on estimates of diagnostic accuracy. Instead, it has been proposed that a systematic review should involve a component approach, where the association of individual quality items with test accuracy are investigated individually [55].
The QUADAS tool [30] was used in the present systematic review since it is a standardised approach to quality assessment and since the criteria needed to assess the quality of diagnostic test evaluations differ from those needed to assess evaluations of therapeutic interventions [56].
In the present review, modifications were done to adapt the QUADAS tool [30] to better correspond to the objectives of the study. Two questions (numbers 6 and 7) were excluded from the 14 questions of the final QUADAS tool [30] and two were added from the original list of 28. In addition, question number 3 was modified into two sub-questions.
When interpreting the studies with the aid of the QUADAS tool [30] it could be established that some studies showed shortcomings in describing the selection criteria clearly and in describing the test method or the reference method in such detail that it could be reproduced. A sufficient description of the tests is important since variations in measures of diagnostic accuracy can be traced back to differences in the execution of the tests. A clear description is also needed in order to implement the test in another setting. None of the included studies reported uninterpretable/intermediate results or data on observer or instrument variation. A diagnostic test can produce uninterpretable/intermediate results with varying frequency. If these results are removed from the analysis, it may lead to biased assessments of the test characteristics. Furthermore, it can be questioned if some of the studies presented appropriate results.
When scoring QUADAS items [30] as unclear it is difficult to be certain if this indicates poor methods with the attendant consequences for bias and/or variation, or simply poor reporting of a methodologically sound study. The STARD initiative [57] has proposed standards for the reporting of diagnostic accuracy studies. If these standards are widely adopted, reviewers might be able to assess methodological quality rather than the quality of reporting. The aim of test accuracy studies is to assess how well a test can distinguish between subjects with and without the disease/condition of interest. There are two basic types of test accuracy study: (1) The single-gate design which includes participants in whom the disease status is unknown, and compares the results of the index test with those of a reference standard used to confirm diagnosis. This design is broadly representative of the setting in which the test would be used in practice. (2) The two-gate design compares the results of the index test in patients with an established diagnosis of the target condition with its results in healthy controls or controls with another diagnosis. This design has inherent problems that may lead to bias. The inclusion of healthy controls is likely to lead to over estimations of specificity and the selective inclusion of cases with more advanced disease is likely to lead to over estimations of sensitivity [58]. The two-gate studies can however be useful in the earlier phases of test development.
Addressing the question formulated to specify the problem, it can be concluded that whilst a variety of tests to diagnose oral dryness have been examined, only a few have been validated in terms of diagnostic accuracy. Eight of the included studies presented their results as percentage of correct diagnoses. Four of these studies used European Community Study Group on classification criteria for Sjögren's syndrome [48–52] as reference method. The European classification criteria for Sjögren's syndrome were developed and validated between 1989 and 1996 and have received broad acceptance by the scientific community. Since the reference standard is an important determinant of the diagnostic accuracy of a test, it raises the question of why all of studies aimed at the evaluation of tests for the diagnosis of Sjögren's syndrome did not use the same reference method.
Although these criteria have received a broad acceptance, some criticism has been raised concerning the inclusion of subjective test (symptoms), physiologic measures that lack specificity and alternate objective tests that are not diagnostically equivalent.
Recently, the American College of Rheumatology [59] proposed new classification criteria for Sjögren's syndrome. These criteria are based on expert opinion elicited using the nominal group technique and analyses of data from the Sjögren's International Collaborative Clinical Alliance [60]. The proposed criteria are: 1) positive serum anti-SSA and/or anti-SSB or (positive rheumatoid factor and antinuclear antibody titer ≥1:320), 2) ocular staining score ≥3, or 3) presence of focal lymphocytic sialadenitis with a focus score ≥1 focus/4 mm2 in salivary gland biopsy samples. Case definition requires at least 2 of the 3 above mentioned objective features. Thus, only objective tests and not subjective tests (symptoms) are included since symptoms of dry mouth and/or eyes can lead to misclassification of asymptomatic patients. For the salivary and ocular phenotypic features of Sjögren's syndrome the results did not identify any suitable alternate tests besides labial salivary gland biopsy. While unstimulated salivary flow rate <0.1 ml/min had good sensitivity, it had low specificity compared to the labial salivary gland biopsy to measure focal lymphocytic sialadenitis with a focus score ≥1 [59]. Seven of the studies interpreted in this review evaluated different tests for determining decreased salivary flow and used sialometry as a reference method. These studies revealed heterogeneity with respect to source of secretion whether unstimulated or stimulated. Cut-off values defining salivary gland hypofunction also varied. As stated earlier, without proper individual baseline information, it is almost impossible to ascertain if the level of a patient's salivary flow rate is below the 'normal'. When using sialometry for diagnosing salivary dysfunction it can be argued if the method is used as a diagnostic tool or rather as a verification of an already established condition. Sreebny [61] proposed that the low cut-off values should be viewed as values which "flag" or "raise suspicion" about the presence of a disease. They do not indicate that the person who demonstrates such values definitely has a disease.
The fact that there is no global consensus regarding the terminology of oral dryness, although many authors distinguish between xerostomia, denoting the subjective feeling, and hyposalivation, denoting a decreased salivary flow rate, creates a problem for research, diagnosis, and therapy. As for research, this problem is illustrated when using Medical Subject Headings (MeSH). MeSH is the National Library of Medicine's controlled vocabulary thesaurus used for indexing articles for PubMed. The MeSH database defines xerostomia as decreased salivary flow, which is incorrect since a sensation of oral dryness can occur in subjects with a normal salivary flow. Nederfors [12] proposed to divide the term "salivary gland hypofunction" into 3 different entities: xerostomia, denoting the subjective feeling; hyposalivation, denoting the decreased salivary flow rate; and altered saliva composition. This classification accepts that xerostomia may exist without signs of hyposalivation, that hyposalivation may be a symptomless condition and that an altered saliva composition may exist even if the saliva secretion rate is unaffected and without subjective symptoms. These three entities are inter-related and can influence each other in different ways.
Over the last decade, advances have been made regarding proteomic and genomic approaches to identify potential biomarkers that may be used in the detection of different diseases, e.g. Sjögren's syndrome [62]. Saliva is a biofluid that is readily accessible via noninvasive methods, and therefore a perfect medium to be explored for purposes to monitor health status, disease onset and progression, and treatment outcome. Salivary diagnostic technologies identifying specific biomarkers associated with disease may in the future be used to verify general diseases behind salivary gland hypofunction [63]. It should also be mentioned that in the absence of an efficient treatment, a diagnostic method has little value. The basic causes of oral dryness are difficult to treat and many methods have been tested to stimulate saliva secretion and ease the patient's discomfort, e.g., saliva-stimulating tablets and artificial saliva. Several studies have evaluated the efficacy of such preparations but there is no documented evidence of their effect on oral health [64–66].
Currently, diagnostic methods are addressing quantity and content of saliva in bulk and few qualitative tests of saliva, in bulk or of saliva as an adsorbed thin film, are at this date available for describing the protective functions of saliva.
Since changes in the protective functions of saliva may occur, there is a need for effective diagnostic criteria and functional tests in order to discern which individuals with oral dryness will require oral treatment, such as alleviation of discomfort and/or prevention of diseases.
An important component in determining the usefulness of a test is the evaluation of the diagnostic accuracy, but the clinical value lies in improving a patient's condition or health. The clinical value, i.e. how the results of a test affects the clinical decision-making and the effect on the patient's wellbeing are important factors when evaluating diagnostic tests or methods. A method with high diagnostic accuracy may not always be efficient and useful for the patient. Studies that investigate the value of diagnostic interventions are scarce and seldom available for new test methods. In addition, appropriate reference standards for many disorders are lacking.
The aim of this systematic review was to evaluate the quality of evidence for diagnostic methods used to identify oral dryness and their clinical application.
After assessing the quality of the retrieved studies, it may be concluded that the evidence for the efficacy of clinical methods to assess oral dryness is sparse. When evaluating the retrieved studies by using the QUADAS tool [30], many of the studies exhibited shortcomings. Standards for the reporting of diagnostic accuracy studies have been suggested, such as the STARD initiative [30]. If these standards are widely adopted, the quality of reporting will be improved and the methodological quality of diagnostic accuracy studies will be easier to assess. This will, as a consequence, benefit patients.
A global consensus regarding the terminology of oral dryness is needed in order to facilitate diagnosis and treatment and continued research.
Changes in the protective functions of saliva may occur, which might affect oral health.
There is a need for effective diagnostic criteria and functional tests in order to detect those individuals with oral dryness who may require treatment, such as alleviation of discomfort and/or prevention of diseases.
This study was supported by the Faculty of Odontology, Malmö University and the Swedish Dental Society.
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Pre-publication history
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Cardi B's much-anticipated debut album will arrive in just a week and a half. Titled Invasion of Privacy, it's out on April 6. Cardi made the announcement and unveiled the cover art via Instagram, which you can see below. She'll be the musical guest on Saturday Night Live the following night, with Black Panther's Chadwick Boseman hosting.
The lineup for the 2018 Pilgrimage Festival in Nashville has been unveiled, with Jack White, Chris Stapleton and Lionel Richie headlining the eclectic event. Set for September 22-23 at The Park at Harlinsdale in Franklin, TN, the lineup also includes Hozier, Brandi Carlile, Counting Crows, Bleachers, Dawes, Amos Lee, Elle King and many more.
Brooklyn's Afropunk Festival will be headlined by Erykah Badu, Janelle Monae and Tyler the Creator. The two-day event will take place at Brooklyn's Commodore Barry Park in Fort Greene on August 25 and 26 and also include performances from Miguel, The Internet, H.E.R., Jaden & Willow Smith and many others.
Chris Brown has announced his upcoming Heartbreak on a Full Moon Tour, with special guests 6lack, H.E.R. and Rich the Kid. The trek begins in Seattle on July 19 and runs up to August 4 in Las Vegas.

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By Dan Lieberman, @LiebermanTweets
Sunnyvale Art & Wine: We're in Art & Wine Festival season on the Peninsula, delighting fans of day drinking and looking at things. This weekend marks Sunnyvale's turn, with Murphy Avenue hosting more than 350 artists, live music, and a selection of beer, wine, champagne, sangria and icy margaritas. The Festival is happening practically on top of the Sunnyvale Caltrain Station, making this an easy weekend destination.
Augmented World Expo: Do you want to be a neuromancer? Then come to the Augmented World Expo 2017 on Wednesday, May 31, and find out how. The Santa Clara Convention Center hosts the world's largest conference dedicated to augmented, virtual & mixed reality. Approximately 250 speakers and 200 startups will be showing off AR and VR toys and tech that may well end up changing the world and redefining how we interact with reality. Hop on Caltrain to the Mountain View Caltrain Station and catch the VTA 902, and question whether that's air you're breathing now.
Nippon Nights at the Roxie: You don't need to have a Ninja Turtle tramp stamp to think that samurai are cool (don't judge me). So get yourself up to the Roxie Theater Wednesday, May 31, and watch Zatoichi Meets Yojimbo, which brings Shintaro Katsu's blind masseuse with a cane sword together with Toshiro Mifune's Clint Eastwood-inspiring nameless ronin as they do badass things. Take Caltrain to the 16th & Mission BART Station and achieve a zen-like calm
TA 101 Managed Lanes Meetings: The San Mateo County Transportation Authority, along with Caltrans and the City/County Association of Governments of San Mateo County (C/CAG), will be hosting two public community meetings to present a proposed Managed Lanes Project on U.S. 101 in Northern Santa Clara County and San Mateo County. The first meeting will be held at 6:30 p.m. on Wednesday, May 31, at San Mateo City Hall, and the second meeting will be held at 6:30 p.m. on Monday, June 5, at Redwood City's City Hall. For more information, click HERE.


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"If they were trying to make this seem like less of a partisan exercise, they're doing a horrendous job of it."
House Republicans gave right-wing media outlets early access to their anti-FBI smear document after its release was authorized by Donald Trump, and they're already paying a price for it.
Before the memo authored by Rep. Devin Nunes (R-CA) was released to the public, or even the media at large, Fox News and the Washington Examiner were treated to an early look at the factually suspect document.
The selective leaking strategy echoes previous right-wing smear campaigns, including the Republican-led investigations of the Benghazi attack, which were repeatedly handed off to Fox News and other conservative outlets.
Journalists quickly pointed out that releasing the information this way showed that the story over the memo originally fueled by right-wing media innuendo and paranoia is just another disinformation campaign.
NBC's Chuck Todd pointed out just how badly Republicans had already botched the roll-out of their memo with this strategy.
"The House Republican intel folks are actually making their partisan case look even worse right now," he said, "because they're releasing excerpts of a memo already to friendly media outlets, almost trying to build a narrative and control headlines, the early headlines and create this, you know, help feed a feeding frenzy."
Todd further explained that "it only lessens the impact of the memo itself because the whole thing just smacks of a partisan exercise how they wrote the memo, how they release the memo, and even now, it's being released to the public, but some people get the memo first, from friendly media outlets."
Perhaps the most devastating condemnation of all was Todd's conclusion: "This is what a campaign would do, not somebody who truly, not an entity that cared about the rule of law and trying to be above politics."
Similarly, The Daily Beast's Sam Stein wrote, "If you have a bombshell memo that is existential in its exposure of corruption at the highest levels of the FBI then you dont release exclusive excerpts to one (partisan) outlet. You let the details stand on their own."
By releasing the document through outlets likely to give its contents the most favorable reading, Republicans gave up the game they have been playing.
The FBI and international intelligence agencies, along with Democratic leaders, have been concerned about the release. Republicans, obsessed with defending Trump, continued to push for it.
But they clearly knew the contents would not withstand scrutiny from real journalists. So, they turned to Fox News and their other propaganda allies.
Trump is under investigation by the special counsel and the FBI for his campaign's activities with Russian operatives during the election. There have been convictions and indictments.
The GOP's sloppy memo, released to their media allies as part of an anti-FBI smear campaign, does not change a single fact in that equation.


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The central precinct contains the spine road which connects the terminal with the entrance gateway to State Highway 21.
From the Council reticulated water supply and sewage network to the full high voltage power cabling and high capacity sub station (which is located within the Park itself), the infrastructure is world class.
The roading and access network have been designed to accommodate heavy traffic and to ensure congestion does not become an issue. And when it comes to future proofing your communications - Titanium Park has been designed to incorporate best of class communication infrastructure with high speed fibre optic cabling to every business.
One of the benefits of Titanium Park being under single ownership and master planned is that lot boundaries are flexible. Accordingly lot sizes can be customised to meet occupants needs.


text: All Ruff R286 wheels purchased through our websites carry the manufacturer's warranties. Since we are a licensed distributor of Ruff R286 wheels, you can rest asured that all Ruff R286 wheels are first line wheels and never blemed Ruff R286 rims. Ruff R286 wheels can be built into a wheel and tire package to fit your car, truck, or SUV. All Ruff R286 wheel and tire packages come with free road force balancing. Most wheels come with polished or chrome lips, which gives the wheel a forged look. Ruff R286 wheels are available in different finishes and, where applicable, custom paint jobs. While looking for Ruff R286 wheels, you can use our custom wheel fitment guide to match up the Ruff R286 wheels to your vehicle. If you are looking for Ruff R286 black wheels and they are not available, they can be custom painted. Typically, we can mount over-sized truck tires on your Ruff R286 truck wheels. For Ruff R286 car rims, we would use high-performance car tires. When you buy Ruff R286 wheel through our websites, we make the process simple and painless. We are the number on wholesaler of Ruff R286 custom wheels on the internet. You can call us toll-free to order your Ruff R286 rims today!


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This article, Zan Jr/Five Traits, is a Role-Play article.
This is the Five Traits of Zan.
Wisdom is the smartess of the Five traits. He is all of Zan's wisdom into one. Wisdom excels in Fire Release, and Earth Release.
Wisdom's techniques
Speed is the fastest of the Five traits, he is all of Zan's speed put into one man. Speed excels in Lighting, and Crystal Release.
Speed's Technqiues
Strength is all of Zan's strength into one body. Strength excels in Water, and Earth Release.
Strength's Technqiues
- Water Release: Water Encampment Wall
- and more
Strategy is all of Zan's strategy, and fighting plans into one single body. Strategy excels in Fire, and Lightning Release.
Strategy's Technqiues
Life is the strongest of the five traits, havintg more chakra/ki than the others. Life is all of the Life spirit, inside of Zan into one body. Life Excels in Wood, and Earth Release.
Life's Technqiues
- Wood Release: Wood Locking Wall
- and more


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This summer, I received the most amazing opportunity to intern with Phillip Anderson, a Princeton physicist. In 1977, he won the Nobel Prize for the Anderson Localization Theory, a concept that explains why insulators are insulators.My task was to read a draft of a book he was writing on the history of high temperature super conductors.
The more I read of Professor Anderson's writing,the more interested I became in his life story. Books and interview transcripts wrote mostly of his physics career, which is oftentimes incomprehensible to the average person.I wanted to be able to understand him. He may be called the God of Princeton, but he was a person just like the rest of us.
As a little kid, he was known as a "bad boy", having gained this reputation to by throwing a cabbage out the window and copying answers. But as he matured and adjusted to school, things became easy for him.He particularly enjoyed math in his high school in Urbana, Illinois; the kids in his class were all very competitive and made a sport out of racing each other to finish the problems.
Though he admitted that school was relatively easy, at every phase of transition, "there would be a period of getting into it [because]no one is successful at all stages."
At sixteen, he embodied the dream of any high school kid after receiving a full-support national scholarship from Harvard. It was evident that he was brilliant, but college was an abrupt change.
"Well, as I said, high school was easy and Harvard wasn't," he recounts.Phil came from an academic family; it was a given that Andersons always got A's. In high school, if his A dipped to an A-, he would immediately start working very hard in that class, but overall, high school was easy. College was a completely different story.
"I started getting A-'s and B's right off the bat," he recounted.
Physics class was an especially radical change for him. He had previously learned that physics was qualitative; the students at his high school were given apparatus to play with but no one had ever explained to him that physics could quantitatively explain everything.
However, his apathy towards high school academic physics didn't belie his true attitude towards the discipline. He had read some books on relativity and was immediately intrigued.
"So I was already a physicist but I didn't know it," he commented.
He said the turning point was then he read a textbook and correctly derived Maxwell's Distribution in his head.
"I was gone," he recalled. "I had been intrigued by physics before but I didn't know it was physics I had been intrigued by."
As someone who went to college as a sixteen year old, he was bound to have a profusion of advice for high school kids on transitioning and adjusting to college life.
He laughed in response. "Well, my advice would be worthless because I didn't adjust very well. I didn't really adjust that first year."
Perhaps it was his age. His freshman year wasn't the glamorous party college was made out to be.
"I remember going over to the dining hall and seeing all the people gathered in groups chattering gaily," he said,"And I would be sitting alone or with my college roommate. It was kind of lonely. There were no girls around and I didn't know how to approach girls."
However, just as he had worked hard in physics and immediately began to understand it, so too college life seemed to become easier. In his sophomore year, all his courses seemed simpler and he spent a lot of time having fun with friends. From then on, he coasted through Harvard.
After a wartime stint at a naval radar research lab from 1943 to 1945, he returned back to Harvard for graduate school. It was during his graduate studies that he met Joyce, his wife of 67 years.They met when Phil was home from graduate school one spring. She was living on a secretary's salary at that time, so Anderson recounts she was glad to be given a free dinner.
"Well, I think it was a done thing by the end of the day," he smiled. "Certainly my mind never changed."
Six weeks later,Joyce gave up her career to marry Phillip Anderson and support him in his pursuits in physics.
Though he didn't follow his own advice, Professor Anderson advised students to do"physics related summers, summer studies or [take]an internship somewhere" if they wished to pursue a physics career.
Now 90 years old, he still drives to work every day. His passion and dedication to physics make him an inspiring figure for aspiring physicists and other people as well. Through the story of his life, we can understand Phillip Anderson, not only as a physicist or the God of Princeton, but also as a human being.
This article originally appeared in the December 2014 issue of UNIT-E. It was written by Kaylee Ding, a student at the International School of Beijing.
About UNIT-E
UNIT-E was founded in the spring of 2010 with the aim of establishing a non-profit, student-run magazine for international students in Beijing. Staffed by current students from a range of international schools, the magazine provides an amalgam of cultural tidbits, fragments of Beijing student life, and a broad spectrum of unique perspectives from a diverse group of young adults.
Photo: Princeton University


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This relish has a delicious earthy beetroot flavour. It is the perfect accompaniment to any sandwich and it is also excellent served with goat's cheese.
Typical values per 100g
Beetroot (32%), Sugar, Water, Onions, Gherkins, Red Peppers, Concentrated Tomato Paste (2.5%), Modified Cornfour, Mustard Seeds, Acetic Acid, Salt, Spice Extracts, Celery Extract. Contains: Mustard, Celery.


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Blue Lamb Furnishings of Newburyport, MA has been redesigning and refinishing vintage furniture since 2012. Phil and Lauren Santoro established Blue Lamb after realizing a shared passion for reviving mid-century relics. Our pieces can be purchased at Salt & Grove in downtown Newburyport, MA, or at The Barn at Todd Farm in Rowley, MA. Contact us at (781) 799-3148 or via email at firstname.lastname@example.com.
Thursday, June 9, 2016
White + Wood MCM Lowboy - SOLD
This sleek white + wood triple dresser was part of a bedroom set that was manufactured in 1966 by the Ward Furniture Manufacturing Company. We love the clean lines, uniquely sculpted wooden drawer pulls, and beautiful wood grain. We restored the wooden surfaces, and refinished the outer laminate surfaces with Benjamin Moore's Advance semi-gloss paint in White Dove OC-17. This piece measures: 62"W x 17 3/4"D x 30"H.
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text:
I cannot pretend that I am not pleased. The good folks at The Jalebi Chronicles have listed my blog among the 10 Indian Blogs You Must Follow. We are living in times where it is important to blow your own trumpet to be heard and I am clearly blowing mine till my lungs are emptied of the last bit of air. I derive confidence from the fact that as readers of my blog, you have put up with worse things in the past, and I am sure you will bear with me yet again.
I am grateful to all my readers and to the young and sassy team at the Jalebi Chronicles (yes, I looked you up and unless your pictures are airbrushed heavily, you all look really young) for encouraging me to write better, if not more often.
I must mention that this blog would not have been possible without the silent support of Olly, my geriatric shih tzu who struggles to wait up with me on those nights when I blog till the
cows mosquitos come home. It must be mentioned that it is very disheartening when he passes out within twenty minutes of us being alone and as I write to the sound of the soft humming of his snores, I wonder if this is the best that I inspire out of people (dogs are people too, you know?).
Being on this list, is therefore, all the more meaningful to me as it has proven that Olly's reaction to my writing is in no way an indication of the effect my blogs have on people.
Before I sign off, I also want to mention that I love my kids, my parents, my husband and my sister Kaveri whose unfailing commitment to alcohol is legendary. As I have clarified in my earlier posts, my sister is not a dipsomaniac or a recovering alcoholic but just a really smart Diageo executive who would like nothing better than for me to endorse her spirits. If she could have her way, she would even make me sign my 'will' off with a Johnnie Walker – Keep Walking.
So even though it makes no sense here, and I would rather be asking you to Keep Reading, I just have to say Keep Walking, you lovely people.
And here's the link: http://thejalebichronicles.wordpress.com/2014/01/22/10-indian-blogs-you-must-follow/


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Carnival: Goodness
Another blogger carnival. Check out more posts here.
Goodness is....
inhaling deeply the aroma of a sleeping baby.
taking a nap with a snoring dog.
belly laughs.
a good friend who doesn't mind snot on their shoulder while they embrace you and your sobbing.
the first budding bulbs announcing spring really is on its way.
those little hints God leaves to remind you he is near.
the smell of banana bread baking while you catch up with friends.
thousands of voices singing praise, acapella.
unexpected tweets from someone who loves you when you feel alone.
the sound of a gentle rainshower.
a husband who rubs my head when the tylenol won't work.
flip flops with a new pedicure.
bouncy hair after a fresh cut.
wrestling with the dog that loves you too much to bite, but also too much not to nibble on you.
sun that arrives, warming your skin after gloomy days.
loving your spouse more, 18 years later, than the infatuation of engagement.
how God changes lives.
how bottoms are really beginnings in disguise.
being so loved you never have enough time for all the lunch dates, coffee dates, or phone calls that you would like.
that the world is larger and smaller than I imagined as a child.
needing to, being able to, wanting to, and being wanted to, take care of my sick husband.
For all You have given,
For all You have withheld,
For all You have withdrawn,
For all You have permitted,
For all You have prevented,
For all You have forgiven me,
For all You have prepared for me,
For the death You have chosen for me,
For the place you are keeping for me in heaven,
For having created me to love You for eternity,
For having created me to love You for eternity,
Thank You God.
You are goodness.


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Subject: Fee Table
From: Ted Wolfstich
February 7, 2018
Good morning,
I just received your fee table Summary piece and had a couple comments. In general, I think it is a good idea, the more transparency in the business the better. One concern however is putting down the services part, specifically financial planning. As you are aware there are years where an advisor might do a lot of planning and years where there is not much work to do for someone. If I was to put down that I do both investment management and financial planning and for a period of time did no planning because none was needed is that some how a liability?
The next question would be do you need to put down the fees of the mutual funds/exchange traded funds that are embedded or is it just if you were to use a separate account manager? I would think if you needed to put down the embedded costs it could be quite onerous if you changed funds etc.
Ted Wolfstich CFP®
Wolfstich Capital


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text: KARACHI: Pakistan Tehreek-e-Insaf Chairman Imran Khan on Thursday said the PTI would take to the streets against the government if they would not get justice. The Pakistan Tehreek-e-Insaf (PTI) is ready to join any grand alliance for the accountability of Panama Papers Scam and corruption, PTI Chairman Imran Khan said on Thursday. Kaptaan said, "The biggest problem of our country is corruption. For eradicating corruption and accountability of Panama Papers scam, PTI is ready to join the movement of any grand alliance of political parties, including the PPP." The country's rulers were incapable and corrupt, he added. "So far the PPP did not contact the PTI for any movement against the government. In this regard, if PPP contacts us we will decide after discussion with the senior leadership of the party," he added. "People of Karachi have high hopes with rangers and military courts and they are optimistic regarding receiving justice." he said. "If the killers of PTI worker Fazal Rahim are not arrested, then the PTI will go on protest." The murder case should be tried in the military court, he demanded. Terrorists killed die-hard PTI worker Fazal Rahim a few days ago. The PTI chairman spent a busy day as he inaugurated the PTI's membership drive in District Central. He also visited Imambargah Babe-e-Ilm and heard grievance of Shias and assured the community elders to resolve their issues. He also visited Fazal's house in Patel Para to condole with the grieving family. Kaptaan also visited Junaid Jamshed's residence. Junaid was aboard a plane that crashed near Havelian a few days ago. Earlier, after laying the foundation stone of Shaukat Khanum Memorial Cancer Hospital, Kaptaan said everyone, rich or poor, would be treated equally at the hospital. "We will try to inaugurate the Shaukat Khanum Cancer Hospital in Karachi by December 29, 2019," said Imran Khan while addressing a gathering. "For an ordinary person cancer treatment is very expensive and so, 90 percent of them cannot afford it, but at Shaukat Khanum Memorial Hospital whether you have money or not, you get the same medical treatment." "About 75 percent patients receive free treatment at our hospitals," Kaptaan said while explaining the need to help unprivileged people in the country when it comes to combating cancer. "SKMCH&RC has spent Rs 26 billion in free cancer treatment," he informed. "Despite all crises, we continued to expand our hospitals in different cities of the country," he added. The ceremony in DHA City was organised by the Shaukat Khanum Memorial Trust. Separately, the PTI announced a schedule of its public meetings. According to a press release, the first public meeting would be held in Hangu Khyber Pakhtunkhwa and Rajanpur District on January 7, 2017. On January 15, a public meeting would be arranged in Dera Ghazi Khan.


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text:
Chalk Talk - Optical Transport Network (OTN)
Loudon Blair provides an overview of the Optical Transport Network (OTN).
There was a problem with your video. Another version is available.
Loudon Blair provides an overview of the Optical Transport Network (OTN).
Joe Shapiro, Senior Director, Product Line Management, explains how Ciena's WaveLogic 5 Extreme provides tunable bandwidth from 200G-800G so network providers can maximize capacity, automate, and evolve to 400G-interface switches and routers
Nic Benvenuti, Senior Director, Product Line Management, gives an overview of Ciena's 6500 Family of Packet-Optical Platforms, that integrate the latest technology innovation across three comprehensive networking layers and multiple chassis
Hear from a few of the people at Ciena who have worked together to bring the industry's first single-carrier 400Gb/s solution to market with Ciena WaveLogic Ai.
Step inside Ciena's Ottawa R&D Lab with senior hardware design engineer Will Leckie for a live demo of Ciena's new WaveLogic Ai coherent chipset that show the various transmission rates and coherent modulation formats that WaveLogic Ai
Joe Cumello, Ciena's VP of Global Marketing, talks to Lightwave from the show floor of OFC'17 and details the company's innovations and awards that were on display at the show.
"On-demand" demands a lot from your optical network—more than it's been capable of delivering. Until now. Introducing software-defined optical, delivered by Ciena's Liquid Spectrum™. It's that good.
Ciena's Liquid Spectrum™ is redefining optical for an on-demand world. Our photonics expert David Boertjes explains how.
In today's content economy, end-customers are demanding more from their network providers – more content, more video, more devices – and the list goes on. As a result, providers need more from their underlying optical networks. Ciena's Scott
With programmable capacity from 200G to 800G, Ciena's WaveLogic 5 Extreme brings new levels of scale, programmability, and economics to optical networking and the ability, for the first time, to evolve to simple, ubiquitous 400GbE client connect
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Big Trucks Live Wallpaper Izinhlelo ze Android ku Google Play
Another Picture of big truck pics:
Police spoke with a woman who said she is being harrassed by another woman, who is continuing to send nude pictures of herself to her husband's phone, The woman showed police the images on the cell phone. She said she "wished to have the continued behavior The New England Food Truck Festival is a family-owned event company that specializes in food truck festivals. Last year's festival at the Big E, the first time the event was held at the West Side venue, attracted more than 19,000 visitors and featured over If 4-wheel-drives get your engine revving, Stewartsville was the place to be Sunday. OK Auto, 4WD and Tire held its 27th annual Oktober Truckfest at the dealership off Route 57 in Franklin Township. The event raises money for Habitat for Humanity and HUNTSVILLE, Alabama-- Twenty-nine years ago, Gary Porter built his first monster truck, Carolina Crusher, for about $11,000 and during competitions he drove wearing jeans and a tee. Since that time he's seen the average cost of those gargantuan, arena Sony Pictures announced today that an animated film based on Hasbro's Tonka Truck brand will be coming to the big screen: TONKA, the Hasbro brand that for 65 years has stood for its line of toy trucks for children, will bring its TONKA toughness to the The largest of artist John Chiara's cameras, on the other hand, is big enough for him to step inside. Transported on a flatbed trailer, that camera takes photographs the analog way; his book "John Chiara: California" (Aperture, $65) presents a collection .
HUNTSVILLE, Alabama-- It's Monster Jam weekend in the Rocket City, which means there will be a lot of noise and destruction going on as monster trucks wreck and ride through the Von Braun Center Propst Arena. This year's event features Whit Tarlton driving I also saw a picture of a pickup truck that broke through around Assembly Point A number of local people shared pictures on Facebook, apparently thinking it was our local Glen Lake, but it was caught on the water of the same name in western Vermont SpaceX's big new rocket blasted off Tuesday on its first test flight, carrying a red sports car aiming for an endless road trip past Mars. The Falcon Heavy rose from the same launch pad used by NASA nearly 50 years ago to send men to the moon. Photos from TV reports showed the big-rig sprawled on its side near a box truck. Two burned, crushed cars were under the and the Destinations Photo Contest is again host to thousands of your amazing vacation photos. .


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When I was a LLL leader I learned about the concept that there is generally a 10 year lag time between scientific validation of a concept or best practice and its recognition/acceptance in general practice. I saw this all the time. A principle of breastfeeding management could be yawningly well established at the research level but years away from being adopted at the level of what a mother might expect to hear from her pediatrician or the nurse in the pediatrician's office.
That kind of lag time between the academy and general practice seems to be occurring in academic theological work as well. Or it may be something worse, as these authors opine–there may be theological bouncers at the door.
Here are two blogs that suggest this:
If They Only Knew What I Thought – Peter Enns, Ph.D. (Harvard, Near Eastern Langauges and Civilizations, currently teaching Old and New Testament at Eastern University)
Lament for a Maternal Home: Is There No Place for Believing Criticism in Evangelicalism – David Lincicim, Lecturer in New Testament Studies at Oxford University