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As the title suggests, I'm currently unable to add images or attachments to posts.
I can choose the file, but when I click to upload I get the following error message:
Testfile.jpg - Imageinfo Failed:
sh: /usr/local/bin/identify: No such file or directory
I'm posting this here largely so I have the error info in one place as we try to fix it, assuming it's not just a temporary problem. But I'm curious if anyone else is having the same problem.

subset: commoncrawl


text: In the Shaw Brother's 1983 Thai boxing film/wizardry flick/Technicolor brain colonic The Boxer's Omen, a black magic practitioner battles a meditating monk using his army of bats, crocodile skulls, and floating heads out of The Thing. It's but another beautifully baffling moment martial arts archivist Sardonicus has brought to our attention. Truth be told, I kind of wish I hadn't eaten lunch prior to watching this.


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Strategic Initiative for Developing Capacity in Ethical Review
The Strategic Initiative for Developing Capacity in Ethical Review (SIDCER) is a network of independently established regional fora for ethical review committees, health researchers and invited partner organizations. The primary objective of SIDCER is to contribute to human subject protections globally by developing local capacity for ethical review of research involving human subjects and for developing policies on the ethics of health research.
SIDCER vision: to ensure protection for all human participants in health research globally.
SIDCER mission: to foster competent, independent, in-country decision making for promoting responsible conduct of human research through its international network of fora, and to monitor the quality and effectiveness of ethical review worldwide, with mutual understanding and respect for cultural, regional and national differences.


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Read About STD Testing in Myerstown PA
Reviewed By: Dr. Kurt Kloss, MD
Last Reviewed Date: Sep 05, 2019
Sexual Health Testing in Myerstown PA
At Health Testing Centers we make sexual health testing in Myerstown easy and convenient by allowing you to avoid the hassle and embarrassment of visiting your doctor. We provide direct access to the same CLIA approved labs in Myerstown, PA and FDA approved tests that your doctor would utilize. Also the results are delivered directly to you and are not a part of your permanent medical record.
STD Statistics in Myerstown
In recent years, Myerstown, Pennsylvania data have echoed the trends occurring throughout the state for two serious sexually transmitted diseases, Chlamydia and gonorrhea. This is concerning, since both diseases can lead to infertility in women and serious health problems in both sexes. As the data indicate, syphilis, an incurable sexually transmitted disease has only affected a minuscule percentage of the Myerstown population in recent years. Fortunately, if treated in its early stages, frightening results such as neurological problems, blindness, mental illness and even death can be avoided. Using the Center for Disease Control's 2016 STD Surveillance Report for chlamydia, gonorrhea, and syphilis and extrapolated using the latest 2011 US Census, it is estimated that 0.1 incidents of syphilis, 13.7 cases of chlamydia and 3.5 cases of gonorrhea, would be attributed to Myerstown in 2016.
As the Myerstown data corroborate, women are much more likely to contract genital herpes than are men. On the national level, 21 percent of women and 11 percent of men were reported by the Centers for Disease Control to have HSV-2, the most common form of genital herpes. Perhaps due to the ongoing public education campaign regarding AIDS and HIV, 2011 data of reported cases show that this disease remains at a very low incidence in the overall population of Myerstown and the state as a whole. Nevertheless, the fact that other STD transmission rates remain high suggests that the behaviors that spread them could also lead to the transmission of AIDS and HIV.
STD Treatment and Counseling in Myerstown
When ordering an STD package or individual test from Health Testing Centers that tests for chlamydia, gonorrhea, trichomoniasis, or HSV type 2, a physician consultation and treatment are included when there is a positive result. If you test positive for any of the 4 mentioned STD's, a telephone or video consultation will be provided at no additional cost by one of our third party physicians. The physician from PWN Health will contact you within 4 to 24 hours of receiving your test result. At the end of the consultation the physician may prescribe the necessary medication for treatment. It is up to the sole discretion of the physician to provide any medical treatment based on test results and any medical information they received during the consultation. Cost of the prescription is not included.
STD Lab Locations in Myerstown, PA
Purchase STD blood testing and get same day testing from FDA approved labs near Myerstown Pennsylvania. Search for your STD lab location using zip code: Visit our Lab Locator.
How It Works
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your doctor.
tests used by doctors and hospitals.
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STD Testing Labs in Myerstown, PA
Whether you're concerned about possible STD exposure or simply want a quick, convenient and confidential way to take control of your sexual health via routine STD screening, our STD testing centers near Myerstown, PA can help. Our testing locations offer private, top-quality STD testing just like you would receive from your doctor's office without the added expense and inconvenience of an office visit just to have that doctor place the order for those tests.
Why is testing important?
Because STDs are more common than you may realize, with nearly 20 million new STD cases occurring every year, according to nationwide CDC estimates. Their affects can be quite serious. For instance, HIV infection can progress to AIDS, and gonorrhea, Chlamydia and syphilis can lead to infertility without treatment. These examples show just how important it is that these and other STDs do not go undetected for lack of a simple health test, easily done via STD testing centers near Myerstown, PA.
When should you seek STD testing?
Clearly, if you know or suspect that a partner is affected by a sexually transmitted disease, looking into STD testing centers near Myerstown, Pennsylvania is important to protecting your health, as is seeking immediate treatment should you receive positive results. However, STD testing is also essential for all sexually active individuals. That's because STDs don't always come with obvious symptoms. Some may produce no symptoms at all, while others may present mild ones that are easily mistaken for a cold or flu. For this reason, ensuring your sexual and overall health means getting regular screening tests for common STDs. Just how often you should schedule test days depends on your individual circumstances. If in doubt, consult a healthcare professional for an appropriate testing routine for your needs.


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Fishful Thinking
Monday, April 6, 2009
I've done it! I've signed up for Fishful Thinking! You've heard of Fishful Thinking, right? Everybody's doing it!
Here's some background on Fishful Thinking:
Pepperidge Farm has been committed to promoting a healthy lifestyle
for over forty years by offering parents wholesome snacks made with
no artificial preservatives. The Goldfish® brand partnered with Positive
Psychology leader, Dr. Karen Reivich, to create Fishful Thinking: a
program for parents that helps them to raise kids who are optimistic
and can confidently tackle life's challenges.
With Fishful Thinking, parents can:
• talk with kids about how to deal with the ups and downs of life
• teach effective problem-solving techniques to help kids grow with
a feeling of competence
• help kids develop an optimistic attitude that allows them to move
past setbacks and obstacles
• help kids to develop their confidence and reach their full potential
• empower themselves to develop positive communication with
their children and practice the skills with their kids using fun,
easy activities
• connect with other parents to find solutions that help develop
happier, healthier, more resilient children
Read more here!
Fishful ThinkingSM is comprised of five key points:
Optimism: Focusing on the positive things in life.
Emotional Awareness: Expressing and controlling your feelings.
Goal Setting/ Hope: Finding ways to achieve your goals.
Resilience: Coping with life's ups and downs.
Empowerment: Identifying and using your strengths and skills.
There are a bunch of activities you and your children can do on the site as well as a quiz that you can take to find out how resilient your child is!
This is a great site that fosters a positive outlook on life and will also strengthen your relationship with your children! I'm going to get my son to explore the site with me very shortly!
I urge you to stop by Fishful Thinking and jump right in to the activities!


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Who says a fifty something can't rock Hello Kitty pajamas and slippers? Anyone? I thought not. 'Nuff said.
If you want a prompt, how about giving it your best shot and write a better caption than I did? Send it to me in the comments and I'll share them in another post.
Related articles
- Hello Kitty goes Rock & Roll (lowpricefabric.wordpress.com)


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Bork Bork Bork
As some of you know, I have a special place in my heart for the Swedish Chef. (This is mostly due to John's dead-on impersonation.) So for today's Wreck, I figured I'd let the Cake Wreck Master show us how it's done (and for once I'm not talking about Sandra Lee).
If that "cake" looks familiar, it may be because you're of the five trillion readers who sent me this some weeks ago:
And if you'd like to see "cannibul cake" (aka Cakey the Cake from Outer Space) sing a little Karen Carpenter, you can go here.
- Related Wreckage: Wedding Crashers, Cake Wrecks Style


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[Look for the podcast play button below.]
The amazing Spanish visual artist, Chris Lopez, returns today for Part 2 of his chat with us in this The Erotic Mind series. He is a joy to talk to and he has such a unique take on the creative process involved in this specialized art form.
But wait, you didn't miss Part 1 of this charming conversation; did you? It appeared here last week at this time. Well not to worry if ya did, because you can find it and all my podcasts in the Podcast Archive right here on my site. All ya gotta do is use the search function in the header; type in Podcast #258 and PRESTO! But don't forget the #sign when you do your search.
Chris and I discuss:
- What is erotic art;
- What differentiates erotic art from pornography;
- Where and how he finds his models;
- His chosen media;
- His drawings;
- The challenges of color;
- Some sites censor his artwork;
- Eroticizing the un-sexy;
- Sexuality and beauty;
- What he looks for in the erotic art of others;
- Being in touch with his customers.
For more of Chris, be sure to visit him on his site HERE! And his blog HERE!
You can also find him on Facebook HERE!
(Click on the thumbnails below for another slideshow of some of Chris's beautiful artwork.)
Check out The Lick-A-Dee-Split Connection. That's Dr Dick's toll free podcast voicemail HOTLINE. Don't worry people; no one will personally answer the phone. Your message goes directly to voicemail.
Got a question or a comment? Wanna rant or rave? Or maybe you'd just like to talk dirty for a minute or two. Why not get it off your chest! Give Dr Dick a call at (866) 422-5680.
Look for my podcasts on iTunes. You'll find me in the podcast section, obviously, or just search for Dr Dick Sex Advice. And don't forget to subscribe. I wouldn't want you to miss even one episode.
Today's Podcast is bought to you by: Fleshlight & FleshJack.
Podcast: Play in new window | Download


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Services on Demand
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SA Journal of Radiology
On-line version ISSN 2078-6778
Print version ISSN 1027-202X
S. Afr. J. radiol. (Online) vol.18 n.1 Johannesburg Oct. 2014
Current radiological strategies for the assessment of right lower quadrant abdominal pain
Pumersha NaidooI; Bhugwan SinghII
IDepartment of Radiology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
IIDepartment of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
Right lower quadrant abdominal pain is a common clinical entity. Imaging and the radiologist play an integral role in achieving a diagnosis, so guiding prompt management of patients. This review discusses the spectrum of pathology and imaging findings, and highlights and contrasts the preferred imaging modalities in different subsets of patients.
Right lower quadrant abdominal pain is a common clinical occurrence, with a wide spectrum of aetiologies that can present a diagnostic challenge for clinicians. Appendicitis is invariably the first differential diagnosis and most common cause of right lower quadrant pain. However, other considerations include infective, inflammatory and malignant conditions involving the ileo-caecal region, right colon, mesentery and surrounding anatomical structures.1HIV has affected the spectrum of pathology afflicting the right lower quadrant and altered the traditional diagnostic challenges presented by this anatomical region. The attendant clinician must be alert to this influence.
Imaging is currently at the forefront in assessing and diagnosing patients with right lower quadrant pain, thus guiding appropriate clinical management. Ultrasound (US) is the preferred imaging modality in children, pregnant women, and generally young patients, owing to the absence of ionising radiation. Advances in computed tomography (CT) with multiplanar reformations and 3D reconstruction have led to some clinicians considering multi-detector CT (MDCT) as the modality of choice when evaluating patients with right lower quadrant pain. CT is considered to be the first line imaging investigation for diffuse or peritonitic clinical pictures, and in elderly patients.1, 2
Magnetic resonance imaging (MRI) has an emerging imaging role in female patients being assessed for gynaecological diseases - during pregnancy for non-obstetric conditions - and in patients where iodinated contrast is contraindicated, as well as for the evaluation of Crohn's disease.1, 3, 4MRI offers short imaging protocols of approximately 10 minutes, and high contrast resolution, without the use of intravenous contrast or radiation burden. MRI and CT yield high sensitivities and specificities, without being user dependent.5
In this review, we consider the spectrum and typical imaging findings of common pathologies affecting the right lower quadrant. We highlight the preferred imaging modalities in accordance with the ALARA (as low as reasonably achievable) principle and diagnostic yield.1
Inflammatory and infective conditions
Acute appendicitis
Acute appendicitis is the most common non-traumatic abdominal emergency. However, only one-half of patients have a classical presentation (leucocytosis, fever and right lower quadrant pain), and the exact cause may be multifactorial. Currently, plain film radiography has a limited role, and has been superseded by US and CT.4MRI is beneficial in those patients for whom a CT scan is not warranted and for whom ultrasound is inconclusive.5Using high-frequency US with mild compression, an inflamed appendix is typically dilated - more than 6 mm in diameter. An appendicular wall thickness of more than 3 mm may be present with peri-appendicular or pericaecal hyperechogenicity - in keeping with fat infiltration from the inflammatory process (Figure 1).2
Typical CT features of an inflamed appendix, using multi-planar reconstruction (MPR), manifest as enlargement of the appendix (diameter > 7 mm), mural thickening and enhancement, and peri-appendiceal fat stranding (Figure 2).
Secondary signs include the presence of an appendicolith, focal wall thickening of the terminal ileum or caecum, and lack of gas and oral contrast within the appendix. Focal caecal wall thickening results in funnelling of oral contrast, termed the arrowhead sign. The complications associated with acute appendicitis include perforation, a peri-appendiceal abscess, pericaecal phlegmon, an extraluminal appendicolith, and small bowel obstruction (Figure 3).6, 7, 8
Distal appendicitis is diagnosed when a normal proximal appendix is visualised with an inflamed distal portion. A transition point is visualised with distal luminal narrowing and wall thickening or enlargement. Surrounding inflammatory changes are usually present; however, there is no caecal apical thickening or the arrowhead sign, as these are contiguous inflammatory changes. The normal appearance of the proximal appendix can lead to a missed diagnosis of distal appendicitis; therefore it is important to trace the appendix in its entirety.5, 9
Stump appendicitis is a rare complication of appendicectomy that can occur from 2 months to 50 years post-surgery. It occurs when the appendiceal remnant becomes inflamed. The imaging features are similar to acute appendicitis. The increased incidence of stump appendicitis is thought to be directly related to the length of the stump (longer stumps are more prone to infection) and the growing number of laparoscopic appendicectomies. It is important to remember that a past history of appendicectomy does not exclude appendicitis.10, 11
An appendicular mass or lump may be individualised; there can be adhesion of adjacent viscera (ileum, bladder, greater omentum) to the infectious location (Figure 4).2
Factors that complicate the diagnosis of appendicitis when using CT include lack of intra-abdominal fat or an unusual location of the caecum or appendix. Intra-abdominal fat acts as a natural contrast agent, allowing easy visualisation of an inflamed appendix. Therefore, in thin patients, the appendix may be difficult to visualise, leading to a false negative diagnosis of appendicitis. Since the caecum is a highly mobile structure and variable in position, locating the ileocaecal valve and accordingly then the appendix, may be beneficial. Multiplanar reconstruction (MPR) images are useful in visualising a retrocaecal, pelvic or transmesocolic appendix.6Two recent studies assessed the value of a non-visualised appendix in patients with clinically suspected appendicitis. They reported that the absence of a visualised appendix on CT almost excludes acute appendicitis (negative predictive value 98%).12, 13
Acute appendicitis is the most common gastrointestinal emergency requiring surgery in pregnant patients. The clinical manifestations in pregnancy are nonspecific and the caecum is displaced anteriorly and out of the pelvis, which makes visualisation of the appendix difficult. There is superior migration and rotation of the appendix as the pregnancy progresses, with the appendix frequently being found in the right upper quadrant.
There is a longstanding dilemma when considering the use of diagnostic imaging for evaluating pregnant patients with non-obstetric conditions such as acute appendicitis. Imaging modalities that do not make use of ionising radiation (such as US and MRI) are preferred as first options. If ionising radiation is to be used, a low radiation dose CT scan must be performed.3The American College of Radiology (ACR) criteria for evaluating pregnant patients for this clinical challenge include the use of targeted right lower quadrant US with graded compression as the first-line imaging modality, with MRI as second option, and followed by abdominal CT scan.3, 14
With targeted compression US, the appendix is better visualised in the first two trimesters. In the third trimester, detection can be improved by placing the patient in the left lateral decubitus position; however, this reduces sensitivity. The sonographic features are similar to a non-gravid patient.
If US evaluation is indeterminate and further imaging is clinically indicated, MRI may be undertaken.3MRI allows cross-sectional imaging with identification of appendicitis, and with no exposure to ionising radiation. With excellent soft-tissue contrast resolution, additional structures may be viewed, thereby excluding other sources of abdominal pain. On MRI, the imaging features of appendicitis include an appendiceal diameter > 7 mm, wall thickness > 2 mm, T2 high signal intensity in the wall and T2 hyperintensity in the peri-appendiceal fat stranding and surrounding fluid.4In the non-pregnant patient, contrast-enhanced and diffusion-weighted imaging may be of value - especially in patients who have equivocal wall thickness and no peri-appendiceal fat stranding. Strong contrast enhancement or restricted diffusion is indicative of appendicitis. In general, the major drawbacks of MRI are high cost, long imaging times and limited availability.5, 15
Appendicitis in pregnant patients is associated with premature labour, foetal mortality and a higher rate of perforation than in the general population. There should be no delay in the diagnosis. If MRI cannot be performed, CT of the abdomen and pelvis should be used as a second-line imaging modality. However, clinicians and radiologists must be aware of the theoretical risk of radiation-induced childhood cancer (approximately one cancer per 500 foetuses exposed to 30 mGy). Intravenous and oral contrast agents are preferred in some centres to improve visualisation of the appendix in pregnant patients.3, 15
Crohn's disease
Crohn's disease is a chronic relapsing auto-immune disorder. Whilst predominantly affecting young patients (between 15 and 30 years), it may occur in older patients up to 65 years of age. The disorder can manifest anywhere in the gastrointestinal tract. The ileocaecal region is the most affected and often mimics acute appendicitis. A CT scan excellently depicts the extent and severity of Crohn's disease. Typical CT scan findings include bowel wall thickening (generally > 1 cm), mucosal hyperenhancement, pericolonic fat stranding, and mural stratification owing to intramural oedema. Segmental involvement of the bowel with skipped normal areas are helpful in distinguishing Crohn's disease from ulcerative colitis. Further findings, such as engorgement of the vasa recta that penetrate the bowel wall (the comb sign), are an important feature of active disease (Figure 5).
Sclerolipomatous or fibrofatty proliferation along the mesenteric border of the affected bowel (the creeping fat sign) may be visualised. Mesenteric lymph nodes may also be present. Associated complications include fistulae, abscesses and small bowel strictures. With the aid of CT MPR, these complications are easily characterised (Figure 6).
Positive oral contrast agents may allow better depiction of fistulous tracts; however, this may obscure bowel wall hyperenhancement. MRI and MR enterography demonstrate similar bowel-related imaging findings noted on CT scan.
Owing to the young patient population affected by Crohn's disease and its chronicity, MRI is considered as the first-line imaging option in some centres, to reduce the radiation burden.1, 2, 16CT enterography and small bowel follow-through studies also have high appropriateness ratings in the diagnosis and monitoring of Crohn's disease.17MRI short tau inversion recovery (STIR) and T2-weighted sequences allow correct localisation of the inflammatory process and the extent of disease. Contrast-enhanced sequences can estimate the severity of the episode and also depict complications such as perforation and abscesses (Figure 7).
The use of diffusion-weighted imaging (DWI) appears to be promising, with restricted diffusion believed to be strongly correlated with severity and complications.5A recent study assessed the capability of MRI to quantitatively assess the response to therapy in Crohn's disease.18The results clearly showed the distinction between normal and pathological bowel wall, and depicted significant variation in bowel wall thickness and enhancement, so reflecting any favourable response to treatment.
Diverticulitis is a common cause of abdominal pain. When encountered in the right lower quadrant, it may be caused by diverticulitis in a loop of the sigmoid colon located in the right iliac fossa or, less commonly, the caecum or ascending colon. Typical features on CT include extensive pericolonic fat stranding (maximal at the site of the diverticulae), mesenteric fluid and bowel wall thickening with enhancement. It is important to differentiate diverticulitis from acute appendicitis; the key finding is visualisation of a normal appendix. Right-sided diverticulae are less common and frequently associated with a stercolith. Furthermore, ileal diverticulae are less frequent than colonic diverticulae; ileal diverticulae are located on the mesenteric border and are usually asymptomatic. When ileal diverticulae are inflamed, these must also be distinguished from appendicitis.
Complications of diverticulitis include fistulae, abscesses, free perforation and bowel obstruction (Figure 8).1, 2, 16
CT is an effective imaging modality that enables prompt diagnosis. Using coronal STIR MRI sequences, the area of inflammation can also be readily identified. Guided by this, bowel wall thickening, diverticulae and a narrowed lumen can be visualised. The inflamed areas will enhance on the post-contrast images and complications can be readily detected.5
Tuberculous enterocolitis
Tuberculosis (TB) is endemic in the South African population, with a marked increase resulting from the AIDS epidemic. TB involvement of the gastrointestinal tract is well recognised, with the ileocaecal region most commonly affected (Figure 9).
With barium studies, an early manifestation is spasm and hypermobility, with oedema of the ileocaecal valve leading to its incompetence (Figure 10).
The caecum and terminal ileum are usually both affected; the CT features are concentric mural thickening and enhancement, which may cause luminal narrowing leading to proximal bowel dilatation and obstruction (Figure 11).
Advanced gastrointestinal TB characteristically appears as napkin ring stenosis, with a conically shaped, shrunken caecum retracted out of the right iliac fossa.19
It can be a radiological and clinical challenge to differentiate TB from Crohn's disease, considering the overlap in clinical presentation and imaging features (Table 1). This is important as it has significant therapeutic implications.20
Epiploic appendagitis
First described by Lynn et al. in the mid-1950s, epiploic appendagitis is a well-recognised cause of pain in the right lower quadrant.2, 21It is thought to be caused by inflammatory and ischaemic changes secondary to torsion or venous thrombosis of the epiploic appendages. The diagnosis is usually established with CT, allowing early recognition and conservative management. The CT appearance is that of an oval lesion of fat density with a hyperattenuating rim. Pericolonic fat attenuation and wall thickening of the adjacent colon may also be present (Figure 12).1, 17, 21
Right lower quadrant pain associated with immunosuppression
Neutropaenic colitis (typhilitis)
Neutropaenic colitis usually occurs in patients receiving chemotherapy for malignancies such as leukaemia, and for other immunosuppressive states. Clinically, it manifests with right lower quadrant pain, fever, diarrhoea and sometimes peritonitis. CT is considered the study of choice, and the features include caecal dilatation, circumferential wall thickening, intramural air and pericaecal fat stranding and fluid (Figure 13).
The presence of pneumoperitoneum, pneumatosis, gastrointestinal bleeding and fluid collections may require urgent surgical care. In an immunocompromised patient with symmetrical and circumferential caecal wall thickening, neutropaenic colitis should be suggested first.1, 2, 16
Right lower quadrant pain associated with neoplastic conditions
Ileocaecal lymphoma is not uncommon. The four forms of ileocaecal lymphoma are the circumferential, polypoid, ulcerative and aneurysmal varieties. Ileocaecal lymphoma usually manifests as areas of bowel wall thickening with uniform attenuation and poor enhancement. Long segments of bowel involvement may be demonstrated. Signs of bowel obstruction are uncommon. The polypoidal variety can act as lead point for intussusception. The ulcerative form can develop fistulous tracts with adjacent structures. The aneurysmal form may demonstrate dilatation of the lumen of the bowel or cavity of the lymphoid mass. Enlarged mesenteric and retroperitoneal lymph nodes are common (Figure 14).1
Colonic carcinoma
Most colorectal carcinomas are adenocarcinomas. In comparison with the left colon, and owing to the larger calibre of the right colon, tumours in the latter location can grow to a large size without causing bowel obstruction (Figure 15).
Patients may present with rectal bleeding, anaemia or a palpable mass.1, 16CT scanning (MDCT and CT colonography) can be used for screening of colon carcinoma for the staging of the disease, for assessing and staging of recurrent disease, and also for detection of distant metastases.22Carcinomas may demonstrate variable appearances, and perforation can occur, leading to peritonitis or intraperitoneal abscess formation (Figure 16).
Abscess formation and peritonitis may simulate an inflammatory process rather than a malignancy (Figure 17).1
Right lower quadrant pain associated with gynaecological diseases
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is seen in sexually active female patients and manifests as lower abdominal pain. The source of infection is usually an ascending lower genital tract infection. PID encompasses endometritis, salpingitis and tubo-ovarian abscesses. Neisseria gonorrhoea and Chlamydia trachomatis are the most common pathogens.23
US may demonstrate loss of normal tissue planes and an ill-defined uterus. Thickening of the endometrium may be present, but is nonspecific. Fluid may also be seen in the endometrial cavity. Salpingitis may progress to hydro- or pyosalphinx, and is usually visualised as complex fluid with echogenic debris distending the fallopian tubes. At a later stage, a tubo-ovarian abscess may form.23
On CT, a complex hypodense fluid collection with thickened and irregular walls of a tubo-ovarian complex, is seen within the pelvis (Figure 18).23
MRI STIR and T2-weighted images may demonstrate a cystic enlarged ovary. On T2-weighted images, signal hyperintensity can be localised within the parametrial tissues. A tubo-ovarian abscess appears with mild T1 hyperintensity and high signal intensity on T2-weighted images. Post-contrast MR images demonstrate a thick, enhancing wall of the abscess - with or without an adjacent hydrosalpinx.5, 17
Endometriosis is a chronic gynaecological disorder characterised by growth of endometrial tissue outside the endometrial cavity - primarily in the pelvis, peritoneum and ovaries.24This ectopic mucosa undergoes cyclical hormonal changes and also bleeds, forming haemorrhagic cysts (Figure 19).
Although US can visualise these lesions, CT and MRI are better for evaluating and characterising them. MRI has a greater sensitivity owing to the detection of blood and blood products. These appear as T1 hyperintensities, also known as the light bulb appearance on fat suppression sequence, which results from the intracellular methaemoglobin.
On T2-weighted images, endometriomas appear hypointense. This hypointense signal can also be described as shading that completely occupies the cyst or is seen as a dependent layer. It is thought to be the result of high concentrations of protein and iron from recurrent haemorrhages.17Minimal enhancement is demonstrated on post-contrast scans (Figure 20).24
Endometriomas are demonstrated on non-contrast CT scan as areas of hyperattenuation with solid and cystic heterogenous adnexal masses and fluid-fluid levels within the cysts. Cysts often rupture, leading to haemoperitoneum. The sonographic appearance of endometrioma demonstrates a uniform, low-level echogenicity or a ground glass appearance. The rupture of endometriomas may simulate complex masses, which can make diagnosis challenging.17, 23
Ectopic pregnancy
When patients present with features suggestive of an ectopic pregnancy, hormonal (β-hCG) levels and pelvic US should be performed. Transvaginal US is the preferred method of evaluation, although abdominal US can demonstrate ectopic pregnancies when β-hCG levels exceed 6 500 mIU/ml.25Tubal pregnancies are the most common ectopic location. On MRI, a tubal pregnancy is described as a sac-like, cystic tubal structure with a T2 hyperintense thick wall. The cystic sac may demonstrate T1 hyperintense to intermediate signal intensity, depending on the haemorrhagic component. It is thought that intravenous contrast may help to confidently diagnose an ectopic pregnancy, but contrast is rarely administered in pregnant patients. T2 hyperintensity or T1 hyperintensity may represent free fluid or haemoperitoneum within the abdomen.26Approximately 35% of ectopic pregnancies may not demonstrate any adnexal abnormalities (Figure 21).25
It is crucial to differentiate normal pregnancy from ectopic pregnancies with the use of US (Table 2).
Right lower quadrant pain associated with miscellaneous causes
Intussusception is not common in adults; it presents as vague abdominal pain, and occurs when a proximal segment of bowel (intussusceptum) telescopes into an adjacent distal segment (intussuscipiens) (Figure 22).
In adults, there is often an underlying lead point such as benign or malignant neoplasms (e.g. lipoma, polyps, lymphoma, carcinoma, metastases and leiomyomas). In contrast with children, operative treatment is usually necessary in adults.1, 16, 27Gayer et al. report an increased incidence of intussusception in patients with AIDS; compare the association of AIDS with numerous infectious and neoplastic conditions (infectious enteritis, Kaposi's sarcoma, non-Hodgkin's lymphoma). Intussusception should be considered in AIDS patients with prolonged abdominal pain.27Although diagnosis can be made using other imaging modalities (including barium enema, US and gastrointestinal series), CT is considered the modality of choice. Not only can the diagnosis be made accurately, but the cause and complications - such as bowel obstruction - can be assessed (Figure 23). The three typical characteristics are the reniform appearance, sausage appearance and target-shaped bowel-within-bowel appearance.1, 16, 27
Caecal volvulus
Caecal volvulus is seen in patients with an abnormally mobile caecum; this allows twisting along the long axis, leading to bowel obstruction. Three types of caecal volvulus have been described:
- type 1: the caecum twists in the axial plane, rotating along its long axis
- type 2: the distended caecum twists and inverts
- type 3: caecal bascule - the distended caecum folds anteriorly, without torsion.
The diagnosis of caecal volvulus and its complications (ischaemia and obstruction) can be readily made using MDCT. A distended caecum and swirl of mesenteric vessels is demonstrated in types 1 and 2 caecal volvulus. Concentric wall thickening, mesenteric fat stranding, and pneumatosis intestinalis are all signs related to complications.1
In addition to the causes of right lower quadrant pain enumerated and discussed above, six other causes are listed, together with their respective imaging findings, in Table 3.
Diagnostic algorithm
There is a wide spectrum of conditions affecting the right lower quadrant, some with disease-specific investigations and imaging modalities. Therefore it is vital that a structured guideline be used. The Department of Health in Western Australia has devised several diagnostic imaging pathways as a guide for their practitioners. These pathways are reviewed and updated periodically. The imaging pathway for right iliac fossa pain is particularly pertinent for use in the South African medical setting as it is practical and takes into consideration local availability and imaging constraints (Figure 24).
Right lower quadrant pain is a common clinical situation. When considering imaging, age and sex of the patient are essential factors, as the differential diagnoses may differ.2ACR criteria still rate US and CT as the primary imaging modalities for evaluating acute abdominal and pelvic conditions such as appendicitis, diverticulitis, PID and ectopic pregnancy.5US is clearly preferred in young and pregnant patients, whilst CT is considered first-line imaging for the elderly and those with peritonism.2MRI is not the modality of choice in all patients, but is a method with high accuracy and may be beneficial in a subset of patients for whom CT is not warranted.5All these imaging modalities are of value under certain circumstances, and must not oppose each other but rather have complementary functions, which will allow precise diagnosis and prompt management of patients presenting with right lower quadrant pain.1, 2
We thank Dr J. Maharajh and Dr A. Mitha for their help in compiling the images.
Competing interests
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
Authors' contributions
Both authors have contributed in various degrees to the article produced. P.N. (University of KwaZulu-Natal) was responsible for the study conception and design, acquisition and analysis of data and drafting of manuscript. B.S. (University of KwaZulu-Natal) was responsible for the analysis and interpretation of data and the critical revision of manuscript.
1. Purysko AS, Remer EM, Leão Filho HM, Bittencourt LK, Lima RV, Racy DJ. Beyond appendicitis: Common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT. Radiographics. 2011;31(4):927-947. http://dx.doi.org/10.1148/rg.314105065 [ Links ]
2. Millet I, Alili C, Pages E, et al. Infection of the right iliac fossa. Diagn Interv Imaging. 2012;93:441-452. http://dx.doi.org/10.1016/j.diii.2012.04.026 [ Links ]
3. Patel SF, Reede DL, Katz DS, et al. Imaging the pregnant patient for non-obstetric conditions: Algorithms and radiation dose considerations. Radiographics. 2007;27:1705-1722. http://dx.doi.org/10.1148/rg.276075002 [ Links ]
4. Spalluto LB, Woodfield CA, DeBenedectis CM, et al. MR imaging evaluation of abdominal pain during pregnancy: Appendicitis and other nonobstetric causes. Radiographics. 2012;32:317-334. http://dx.doi.org/10.1148/rg.322115057 [ Links ]
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6. Kin HC, Yang DM, Fin W, et al. Added diagnostic value of multiplanar reformation of multidetector CT data in patients with suspected appendicitis. Radiographics. 2008;28:393-406. [ Links ]
7. Simpson J, Scholefield JH. Acute appendicitis. Surgery. 2008;26(3):108-112. http://dx.doi.org/10.1016/j.mpsur.2008.01.003 [ Links ]
8. Rao PM, Wittenberg J, McDowell RK, et al. Appendicitis: Use of the arrowhead sign for diagnosis at CT. Radiology. 1997;202:363-366. http://dx.doi.org/10.1148/radiology.202.2.9015058 [ Links ]
9. Rao PM, Rhea JT, Novelline RA. Distal appendicitis: CT appearance and diagnosis. Radiology. 1997;204:709-712. http://dx.doi.org/10.1148/radiology.204.3.9280247 [ Links ]
10. Shin LK, Halpern D, Weston SR, et al. Prospective CT diagnosis of stump appendicitis. AJR. 2005;184:S62-S64. http://dx.doi.org/10.2214/ajr.184.3_supplement.01840s62 [ Links ]
11. Sharma M, Agrawal A. Pictorial essay: CT scan of appendicitis and its mimics causing right lower quadrant pain. Indian J Radiol Imaging. 2008;18:80-89. http://dx.doi.org/10.4103/0971-3026.37051 [ Links ]
12. Ganguli S, Raptopoulos V, Komlos F, et al. Right lower quadrant pain: Value of the nonvisualised appendix in patients at multidetector CT. Radiology. 2006;241:175-180. http://dx.doi.org/10.1148/radiol.2411050191 [ Links ]
13. Nikolaidis P, Hwang CM, Miller FH, et al. The nonvisualised appendix: incidence of acute appendicitis when secondary inflammatory changes are absent. AJR. 2004;183:889-892. [ Links ]
14. Tkacz FN, Anderson SA, Soto F. MR imaging in gastrointestinal emergencies. Radiographics. 2009;29:1767-1780. http://dx.doi.org/10.1148/rg.296095509 [ Links ]
15. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute appendicitis in pregnancy. Radiology. 2006;238:891-899. http://dx.doi.org/10.1148/radiol.2383050146 [ Links ]
16. Silva A, Beaty SD, Hara AK, et al. Spectrum of normal and abnormal CT appearances of the ileocecal valve and cecum with surgical correlation. Radiographics. 2007;27:1039-1054. http://dx.doi.org/10.1148/rg.274065164 [ Links ]
17. Singh A, Danrad R, Hahn PF, et al. MR imaging of the acute abdomen and pelvis: Acute appendicitis and beyond. Radiographics. 2007;27:1419-1431. http://dx.doi.org/10.1148/rg.275065021 [ Links ]
18. Sempere GA, Sanjuan VM, Chulia EM, et al. MR evaluation of inflammatory activity in Crohn's disease. AJR. 2005;184(6):1829-1835. http://dx.doi.org/10.2214/ajr.184.6.01841829 [ Links ]
19. Burrill J, Williams CF, Bain G. Tuberculosis: A radiologic review. Radiographics. 2007;27:1255-1273. http://dx.doi.org/10.1148/rg.275065176 [ Links ]
20. Pulimood AB, Amarpurkar DN, Ghoshal U, et al. Differentiation of Crohn's disease from intestinal tuberculosis in India in 2010. World J Gastroenterol. 2011;17(4):433-443. http://dx.doi.org/10.3748/wjg.v17.i4.433 [ Links ]
21. Bunni J, Corrigan A, Jacob K, et al. Epiploic appendagitis: A case report highlighting correlation between clinical features, computed tomography images and laparoscopic findings. Int J Surg. 2010;8:401-403. http://dx.doi.org/10.1016/j.ijsu.2010.04.010 [ Links ]
22. Taylor CR, Pfeifer KE, Wang SY. Imaging in adenocarcinoma of the colon [homepage on the Internet]. [ Links ] No date [cited 2013 Aug. 7]. Available from http://emedicine.medscape.com/article/367061-overview
23. Potter AW, Chandrasekhar CA. Ultrasound and CT evaluation of acute pelvic pain of gynaecological origin in nonpregnant premenopausal patients. Radiographics. 2008;28:1645-1659. http://dx.doi.org/10.1148/rg.286085504 [ Links ]
24. Chamie LP, Blasbalg R, Pereira RMA, et al. Findings of pelvic endometriosis at transvaginal US, MR imaging and laparoscopy. Radiographics. 2011;31:77-100. http://dx.doi.org/10.1148/rg.314105193 [ Links ]
25. Lin PE, Bhatt S, Dogra VS. Diagnostic clues to ectopic pregnancy. Radiographics. 2008;28:1661-1671. http://dx.doi.org/10.1148/rg.286085506 [ Links ]
26. Parker III RA, Yano M, Tai AW, et al. MR imaging findings of ectopic pregnancy: A pictorial review. Radiographics. 2012;32:1445-1460. http://dx.doi.org/10.1148/rg.325115153 [ Links ]
27. Gayer G, Zissin R, Apter S, et al. Adult intussusception - a CT diagnosis. Br J Radiol. 2002;75(890):185-190. http://dx.doi.org/10.1259/bjr.75.890.750185 [ Links ]
28. Angelelli G, Scardapane A, Memeo M, et al. Acute bowel ischemia: CT findings. Eur J Radiol. 2004;50(1):37-47. http://dx.doi.org/10.1016/j.ejrad.2003.11.013 [ Links ]
29. Brandt LJ, Feuerstadt P, Blaszka MC. Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: A study of 313 cases supported by histology. Am J Gastroenterol. 2010;105(10):2245-2252. http://dx.doi.org/10.1038/ajg.2010.217 [ Links ]
30. Romano S, Romano L, Grassi R. Mulidetector row computed tomography findings from ischemia to infarction of the large bowel. Eur J Radiol. 2007;61(3):433-441. http://dx.doi.org/10.1016/j.ejrad.2006.11.002 [ Links ]
31. Stark JE, Siegel MJ. Ovarian torsion in prepubertal and pubertal girls: Sonographic findings. AJR. 1994;63:1479-1482. http://dx.doi.org/10.2214/ajr.163.6.7992751 [ Links ]
32. Vijayaraghavan SB. Sonographic whirlpool sign in ovarian torsion. J Ultrasound Med. 2004;23:1643-1649. [ Links ]
33. O'Conner OJ, Maher MM. Imaging of cholecystitis. AJR. 2011;196(4):W367-W374. http://dx.doi.org/10.2214/ajr.10.4340 [ Links ]
34. Kambadakone AR, Eisner BH, Catalano A, et al. New and evolving concepts in the imaging and management of urolithiasis: Urologists' perspective. Radiographics. 2010;30:603-623. http://dx.doi.org/10.1148/rg.303095146 [ Links ]
35. Takahashi N, Vrtiska TJ, Kawashima A, et al. Detectability of urinary stones on virtual non-enhanced images generated at pyelographic-phase dual-energy CT. Radiology. 2010;256(1):184-190. http://dx.doi.org/10.1148/radiol.10091411 [ Links ]
36. Macari M, Hines J, Balthazar E, et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. AJR. 2002;178:853-858. http://dx.doi.org/10.2214/ajr.178.4.1780853 [ Links ]
37. Lucey BC, Stuhlfaut JW, Soto FA. Mesenteric lymph nodes seen at imaging: Causes and significance. Radiographics. 2005;25:351-365. http://dx.doi.org/10.1148/rg.252045108 [ Links ]
38. Puylaert JBCM. Right-sided segmental infarction of the omentum: Clinical, US, and CT findings. Radiology. 1992;185:169-172. [ Links ]
39. Pereira JM, Sirlin CB, Pinto PS, et al. Disproportionate fat stranding: A helpful CT sign in patients with acute abdominal pain. Radiographics. 2004;24:703-715. http://dx.doi.org/10.1148/rg.243035084 [ Links ]
40. Department of Health Western Australia. Diagnostic Imaging Pathways [homepage on the Internet]. Available from http://imagingpathways.health.wa.gov.au [ Links ]
Pumersha Naidoo
25 The Curl, Sunningdale
Durban 4051, South Africa
Email: email@example.com
Received: 18 July 2014
Accepted: 14 Sept. 2014
Published: 05 Dec. 2014


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Snapshots from the 2011 Harvest in the Finger Lakes, NY
Snapshots from where wine comes from.
The grape harvest has begun in the Finger Lakes!
Thanks to Upstate Wine Company, which distributes many Finger Lakes wines to restaurants and wine shops in the NYC area, I had the chance to visit a handful of vineyards this week (and taste more than a handful of wines.) Highlights of the trip included sampling grapes on the vine, learning about harvest-time decision making from local winemakers, and discovering quite a few excellent bottles from this often underestimated region.
Check out the slideshow for some grape-smashing wine country fun and a peek behind the scenes in the wineries »
If you think you don't like New York wine, you haven't tasted widely enough. Look out for riesling and lemberger, which is what many wineries in the Finger Lakes call blaufränkisch. My personal favorite of the dry rieslings was the mineral-and-tart Red Newt Cellars' Lahoma Vineyards Riesling, and the semi-dry and late harvest riesling from Sheldrake Point.
This post may contain links to Amazon or other partners; your purchases via these links can benefit Serious Eats. Read more about our affiliate linking policy.


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Eric Young Jr., who was promoted from Triple-A Colorado Springs to the Rockies' ranks again in May, is still trying to make a name for himself in the big-leagues. But not a new name, his own name.
This week, EY Jr. will be on the hot seat. He'll answer your questions in a special Father's Day edition of The Denver Post's "Fan Mail."
Send your questions for Eric in an email to firstname.lastname@example.com. Hurry them in by Wednesday morning, so he can answer them for Thursday's paper and online.
Eric Young Sr. is, of course, well known among Rockies faithful. And there was much anticipation for Junior when he was first called-up in 2009. Since then, he's bounced back and forth down Interstate-25. He had a .242 average over 269 at-bats before Monday.
But Young is improving, earning admiration from Rockies' manager Jim Tracy, who sees the speedster as a potential leadoff hitter who can play any of the outfield spots, or second base.
What's it like playing for the same team his dad played for? What does see his role as with the Rockies? How can the team get out of its recent slump? All these questions and more are up for asking. So ask away.


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Wherein I refer to one particular attorney as a "worthless piece of garbage." Need I say more?
A few weeks ago, I did an episode of Lehto's Law about bad judges. And the peanut gallery was wont* to ask, "Are there not bad attorneys as well, sir?"
Pray tell, yes. So I give you bad attorneys I interacted with personally. One was disbarred, another was fined (and had to give me the money), one was suspended for three years after I testified against him and the last was disbarred and thrown in jail. Good times.
Without further ado - The audio:
And, the video:
*wont is correct. Look it up before you write angry comments about the descent of journalistic standards and the dearth of editorial oversight on this site.
Follow me on Twitter: @stevelehto
Hear my podcast on iTunes: Lehto's Law
Steve Lehto has been practicing law for 24 years, almost exclusively in consumer protection and Michigan lemon law. He wrote The Lemon Law Bible and Chrysler's Turbine Car: The Rise and Fall of Detroit's Coolest Creation.
This website may supply general information about the law but it is for informational purposes only. This does not create an attorney-client relationship and is not meant to constitute legal advice, so the good news is we're not billing you by the hour for reading this. The bad news is that you shouldn't act upon any of the information without consulting a qualified professional attorney who will, probably, bill you by the hour.


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Zone géographique: Amérique du Nord
Secteur d'activité: Healthcare
With CA Release Automation, we can deliver outstanding quality, customer service, and software solutions to our customers while optimizing resources and reducing overall budgetary requirements.
Mandi Haas
, Director, Release Management and HealthPAS Administrator Team , Molina Medicaid Solutions
Molina Medicaid Solutions (MMS) is a wholly-owned subsidiary of Molina Healthcare providing business processing and IT administrative services to Medicaid agencies in five US states and one US territory.
To improve quality and reduce cost, MMS needed to automate application release deployments for critical customer-facing solutions. Errors and extensive project timelines were exhausting resources, and inhibiting desired growth in the area of customer service.
CA Release Automation provides MMS with efficient, repeatable processes for application release and patch deployments to greater than 500 servers across 20+ complex software environments.
Deployment time has been consistently reduced from over 12 hours to less than 45 minutes, dramatically decreasing resource requirements, human error, and significantly improving customer service.


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Prices of everything from cotton to sugar are on pace for the biggest monthly loss since June as sowing accelerated and rains eased dry-weather concerns.
The Standard & Poor's Agricultural Spot Index fell 7.9 percent in May, and is heading for a fifth straight weekly drop. Rains across the U.S. Great Plains have boosted wheat plants, and American farmers are forecast to collect record corn and soybean harvests. Money mangers are holding the fewest bullish bets since early March.
Crop prices are dropping after rallying the most ever for the period in the first four months of the year as drought in Brazil threatened coffee, sugar and citrus supplies. Now, U.S. and Canadian farmers are speeding up sowing, while rising coffee stockpiles in America cushion the impact of production losses.
"The weather is good, and people have gotten the crops in," said Shonda Warner, managing partner of Chess Ag Full Harvest Partners in Clarksdale, Mississippi, which oversees about $150 million. "It seems we're going to have abundant harvests," she said in a telephone interview from Chicago.
The S&P GSCI Agricultural Index of eight crops dropped 1.9 percent this week to 390.4055. The wider GSCI gauge of 24 commodities fell 1.3 percent this week, and slipped 0.3 percent in May. This month's losses were led by coffee and wheat, which are both poised for 13 percent declines, the biggest since September 2011.
Winter Wheat
Thirty percent of U.S. winter wheat was in good or excellent condition as of May 25, up from 29 percent the prior week, the Department of Agriculture said. Areas of Texas, Oklahoma and central Kansas received an inch (2.5 centimeters) of rain in the past week, government data show. Accelerated planting in Canada and Ukraine supports the USDA's forecast for world reserves to rise to a three-year high.
"Global grain supplies are on the rise, and that remains the biggest negative for the market," Greg Grow, the director of agribusiness for Archer Financial Services Inc. in Chicago, said in a telephone interview. "There just are not any major weather problems developing."
U.S. farmers planted 88 percent of the corn crop as of May 25, matching the five-year average pace, and soybean sowing was 59 percent complete, the USDA said May 27. Widespread rain in the next two weeks will boost soil moisture and crop development, according to T-Storm Weather LLC.
Arabica coffee headed for the biggest monthly drop since 2011 on speculation that global supplies will be enough to meet demand, even as a drought in the first quarter damaged plants in Brazil, the top grower. Stockpiles of unroasted beans in the U.S., the world's biggest consumer and importer, rose 7.6 percent in April from a year earlier, the New York-based Green Coffee Association said May 15.
"Speculative buying interest in commodities is waning," Sterling Smith, a futures specialist at Citigroup Inc. in Chicago, said in a telephone interview. "We're looking at a very large corn crop and potential record soybean supplies. Combine that with spectacular weather, and it creates pressure."


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WSET Level 4 Practice Tastings - Fall 2014 Program
Our regular WSET L4 practice tasting sessions will return in the Fall 2014!
This time, we will limit attendance to 12 people for each session. The structure will be slightly different in that we will taste blind 6-8 wines at the beginning of the session. I will then guide the remainder of the session so that we can together identify each wines before releasing the labels.
Each session will focus will be on clues from tasting notes, style, quality, production methods, and ageing potential. We will practice tasting notes benchmarks (levels), identification of the essential clues blind, argue answers for each paper 1 to 4 (grape, region, quality, ageing potential, identification).
The cost for each session will be HKD 450. This will include the wines as per the themes below. As well, we will supply all of the glasses for these sessions (iso size). No need for you to bring glasses.
The tastings will be held tat the tasting rooms of L'Impératrice Fine Wine on Hollywood Road in Sheung Wan.
The objective of these practice will be to develop very high levels of blind tasting skils.
Anyone taking WSET L4 or higher is welcome to join. Confirmation of attendance will be based upon payment in advance via this site (Eventbrite) or by cheque by post in advance of each session.
Themes for each session as follow:
09 - Cool Climate White Wines
16 - Warm Climate White Wines
23 - Cool Climate Red Wines
30 - Warm Climate Red Wines
20 - Cabernet Sauvignon
27 - Chardonnay
11 - Big Reds
18 - Aromatic Whites


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COLUMBUS, Ohio (AP) — A change in the way the state is funneling federal money to local communities to help addicted Ohioans is creating a $20 million shortfall over the next year, causing challenges for agencies trying to treat and prevent addiction.
The plan by the Department of Mental Health and Addiction Services to distribute $63 million in federal money over 18 months instead of a single year is meant to address cash flow problems that at times have left addiction services providers scrambling to cover payroll. Federal money approved last fall, for example, wasn't available until March this year.
Once implemented, the plan will ensure a more stable funding stream for local boards and agencies helping addicted Ohioans, said Tracy Plouck, Mental Health and Addiction Services director.
"We are mindful this will create some short-term challenge for the recipients of the funds, but if we don't fix it, we're going to have the problem indefinitely," Plouck said in an interview.
Gov. John Kasich's upcoming budget may help cover part of the gap, and Ohio's decision to expand Medicaid eligibility for more poor Ohioans should help ease the blow, Plouck said.
The Ohio Association of County Behavioral Health Authorities, representing local boards, proposed a one-year delay to allow Medicaid expansion more time to work.
The Ohio Council of Behavioral Health & Family Services Providers, representing front-line agencies, supports the state's action, saying the cash flow problems created huge burdens for its small, nonprofit members.
David Pepper, the Democratic candidate for attorney general, criticized the timing of the funding decision.
"I can't think of a worse time to do such an enormous cut to the ability to provide treatment across the state," said Pepper, who has been critical of the state's reaction to the heroin epidemic and has called for a more comprehensive approach.
His opponent, GOP incumbent Attorney General Mike DeWine, calls the heroin epidemic an unprecedented crisis. In response, he's created a special police unit to beef up investigations of heroin rings and has held town halls across Ohio to alert communities to the problem.
This week, Ohio Democratic Party Chairman Chris Redfern criticized those town halls, saying, "Ohio needs real action, not pep talks."
The state saw a record 1,914 drug overdose deaths in 2012, according to Department of Health data. Heroin-related deaths soared 60 percent to 680 in 2012, the most recent year of available data, the Health Department found.
In Lorain County, the shortfall represents a 40 percent budget cut at a time of increasing need, said Elaine Georgas, executive director of the county's Alcohol and Drug Addiction Services Board.
As recently as 2011, the county saw 22 heroin-related deaths. That jumped into the 60s in 2012 and last year, and would have been even higher last year if not for the availability of an anti-overdose drug for emergency responders, Georgas said.
"People understand why families need support and treatment now more than ever," she said. "With this reduction, we're going to have to tell them again services aren't available unless you're Medicaid eligible."


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Home > Prescription Glasses > Marc Jacobs > MARC 53 (TPE)
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This frame was specially designed for genuine power women. Graceful design and expressiveness are interspersed with classical chic. Full rim frames completely enclose the lenses within the frame. For a convinced eyeglass wearer, any other frame style is ruled out, with very few exceptions. The cat-eye frame lifts the face optically and its outer tips make the frame shape particularly favourable for square faces. Plastic is a very lightweight and flexible material. This ensures a long life and a high level of comfort. The bold colour blue is the perfect choice for self-confident personalities. With this colour you quickly become the centre of attention.
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Another summer gone and another British success story at Le Tour, as well as our annual opportunity to win 'His and Hers' Boardman bikes. In The Race Against Time Edward Pickering takes us back 20 years to find out just how success began for British riders and also Uncle Chris's bike empire.
The Race Against Time dissects the rivalry between two peculiar men for the hour record, a few of the characters surrounding them, and the spin offs and the resonances for British cycling's fortunes the Hour record created.
If reading about two compulsive obsessives going very quickly around and around a track doesn't grab you I don't blame you. I wasn't expecting it to be fascinating either, but having seen the film of The Flying Scotsman with Stephen Berkoff hamming it up beautifully as an Anton Differing style Hein Verbruggen I was prepared to give it a whirl. Surprisingly it was even more entertaining and bizarre than Mr Berkoff.
Next time you watch Chris Boardman in his sensible pullover analysing a Tour de France stage with all the expressive vim of a driving test examiner explaining your failure points it's worth remembering that this was a man who was, in his youth, riding right along the ragged edge - both mentally and financially - all for the sake of racing against the clock.
Time trial, as Pickering admits, is 'to cycle sport what prog rock is to modern music. It's a dorky subsection of the form, populated by obsessives outside the mainstream'. Boardman and Obree were certainly nerdy; they still are today, but the technical and physiological advances both riders made in their struggle to go faster than anyone else and then faster than each other is the bed rock of modern pro cycle training and also adds another embarrassing chapter to UCI history.
It's interesting to find a certain Mr Verbruggen finding more and more desperate reasons to ban Obree's brilliant technical advances in position and frame set up, even after everyone else including Boardman were emulating the innovations. On one occasion Obree elegantly satisfied the UCI's ruling that 'the tip of the saddle must be 50 millimetres behind the centre of the bottom bracket' by putting the saddle as far forward as it would go and then cutting its nose off.
Then there's the relationship between Boardman and Peter Keen. Keen was the forerunner to Brailsford who really started the wheels rolling for British track success but is now more famous the the one who doesn't have a knighthood but should. Keen and Boardman's hard work on how to use wattage as a consistant marker for performance culminated in last year's marginal gains win by Wiggins. Wiggins 'won the time trial and time trialled the hills' to win the Tour and his success was a direct legacy of Boardman and Keen's analytics on how to produce every watt of effort.
It isn't just the elusive Peter Keen who is re-interviewed. There are the largely unsung but key figures such as Doug Dailey, the BC National Coach, who supported both riders and coached Obree while Keen looked after Boardman. Along with Keen, Dailey was instrumental in nurturing cycle talent and building the personal support ethos which is proving so successful today. There's also the original secret squirrel Mike Burrows 'a visionary engineer with seventies hair' - and perhaps a casualty of resin fumes - who first tinkered with carbon fiber in the early 1980's.
'We were going, 'Shit! Ooh! Stuff!' Burrows recalls enthusiastically. 'What can we do with this?'
Burrows was dismissed by a puzzled cycle manfacturing industry who couldn't comprehend the moncoque frame with no centre triangle space that he was showing them.
'They said, 'Why did you cover the frame up?' 'I didn't cover the frame! This IS the frame!' I got nowhere. They were as thick as shit the lot of them.'
The old adage that history is written by the victors is, unfortunately, often superseded by the adage that states that history is written by those with the cash. It explains why Simon Cowell is 'a genius' - rather than someone who just rehashed Opportunity Knocks and got very lucky.
In a similar vein Lotus took an awful lot of credit for making Boardman's bike - just as Formula One were credited two years back for for creating Cav's winning bike. In truth what happened was that post Olympic gold at Barcelona in 1992 Boardman was so skint (in those days cereal manufacturers couldn't see the relevence of cycling in general - let alone track cycling) he had no bike to use for the hour record. Both Lotus and Halfords - who also owned one of Boardman's Olympic bikes - refused to lend him theirs. How things change. Well sort of... Although Lotus are still struggling with Noddy cars at least Halfords have shown a little more interest in Boardman in recent years.
All in all it's a fine read, although being reminded of Boardman's proclivity for yellow and purple kit is an unwelcome part of the photo sections. The Race Against Time is beautifully researched and written and an essential reference for anyone interested in the roots of British cycling success on track and road.
Precise and entertaining, like the gentlemen concerned.
If you're thinking of buying this product using a cashback deal why not use the road.cc Top Cashback page and get some top cashback while helping to support your favourite independent cycling website
road.cc test report
Make and model: The Race Against Time - Ed Pickering
Size tested: na
Pull off the dramatic black cover and Uncles Chris and Graeme are gurning in full frontal balanced black and white action portraits on back and front cover. Proper attention to classic detail.
Did you enjoy using the product? Yes.
Would you consider buying the product? Yes.
Would you recommend the product to a friend? Yes.
About the tester
Age: 47 Height: Weight:
I usually ride: A 20 year old Condor Italia on the school run. My best bike is: Condor Moda Ti - summer bike
I've been riding for: Over 20 years I ride: Every week I would class myself as: Experienced
I regularly do the following types of riding: road racing, club rides, sportives, general fitness riding,


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Ketchup-Mush Field
Heinz Field is the biggest piece of Crap football playing surface left in the NFL. Maybe instead of producing all of those damn Terrible Towels they could spend some money on putting together a field that's just slightly better than the pile of dirt I played in growing up. Or at least use those towels to sop up some of the mud.
Same Color Unis.
It's bad enough that everyone else has to see that stupid black and gold for the Squealer fans, but to be as unimaginative as to have all of your teams dress in the same color unis? Pssssshhhh…lame. At least the Penguins have those sweet powder blue jerseys.
Terry Badshaw (see what I did there /poke poke)
Career Numbers: 212 TDs, 210 Ints; 51.9 Completion %, 70.9 Passer Rating. What. The. Fudge?
Seriously… those numbers are terrible. Here are all the QBs this season who have a worse completion % than Terry's career average: JaMarcus Russell, Derek Anderson. That's it.
Not enough you say? Here are all the QBs this season who have a worse Passer Rating than Baldy McBlond put together: Marc Bulger, Brady Quinn, Matthew Stafford, Jake Delhomme, Kerry Collins, Mark Sanchez, JaMarcus Russell, Derek Anderson. Their teams have a combined 12 wins with them at the helm this season.
Bradshaw gets so much credit for being on those Super Bowl teams when it is clear that Trent Edwards or Shaun Hill could easily have outperformed him if playing for the Steelers. I'm glad my team history isn't saturated with this backwater hillbilly asshole.
Steely McBeam
Do I need to rant on this one… here I'll let you finish my thoughts…
"I haven't seen anything this gay since _________"
No Cheerleaders
Come on really? Even Fox and CBS can find some Michael Tafoya to throw down to the sideline during game day. Is the "talent" in Pittsburgh that bad that they can't put together a squad of 25 decent looking girls? (<-That question is rhetorical) I mean, I'd be willing to bet Philly has enough leftovers to throw your way Pittsburgh.
No Wardrobe
Am I the only one who ever notices this? Everywhere I go, no matter the month, day of week, time of day, venue of the moment… I find people wearing Steelers clothes. Holy Cow Turd. How is this possible? Are you seriously that pathetic you have nothing else to wear?
I feel like these people are everywhere. Walking their dogs, getting on planes, even church. Maybe their Xmas wish list should consist of normal clothing.
Troy/Ben Media Bromance
I am so damn sick and tired of hearing how awesome these players are. Every pre-game, "so what do you think about the Steelers Game today?"
"Well if Troy and Ben play…" Give me an effin break, what does their whole team just explode without them? "Oh no Troy and Ben are out? Well gang, we knew this day would come, on the count of 3 everyone hit their Self-Destruct button… 3. KABLAMMO!!!!" Is the movie 2012 secretly about Pittsburgh and the Steelers when "Troy and Ben" leave? And have you noticed that unlike the other 1553 NFL players, these two only have first names? Really people? You would think that these were the only two players on the team. Enough already.
Bandwagon Fans.
This had potential #1 written all over it. If I were a TRUE Steelers fan – from the Pittsburgh area, my parents loved them, their parents liked them and their parents were bandwagon jumpers when they came into the league (of course average life span of Pittsburgh residents back then was probably about 30) – I'd be choking on my french fry sandwich in anger if all the sudden I turned around and every where I go there are 37,839,302,571 "Steelers fans" wearing Super Bowl Forty-Blahblah t-shirts on underneath their "Ben" jerseys.
That bandwagon is FULL people! Get off, and get off quickly, especially since, in case you didn't hear, the movie 2012 is about the Steelers.
"Real" Steeler Fans
That's how I would feel if I were a Steeler fan looking at our fan base. There is no better reason to be thankful… except!!!!
Jeff Reed
Wait? What's wrong with Jeff Reed?
You're just jealous cause your kicker was never a bride-to-be!
Your kicker can't party like Jeff Reed!
He can't rip paper towel dispensers off the wall like Jeff Reed!
Your kicker doesn't have mirror self pics like Jeff Reed!
And your kicker can't even come close to tackling like Jeff Reed (:29 seconds in)!
And with that, we'd like to wish a Happy Thanksgiving to all you Nestgoers! Sure, being a Ravens fan is tough sometimes…but it could be so much worse.


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Originally posted by Kathy
: : I was wondering if someone could give me
: : a better detailed direction to Tumco, California.
: : A closer landmark then Yuma , Arizona would be
: : helpful. Thank you.
: Ross, My book, GHOSTTOWNS of the WEST, ( page 15) shows Tumco
: to be between Yuma and ElCentro, nearer to Yuma.Page 53 shows it to be just off Route534 and north of Ogilby Cemetery Historic Landmark.
: Hope this helps. Kathy


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Sunday, September 27, 2009
Sunday Quick-hitter
Ricciardi also said that he believes that Scott Downs and Jason Frasor could wind up sharing the closer's duties next year and that pitcher Dustin McGowan, who has missed all season after shoulder surgery, is progressing well.
"He's letting it fly," Ricciardi said of McGowan, who has been throwing on flat ground.
Ricciardi said McGowan is pain free and will start throwing off a mound next week and appears to be in tremendous physical condition.
I'm going to try containing my excitement regarding a McGowan comeback, because we know all too well what a bad shoulder means for a flamethrower like Dusty.....but, uh, holy shit. McGowan is a good guy to root for, having overcome a bum elbow, diabetes, and now the shoulder.
Think the Jays could use his arm next season?
13 comments:
- SP said...
"letting it fly"..."tremendous physical condition"...when the hell did all this happen? But yea, I'm rooting for Dusty and hope he becomes our next Chris Carpenter, except on the Jays this time.
- September 27, 2009 at 10:56 AM
- Mattt said...
I believe in Dustin.
- September 27, 2009 at 11:43 AM
I think the knee injury was probably a good thing for him. There was no need for him to join this shitshow midseason. A few extra months of rest and healing for the tissue is all good.
- September 27, 2009 at 12:21 PM
You actually believe that?
- September 27, 2009 at 12:48 PM
- Ty said...
Ricciardi's not the only one who said he looks good... everybody else who's seen him/talked to him this week has said the exact same thing. I don't see any reason not to believe it.
- September 27, 2009 at 12:55 PM
- Roy-Z said...
Best news of the season if it's true. Pencil him into the middle of the roto, he doesn't need the stress of being the Ace if Roy is gone.
- September 27, 2009 at 1:01 PM
- Tao of Stieb said...
Am I the only one who likes the idea of Dusty Lambchops as a closer?
I'd rather have him pitch 60 high leverage innings and stay healthy rather than trying to run him through 180 innings as a starter.
- September 27, 2009 at 1:13 PM
- Mark said...
It'd be better for his arm to stay a starter because he'd pitch once a week vs 3-4 times a week. It's weird, but in a way it's less stressful to have him be a starter. Even though he pitches more innings, he's gonna get less stress starting.
- September 27, 2009 at 1:35 PM
- Gil Fisher said...
Rance mentioned that, but I'd be inclined to believe the stress on the arm is higher for a starter than a reliever.
- September 27, 2009 at 2:29 PM
At the very least, he would be a closer we could get excited about.
(No disrespect to Jason Frasor, who was good this year)
- September 27, 2009 at 7:18 PM
- eyebleaf said...
I'll believe it when I see it.
- September 27, 2009 at 11:41 PM
- eyebleaf said...
But I'm rooting for him. Definitely rooting for him.
- September 27, 2009 at 11:41 PM
So what other pitchers have had TJ surgery, rotator cuff surgery and a frayed labrum to boot? Anybody to compare his odds of success to??
- September 28, 2009 at 1:17 AM


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As New York celebrates the sharp decline in crime — earlier this year the city revealed that the 494 homicides in 2007 were the fewest since reliable police statistics became available in 1963 — the crime writer may be the only New Yorker for whom that drop is not an unequivocal blessing. Just as the breakup of the Soviet Union caused problems for writers whose plots hinged on the dark doings of the cold war, so New York's crime writers are wondering where to find grist in a far safer city.
[...]Sometimes New York's crime writers grow wistful about the bad old days for unexpected reasons, as was the case with Donald Bain, the highly successful author of more than 30 "Murder, She Wrote" books along with other crime novels.
In January, Mr. Bain was the main speaker at a meeting of the Mystery Writers of America, held at the National Arts Club, opposite Gramercy Park.
At dinner in the club's high-ceilinged dining room, Mr. Bain, a tall man with a white beard, reminisced about the early '90s, when his daughter lived on Sullivan Street in Greenwich Village. Her apartment building was next to a social club run by Vincent Gigante, a k a the Chin, the mobster whose associates used to sit outside the club, playing cards and drinking late into the night. If one of the men saw his daughter emerging from the subway station a few blocks away, Mr. Gigante dispatched one of them to walk her home safely.
The other writers at the table laughed, but their laughs were tinged with nostalgia for a vanished version of New York that could hand you a scene, just like that.
New Books and Birthdays - On the day that a new book is released, people often wish its author "Happy Book Birthday!" It is indeed an eventful moment--the culmination of months or y...
1 week ago


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Fancy tamagoyaki bento
Oh my, this one is both a looker and tastes amazingly! :-) This bento idea is based on the basic tamagoyaki recipe, so feel free to use your favorite ingredients: champignons or chanterelle mushroom, herbs, different kinds of onion, bacon bits, ham shavings etc. Go crazy! :-) It's also a very good side dish!
Marinated beef and pasta bento
Bento is not only rice, but also other ingredients, like... pasta. This recipe came to life when I had some uncooked beef left-overs and just wondered what to do with them. Cooking them as a part of bento was a great idea!
Vegetarian bento
Today was one of these days that my coffee needed a coffee... And I really couldn't make myself cook in the morning. So, the vegetarian bento was made! It's fast, it's simple, and it tasted great. Consider that a fancy salad for lazy days.
Sweet Mustard Eggs Bento
I got tired of sausages after yesterday's deluxe bento, so today I decided to have some eggs with lunch. I put some sweet mustard over the cooked yolk to have them pack some punch and they were really interesting!
I prepared also hand-made furikake (rice sprinkles) with ingredients I like, which made my rice extra tasty today!


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They say Moritz Erhardt was caught up in what the banking industry calls a "magic roundabout," in which a taxi drives you home after a 24-hour shift, waits outside while you shower and change, then drives you right back for another daylong stint at the office.
After three days of endless work and six weeks of sometimes 100-hour-or-more work weeks, the 21-year-old German exchange student working a summer gig at Bank of America Merrill Lynch in London collapsed and died in his shower. The tragedy flicked the spotlight on the banking industry, with its punishing hours and demanding internships.
Students happily accept a summer internship believing it could lead them to their dream job only to find out it's a brutal three months full of all-nighters, office-bound weekends and the magic roundabout, a spokesperson from career advice group FinanceInterns tells the U.K. Independent.
Perhaps Erhardt had epilepsy, as some reports suggest. Perhaps he popped stimulants to keep awake long hours. Perhaps he pulled the all-nighters by the sheer strength of his own volition. Regardless of the specific cause, the circumstances leading to his death seem unforgivable for a young man bent on proving himself. The hours he kept, though evidently typical, were inhumanly arduous and exploitative. Any doctor will tell you that fatigue that great can make a person susceptible to fatal collapse.
In Japan, there's a word for it. Karoshi refers to death by overwork, a legal term that allows surviving family to petition a judge for compensation for damages from the government and the company. Toxicology and inquest are pending, but in the West we have no such legal designation of protracted corporate suicide.
Erhardt almost made it through his well-paid internship. He was nearing the end of his placement and emerging as one of the top performers – a superstar, his colleagues say. The University of Michigan business student was exactly the kind of guy a high-caliber financial firm would want as an intern.
Bank of America head of international communications John McIvor declined to speculate about how much the industry should rethink its expectations.
"I have not got any comment to make on our work patterns," he says dismissively. "Do people in investment banking sometimes work long hours? Yes they do."
Now, commentary is coming out about how long-hours culture is more political than productive. People stay past midnight not because they're getting more done, but because they don't want to be the first to leave, even though it's been documented that sleep-deprivation blunts cognitive ability, leading to dumb decisions and questionable judgment.
"Sure, you may not be achieving much by midnight, but do you really want to be one of the first in the team to leave your desk?" George Herbert at PolicyMic asks. "If you're always the one who leaves first will your boss question your commitment when it comes to calculating your annual bonus or deciding whether to take you onto a regular contract?"
Apparently yes. And that's a pressure brutally amplified on the young and desperate.
Find Jennifer Wadsworth at @jennwadsworth.


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For nearly 60 years, St. Jude Medical Center has met the needs of the community, by offering the highest quality care with compassion and respect. We are one of Southern California's most respected and technologically advanced hospitals, and our four core values: dignity, excellence, service and justice are the guiding principles for everything we do. St. Jude is synonymous with exceptional care that extends beyond good medicine to a commitment to caring for you – mind, body and spirit.
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Today, St. Jude Medical Center's commitment to excellence is more important than ever—and it is a generous community that makes that commitment possible. But as the medical needs of this community continue to grow, so does the importance of those willing to give to ensure state-of-the-art care. There are many ways you can help. To learn more, please call the St. Jude Memorial Foundation at (714) 992-3033.
Tell Us Why St. Jude is Your Hospital.


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Sam Brownback's Tax-Cut Push Puts Kansas Out on Its Own
Fellow Republican Governors Are Slow to Follow Example Given His State's Finances
TOPEKA, Kan.—Two years ago, Kansas Gov. Sam Brownback laid out an aggressive program of tax cuts to turn this slow-growing state into a Texas-like economic powerhouse—and serve as a model for Republican leaders in other states.
So far, the results are serving as more of a warning than a beacon. Employment growth is below the national average, while Kansas faces plunging revenue, dwindling reserves and a rare debt downgrade.


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Discover Elk City
Located off I-40 near Route 66 Museum and Ackley Park
Receive a warm welcome at our Days Inn Elk City hotel, off I-40 and near Route 66 Museum and Ackley Park. Park your car or large vehicle for free, then settle into your comfortable room. Our hotel provides friendly service and easy access to area attractions.