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2 Nov 2012: Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ (2012) Correction: Colorectal Cancer Screening for Average-Risk North Americans: An Economic Evaluation. PLOS Medicine 9(11): 10.1371/annotation/0fd49c83-2c6d-42b5-a8c1-45a0aaedaa77. https://doi.org/10.1371/annotation/0fd49c83-2c6d-42b5-a8c1-45a0aaedaa77 View correction
Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs.
Methods and Findings
An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,782 and the number of CRC deaths from 1,393 to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive.
Citation: Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ (2010) Colorectal Cancer Screening for Average-Risk North Americans: An Economic Evaluation. PLoS Med 7(11): e1000370. https://doi.org/10.1371/journal.pmed.1000370
Academic Editor: Eduardo L. Franco, McGill University, Canada
Received: June 3, 2010; Accepted: October 14, 2010; Published: November 23, 2010
Copyright: © 2010 Heitman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This project was supported by the Canadian Agency for Drugs and Technologies in Health and Alberta Innovates - Health Solutions. BJM and RJH are supported by Alberta Innovates - Health Scholar Awards. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: CRC, colorectal cancer; CTC, computed tomographic colonography; FDNA, fecal DNA assay; FOBT, fecal occult blood test; FIT, fecal immunochemical test; QALY, quality-adjusted life-year; RCT, randomized controlled trial
Editors' Summary
Colorectal (bowel) cancer is the second leading cause of cancer deaths for both men and women in North America. Colorectal cancer screening is an important means for reducing morbidity and mortality and fulfils the World Health Organization criteria for mass screening. However, a variety of CRC screening approaches are available. Colonoscopy is viewed as the gold standard of colorectal cancer screening as it has a high sensitivity for identifying adenomas and cancer and polyps can be removed during the screening examination. However, colonoscopy is associated with a number of complications and there are also barriers to access. Another type of test, the guaiac fecal occult blood test, has been shown to reduce mortality from colorectal cancer but this test has low sensitivity for identifying colorectal neoplasia, particularly adenomas. Fecal immunochemical tests, which also detect blood in the stool, have improved test performance characteristics (high sensitivity and specificity) and the potential to improve participation rates compared to guaiac fecal occult blood test and flexible sigmoidoscopy. Fecal DNA (a stool test, based on the detection of DNA shed by cancerous tissue) is another screening option, as is computed tomographic colonography ("virtual" colonoscopy), that might rival colonoscopy in detecting advanced adenomas and colorectal cancer but is expensive and requires a full colonic preparation.
Why Was This Study Done?
In the absence of firm comparative evidence to guide the selection of any one screening modality and given the varied test performance characteristics and the significant differences in costs and resources associated with each, a robust cost-effectiveness analysis might help health policy makers in deciding whether or not to offer screening and if so, in selecting the most appropriate and cost effective screening modality. In this study the researchers conducted a full economic evaluation of all relevant colorectal cancer screening modalities in North America.
What Did the Researchers Do and Find?
The researchers used an incremental cost-utility analysis, a sophisticated modeling technique, and two hypothetical patient cohorts (individuals with an "average risk," i.e., no family history of colorectal cancer, aged 50–64 and 65–75) to compare guaiac-based fecal occult blood test or fecal immunochemical test annually (the researchers considered three distinct fecal immunochemical testing strategies on the basis of assays and collection methods taken from studies that have reported "low," "mid," and "high" test performance characteristics), fecal DNA every three years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. The researchers also included a no screening natural history arm as a comparison to each screening approach. For the baseline data of their model, the researchers used adenoma and colorectal prevalence rates from a recent systematic review and based screening adherence, test performance, and colorectal treatment costs on available data. The researchers found that annual fecal immunochemical testing with mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening). Using this screening modality, among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 and the number of deaths from colorectal cancer from 1,782 to 457, while saving CAN$68 per person. Although in the sensitivity and scenario analysis, screening patients using fecal immunochemical testing became more expensive than a strategy of no screening when the test performance of fecal immunochemical testing was reduced, or the cost of managing colorectal cancers was lowered, the researchers found that screening for colorectal cancer with fecal immunochemical testing remained the most economically attractive screening option.
What Do These Findings Mean?
This model-based economic analysis found that fecal immunochemical testing is more effective and less costly than all other colorectal screening strategies, including the most commonly-used stool-based screening test, guaiac-based fecal occult blood testing, and no screening. Furthermore, this study suggests that annual screening with fecal immunochemical testing (assuming mid-range test performance characteristics) reduces the risk of colorectal cancer and colorectal cancer–related deaths, and lowers health care costs in comparison to all other screening strategies and to no screening. Therefore, health policy makers should consider prioritizing funding for fecal immunochemical testing as the screening modality for colorectal cancer.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000370.
- Cancer.org has information for patients on colorectal cancer
- The US Centers for Disease Control (CDC) list colorectal screening guidelines
- The CDC also provides patient information on colorectal cancer Screening
As the fourth most common cancer and second-leading cause of cancer death among men and women [1], colorectal cancer (CRC) is an important health issue. CRC fulfills the World Health Organization (WHO) criteria for mass screening [2], and existing clinical practice guidelines recommend that average risk individuals begin screening at age 50 [3]–[6]. A variety of CRC screening modalities are available, including stool-based tests and radiological and endoscopic examinations of the colon. Colonoscopy has high sensitivity for identifying adenomas and cancer and permits the removal of polyps during a screening examination [7]. However, the risk of complications (including bleeding, perforation, and death) and barriers to access including limited availability and high patient-borne costs [8] diminish its appeal. The guaiac-based fecal occult blood tests (FOBTs) have been shown in randomized controlled trials (RCTs) to reduce CRC mortality [9]–[11]. However, FOBT has low sensitivity for identifying colorectal neoplasia, in particular adenomas. The fecal immunochemical tests (FITs) have improved test performance characteristics [12] and potential to improve participation rates compared to FOBT and flexible sigmoidoscopy [13]. A third type of stool test, based on the detection of DNA shed by neoplastic tissue (fecal DNA) is also available [14],[15]. Lastly, computed tomographic colonography (CTC) or "virtual" colonoscopy is a promising new modality [6]. Although recent studies [16]–[18] have shown CTC to rival colonoscopy in detecting advanced adenomas and CRC, CTC is expensive, requires a full colonic preparation, and the available cost-effectiveness data have been contradictory [19]–[21].
In light of the rapidly rising costs of chemotherapy for CRC [22], and evidence that CRC mortality can be reduced by screening [9]–[11], population-based screening programs for average risk individuals are being considered in several countries. In the absence of firm comparative evidence to guide the selection of any one modality, the practice in some jurisdictions has been to recommend choice among the available screening options [3]–[5]. However, some countries do not support population-based CRC screening and many with organized programs do not offer choice [23]. Given the varied test performance characteristics and the significant differences in costs and resources associated with each, health care decision makers should consider the results of cost-effectiveness analyses when deciding whether or not to offer screening and in selecting the most appropriate screening modality.
There have been several previous economic analyses of CRC screening [24], though recent studies have failed to consider all potentially relevant strategies including CTC [25],[26] and FIT [27]. Furthermore, a wide range of FIT test performance has been reported, the impact of which requires further exploration in cost-effectiveness analyses. Finally, many studies have not considered current CRC treatment costs, nor the different nonmedical costs between CRC screening strategies, both of which may be important. Given these limitations, we performed a full economic evaluation of all relevant CRC screening modalities in North America, and present our results in a transparent fashion to assist medical decision makers.
An incremental cost-utility analysis was performed comparing the following CRC screening modalities: guaiac-based FOBT, FIT, fecal DNA, colonoscopy, flexible sigmoidoscopy, and CTC. These modalities were compared to each other and to a no screening natural history arm among average-risk individuals, aged 50 to 75 y. Two average-risk age-stratified patient cohorts were simultaneously modelled: people aged 50–64 and 65–75. In the base case, screening was assumed to continue from age 50–75, but the analysis continued over the lifetime of the cohorts. Average risk was defined as asymptomatic individuals with no personal or family history of CRC or adenomatous polyps and no history of preexisting medical conditions known to increase the risk of CRC (e.g., inflammatory bowel disease).
Although we acknowledge that many jurisdictions are already committed to CRC screening, we included a no screening strategy given that, despite widespread screening recommendations, the majority of individuals are not being screened [28]. In the base case analysis, costs were those relevant to a publicly funded health care system and included patient time and travel costs in keeping with recent guidelines [29]. Consistent with contemporary guidelines and the perspective of the publicly funded health care system, costs resulting from lost productivity were not considered [29]. Given the impact of CRC on both quantity and quality of life, health benefits were measured in quality-adjusted life-years (QALYs) gained over a lifetime horizon. Future costs and benefits were discounted at 5% annually [29]. Base case analyses were performed using Markov cohort simulation; second order probabilistic sensitivity analysis was used to derive 95% confidence intervals around mean costs and QALYs, and for probabilistic sensitivity analysis (see below). First order Monte Carlo simulation was used to estimate CRC incidence and death rates and the number of primary screening tests and colonoscopies required. Incremental analyses (expressed as the cost per QALY gained) were performed by rank ordering all competing strategies by increasing cost after eliminating strategies that were more costly and less effective (i.e., dominated).
Model Validation
Consistent with guidelines for good modeling in health care [30], the validity of our model was formally established including extensive "debugging" exercises and calibration to published clinical datasets [9]–[11]. Gastroenterologists, including two of the authors (SJH and RJH), carefully reviewed the structure and flow of the model. The model was also reviewed by Alaa Rostom, Gastroenterologist and Medical Director at the Forzani and MacPhail Colon Cancer Screening Centre in Calgary, Alberta. Ultimately, it was determined that the model had good face validity. After ensuring that there were no syntactical errors, we first calibrated the model's no screening arm against the no screening control arms of the landmark FOBT RCTs [9]–[11]. For this we used baseline adenoma and CRC prevalence rates from a contemporary meta-analysis [31] and ensured that the number of cancers and cancer deaths generated by our model closely approximated the control arms of the clinical trials over an identical follow-up period. We next ensured that the number of cancers and cancer deaths predicted by the FOBT screening arms closely approximated those noted within the FOBT arms of the FOBT RCTs. All of the other strategies were validated in a similar fashion assuring face validity and calibration. Finally, we also compared our CRC and CRC death rate with those generated by another validated decision analytical model, noting near perfect correlation [32].
Computer Simulation Model
The Markov model was constructed using decision analysis software (TreeAge Pro Suite 2007). It was assumed that all CRCs arise through the following sequence: normal colon → nonadvanced adenoma → advanced adenoma → CRC. Nonadvanced adenomas were defined as tubular adenomas <10 mm in size. Advanced adenomas comprised any adenoma ≥10 mm regardless of histology, and adenomas <10 mm containing at least 25% villous component and/or high grade dysplasia. We considered several general health states, including (1) alive with no prevalent or prior history of adenomas or CRC, (2) alive with a missed adenoma, (3) alive with a missed asymptomatic CRC, (4) alive with a missed CRC after presenting with symptoms, (5) alive with a CRC found by screening, (6) alive post polypectomy, and (7) dead. Each year (1-y cycle length), individuals with or without adenomas or CRC could either remain in the same health state, progress to another health state, or die (Figure 1).
This diagram depicts the general health states and flow through the model.
In the base case, screening was offered annually for FOBT and FIT, every 3 y for fecal DNA, every 5 y for flexible sigmoidoscopy and CTC, and every 10 y for colonoscopy. Once a patient was diagnosed with either an adenoma or CRC, the model's design permitted subsequent surveillance with colonoscopy at either 3- or 5-y intervals depending on the results of the last colonoscopy, consistent with current guidelines [4]–[6]. Screening and surveillance commenced at age 50 and stopped at age 75.
Data Inputs
Risk of polyps and CRC and the adenoma-carcinoma sequence.
We based our prevalence estimates of adenomatous polyps and CRC on a recent systematic review among those at average risk for CRC [31]. Age was determined to be an important source of heterogeneity in the pooled estimates [31], and thus the prevalence rates in our model were stratified into two age categories: 50–64 and 65–75 y (Table 1).
Not all polyps are adenomatous. However, determining a polyp's histology generally requires that it be biopsied or removed. As a result, some polypectomies expose patients to complications without reducing the risk of CRC. We estimated that 41% [33] of polyps <10 mm were adenomatous compared to 82% of polyps ≥10 mm (Table 1) [16]. Screening guidelines recommend that all polyps be removed at the time of a colonoscopy to determine histology and establish an appropriate surveillance interval. Although some advocate for ignoring polyps <5 mm in size found on CTC, we assumed that all patients with polyps found on CTC regardless of size would be referred for colonoscopy. The risk of proximal adenomatous polyps and CRC is increased among those with adenomatous polyps in the left colon [34]. As such, we assumed that patients with left-sided adenomas found on flexible sigmoidoscopy would be referred for colonoscopy consistent with general clinical practice.
The rate of progression of adenomatous polyps is not well established. We initially chose progression rates that were consistent with other published models [32], and made small adjustments to these rates to ensure that the total number of CRCs in our natural history/no screening strategy closely approximated the number of CRCs found in the control arms of the FOBT trials [27].
Death occurred according to either age-dependent population mortality rates observed for Canadians [35] or based on the mortality rates observed for patients with CRC according to their stage at diagnosis (Table 1) [36]. Those with CRC found through screening were assumed to have improved survival over patients presenting with symptomatic cancer, on the basis of a more favorable stage distribution (i.e., more early stage cancers) at diagnosis (Table 1).
Screening adherence.
Adherence is important to the overall effectiveness of a screening program. Even in a randomized trial comparing annual FOBT with no screening, only 68% of patients who were randomized to FOBT actually completed the initial screen and 63% were compliant with subsequent rescreening. Moreover, for patients with positive FOBT results, only 81% had a colonoscopy [11]. We adopted these imperfect adherence rates and assumed in the base case that adherence would be the same across strategies (Table 1).
Test performance characteristics of the CRC screening strategies.
The only method for properly assessing the test performance of a given screening modality is to compare it with a reference standard in all cases. Although colonoscopy is not infallible [7], it remains the accepted gold standard for evaluating the entire colon. Therefore, the base case sensitivities and specificities for polyps and CRC for each of the screening modalities were taken from the literature following a thorough search for properly designed studies that included at least a full colonoscopy in all individuals (Table 2). For the stool-based tests and for CTC, the test performance characteristics were considered on a per person basis.
Stool-based tests.
Given significant differences even between the alternative stool-based screening tests themselves (often due to different collection methods or assay types), it would not be appropriate to consider them as a class [37]. As such, we modeled different test performance scenarios for each test. A low [38] and high [14] performance level was modeled for FOBT tests that have reported in the literature (FOBT-low and FOBT-high, respectively) and a low [39],[40], mid [41], and high [42] performance level was modeled for FIT assays that have been reported in the literature (FIT-low, FIT-mid, and FIT-high, respectively). The intent of modeling different levels of test performance for FOBT and FIT was to represent the range reported in the literature. This range is greatest for FIT, likely due to differences in collection methods and assays (Table 2). FIT-low represents that reported by Morikawa et al. [39],[40] who studied the Magstream system with 1 d of stool collection. FIT-mid represents that reported by Nakama et al. [41] who used a 2-d method with the Monohaem system. FIT-high represents that reported by Levi et al. [42] who used the FlexSure OBT technology following 3 d of fecal collection. Both the first- [38] and second- [14] generation fecal DNA assays were modeled (FDNA-SDT1 and FDNA-SDT2, respectively).
Flexible sigmoidoscopy.
Flexible sigmoidoscopy can evaluate the left colon to the splenic flexure, although this is not always possible [43]. Routine clinical practice is generally to perform a full colonoscopy in individuals found to have an adenomatous polyp on flexible sigmoidoscopy. As such, the sensitivity of flexible sigmoidoscopy includes the additional lesions found by colonoscopy in patients identified as having an adenoma on flexible sigmoidoscopy [44]–[46].
CTC and colonoscopy.
Landmark studies [16],[18] that employed segmental unblinding methodology [47] provided the base case test performance estimates for both CTC and colonoscopy when possible. The sensitivity and specificity of CTC for polyps ≥10 mm was taken from the National CT Colonography Trial of the American College of Radiology Imaging Network (ACRIN) [16], a large multicenter study of CTC among primarily average-risk individuals. Polyps <5 mm were not reported in this study or other large cohorts of average risk individuals. However, we optimistically assumed that the sensitivity reported for 6–9 mm polyps would be the same for all polyps <10 mm. In a sensitivity analysis we reduced the sensitivity of polyps <10 mm to that reported in a meta-analysis of CTC that included higher risk patients [48]. The sensitivity of colonoscopy for polyps ≥10 mm was taken from the study of Pickhardt et al. [18], which reported the test performance of both CTC and colonoscopy based on segmental unblinding. As this study also did not report data for polyps <5 mm, the sensitivity of colonoscopy for polyps <10 mm was taken from two back-to-back colonoscopy studies (Table 2) [49],[50].
Screening-related risks.
Flexible sigmoidoscopy and colonoscopy are associated with risks including bleeding, perforation, and rarely, death (Table 1). Even though CTC is less invasive than colonoscopy, colonic perforations have been reported [51]–[53], though many of the small CTC induced perforations diagnosed with the CT in asymptomatic individuals may not be clinically important. We assumed a low risk of CTC-induced perforation in the base case analysis [51],[52], and that this would never result in death (Table 1).
Costs related to screening. All costs are reported in 2008 CAN$. The direct costs of flexible sigmoidoscopy and colonoscopy, as well as costs attributed to bleeding and perforation complications [54], were based on local estimates derived from the Calgary Health Region costing database [55] and included the nonphysician costs (capital, nursing, drugs, and cleaning costs) and the physician fees for the procedure (Table 3). CTC for primary CRC screening is not currently part of the schedule of medical benefits in any province in Canada. The direct costs of CTC were therefore conservatively assumed to be the same as that of a CT abdomen/pelvis, likely an underestimate (Table 3). We assumed that stool-based screening would be offered at a person's annual visit to their general practitioner, and as such, we only considered the cost of the screening kit and related laboratory/processing costs (Table 3).
For all screening modalities, we included the relevant patient ± caregiver time and travel costs (nonmedical costs), on the basis of available surveys for flexible sigmoidoscopy, colonoscopy, FOBT, and CTC (Table 3) [8],[56],[57]. The nonmedical costs of FIT and fecal DNA were assumed to be the same as FOBT. In the base case, we did not consider the capital costs of initiating or administering a screening program and thus assumed that screening would be opportunistic in all strategies.
Costs related to managing CRC. Existing published data on the total costs of managing patients with CRC are outdated. We assumed that the cost of surgery for CRC has remained relatively stable and thus based our surgical costs on a Canadian study reporting 1998 figures, inflation adjusted to 2008 dollars [58].
In contrast, the cost of treating CRC with chemotherapy has increased substantially because of the development of more expensive agents [22]. To estimate the cost of chemotherapy provided for advanced CRC, we used data from the Canadian Inter-Provincial Joint Oncology Drug Review (JODR) Process [59]. These estimates were the average stage-based treatment costs for chemotherapy, taking into account that not all patients would be eligible for or would comply with treatment. Patients with stage IIB disease (∼50% of stage II patients) are generally managed with adjuvant chemotherapy using eight cycles of capecitabine [60],[61]. First line therapy for patients with stage III CRC was assumed to be 6 mo of oxaliplatin-based therapy [62]. Considering the most recent clinical trials and assumed standards of care, the average patient with stage IV CRC received approximately 10 mo of infusional fluorouracil (5-FU), leucovorin, and oxaliplatin (FOLFOX) in combination with bevacizumab, followed by 14 doses of infusional 5-FU, leucovorin, and irinotecan (FOLFIRI). Those lacking K-Ras mutations were assumed to go on to receive 4 mo of anti-epidermal growth factor receptor–based inhibition therapy. We did not include the potential costs of liver metastectomy among stage IV patients, or the cost of preoperative radiation therapy in patients with operable rectal cancer.
Valuing health benefits.
Health benefits were measured in terms of QALYs gained. We obtained utilities for relevant health states on the basis of a study that used a standard gamble exercise in patients with a previous history of CRC or polyps who were presented with stage-dependent outcome states for CRC (Table 1) [63].
Sensitivity Analysis
Allowance for uncertainty in the base case polyp and CRC prevalence estimates, mortality assumptions, screening test performance characteristics, screening-related risks, and costs were considered through the use of univariate and probabilistic sensitivity analyses. A number of scenario analyses were also included. We considered a scenario in which the additional costs of biologic chemotherapies for advanced stage CRC were excluded. We also examined scenarios where FIT was offered every 2 y instead of annually and analyzed our results without nonmedical costs. We assessed the impact of differential adherence rates across strategies at the initial screening encounter. For this analysis, we used the adherence rates determined by Hol et al. in a RCT comparing participation rates of FOBT, FIT, and flexible sigmoidoscopy in a screening population [13]. As Hol et al. [13] did not study fecal DNA, colonoscopy, or CTC, we assumed that fecal DNA would have the same adherence as FIT due to its comparable simplicity for patients, and we assumed that colonoscopy would have the same adherence as flexible sigmoidoscopy. We also assessed the impact of lower subsequent adherence for the annual stool-based tests, since screening noncompliance may be more prevalent with an annual test compared to one offered less frequently. To do this assessment, we examined scenarios with decreased FOBT and FIT follow-up adherence.
Because we did not include any administrative costs for any of the CRC screening programs, we performed a sensitivity analysis to assess the impact of including administrative costs for the various screening tests. We were unable to identify a document that has reported the setup and operating costs for a population-based CRC screening program, but it is possible that programs that screen annually (i.e., stool-based tests) might have higher administrative costs than ones that screen patients every 10 y (i.e., colonoscopy). We provide sensitivity analyses varying the administrative costs per screening test between CAN$10 and CAN$50 to determine the impact on the results, making the assumption that programs screening more frequently will incur higher administrative costs.
To address limitations in classic univariate sensitivity analysis, we also performed probabilistic sensitivity analysis, which allows for the simultaneous sensitivity analysis of all variables over their plausible range [64],[65]. It does so by replacing estimates of probabilities, utilities, and costs with specific probability distributions, which are based on the reported means and variances for each variable. Statistical distributions were created around all of the variables for which there was substantial measurement uncertainty, including use of a beta distribution for proportions (i.e., mortality, proportion of patients with Stage I, II, III, and IV cancer), use of a normal distribution for normally distributed variables (i.e., certain costs and utility measures), log-normal distribution for skewed variables (i.e., certain costs), and triangular distributions for variables with a range, but no statistical distribution (i.e., adenoma transition over time, probability of adherence). Given that sensitivity and specificity are linked variables that do not vary independently (linked via receiver operating curves that were unavailable), these variables were not included within the probabilistic analyses—as noted above, the sensitivity and specificity of the various screening tests were subjected to wide sensitivity analysis using the testing characteristics provided by different primary studies.
Base Case Analysis
Annual CRC screening using FIT, assuming mid-range test performance characteristics, was the preferred strategy for average risk individuals in the base case analysis (Table 4). It was more effective and less costly than almost all of the other strategies including no screening. Only FIT when assuming even better test performance characteristics (i.e., FIT-high) produced more QALYs and resulted in fewer CRCs than FIT-mid, but at an additional cost of CAN$85,150 per QALY gained.
Using base case estimates, over the lifetimes of a 100,000 patient cohort, 4,857 and 1,782 individuals would develop and die from CRC, respectively, if CRC screening was not undertaken (Table 5). This "no screening" strategy would be expected to cost an average of CAN$1,901 per patient. Annual screening with FIT-mid would reduce the overall number of cancers by 71% and CRC mortality by 74% while saving CAN$68 per patient. Compared with the most effective FOBT strategy, FIT-mid would be expected to reduce the number of cancers by 60%, and CRC mortality by 63%, while saving CAN$362 per person.
Sensitivity Analysis
Under no circumstances did flexible sigmoidoscopy, FOBT, CTC, or fecal DNA appear attractive in comparison to other CRC screening modalities. As such, these strategies are not reported in our sensitivity analysis table (Table 6). Lowering the cost of CRC treatment by excluding the use of biologic chemotherapies resulted in a scenario where FIT-mid resulted in additional costs compared to no screening (CAN$163 per patient or CAN$3,691 per QALY gained). Increasing the cost of FIT testing by 50% had a similar effect; FIT-mid cost an additional CAN$105 per patient and was associated with a cost per QALY of CAN$2,375 compared to no screening. Biennial screening using FIT-mid increased the cost savings when compared to no screening. However, performing FIT less frequently also made it less effective.
When the initial adherence rates for each of the strategies was no longer assumed to be identical, FIT-mid remained dominant over no screening (Table 6). Assuming the base case initial adherence rates, when we dropped the adherence rates for subsequent screens for all of the annual fecal-based strategies, FIT-mid remained dominant over no screening. However, when subsequent adherence for FIT was dropped from 63% to 40%, both FIT-mid and FIT-high became dominant over no screening, and colonoscopy became the most effective strategy at a cost per QALY gained of CAN$300,609 compared to FIT-high. When subsequent adherence for FIT was decreased to only 20%, colonoscopy remained the most effective strategy, at a cost per QALY gained of CAN$32,912 compared to FIT-high (Table 6).
Finally, we performed a sensitivity analysis to assess the impact of higher administrative costs that might be associated with an annual screening program (i.e., FIT) compared to one offered less frequently (i.e., colonoscopy). We noted that FIT remained dominant over no screening unless the administrative costs were ∼CAN$10 per test. If administrative costs were CAN$30 per test, annual FIT was associated with a cost per QALY of CAN$3,120 compared with no screening. However, if the administrative costs were CAN$50 per test, then colonoscopy would be the preferred screening modality compared with FIT, and would be associated with a cost per QALY gained of CAN$5,903 compared with no screening.
Our probabilistic sensitivity analysis revealed that FIT-mid was cost saving and more effective compared with no screening in nearly 100% of the simulations performed, confirming the robustness of the results (Figure 2).
An incremental cost-effectiveness scatterplot comparing FIT-mid with no screening in which the uncertainty in all model inputs has been tested simultaneously. Data points in the lower right quadrant reflect situations where FIT-mid is more effective and less costly than no screening.
Our study demonstrates that annual screening with FIT, assuming mid-range test performance characteristics, is more effective and less costly than other CRC screening strategies, including the most commonly used stool-based CRC screening test, FOBT, and no screening. Among a cohort of 100,000 average risk individuals followed until death, 4,857 cancers and 1,782 cancer-related deaths would be expected with no screening. An annual FIT with high sensitivity for cancer (81%) and moderate sensitivity for advanced adenomas (54%) [41] could reduce costs and decrease the number of CRCs and cancer-related deaths to 1,393 and 457, respectively. Screening with FIT was also more effective at reducing cancer and cancer-related deaths at lower costs compared with FOBT.
FIT represents a significant advance over the traditional guaiac-based FOBTs, in large part due to FITs improved sensitivity for identifying adenomatous polyps. Our findings underscore the importance of identifying patients with advanced adenomas and preventing cancer through the identification and removal of precancerous polyps. Indeed, changing the sensitivity of FIT for cancer had relatively little impact on our results, whereas reducing the sensitivity of FIT for advanced adenomas from 54% to below 45% resulted in FIT no longer being cost saving compared with no screening.
Although it may seem counter-intuitive that screening with FIT could be even more effective than colonoscopy, this is due to the more frequent screening interval with FIT. In base case analyses, and consistent with current guidelines [3],[6], screening with FIT was done annually compared to every 10 y with colonoscopy. Therefore, even though the test performance of a single FIT test was inferior to colonoscopy, there were more opportunities to identify previously missed pathology with FIT compared to colonoscopy.
Our results are robust. FIT with mid-range performance (FIT-mid) remained optimal compared with no screening and all the other strategies except FIT with even better test performance (FIT-high) unless the cost of CRC treatment was reduced, or the sensitivity for advanced adenomas was decreased significantly. However, even with lower CRC treatment costs, FIT remained economically attractive. Many health jurisdictions now fund biologic chemotherapies for advanced-stage CRC and with further advances in CRC chemotherapy, it is unlikely that management costs for CRC will decrease [22]. In addition, our modeled CRC treatment costs were lower than those used in a recent US study that had similar results [25], lending further support to the notion that CRC screening can indeed save money.
It is possible that the administrative costs of annual screening programs such as FIT would be more expensive over the long-run compared with those offered every 5 or 10 y. As these data are not known, we did not consider administrative costs or the costs to build and staff additional screening centers in our primary analysis. However, in sensitivity analysis, we noted that FIT-mid remained cost saving if the administration costs were <CAN$10 per test, and remained attractive compared with colonoscopy even if the administrative costs per test were CAN$30 per test. It should also be noted that the additional infrastructure required to implement primary screening with CTC, flexible sigmoidoscopy, or colonoscopy would likely counterbalance a substantial portion of these additional administrative costs of an annual screening program.
We assumed in the base case that adherence would be identical across all of the CRC screening strategies. Although this may not be true, we are unaware of a study that has evaluated screening uptake for all of the strategies we considered. However, fecal-based screening does not require a bowel preparation, is associated with lower patient-borne costs, and is safe to perform, which may be more appealing to the general population. Furthermore, FIT does not require any dietary restrictions. Indeed, in a recent randomized trial, FIT was associated with higher screening uptake than flexible sigmoidoscopy and FOBT [13]. Of course, this finding only strengthens our conclusions as illustrated in our scenario analysis in which FIT had relatively higher adherence than all of the other strategies (Table 6). Recent data suggest that screening adherence with FOBT may drop by 50% after only 2 y in a biennial screening program [66]; this may affect programs with frequent screening (i.e., annual fecal-based strategies) to a greater extent than programs requiring less frequent screening (i.e., colonoscopy). As expected, when we dropped our subsequent adherence rates for FOBT and FIT, FIT-mid became less effective, though it remained dominant compared with no screening. In contrast, colonoscopy became the most effective strategy when the subsequent adherence rates for FOBT and FIT were dropped from 63% to 40%, though it was associated with an unattractive incremental cost per QALY. It is clear that further information on long-term adherence rates for annual stool-based tests are needed.
Our study has limitations. As with most economic evaluations, our results are limited by available evidence. The natural history of adenomas and their progression to cancer is not clearly known. However, we populated our model with the best available evidence including a systematic review of adenoma and CRC prevalence rates [31] and modeled new adenoma growth and adenoma progression over time to closely match high quality clinical datasets [9]–[11]. We did not model cancers arising from lesions other than adenomas. However, most CRCs arising in average risk individuals are believed to develop via the traditional adenoma-carcinoma sequence. A small proportion of CRC may develop from undetectable lesions (i.e., flat or depressed adenomas), and it is known that some interval cancers can arise through a rapid adenoma-carcinoma sequence between screening studies [67]. It should be noted that this potential issue would impact the effectiveness of all CRC screening modalities, and thus would be unlikely to impact the differential effectiveness between our modeled strategies. Given data limitations, we modeled identical CRC stage distributions for cancers detected using all of the stool-based strategies despite differences in testing characteristics. Given FIT's superior sensitivity compared to FOBT, patients diagnosed with CRC might be expected to have more earlier stage cancers, which again would make FIT appear more attractive. We assumed that the results of each screening test were independent of the prior test result. While not informed by evidence, it is possible that this is not entirely true; however, it is important to note that the results of our analysis were robust to small changes in the sensitivity and specificity of each of the screening tests. Finally, although we did model the most widely available and promising screening strategies, additional technologies are being developed and it is possible that other screening paradigms, including nurse-based endoscopy, may become viable in the future as a means to reduce the cost of delivering flexible sigmoidoscopy and potentially colonoscopy.
In conclusion, annual screening with FIT having test performance characteristics within the mid-range reported in the literature is both more effective and less costly than other CRC screening modalities, including FOBT and colonoscopy, and not screening for CRC. Even if this level of test performance is not attainable in clinical practice, annual screening with a lower performing FIT is still highly attractive with a cost per QALY gained of <CAN$5,000 compared to no screening. Our results are robust suggesting that screening for CRC with FIT should be considered the modality of choice for average risk patients between the ages of 50 and 75 in North America.
Author Contributions
ICMJE criteria for authorship read and met: SJH RJH FA SD BJM. Agree with the manuscript's results and conclusions: SJH RJH FA SD BJM. Designed the experiments/the study: SJH RJH BJM. Analyzed the data: SJH FA BJM. Collected data/did experiments for the study: SJH FA SD BJM. Wrote the first draft of the paper: SJH FA. Contributed to the writing of the paper: RJH FA SD BJM.
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text:
CFP: Dime Novels/Pulps/Juvenile Series (11/1/06; PCA/ACA, 4/4/07-4/7/07)
Popular Culture Association/American Culture Association
Joint Annual Conference
Boston Marriot Copley Place
Boston, Massachusetts - April 4-7, 2007
The PCA Dime Novels, Pulps, and Juvenile Series Books division invites interested parties to submit papers for presentation. Papers may cover (but are not limited to) any aspect of the following topics: authors, major characters, themes, readership, bibliography or research methods, social commentary, early genre forms, special collections, and matters of gender, race, class, image or attitude.
Participants do not need to be PCA/ACA members, academics, or professional writers to submit proposals; however, membership in either PCA or ACA and conference registration are required in order to present. The deadline for conference registration is February 1, 2007.
All participants are requested to submit a 250 word abstract with title. First-time participants with this division must submit a 1-2 page proposal, including a bibliography of reference sources, along with the abstract. Send all materials by November 1, 2006 to:
Marlena E. Bremseth, Area Chair
Howard University
Department of English
248 Locke Hall
Washington D.C. 20059
(703) 339-8910
mbremseth_at_howard.edu or Raven04_at_aol.com
Additional information regarding PCA/ACA, membership, and the conference can be found at http://www.h-net.org/~pcaaca.
From the Literary Calls for Papers Mailing List
Full Information at
or write Jennifer Higginbotham: higginbj_at_english.upenn.edu
Received on Tue Jul 18 2006 - 17:42:33 EDT

subset: commoncrawl


text:
Blue Glass Vase with Shells
- Description
10.5" tall....Blue Glass Vase with Shells
Get in touch
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text:
Cheung Khlang Knong Piphop Kun
Hei Feng Xi is handsome and elegant, while Bai Feng Xi is majestic and unrestrained. Opposites attract as both are unrivaled in skill and intellect. Caught in the warfare and chaos of the martial arts and political worlds, the flowers of love begin to bloom amidst the blood that has been sacrificed within the last ten years.
Trying to keep their identities hidden, they constantly have to be three steps ahead when dealing with much political unrest, betrayal, infighting, and the ultimate battle for the imperial throne. They join hands, seeking justice while trying to calm the ever-growing uncertainty brought on by unseen malice. But will their love bring peace to a chaotic time, and who will ultimately rule the world?
(Source: ChineseDrama.info; edited by MyDramaList)


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2022 World Cup Sparks Labor Reform, Just Not In Qatar – Analysis
The 2022 Qatar World Cup may be sparking social change in the Gulf, just not (yet) in Qatar.
Qatar's winning of the hosting rights for the World Cup gave human rights and trade union activists the leverage they needed to more effectively pressure the Gulf state for reform, if not abolition, of its controversial kafala or labour sponsorship system that puts employees at the mercy of their employers.
While focused on Qatar, the campaign also targeted other Gulf states and prompted other activists to focus on high-profile construction projects like sites for Western museums and universities in the UAE. It also motivated countries across the region to tinker with their labour systems. While Qatar made lofty promises of reform and engaged with its critics, the UAE and other Gulf states rejected criticism and barred activists entry to their countries.
Now however, as Qatar continues to dither, the UAE has decreed the very reforms, Qatar has yet to implement nationwide, and a prominent Saudi intellectual has called for abolition of kafala in the kingdom. Kuwait recently became the first Gulf state to pass legislation granting domestic workers greater rights. By contrast, students last month denounced conditions for workers at Weill Cornell Medical College in Doha.
The UAE move and public debate in other Gulf states deprives Qatar, a supporter of change across the Middle East and North Africa with the exception of the Gulf, of its claim to be on the cutting edge of transition in the region. It also casts further doubt on the sincerity of Qatar's promises.
Qatar has promised to pass legislation by the end of this year that would ease procedures for exit visas and improve recruitment, housing and working conditions for migrant workers who constitute a majority of the Gulf state's population.
Several major Qatari institutions, including the 2022 Supreme Committee for Delivery & Legacy and Qatar Foundation, have adopted standards that go a far way to meet activists' demands but these have yet to be enshrined in national law. Qatar has suggested that its emir, Sheikh Tamim bin Hamad bin Khalifa Al Thani, would approve legislation by the end of this year.
International Trade Union Confederation (ITUC) secretary general Sharon Burrow noted after a visit to Oman last month that the Gulf state had just about as many migrant workers as Qatar does but that its laws did not discriminate between Omani and foreign workers even though Omanis, migrant workers and western expatriates have different contract terms. Ms. Burrow further noted that in contrast to Qatar workers were allowed to unionize and elect their leaders and were accorded "humane accommodation."
"In Oman you feel optimism and the hope of a shared future. In Qatar you feel discrimination, denial and a master-servant relationship. Common region, shared cultures, neighbours – why the difference?" Ms. Burrow asked.
Leaving Qatar looking like a straggler, the UAE last month decreed labour reforms that aim to tighten oversight of employment agreements for migrant workers with the exception of domestic labour. The decrees focus on improving transparency of job terms and employment contracts, spell out how contracts can be broken, and could make it easier for workers to switch employers.
Under the new policies, prospective workers would be asked to sign a standard employment offer in their home country that would in turn be filed with the labour ministry before a work permit is issued. That agreement would then be registered as a legal contract once the worker arrives in the country, and no changes would be allowed unless they extend additional benefits that the worker agrees to. Contracts can be broken by either side under certain circumstances, and workers would be free to switch to a new employer after obtaining labour ministry authorization.
In Saudi Arabia, Khaled Almaeena, a prominent Saudi journalist, called recently for the abolition of the kafala system in the kingdom. Noting that his repeated efforts to get ministers to focus on labour reform had gone unheeded, Mr. Almaeena wrote last month that "a media campaign should be conducted and people, both the workers and the employees, should be made aware of their rights and obligations. Contracts should be lodged with the Ministry of Labour rather than with employers. And the Kafala system must go."
The push for reform in the Gulf is about more than ensuring adherence in the region to international labour standards. In the smaller Gulf states it raises the spectre of giving rights to a majority of the population against the backdrop of a minority citizenry that fears losing control of its culture and way of life.
Concern is heightened by the fact that the social contract in Gulf states that involves surrender of political rights in exchange for a cradle-to-grave welfare system is fraying at the edges. Faced with population growth and reduced oil revenues, Gulf states have begun to roll back subsidies, sparking sharp rises of food prices in Bahrain and bringing fuel prices in the UAE to world market levels. Oman is mulling also raising fuel prices while Kuwait is looking at the introduction of a value added tax and road tolls.
Labour reform is to many in the Gulf a Pandora's Box, not only in terms of potentially laying the groundwork for foreigners demanding ever more rights but also with regard to badly needed sweeping economic reforms in preparation of a post-oil age. Newly born in all Gulf states with the exception of Qatar and Kuwait are expected to witness their countries running out of fossil energy resources within their lifetimes.
Reforms would have to rebalance the relationship between the state and a private sector that remains dependent on government. They would also have to restructure labour markets in which citizens who largely enjoy comfortable government jobs would have to compete with expatriates likely to sell their services at a lower price. As a result, Kuwait has moved to subsidize salaries of Kuwaitis employed in the private sector.
Inevitably, the reforms will be building blocks for a move from a rentier to a productive economy in which citizens become productive rather than entitled members of society. That could spark greater interest in political change. That change is inevitable and is likely with or without the 2022 World Cup. The tournament however is proving to be a catalyst.


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Serena Remote Controlled Cellular Shades from Lutron make for a simple, affordable room upgrade, providing privacy, practicality and convenience at the touch of a button. Raise or lower Serena Shades from anywhere in the room as daylight patterns change to avoid glare, keep out UV rays and protect floors, fabrics and furnishings. Serena Shades also allow you to increase privacy while reducing heating and cooling costs.
Lutron's Serena Remote Controlled Cellular Shades are battery powered and easy to install, with no wiring required. Innovative technology provides a three-year battery life with the use of standard D-cell batteries, and Serena Shades are available in styles, textures and colors to suit every room design. Learn more about Serena Shades and get started in the idea gallery at www.serenashades.com.


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Today's been the single biggest polling day in my estimation since the 2010 elections. Three major releases all containing interesting data. The third and most surprising of those comes from Fox News, which shows Herman Cain not just in third place, but taking a top-tier position usually held in recent weeks by Michele Bachmann or Ron Paul.
Facts: 364 Republican primary voters, phone survey with landline and mobile handling included. MoE 5.
As I said, Herman Cain has arrived. Mitt Romney gained one point from last month to lead at 23, Rick Perry notably lost 10 points to land at 19, and Herman Cain gained 11 to finish at 17. Newt Gingrich jumped up 8 points to round out the double figures candidates at 11.
What do these three big movers have in common? Rick Perry is beginning to get a reputation for poor debating, while Cain and Gingrich are getting comments that they debate well. Much as Tim Pawlenty crashed after he disappointed in a debate, giving away his support to Michele Bachmann who was ready, now it appears that Herman Cain appears viable to Perry supporters whose eyes are straying.
I want to start seeing favorability and unfavorability ratings for Romney, Perry, and Cain, stat. Cain, as Perry before him, will get heightened scrutiny now. Will he hold up, is the key question right now.


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Sustainable Seaweed: Researchers Explore Algae-Based Animal Feed
The pigs and poultry in Professor Xingen Lei's lab have been consuming feed one wouldn't expect in Ithaca: marine algae.
The pigs and poultry in Professor Xingen Lei's lab have been consuming feed one wouldn't expect in Ithaca: marine algae.
The Cornell University animal science professor is testing the unlikely material as a new protein-rich source of feed to supplement and replace some of the corn and soybean meal mix traditionally given to food-producing animals.
By doing so, he could transform a biofuel byproduct into a valuable commodity, potentially freeing thousands of acres of cropland.
"Current animal feed directly competes against human food sources and, thus, is unsustainable," Lei said. "We must develop alternatives to soybean and corn for animal feeds."
Algae produces 50 times more oil per acre than corn, with a much smaller carbon footprint; uses nutrients more efficiently than land plants, with no runoff; and places no demand on high-quality agricultural land or freshwater supplies.
There are an estimated 1 billion swine, 1 billion cattle, 2 billion sheep and goats and 40 billion poultry worldwide. The average pig consumes about 660 pounds of feed by the time it goes to market, Lei said, so replacing just 10 percent of that feed with algae would save a whopping 33 million tons.
Lei's preliminary research found that dried defatted algae derived from biofuel production can replace up to one-third of soybean meal in diets for pigs and chickens. It is an attractive source because it is high in protein -- 20-70 percent, compared with about 10 percent in corn and 40 percent in soy.
Lei and his researchers are now working to determine which algae are best, and the proper ratios of algae, soybean and corn. They are also discerning whether there are risks or additional health benefits for humans in resultant products, such as meat and eggs.
The samples are shipped to his lab from Hawaii, where algae is being cultivated on a few acres near the Kailua Kona Airport as part of a $15 million pilot project by Cellana and a multi-university consortium led by Cornell professors Chuck Greene, professor of earth and atmospheric sciences, and Jeff Tester, professor of chemical and biomolecular engineering.
Ramping it up to commercial scale will require thousands of acres and hundreds of millions of dollars, said Greene.
Which is where Lei can help. Turning a biofuel byproduct into a value-added product could be the key to commercial viability and may spawn other new industries. The global animal feed market is expected to exceed 1.5 billion tons per year by 2020, 15 percent of which (220 million tons) is protein, Lei said.
Not the seaweed found along coastlines or in sushi, Lei's algae is a dried version of their single-cell cousin. Its simpler structure means it is easier to break down, without the complex cellulose that presents challenges to the production of plant-based biofuels like corn-derived ethanol.
It also has a high lipid, or oil, content -- around 30 percent, compared with 4 percent in corn -- and its own inherent stress response can be harnessed to help in oil production. When starved of nutrients, the algae undergoes physiological changes causing it to exude oil -- a process being studied by Beth Ahner, professor of biological and environmental engineering, and Ruth Richardson, associate professor of civil and environmental engineering.
With further innovations, the process could actually remove substantial amounts of carbon dioxide from the atmosphere, Greene said, and its use in the production of jet fuel could help the U.S. military meet its goal of switching to a 50/50 blend of fossil and biofuels by 2020.


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I'm happy to report that our two day FreeBSD Developer Summit following MeetBSD has been a success. We had over 30 attendees from the FreeBSD Developer Community as well as engineers from Yahoo, NetApp, Isilon, QLogic, Huawei, Google, Juniper, Cisco, Facebook, ISC, Metaweb, and other technology companies using or looking at using FreeBSD. There were formal presentations on the first day, followed by less structured hacking during the second day. The agenda of talks for the first day is available here. This concludes I think the end of a very busy summer/fall period with BSD Conferences and developer summits in Ottawa, New York, Tokyo, Strausburg, and Mountain View. Next up is Ottawa and Cambridge, UK in 2009. Thanks to Leslie Hawthorne and Xin LI for their help in organizing the summit.
Tuesday, November 18, 2008
FreeBSD Developer Summit at Google
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Today, we have a contemporary fiction novel for women in our book spotlight. Check out The Year of Loving by Traci L. Slatton--and enter for a chance to win a $20 Amazon gift card in the book tour giveaway at the end of this post!
Year of Loving
Traci L. Slatton
Contemporary Women's Fiction
gallerist Sarah Paige's world is crumbling. One daughter barely
speaks to her and the other is off the rails. Sarah is struggling to
keep her gallery afloat in a tough market when she learns that her
most beloved friend has cancer. In the midst of her second divorce,
two men come into her life: an older man who offers companionship and
stability and an exciting younger man whose life is as chaotic as
courage, humor, and spirit strengthen her, but how much can she bear,
and what sustains her when all else falls away?
L. Slatton is the international bestselling author of historical,
paranormal, and romantic novels, including IMMORTAL (BantamDell) and
BROKEN; the award-winning dystopian After Series which includes
FALLEN, COLD LIGHT, FAR SHORE and BLOOD SKY; the bittersweet romantic
comedy THE LOVE OF MY (OTHER) LIFE; and the vampire art history romp
THE BOTTICELLI AFFAIR. She has also published the lyrical poetry
collection DANCING IN THE TABERNACLE and THE ART OF LIFE, a
photo-essay about figurative sculpture through the ages. Her book
PIERCING TIME & SPACE explores the meeting ground of science and
spirituality. Her latest novel THE YEAR OF LOVING follows an art
gallerist through a steamy love triangle and a challenging year of
love and travail. This story seeks to answer the question, What
sustains you when all else falls apart?
the tour HERE
for exclusive content and a giveaway!


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Thursday, August 15, 2013
13 comments:
- Shani said...
Absolutely love this!! Have you thought about doing another one?
- August 15, 2013 at 8:36 AM
- Anonymous said...
- August 15, 2013 at 12:51 PM
- Julie Ferguson said...
Those are cool!
- August 15, 2013 at 2:31 PM
- Rot said...
We were toying with another shorter film of a different sort, but every time I think about the amount of work and time Swamp Foetus took, I cringe. - August 15, 2013 at 2:43 PM
- Shani said...
I can imagine how much time and work you guys put into this!! You did an incredible job! Hey...while I'm thinking about it...any chance of a Peddlers Village scarecrow this year? =)
- August 15, 2013 at 4:55 PM
- Rot said...
I came very close to doing it again this year, but opted out due to timing.
The Knight prop was going to become Knight of the Crows....but I need the time to work on my Haunt. - August 15, 2013 at 5:07 PM
- ShellHawk said...
*happy sigh*
- August 15, 2013 at 8:35 PM
- Willow Cove said...
I watch these and keep thinking if they were made into those lenticular moving pictures. you know, like the ones that came in cracker jack box before the haunted portraits came one the scene. A Pumpkinrot lenticular card would have blown my mind as a kid.
- August 15, 2013 at 9:13 PM
- girl6 said...
my eyes are so bad, i read Gift first & then that instantly took me to, "Thirsty--have a fetus?".. : D
hahahhahahha...i Totally stole that from Guillermo del Toro.
then...well, i just browned out, for like a Lonnnnng time, cause those Gifs are hypnotic like that.
You guys...<33333333333
Mr. & Mrs. Jones... :):):) - August 15, 2013 at 9:55 PM
- girl6 said...
& i SWEAR...if Jamie Wyeth saw this, he would have to smoke a Effin' Carton of Cigarettes!!!..BIG Time.
- August 15, 2013 at 10:43 PM
- K.O. said...
These gifs are amazing!! Each one tells a story.
- August 15, 2013 at 11:26 PM
- Shani said...
Girl6.....LMAO!!! Your post is cracking me up!! =)
@Rot....Ahhh...I was hopeful! I get it though...don't want one to take away too much time from the other. I have to admit...going to see the scarecrows isn't quite as exciting without ya there. - August 16, 2013 at 7:08 AM
- Tim the Braineater said...
By far my favorite short film so far! So much emotion and creepiness in less than 10 minutes! awesome!
- August 23, 2013 at 12:33 PM


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Silky shag rugs are softer and silkier than traditional shag rugs made from wool or synthetic fibers. Our rugs have a uniquely luxuriant look and feel due to custom specified blended yarn (50% rayon made from bamboo, 50% cotton). This custom blended yarn combines bamboo viscose and cotton and highlights the best qualities of each material. The cotton provides heft and fluffiness while the bamboo viscose provides a subtle silky sheen.
- Color: Crimson
- Machine tufted
- Pile: 50% rayon made from bamboo and 50% cotton
- Backing: Cotton and natural latex
- Weight: 4500 g/sm
- Rug pad recommended


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Friend of the blog Elisabeth Dickinson, a correspondent for The National , has a Kindle Single out today about the 2011 uprising in Bahrain and its subsequent repression. From the blurb:
Who Shot Ahmed? recounts the murder of a 22-year-old videographer, killed in cold blood in the dead of night at the height of Bahrain's Arab Spring revolution. On a small island Kingdom swirling with political, economic, and sectarian tensions, Ahmed's murder epitomized everything that had gone wrong since 2011, when pro-democracy protesters took to the streets in droves. Drawing on dozens of testimonies, journalist Elizabeth Dickinson traces the tale of Ahmed's death and his family's fearless quest for justice. Darting between narratives and delving into characters, it is a tale of a life lost and the great powers—from Washington to London, and Riyadh to Manama—that did nothing to stop the crisis. Dickinson has a deep knowledge of the region, but she brings a story from a foreign land straight back home: Ahmed could be any of our sons.
You can find out more about the book on the publisher's page, its Facebook page or on Twitter at @WhoShotAhmed. I just bought my copy, get yours by clicking on the cover above!


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- States:
- California
- New Mexico
- Kentucky
- Vermont
- Alabama
Travelers worldwide flock to the USA to explore its dramatic landscapes.
Vast deserts, thick forests, rolling fields, deep canyons and rugged coastlines lure adventurous visitors. Add a hot air balloon to the scenery, as they do at each of these five festivals, and the views get even better – especially for the riders.
BB&T Great BalloonFest
Louisville, Kentucky
Festival highlight: Part of the annual month-long Kentucky Derby Festival, which precedes the prestigious horse race, the BB&T Great BalloonFest features several ballooning events. During the nighttime Great Balloon Glow, the pilots of earthbound balloons fire their burners in sync to a musical score.
How to get there: Louisville International Airport is about 1 kilometer southwest of the Kentucky Exposition Center, where many festival events are held.
What else to do: Kentucky is home to the top bourbon distilleries in the world. To learn how this variety of whiskey is made — and taste the results — visit the Evan Williams Bourbon Experience in Louisville or head just east of the city and tour the distilleries along the Kentucky Bourbon Trail.
Albuquerque International Balloon Fiesta
Albuquerque, New Mexico
Festival highlight: Held annually in October with more than 500 balloons, the Albuquerque International Balloon Fiesta in New Mexico is what the city touts as the largest hot air balloon festival in the USA and one of the largest in the world. That's no surprise given the ornate designs on the balloons, with fractal and kaleidoscope patterns, and the backdrop of the Sandia Mountains. The fiesta is one of the rare hot-air balloon events where you can walk among the balloons and chat with the pilots, too.
How to get there: Albuquerque International Sunport is 25 kilometers south of Balloon Fiesta Park.
What else to do: While it incorporates Native American, Mexican and Spanish flavors, New Mexican cuisine's use of red and green chiles gives it a unique flavor. Visit restaurants along Central Avenue to taste some of the creative ways Albuquerque chefs are using chiles.
Hot air balloons at sunset in Albuquerque
Sonoma County Hot Air Balloon Classic
Windsor, California
Festival highlight: Want to ride in a hot air balloon ride but feel a bit nervous about the experience? The Sonoma County Hot Air Balloon Classic in California offers five- to 10-minute rides in balloons that are tied to the ground. The journey could give you a good look at the city's old downtown and lush parks.
How to get there: Fly into San Francisco International Airport and then drive 134 kilometers north on US Highway101.
What else to do: Sonoma County is one of the top U.S. wine regions, so don't leave without visiting at least a few of the area's more than 400 wineries.
Getting a hot air balloon ready to take off
Gulf Coast Hot Air Balloon Festival
Foley, Alabama
Festival highlight: Volunteer at the Gulf Coast Hot Air Balloon Festival in Alabama for an up-close look at the balloons – and the chance to fly in one and see the Gulf of Mexico shoreline. (Also, you'll get a free T-shirt.)
How to get there: Pensacola (Florida) International Airport is 55 kilometers east of the Foley Sports Complex.
What else to do: For insight into a less leisurely form of air travel, head back to Pensacola and visit the National Naval Aviation Museum, where you can experience a fighter-jet simulator.
2014 Gulf Coast Hot Air Balloon Festival
Quechee Hot Air Balloon Craft and Music Festival
Quechee, Vermont
Festival highlight: The Quechee Hot Air Balloon Craft and Music Festival in Vermont offers 40-minute ascension rides (weather permitting) that can provide stunning views of the 50-meter-deep Quechee Gorge. And, keeping with a ballooning tradition, the rides end with a glass of sparkling wine.
How to get there: Logan International Airport in Boston, Massachusetts, and Bradley International Airport in Hartford, Connecticut, are both about 220 kilometers away.
What else to do: For a closer look at Quechee Gorge, hike in Quechee State Park.
Related Topics:
More experiences nearby
Explore more
History of Mardi Gras in the USA
5 Ancient Wonders of New Mexico
The Treasures of Gold Country
5 Flowers You'll Only Find in the USA
5 Rejuvenating Resorts in the USA
4 Parks Within 3 Hours of Las Vegas
4 Rare Birds to Look For in the USA


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Bright. It's the first thing that came to my mind when I took the inaugural bite of a Pink Lemonade cupcake I whipped up for last weekend's bridal shower. Bright – and I ain't talking about color. Imagine taking a perfect summer afternoon, piping pink icing on top, and sprinkling it with colored sugar. Absolutely awesome 🙂 They were the perfect compliment to the margarita cupcakes and part-inspiration behind the bright pink & green colored theme of the tapas party and shower. Nice and bright.
I used a similar wet-to-dry ratio in the pink lemonade cupcake recipe that I used in the margarita cupcake recipe with a slight modification and a shortcut – I decreased the liquid to 9 oz and used frozen pink lemonade concentrate. I knew that the delicate flavor of the pink lemonade would probably get lost in the baking process and I wanted a flavor intensity similar to the margarita cupcakes. I thought the batter looked perfect after adding 9 oz of the concentrate – any more might have been too much more.
I will say, the recipe appears at least somewhat versatile and I plan on substituting the 9-10 oz of liquid for many other flavors in the coming months. The margarita and pink lemonade cupcakes might have been the first cupcakes I've ever made (since I was 8 years old) but they sure won't be the last – I'm totally hooked!
Looking for a from-scratch pink lemonade cupcake? Try these strawberry lemonade cupcakes!
Pink Lemonade Cupcakes
Pink, tart cupcakes that are reminiscent of the beverage.
- For the cupcakes:
- 1 1/8 cup (9 oz) frozen Pink Lemonade Concentrate, thawed*
- White cake mix (yes, the boxed stuff)
- 3 egg whites
- 2 Tbsp vegetable oil
- Non-stick spray
- For the frosting
- 3 cups + 3 Tbsp confectioners sugar
- 1 stick unsalted butter at room temperature
- 1/8 tsp salt
- 2 Tbsp lemon juice
- Red food color (to color icing and sugar, optional)
- 1/4 cup granulated sugar (optional)
- *To make the cupcakes:
- For a less tart cupcake (and these babies do pack a punch), try reducing the amount of pink lemonade. 3/8 cup water and 3/4 cup pink lemonade will cut the tartness.
- In a stand mixer, add the cake mix, egg whites, vegetable oil, and the pink lemonade concentrate. Mix on low for about 30 seconds and then increase to medium speed for 90 seconds (the batter will still be a bit lumpy; take care not to overmix so you don't end up with dry cupcakes).
- Spray each cupcake liner with the non-stick spray and spoon the batter into a prepared muffin pan (fill the cups between 2/3 and 3/4 full). Bake at 350 for about 25 minutes or until a toothpick registers "done" in the center cupcake. Remove the pan from the oven and cook 5 minutes. Remove the cupcakes and cool completely on a baking rack.
- Once the cupcakes have cooled, make the icing and ice the cupcakes.
- *To make the frosting:
- Add the butter, confectioners sugar, salt, lemon juice, and food coloring (if using) to the stand mixer and mix on low using the paddle attachment until combined. Turn the speed to med-high until the icing is fluffy and uniformly pink. Add the icing to a pastry bag fitted with a 2D tip and ice the cupcakes.
- Optional - Add the sugar and a couple drops of the food coloring to a food processor. Process until the sugar turns pink. Spread the sugar onto a plate and let dry for 15 minutes. Sprinkle onto freshly-iced cupcakes.
Yields: ~24 servings
Estimated time: 1 hour


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Beats Electronics, based in Santa Monica, Calif., said equity investment giant Carlyle Group has purchased a minority share of the company for $500 million.
Beats, founded by music producer Jimmy Iovine and rapper Andre Young — known as Dr. Dre — is a rapidly expanding maker of high-end headphones costing between $200 and $400.
Terms of the deal with Carlyle Group were not disclosed, but the deal values Beats at more than $1 billion, The Wall Street Journal reported Saturday. When smartphone maker HTC invested in Beats two years ago, the company had a valuation of about $600 million, the Journal said.
Carlyle's investment was announced simultaneously with news that Beats had agreed to buy out HTC Corp.'s 24.84 percent of the company in a deal valued at $265 million.
"These transactions represent the evolution of the financial strength and significant growth prospects of Beats," said Iovine, who also is chairman of Interscope Geffen A&M.
The Hollywood Reporter said the deal is expected to help Beats expand, especially overseas.
Carlyle Group, based in Washington, is the second-largest private equity firm in the world with $180 billion in assets under its management and is known to have friends in high places, the Journal said.
"Carlyle has a strong history of helping great brands expand globally, and we are thrilled to partner with Jimmy Iovine, Dr. Dre and their talented management and product teams," said Sandra Horbach, the equity firm's managing director and head of consumer and retail.
Copyright 2013 by United Press International


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Green Cities
The Greenest Super Bowl Ever?
January 31, 2014
With the weekend quickly approaching, there's one thing that's on the minds of most Americans- the Super Bowl. Super Bowl XLVIII will be held at New Jersey's Metlife Stadium, the home of the New York Giants and New York Jets, this Sunday, Feb. 2nd. The teams competing for the ultimate prize in football are from Denver and Seattle, arguably two of the greenest cities in America. But no matter how green a city is, NFL games are usually anything but environmentally-friendly events. Metlife Stadium has a seating capacity of over 82,000. That means that more than 82,000 people will be transporting themselves to the stadium, many by car, and consuming hundreds of thousands of food and drink items, each with its own paper cup or plate that will inevitably be discarded shortly after the purchase. As a matter of fact, Metlife Stadium alone produced 195 tons of food waste in 2013. Fortunately for the environmentally conscious, the NFL actually does take the environment into consideration occasionally, and promises us that Super Bowl XLVIII will be the greenest Super Bowl to date.
While it is true that the NFL promises every Super Bowl will be the greenest yet (at least for the last 20 years), Jack Groh, longtime director of the NFL's environmental program said in a statement, "we try and stay ahead of the curve. We try and push the envelope every year." This year is no exception. Not only is Metlife Stadium already one of the greenest NFL stadiums, complete with bike racks, LED lighting, waterless urinals, and seats made from recycled plastic, but it also has one of the best recycling programs in the league. This year, to do even more, Metlife Stadium officials have initiated a composting program for the first time in NFL history that hopes to turn every bit of food waste from Super Bowl XLVIII into fertilizer. All leftover non-scrap food will be donated to soup kitchens, homeless shelters, and local charities. All leftover oil used in cooking will also be converted in biofuel and used to power backup generators at Metlife Stadium. The NFL also sponsored an e-waste drive where people turned in their old cell phones and other devices to be properly disposed of, as well as a campaign that was responsible for planting thousands of trees in the NYC metropolitan area to offset the amount of carbon emissions from the Super Bowl.
So while the Super Bowl may still be far from a carbon-neutral event, the NFL is at least putting forth a decent effort to reduce the event's environmental impact. Even if it is only a small step, it is still a step in the right direction. And at the very least, we have many more green initiatives and environmentally conscious changes to look forward to with the future of the NFL.


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Scott Macaulay chats with Paz de la Huerta, the actress who plays the enigmatic Nude in Jim Jarmusch's latest film, The Limits of Control.
One of the great pleasures of Jim Jarmusch's new The Limits of Control is solving for oneself at least a few of the film's many mysteries. The story of a Lone Man who treks across Spain on an assignment involving matchboxes full of diamonds, coded messages and a series of idiosyncratic messengers, The Limits of Control is both an immersive film environment requiring viewers to interact with its textured riddles and a spy movie. Among these puzzles is a character simply identified in the credits as "Nude" who is played by Paz de la Huerta. "She's an enigma," de la Huerta says about her character, who is first seen naked and pointing a gun while reclining in the Lone Man's bed. "Hopefully the audience will feel about her what they wish."
The 24-year-old De la Huerta was born in New York City and made her screen debut in Nicholas Hytner's 1998 film The Object of My Affection, broke out with her part the next year in Lasse Hallström's The Cider House Rules, and has since alternated between studio films and independent movies like Ethan Hawke's Chelsea Walls and Amy Redford's The Guitar. While growing up, she also bounced between New York and Spain, where she spent summers with her father. "My father lived on a ranch when I was a little girl," she says, "and we were completely separated from city life. I thought the Spanish landscape had a lot of mystery to it — for me, there are so many hidden things in Spain — and the women there are quite secretive."
Of the Nude's secrets, de la Huerta says, "She has an innocence about her, but she's also a bit tragic and very mysterious. I think she's very honest but then again she plays a lot of games. She has this deep connection to the Lone Man. For me to play her, I had to tune into something in myself, a sense of doom."
She continues about the experience of making the film: "When I do a film, I start living the life that I think my character might live, and [when I did this], strange things started to happen. It was all about being open to the moment, being there in Spain, inside this haunted, mysterious building [Madrid's modernist Torres Blancas]. Also, for me film is a group effort, and the way Jim makes movies, with an amazing team [around him] — he made me feel secure and safe so that I could go really far with my role. The brilliance of Jim is that he makes an atmosphere that is so complete from the moment you walk on the set. Everything is created so purely for you that you just have to be present. "
In mid-May, de la Huerta will be seen in another high-profile film, French provocateur Gaspar Noé's long-awaited Enter the Void. She plays a stripper in Tokyo who is looked after by the spirit of her slain brother as he departs from the world. "It was an incredible experience," she says of her experience on the film, "both completely healing and traumatizing at the same time. I was alone in that foreign city for four months while making the film, and I feel I lived what that girl, Linda, goes through."
As we conclude our conversation, de la Huerta, who has a passion for music and is also a painter and designer, tells me that after shooting The Limits of Control in Spain that she's become interested in flamenco. "I may want to commit to it," she says, "become a flamenco singer or dancer." But like Jarmusch, who chose as the key flamenco piece in the film a peteneras, the slower, tragic and somewhat taboo form of the genre, de la Huerta is attracted to its darker and, yes mysterious elements. "Making Jim's film and being in Spain was very emotional for me," she says. "My character's sense of doom and all that she goes through is very much like flamenco, with all the tristesse. In even beauty there is a sadness."