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February 28, 2013
The Reading Group, LLC, a provider of vocational truck equipment, announced several key additions to its executive team.
Ken Spear, Vice President of Engineering
Ken Spear joined The Reading Group in October 2012. In the position of VP of Engineering, Spear is responsible for driving new product development and evaluating the existing product portfolio.
Spear previously held senior engineering management and executive leadership positions at Hardi North America, Bush Hog LLC, Dixon Industries and Ames True Temper.
Bob Besse, Vice President of Sales & Marketing
Bob Besse joined The Reading Group in December 2012. In this role, Besse is responsible for leading the company's go-to-market approach.
Besse has previously held senior sales and marketing management positions at companies including Supreme Corp., Grumman Olson, and Dover – Chief Automotive Systems.
Susan Mitchell, Director, Human Resources
Susan Mitchell joined The Reading Group in November 2012. In this position, Susan is responsible for cultivating the employee talent level, recruiting, and hiring for new positions as the company continues to grow. Susan brings 20-plus years of HR experience in heavy manufacturing, alternative energy and distribution environments at companies including Cambridge Lee Industries, Allied Wire and Cable, and International Battery Inc.
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To the Editor: The care that physicians provide to terminally ill and end-stage patients has received growing attention. Numerous specialty boards and organizations, including the Academy of Psychosomatic Medicine, have developed professional standards on end-of-life care for their members (1–3). Although there are several reasons for less than adequate end-of-life care, insufficient training of clinicians in this area is a major concern (4).The textbooks used to train clinicians deserve their fair share of the blame. Our research (5) has identified major deficiencies in the end-of-life content of 50 best-selling medical textbooks, including three top psychiatry textbooks.At first glance, these three textbooks may be praised for scoring significantly higher than other specialty texts. As a group, these textbooks contained helpful information (mean=34.4% of their content) regarding end-of-life care. The textbook with the highest overall score for helpful end-of-life content (44.2%) was a psychiatry textbook. Unfortunately, these figures are praiseworthy only when compared to the paucity of information in texts from other specialties. On their own, these scores call for drastic changes in content.
In the face of such alarming findings, we have led an effort to encourage publishers, editors, and authors to improve their textbooks' content on end-of-life care, including book chapters, cross-referencing, and indexing (6). In following up this effort, we recently surveyed textbook publishers and editors to assess their progress in revising their texts.
We have been encouraged by a very positive response overall. To date, we have received responses to our follow-up survey from 19 publishers and 23 editors (including two of three editors of the psychiatry texts) of the 50 textbooks surveyed. These responses indicate plans to expand the end-of-life care content in the next editions of 22 textbooks, including 17 textbooks with new chapters regarding end-of-life care, 11 with expanded cross-referencing, and 17 with revised indexes. Hence, of the 50 textbooks, over one-third are expanding the end-of-life care content in their next editions. Finally, we have received six personal letters of support from editors and publishers, including a poignant one from an editor who was dying of metastatic melanoma when he wrote to us.
Recently, the Robert Wood Johnson Foundation honored textbook authors, editors, and publishers who have undertaken significant efforts toward making important changes. On Feb. 21, 2001, the Last Acts Project held an awards ceremony for the occasion. The foundation presented awards to the editors of three medical textbooks (Emergency Medicine, 5th ed., editor-in-chief, Judith Tintinalli; Nelson Textbook of Pediatrics, 16th ed., editors, Richard Behrman, Robert Kliegman, and Hal Jensen; and Textbook of Primary Care Medicine, 3rd ed., senior editor, John Noble) and to one medical textbook publisher (Lippincott Williams & Wilkins).
It is unfortunate that there is still much work to be done. Many best-selling textbooks have not yet responded to the suggestions of their specialty boards, the needs of their readers, or the demands of patients and families to improve clinician education in the care of patients at the end of life. We will continue monitoring textbooks over the next several years, and the Robert Wood Johnson Foundation will continue to offer awards to the publishers, editors, and authors who improve the end-of-life content in their books. It is of the utmost importance that current knowledge and ongoing research in palliative care published in this journal quickly find its way into best-selling psychiatry textbooks.
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4 reasons the recovery may be real this time
Improving economic numbers and a rising stock market have fooled us before, and there could another shock ahead. But here's why this move up looks different.
By Rick Newman for U.S. News and World Report
We've seen this movie before, right? It begins with signs of an improving economy, but the plot reversal happens as oil and gas prices surge, Europe implodes, Washington threatens reckless policies, or some other shock chokes off the nascent recovery.
That's what happened in 2010 and 2011, so it makes sense that something similar could happen this year. Even though unemployment is falling, the stock market is buoyant and consumer confidence is growing, there's still plenty that could go wrong. Greece could violate its bailout terms and completely collapse. A war in Iran could send oil prices skyrocketing. Congress could flub some big decisions due by the end of the year on taxes and spending.
Yet the economy seems to be showing unusual moxie, shrugging off most of those concerns and doing better than expected. At the beginning of the year, many economists expected lackluster growth of less than 2 percent in 2012. Those forecasts are steadily being revised upward, with more room to rise. "For all of the weakness that is expected to play out through 2013," economist Jeffrey Rosen of Briefing Research recently predicted, "we see more upside potential than downside risk."
So is this one more bubble that's about to pop? Or a long-overdue updraft that's likely to continue? Economists aren't sure, needless to say, but the evidence of a lasting recovery is much stronger than it was last year or the year before. Here are four reasons that this time, the recovery might be real:
Time has passed
The recession that began at the end of 2007 officially ended in the middle of 2009—nearly three years ago. Yet the lackluster performance of the economy since then makes many people feel like we're still in a recession. Over that time, however, economic wounds have slowly been healing, and sooner or later that will produce an economy that's actually healthy.
Banks, for one thing, have been gradually disgorging bad loans and improving their once-precarious financial positions. Bank of America Merrill Lynch estimates, for example, that the financial sector has cut its debt load by a hefty $3.5 trillion since 2009. Some banks still have further to go, but credit standards generally are loosening, which is vital for a true recovery.
Consumers have been paying off debt as well, and improving their finances. One recent survey found that the percentage of employees saying they're under severe financial stress fell from 33 percent in 2009 to 19 percent in 2011. Painful declines in home prices, meanwhile, may now be close to a bottom. And companies that have cut every imaginable cost can scarcely afford to lay off one additional worker. Those developments don't characterize a robust economy, but they set the stage for it.
Debt burdens have fallen dramatically
The dollar value of household debt held by Americans is still uncomfortably high. But low interest rates, largely engineered by the Federal Reserve, have sharply reduced the "debt burden" many consumers feel, in terms of the amount of income it takes to make payments on their debt every month. Many new mortgages and car loans have come at record low interest rates, and some consumers have been able to refinance old debts at much lower rates. "Even though Americans have a lot of debt by historical standards, they have a low debt burden," says Rosen.
By one measure, the amount of disposable income available to the typical consumer is at the same level as in the mid-1990s, when the economy was in the early stages of a boom. That doesn't mean that gun-shy consumers will spend every last dollar they have. But it does mean that restraints on spending are loosening up, and just as important, that consumers have less reason to feel panicky.
Stuff is cheap
A combination of low interest rates and falling home prices has made housing more affordable than at any time over the last 40 years. Cars and other high-ticket purchases that often require financing are relatively cheap too, thanks to low interest rates. And improving credit standards are giving more people—including subprime borrowers—access to loans. As confidence improves, more consumers will take advantage of these terrific deals and start spending, which will help generate other kinds of economic activity and bring back jobs.
It's already happening in the auto market, where car sales have risen from dismal levels of less than 10 million per year in 2009 to a rate of more than 14 million so far this year. Many economists expect to see a similar trend in housing, though it will take longer to materialize. But once home buyers feel housing prices have bottomed out for good, a housing rebound could be the very thing that cements a recovery.
There's a lot of money on the sidelines.
Big companies are sitting on as much as $2 trillion in cash that they've been reluctant to spend. Many private investors are hoarding cash as well, or keeping their money in super-safe securities such as low-yielding treasury bonds, since they're still shell-shocked by the volatile markets of the last few years. "Investors tend to extrapolate from the most recent past," says Mark Luschini, chief investment strategist for Janney Montgomery Scott. "We have to break the thinking that what we've seen over the last 12 to 18 months is what will happen in the future."
Once CEOs and reluctant investors start to become convinced that the worst is over, they'll begin to deploy all the money they're sitting on, another key step toward building a self-sustaining recovery. There may still be a few more hurdles before that happens. But every day that passes without an economic disaster represents one additional step toward a recovery that actually feels like one.
Rick Newman is the author ofRebounders: How Winners Pivot From Setback to Success, to be published in May. Follow him on Twitter: @rickjnewman
Related at U.S. News:
- Why running for president is a great career move.
- 3 myths about Mitt Romney and the rich.
- How Iran could affect your wallet in 2012.


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You Are Here: U.S. Preventive Services Task Force > Topic Index > Screening for Carotid Artery Stenosis > Update of the Evidence
Screening for Carotid Artery Stenosis
Update of the Evidence for the USPSTF
Tracy Wolff, MD, MPHa; Janelle Guirguis-Blake, MDb; Therese Miller, DrPH.a; Michael Gillespie, MD, MPH;b and Russell Harris, MD, MPHd
This article was first published in the Annals of Internal Medicine. Select for copyright and source information.
Background: Cerebrovascular disease is the third leading cause of death in the United States. The proportion of all strokes attributable to previously asymptomatic carotid stenosis is low. In 1996, the US. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening of asymptomatic persons for CAS by using physical examination or carotid ultrasonography.
Purpose: To examine the evidence of benefits and harms of screening asymptomatic patients with duplex ultrasonography and treatment with carotid endarterectomy for carotid artery stenosis (CAS).
Data Sources: MEDLINE® and Cochrane Library (search dates January 1994 to April 2007), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts.
Study Selection: English-language randomized, controlled trials (RCTs) of screening for CAS; RCTs of carotid endarterectomy versus medical treatment; systematic reviews of screening tests; and observational studies of harms from carotid endarterectomy were selected to answer the following questions: Is there direct evidence that screening with ultrasonography for asymptomatic CAS reduces strokes? What is the accuracy of ultrasonography to detect CAS? Does intervention with carotid endarterectomy reduce morbidity or mortality? Does screening or carotid endarterectomy result in harm?
Data Extraction: All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.
Data Synthesis: No RCTs of screening for CAS have been done. According to systematic reviews, the sensitivity of ultrasonography is approximately 94%, and the specificity is approximately 92%. Treatment of CAS in selected patients by selected surgeons could lead to an approximately 5-percentage point absolute reduction in strokes over 5 years. Thirty-day stroke and death rates from carotid endarterectomy vary from 2.7% to 4.7% in RCTs; higher rates have been reported in observational studies (up to 6.7%).
Limitations: Evidence is inadequate to stratify people into categories of risk for clinically important CAS. The RCTs of carotid endarterectomy versus medical treatment were conducted in selected populations with selected surgeons.
Conclusion: The actual stroke reduction from screening asymptomatic patients and treatment with carotid endarterectomy is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment.
Cerebrovascular disease is the third leading cause of death in the United States.1 Approximately 500 000 people in the United States each year experience a first stroke.1 The mortality rate for cerebrovascular disease has declined by nearly 70% since 1950.2 Much of the decrease is probably due to reduced cigarette smoking and improved control of hypertension.
Carotid artery stenosis (CAS) is pathologic atherosclerotic narrowing of the extracranial carotid arteries. The contribution of CAS to overall stroke burden is difficult to approximate. Eighty-eight percent of strokes are ischemic, and 20% or fewer of these are due to large-artery stenosis.3-9 A subgroup of patients have large-artery stenosis due to stenosis of the carotid bifurcation or proximal carotid artery that is approachable by carotid endarterectomy; some of these patients are asymptomatic.
A "clinically important degree of CAS" is defined as the percentage of stenosis that corresponds to a substantially increased risk for stroke. Because stroke risk depends on more than the degree of carotid artery narrowing, it is difficult to define categories of CAS that are associated with various risk levels of stroke in asymptomatic people. Most studies of treatment for CAS consider stenosis of 50% or greater or 60% or greater to be clinically important. The most important risk factor is previous cerebrovascular disease. Other risk factors include hemodynamic factors; atrial fibrillation; collateral circulation; patient age (>65 years); male sex; comorbid conditions; and cardiovascular risk factors, such as hypertension, cigarette smoking, clotting mechanisms, and plaque structure.10-16 The presence of the strongest reported risk factors, smoking or heart disease, approximately doubles the risk for CAS.14,15 However, no single risk factor or clinically useful risk model incorporating multiple factors clearly discriminates people who have clinically important CAS from people who do not.
Several population-based cohort and cross-sectional studies have examined the prevalence of CAS. These prevalence estimates are based on a positive result on a screening carotid ultrasonography. Estimates of the prevalence of CAS from population-based studies range from 0.5% to 8%.5,10,17-19 On the basis of population-based studies and the accuracy of ultrasonography, we estimate the actual prevalence of clinically important CAS (60% to 99%) to be approximately 1% or less in the general primary care population and about 1% in persons age 65 years or older. A detailed discussion on the prevalence of CAS is available in a larger report at www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm.20
Carotid endarterectomy has been proposed as a strategy for reducing the burden of suffering due to stroke, in addition to controlling such risk factors as tobacco use and hypertension. Randomized, controlled trials (RCTs) have shown that carotid endarterectomy effectively reduces stroke among people who have severe CAS and have had a transient ischemic attack or "minor stroke." It is not clear, however, whether screening asymptomatic people (those who have never had a transient ischemic attack) to detect CAS and treatment with carotid endarterectomy are effective in reducing stroke.
Before carotid endarterectomy, cerebral angiography after ultrasonography may be used to confirm CAS. A small percentage of patients will be harmed by the angiographic procedure itself. In an RCT of carotid endarterectomy in asymptomatic patients, 1.2% of patients who had angiography had a nonfatal stroke. Prospective studies of cerebral angiography have found rates of persistent neurologic complications of 0.1% to 0.5%.21-23 Because of the increased risk for stroke, there is disagreement on whether cerebral angiography should be used to confirm a positive ultrasonography screening result. Current practice varies widely: Some surgeons do other confirmatory tests, such as magnetic resonance angiography (MRA) or computed tomographic angiography (CTA), whereas others request angiography before carotid endarterectomy.
In 1996, the U.S. Preventive Services Task Force (USPSTF) concluded that evidence was insufficient to recommend for or against screening of asymptomatic persons for CAS by using physical examination or carotid ultrasonography.24 This recommendation was based on new evidence at the time, including data from ACAS (Asymptomatic Carotid Artery Study), an RCT involving 1662 persons with asymptomatic stenosis greater than 60%. Results of ACAS suggested that the overall benefit of treatment with carotid endarterectomy depends greatly on the perioperative complications. At that time, information was limited about carotid endarterectomy complications in the general population. Since the previous Task Force review, the largest RCT of carotid endarterectomy versus medical treatment for asymptomatic CAS, the ACST (Asymptomatic Carotid Surgery Trial), and several large studies on actual harms of carotid endarterectomy have been published.
This review updates the 1996 USPSTF review of screening for CAS, focusing on duplex ultrasonography as the screening test (with various confirmatory tests) and carotid endarterectomy as the treatment for clinically important CAS. Medical interventions and screening with carotid auscultation were not reviewed in this report. The USPSTF has reviewed screening for several known risk factors of carotid artery stenosis and stroke, including hyperlipidemia, hypertension, aspirin prophylaxis, and smoking. The evidence reports and recommendations are available at the Agency for Healthcare Research and Quality (AHRQ) Web site at www.uspreventiveservicestaskforce.org.
Figure 1 shows the analytic framework for this review, which was developed by following USPSTF methods.25 The USPSTF developed 4 key questions from the analytic framework to guide its consideration of the benefits and harms of screening with ultrasonography for CAS. The key questions were as follows.
Key question 1: Is there direct evidence that screening adults with duplex ultrasonography for asymptomatic CAS reduces fatal or nonfatal stroke?
Key question 2: What is the accuracy and reliability of duplex ultrasonography to detect clinically important CAS?
Key question 3: For people with asymptomatic CAS 60% to 99%, does intervention with carotid endarterectomy reduce CAS-related morbidity or mortality?
Key question 4: Does screening or carotid endarterectomy for asymptomatic CAS 60% to 99% result in harm?
The USPSTF designated key questions 1, 2, and 3 as subsidiary questions for which they requested nonsystematic reviews to assist them in updating their recommendations. Key question 4 was the only key question for which the USPSTF requested a systematic evidence review.
Data Sources and Searches
We searched MEDLINE® for English-language articles published between 1 January 1994 and 2 April 2007 that addressed key questions 1, 2, and 3. We identified additional studies by examining the reference lists of major review articles and by consulting experts. For key question 3, we performed a MEDLINE® search for RCTs, systematic reviews, and meta-analyses that compared carotid endarterectomy with medical therapy for asymptomatic people with CAS. We identified 1 in-process RCT by its inclusion in a systematic review, and we included it once it was published.
For key question 4, we performed a systematic search of MEDLINE® for English-language articles published between 1 January 1994 and 2 April 2007 by using the focused Medical Subject Heading terms endarterectomy, carotid and outcome and process assessment. We also selected a key study from this search and identified related articles through MEDLINE®. Additional studies were identified through a search of the Cochrane database, discussions with experts, and hand-searching of reference lists from major review articles and studies.
Study Selection
Titles and abstracts of articles retrieved for key questions 1, 2, and 3 were nonsystematically selected and reviewed by 2 reviewers. The process was considered nonsystematic because articles were selected for review and abstracted by 1 reviewer. Articles for key question 1 were selected for inclusion if they were RCTs; compared screened versus nonscreened groups; used ultrasonography, MRA, or CTA as screening methods; reported outcomes of strokes or death in asymptomatic persons; and were performed in a population generalizable to the United States. For key question 2, we included systematic reviews that compared screening tests (ultrasonography, MRA, or CTA) with angiography in asymptomatic persons and were performed in a population generalizable to the United States. Articles for key question 3 were included if they were RCTs of carotid endarterectomy comparing surgical treatment with medical treatment, reported 30-day complication rates (stroke and death) of carotid endarterectomy, included only asymptomatic patients, and were performed in a population generalizable to the United States.
For key question 4, 3 reviewers independently reviewed the abstracts and selected articles from titles and abstracts on the basis of inclusion and exclusion criteria. In general, studies were selected if they were large, multi-institution, prospective studies that reported 30-day mortality or stroke outcomes for asymptomatic patients undergoing carotid endarterectomy. Studies were excluded if they did not report outcomes by symptom status, included patients receiving carotidendarterectomy combined with other major surgeries, were not performed in the United States, included patients with re-stenosis, or covered patients at extremely high risk. Appendix Table 1 shows detailed search terms and inclusion and exclusion criteria. Abstracts that were chosen by fewer than 3 reviewers were discussed and selected on the basis of consensus.
Data Extraction and Quality Assessment
For all citations that met the eligibility criteria, 2 authors reviewed the full articles and independently rated their quality. The 2 reviewers achieved consensus about article inclusion, content, and quality through discussion; disagreements were resolved by the involvement of a third reviewer. Data on the following items were extracted from the included studies for key question 4: source population; sample size; average age; proportion white; proportion male; average degree of stenosis; and the proportion of persons with important comorbid conditions, including contralateral stenosis, smoking, diabetes, hypertension, and coronary artery disease. Quality evaluations of articles for all key questions were performed by using standard USPSTF methods for determining internal and external validity.25 We evaluated the quality of RCTs and cohort studies on the following items: initial assembly of comparable groups, maintenance of comparable groups, important differential loss to follow-up or overall high loss to follow-up, measurements (equality, reliability, and validity of outcome measurements), clear definition of the interventions, and appropriateness of outcomes. We evaluated systematic reviews and meta-analyses on the following items: comprehensiveness of sources considered, search strategy, standard appraisal of included studies, validity of conclusions, recency, and relevance. Appendix Table 2 describes the criteria and definitions for USPSTF quality ratings more thoroughly.
Data Synthesis and Analysis
Because the review was nonsystematic, we synthesized data from the included studies for key questions 1, 2, and 3 qualitatively in tabular and narrative format. Although we performed a systematic review for key question 4, we synthesized the data qualitatively rather than quantitatively because of the different patient characteristics and varied outcome assessments. Synthesized evidence was organized by key question.
Role of the Funding Source
The general work of the USPSTF is supported by the Agency for Healthcare Research and Quality. This specific review did not receive separate funding.
In summary, we found no direct evidence of the benefit of screening with ultrasonography for CAS in asymptomatic adults (key question 1). We found 2 systematic reviews on the accuracy of ultrasonography screening (key question 2); for CAS 60% to 99%, the sensitivity is approximately 94% and the specificity is approximately 92%. Three fair- or good-quality RCTs were found and reported that in selected patients with selected surgeons, treatment with carotid endarterectomy for asymptomatic CAS could lead to an approximately 5—percentage point absolute reduction in strokes over 5 years (key question 3).
For key question 4, the initial literature search for the systematic review returned 397 titles. The titles, abstracts, and full articles were reviewed by 3 reviewers, who excluded 232 studies after review of returned titles. Most of the studies were excluded at the title stage because they were not on carotid endarterectomy, were not multisite, or only included outcomes for symptomatic persons. The reviewers excluded 134 studies at the abstract stage (Figure 2). Most studies were excluded because they included only symptomatic persons, were not multisite, had no relevant outcomes, or had a small sample. Three full articles were identified through expert consultation or from reviewing the reference lists of major review articles. Twenty full articles were excluded because they were an incorrect type, were not multisite, only included symptomatic persons, or did not report relevant outcomes. Fourteen articles were ultimately included for key question 4 on the harms of carotid endarterectomy. In addition, 3 good- or fair-quality RCTs identified for key question 3 provided evidence on harms under trial conditions.
The harms of carotid endarterectomy for asymptomatic CAS, reported in most studies as 30-day stroke and death rates, vary from 2.7% to 4.7% in the RCTs; higher rates have been reported in observational studies (up to 6.7%). The results of the literature search and synthesis are discussed below, under the corresponding key question subheading.
Key Question 1
Is there direct evidence that screening adults with duplex ultrasonography for asymptomatic CAS reduces fatal or nonfatal stroke?
We found no studies addressing this question that met our inclusion criteria.
Key Question 2
What is the accuracy and reliability of ultrasonography to detect clinically important CAS?
We found 2 meta-analyses on the accuracy of ultrasonography to detect clinically important stenosis. A recent meta-analysis by Nederkoorn and colleagues included studies published from 1993 through 2001 and estimated the accuracy of carotid duplex ultrasonography using digital subtraction angiography as the reference standard; this meta-analysis was rated as fair quality because it had limited sources for studies and did not have information on the standard appraisal of studies.26 Carotid duplex ultrasonography had an estimated sensitivity of 86% (95% CI, 84% to 89%) and a specificity of 87% (CI, 84% to 90%) for detecting CAS of 70% to 99%.26 A second meta-analysis of carotid duplex ultrasonography found similar sensitivity and specificity for carotid duplex ultrasonography to detect 70% or greater stenosis (90% [CI, 84% to 94%] and 94% [CI, 88% to 97%], respectively).27 This meta-analysis was rated good quality because of the comprehensiveness of sources and search strategies, the explicit selection criteria, and the standard appraisal of studies. To detect CAS 50% or greater, the authors suggested a cut-point that had a sensitivity of 98% and a specificity of 88%. By using a graph in that article and applying the same cut-point as was suggested for detecting CAS 70% or greater, we estimate that the sensitivity of carotid duplex ultrasonography to detect CAS 60% or greater is about 94%, with a specificity of about 92%.
The reliability of carotid duplex ultrasonography is questionable. One meta-analysis noted that the measurement properties used among various ultrasonography laboratories varied greatly, to a clinically important degree.27
We found 1 meta-analysis on the accuracy of MRA and 1 meta-analysis on the accuracy of CT in detecting clinically important carotid stenosis. The fair-quality meta-analysis by Nederkoorn and colleagues reported that MRA has about the same accuracy as ultrasonography.26 CTA has gained wide acceptance in some centers as a follow-up test to ultrasonography in confirming CAS. In certain cases, it has been used in place of vascular arteriography. A recent good-quality systematic review that used comprehensive data sources and a standard appraisal of studies found that the accuracy of CTA does not greatly differ from that of ultrasonography and MRA28 Although CTA is safer than angiography as a confirmatory test, it is unlikely to be a useful screening test because of its cost and because it entails radiation exposure and injection of intravenous contrast dye. Although MRA does not use contrast dye or have significant radiation exposure, it is time-consuming and costly and is also not suitable as a screening test at this time.
Key Question 3
For people with asymptomatic CAS 60% to 99%, does intervention with carotid endarterectomy reduce CAS-related morbidity or mortality?
We identified 5 RCTs comparing carotid endarterectomy and medical management for asymptomatic CAS: the WRAMC (Walter Reed Army Medical Center) study,29 the MACE (Mayo Asymptomatic Carotid Endarterectomy) study,30 the VACS (Veterans Affairs Cooperative Study,31 ACAS,32 and ACST.33 We selected for inclusion 2 good-quality studies (ACAS and ACST) and 1 fair-quality study (VACS). We excluded the WRAMC study because it did not use ultrasonographic assessment of CAS, had few participants, and used unclear definitions of outcomes. We excluded the MACE study because of its small number of participants, small number of strokes, and lack of aspirin treatment in the surgical group.
Study Characteristics
The 3 fair- or good-quality studies, VACS, ACAS, and ACST, compared carotid endarterectomy plus medical management with medical management alone in persons without symptoms attributable to the studied artery. Table 1 shows characteristics and outcomes of these studies, and Appendix Table 3 provides more detail on all RCTs. Medical management included the standard risk factor management at the time of the trials, including aspirin and some degree of blood pressure and lipid control. In VACS, 444 men with 50% to 99% stenosis confirmed by angiography were randomly allocated and followed for a mean of 47.9 months.34 All participants were male, 88% were white, and the median age was 64.5 years. The participants had a generally high cardiovascular risk: Approximately 50% were current cigarette smokers, about 30% had diabetes, and 63% had hypertension.
The ACAS screened about 42 000 people and selected 1662 with angiographically confirmed CAS 60% or greater for random allocation to carotid endarterectomy or medical therapy.32 The sample was 95% white and 66% male, and the mean age of participants was 67 years. The participants had high cardiovascular risk: About 20% had had a previous contralateral carotid endarterectomy, more than 20% had had a previous contralateral transient ischemic attack or stroke, 64% had hypertension, 26% smoked cigarettes, and 23% had diabetes. Surgeons with low carotid endarterectomy complication rates were selected for participation in the study.
The international, multicenter ACST randomly assigned 3120 persons with CAS 60% or greater and followed them for a mean of 3.4 years.33 Both groups received medical management by their primary care providers. Although it is difficult to determine the intensity of medical management, the mean systolic blood pressure at baseline for all participants was 153 mm Hg and mean total cholesterol level was 5.8 mmol/L [224 mg/dL]. Aspirin was widely used. More than 50% of the patients were receiving antihypertensive medications, but the achieved systolic blood pressure was not reported. Lipid-lowering agents were used less frequently at the beginning of the study and were used by more than 50% of participants during the last 3 years of the study. The degree of CAS was determined by ultrasonography. Angiography was not required but was often used for confirmation of CAS during the first few years of the study, and less frequently used in the final years. As in ACAS, patients were carefully selected and were generally at high cardiovascular risk, and surgeons were carefully selected for low complication rates. The mean age was 68 years, and 66% of participants were male, 65% had hypertension, 20% had diabetes, and 24% had had a previous contralateral carotid endarterectomy.
Summary of Study Results
The 2 largest and highest-quality RCTs have shown an absolute reduction of stroke and perioperative death of approximately 5% from carotid endarterectomy compared with medical treatment for CAS 60% to 99% in selected patients with selected surgeons. This benefit includes an approximate 3% rate of perioperative stroke or death.
After 4 years of follow-up, the stroke rate in VACS was lower in the carotid endarterectomy group than in the medical treatment group (8.6% vs. 12.4%). However, the incidence of perioperative stroke or death in the carotid endarterectomy group was 4.7%. When all strokes or perioperative events were considered, there was no difference between carotid endarterectomy and medical management. After 2.7 years of follow-up, the ACAS investigators calculated 5-year outcomes on the basis of Kaplan-Meier curves. They estimated that the 5-year rate of ipsilateral stroke and any perioperative stroke or death was lower in the carotid endarterectomy group than in the medical therapy group (5.1% vs. 11.0%; relative risk reduction [RRR], 0.53 [CI, 0.22 to 0.72]) If strokes associated with angiography were included, the difference between groups was 5.6% versus 11.0%, or an absolute difference of 5.4 percentage points over 5 years. These rates include a perioperative rate of stroke or death of 2.7% overall (1.7% for men and 3.6% for women). The estimated RRR was greater for men than for women: 0.66 and 0.17, respectively. The treatment groups did not statistically significantly differ in all-cause mortality. After 3.4 years of follow-up, the ACST investigators calculated 5-year outcomes. They estimated that the carotid endarterectomy group would have a lower 5-year rate of any stroke or perioperative death than the medical group: 6.4% versus 11.8% (difference, 5.4 percentage points [CI, 2.96% to 7.75% percentage points]). About half of the strokes prevented by carotid endarterectomy were disabling. The perioperative rate of stroke or death was 3.1% overall and was higher for women than for men (3.7% vs. 2.4%). The groups did not statistically significantly differ in all-cause mortality.
The RCTs on carotid endarterectomy for asymptomatic CAS have important limitations. The participants and surgeons in the RCTs were highly selected, which reduces the generalizability of the findings to the primary care setting. In addition, the 30-day perioperative results of the RCTs were reported as a combined outcome and did not include an important complication, acute nonfatal myocardial infarction. Another important limitation of the RCTs on treatment with carotid endarterectomy is that the medical treatment arm in the RCTs was poorly defined, was not kept constant over the course of the study, and was probably not comparable to current standards of optimal medical management.
Key Question 4
Does screening or treatment for asymptomatic CAS 60% to 99% with carotid endarterectomy result in harm?
The potential harms of a program of screening for CAS for the purpose of performing carotid endarterectomy include the harms associated with false-positive screening tests (for example, anxiety; labeling; the harms of any confirmatory work-up, such as angiography; or the harms of unnecessary carotid endarterectomy in people who do not undergo angiography); and the harms of carotid endarterectomy itself (for example, bleeding, infection, stroke, and death). The harms of angiography are discussed in the introduction to this article. We found no studies on anxiety or labeling among people with false-positive results on ultrasonography screening. We did find evidence concerning the harms of carotid endarterectomy. Carotid endarterectomy entails a clear risk for perioperative complications of carotid endarterectomy, including stroke, death, and myocardial infarction. Some observational studies have shown rates of perioperative complications that were higher than the 3% reported in the RCTs.
Study Characteristics
We identified 14 good- or fair-quality studies that met our inclusion criteria and evaluated carotid endarterectomy complications in patients with asymptomatic CAS. Appendix Table 4 shows detailed study characteristics, quality ratings, and results of the observational studies. Thirteen observational studies were secondary analyses of administrative databases: 2 studies used data on patients attending a Veterans Affairs medical center,.35-36 7 studies used data from patients receiving Medicare benefits,.37-43 and 4 studies used a similar data set of patients admitted to 6 New York hospitals.44-47 The final study was a systematic review of studies published between 1994 and 2000 on harms of carotid endarterectomy.48 The primary perioperative complication measure in the studies was either death/stroke or death/stroke/myocardial infarction within 30 days of surgery. All of the observational studies included patients referred to a hospital or medical center for carotid endarterectomy as a result of CAS. Few data were provided on the severity of stenosis. The studies included patients who did and did not have neurologic symptoms, but we reviewed only studies that reported complication rates separately for asymptomatic patients. The mean age of patients ranged from 67 to 74 years. Six of the studies collected information on race; in those studies, most participants were white (range, 87% to 95%). Almost all participants in the 2 Veterans Affairs studies were male, whereas the other studies include 36% to 47% women.
Bratzler and colleagues used a claims database and medical records from Medicare recipients who underwent carotid endarterectomy in 1993 or 1994.37 We quality rated this study as good: Data for outcomes were collected from 2 sources, correlation between data abstractors was high, and the investigators used standard definitions of outcomes. The fair-quality study by Cebul and colleagues used Ohio Medicare claims data on patients who underwent carotid endarterectomy between July 1993 and June 1994; their sample was predominantly white, and the study used only a subset of all patients receiving carotid endarterectomy during the time frame.38
Two good-quality studies on the same database of patients undergoing carotid endarterectomy at Veterans Affairs medical centers had well-defined inclusion criteria and abstraction processes and used methods that probably limited differential outcome measurement, including contacting all patients and families 30 days after surgery35-36 Two good-quality studies by Kresowik and colleagues used Medicare claims databases from 10 states; the first was conducted for June 1995 to May 1996, and the second for June 1998 to May 1999.41-42 These studies were very large and included medical record data in addition to data in the claims database. Another good-quality study by Kresowik and colleagues used similar methods as above but used the Iowa Medicare database.43 A fair-quality study by Karp and colleagues used Medicare claims data from Georgia; agreement between the reviewer and the physicians on indications for surgery was limited.40
Four studies used the same database of Medicare recipients from 6 New York hospitals who had carotid endarterectomy in 1997 or 1998.44-47 The individual studies used similar methods but had different research questions and consequently excluded cases with missing data using different criteria. Although these 4 studies had some limitations, the overall quality of the studies was rated as good because both outpatient and inpatient data were used for outcome measurement, studies used trained independent abstractors, 2 investigators independently reviewed records of patients with an outcome, and few patients were excluded because of missing data.
The 2007 study by Halm and colleagues was performed on an administrative database of Medicare recipients in New York State who received carotid endarterectomy between January 1998 and June 1999.39 We rated this study as fair-quality owing to several limitations, including the exclusion of many patients because of missing data. The systematic review by Bond and colleagues included studies that reported 30 day stroke and death rates by indication and excluded studies on combined carotid endarterectomy and coronary artery bypass grafting.48 This study had several limitations, including a lack of discussion on the standard assessment of study quality, that resulted in a fair-quality rating.
Summary of Study Results
The 30-day perioperative stroke or death rates in asymptomatic persons in the Medicare and New York City studies ranged from 2.3% to 3.7%. One Veterans Affairs study showed a perioperative stroke or death rate of 1.6%.35 The systematic review of 103 studies found an overall stroke and death rate at 30 days of 3.0% in studies published since 1995.48
The observational studies that reported on perioperative nonfatal myocardial infarction showed a rate of approximately 0.7% to 1.1%,35,40,44 Patients with more comorbid conditions had a rate of nonfatal myocardial infarction up to 3.3%.44 The rate of nonfatal perioperative myocardial infarction reported for the surgical group in the RCTs varied from 1.9% in VACS to 0.6% in ACST.31,33 The participants did not receive routine postoperative electrocardiography or serum markers of myocardial involvement.
Two Medicare-based studies found variation in perioperative stroke and death among 10 states.41,42 In the first study, the statewide rates ranged from 2.3% in Indiana to 6.7% in Arkansas.41 A follow-up study for the same 10 states found similar results as in 2001, with rates ranging from 1.4% in Georgia to 6.0% in Oklahoma.42
Studies provided little information about rates of other complications, including the impact on quality of life. None of the observational studies that we evaluated gave specific rates of other complications for asymptomatic patients. However, among the RCTs, the VACS reported a surgical complications rate of 3.8% for cranial nerve injuries (none of these injuries were permanent), 5.2% for hypotension, and 25% for hypertension.34
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Death from the skies! : these are the ways the world will end
Philip Plait
Adult Nonfiction QB638.8 .P53 2008
Philip Plait
Adult Nonfiction QB638.8 .P53 2008
Summary: According to astronomer Plait, the universe is an apocalypse waiting to happen. With humor and wit, Plait details the myriad doomsday events that the cosmos could inflict to destroy the planet and life in general.
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Ryse: Son of Rome Review: Roma Ignis
Ryse: Son of Rome is an extremely conflicting game. On one hand, you have an incredibly gorgeous game, quite possibly one of the prettiest on the Xbox One, with combat that's more tactical than you'd think. On the other hand, the game isn't much more than that. It's a series of combat bouts against an onslaught of barbarians through gorgeous and varying vistas that will... Read More


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When families make a decision to have children or not, finances often weigh heavy in their decision. They consider things like if one parent can afford to stay home or not, how many years of daycare they may need, and plenty of other financial factors. What many fail to add into the equation, however, is what if that child has autism.
According to recent study, families of children with autism are hit not only emotionally when their child is diagnosed, but they take significant financial blows as well. A new report says families with autistic children earn $18,000 less than those whose children don't. That's a lot of money, and it's primarily due to the mother not being able to work as much or at all.
The study showed those with autistic children were 6 percent less likely to be employed, worked seven hours less per week, and they had less than half the annual income than those whose children had no disability. David Mandell, associate director of the Center for Autism Research at The Children's Hospital of Philadelphia, told Reuters Health, "Mothers are leaving the workforce to cobble this care together for their kids."
It's such a sad statement about the care options available to families facing autism, and it's frightening because the cost of raising a child with autism can be so high. While most of us look forward to the day we pay for what we can of our kids' college, then let them fend for themselves, many parents of children with autism are faced with supporting their children for life. Some estimates say their extra care may cost $3.2 million over a lifetime. I'm sure parents of children with many disabilities face similar challenges.
It's a clear sign that something more has to be done to help families who are sacrificing so much to do what's best for the children they love. We have to find ways to help them and let them help themselves by working, if that's what they choose.
It's not that surprising I guess given the struggles I've heard from friends and others who are trying to navigate services for their autistic children, it's just jolting to see how large the impact of autism is financially ... in addition to the many other ways their lives are forever changed by it.
Are you surprised that families raising children with autism are financially impacted this significantly? If you have a child with autism, how has your work situation been affected?
Image via Lance Neilson/Flickr
I am a single mom with two autistic boys. It is really hard to raise them and to have everything they need. It is ridiculously expensive and devastating when you cant get everything for them!
My son is 5 and has high-functioning autism. If my MIL wasn't willing to watch him, I don't know if I'd be able to work. He's been kicked out of daycare because they don't want to deal with him (and I can't blame them, they aren't trained for it).
My son isn't autistic, but he is severely impaired physically and cognitively and non-verbal. The only reason I have been able to keep a job is because my parents retired to be my "nannies." I literally don't know what I would have done without their daily support, and I'm married! Its like my son has 2 sets of parents, and dang it- he needs that many. And still, the money drain to get him what he needs is unbelievable.
If your child needs you and you are not a single mother why are you still working?


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It's Hot Out There, and Cool on Baldy
It seems that July has finally arrived, and now it's getting pretty hot out there around town. It could be in the 80′s today, possibly even the 90′s by the weekend. The coolest place in the valley will have to be the Roundhouse up on Baldy. Great place for lunch at the BBQ on the deck, or a nice sitdown meal inside around the fireplace. They are telling us that the restaurant is considerably less crowded than it was last weekend, so it might be a great time to get up there and give it a look. And you can ride right on up to the summit at the old Lookout building, stroll around take some pics, and if you are lucky, it is always fun to watch the parasailers take off from the top.
Ask the mountain guys about the walking trails available, and bike rentals there at Pete Lane's. Kaleb is almost always there and will be happy to supply maps, directions, schedules, even water and snacks if needed.
Look at our previous blog about the Bald Mountain Trail, it describes the hike up, but you could always use it for the walk down just as easily. Think about bringing a light jacket or sweater as well so you don't get surprised…
See you there


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NBC2 has learned the man accused of attacking a Fort Myers woman inside her home is scheduled to be in court Monday afternoon to take a plea deal in the case.
The state recently reduced the charges against 32-year-old John Maatsch. He's now charged with Attempted Second Degree Murder and Burglary.
On December 26th, Tracey Marazzi woke up in the middle of the night to a man stabbing her. Maatsch showed up at the crime scene later dressed in women's clothing.
Police arrested him, and he's been in custody since his first court appearance.
His attorney says he is scheduled to be in court Monday to enter a guilty plea and will then be sentenced to prison. But the attorney cautioned things could change over the weekend.
Marazzi is also expected to be in court and speak at the hearing.


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GREEN BAY, WI (WTAQ) - Green Bay Packers fans better get ready to shell out more money for tickets next season.
The Packers announced Monday they are raising ticket prices $3 on stadium bowl tickets.
With that increase, here is the breakdown of costs to see the Packers at Lambeau Field:
-End zone seats: $77-South end zone, 700 Level: $85-End zone to the 20-yard line: $88-South end zone, 600 Level: $92-Between the 20-yard lines: $100
Lambeau Field suite tickets will also increase $3 in 2014 to $100.
"Our goal for ticket pricing is to be just below the League average," Packers President and CEO Mark Murphy said in a brochure mailed to season-ticket holders. "With this increase, we project to rank 17th in average ticket price, which accomplishes the goal and maintains a fair visiting team contribution, as well. We're confident our top-rated Lambeau Field experience remains a great value for (ticket holders)."
Payment is due to the Packers ticket office by March 31.
As for the playoff ticket invoicing procedure, the Packers anticipates offering a "pay as we play" type of option for ticket holders that will have payment applied only when a game is certain to occur. A number of details are being worked through, and options for payment will be communicated when the procedures are finalized.


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2009 Culture of Peace Lecture Series Schedule: Download PDF
Child Rights and the Culture of Peace
Kimmie Weeks has worked to alleviate poverty and human suffering in Africa and around the world since he was fourteen years old. Kimmie was born in Liberia, West Africa in 1981. At the young age of nine he came face to face with civil war, human suffering, and death. Weeks can still vividly recall eating roots and wild leaves when his family did not have access to food, drinking infested water when national water supply was shut off, and nearly being buried alive after epidemics had wrecked his emaciated body.
Affirming the Dignity of All
Lawrence Edward Carter Sr., is the first Dean of the Martin Luther King Jr. International Chapel and tenured Professor of Religion, and College Curator at Morehouse College since 1979. He has also been an Instructor at the Morehouse School of Medicine in the Master of Public Health Program. For forty-six years, Dr. Carter has studied and worked in fourteen American universities, colleges, and professional schools, spoken at over one-hundred different colleges, universities, and seminaries, and received over five-hundred speaking engagements from eighteen denominations, and traveled to thirty-five foreign countries. He has made over sixty radio and television appearances, including nationwide in England, Canada, Japan, New Zealand, Australia, South Africa, and continent wide in Africa.
Pursuing Peace: The Role of Individuals in Resolving International Conflict
Anna Spain is the Deputy Director of the Burkle Center for International Relations and a Lecturer in Law at the UCLA School of Law where she teaches international dispute resolution. Her scholarship focuses on the intersection of international law and dispute resolution and on the study of international and cross-cultural conflict.
Teaching Peace in Our Schools
Colman McCarthy is a speaker whose fresh ideas, sense of social justice and sparkling wit have been stirring audiences for the past 25 years. He lectures at more than 20 colleges and universities a year, as well as at conferences for groups ranging from educators and social
workers to policy centers and corporations.
Speaking From the Heart to Bridge the Divide in the Middle East
Mona Eltahawy is an award-winning syndicated columnist and an international public speaker on Arab and Muslim issues. She is based in New York.
A Holistic, Integrative View of Peace Based on Evolving Views of Peace and Nonviolence
Linda J. Groff, Ph.D. is Professor, Political Science & Future Studies, California State University, Dominguez Hills, Carson, CA. She is a Global Futurist & Synergist who is also Co-Director of Global Options.
Global Migration and the Challenge of Development
Ali Modarres is the Associate Director of the Edmund G. "Pat" Brown Institute of Public Affairs at California State University, Los Angeles and a Professor at the Department of Geography and Urban Analysis on the same campus. He specializes in urban geography and his primary research and publication interests are community development and planning. He has published in the areas of urban development, transportation planning, environmental equity, social geography, immigration, and race and ethnicity as they relate to the issues of access and the role of public policy in creating disadvantaged communities.
Dance Changed My Whole Life: I Became the Champion of My Dreams
Pierre Dulaine (born 1944) is a well-known ballroom dancer and dance instructor. He invented the Dulaine method of teaching dance.
New York Learns from Atomic Bomb Survivors
International Human Rights and the Culture of Peace
David Kaye is the Executive Director of the UCLA School of Law International Human Rights Program. He teaches International Human Rights and directs an International Human Rights Clinic. For more than a decade, David Kaye served as an international lawyer with the U.S. State Department, responsible for issues as varied as human rights, international humanitarian law, the use of force, international organizations, international litigation and claims, nuclear nonproliferation, sanctions law and policy, and U.S. foreign relations law. He was a legal adviser to the American Embassy in The Hague, where he worked with the international criminal tribunals and acted as counsel to the United States in several cases before the International Court of Justice and the Iran-U.S. Claims Tribunal. From 1999 to 2002 he was the principal staff attorney on humanitarian law, handling issues such as the application of the law to detainees in Guantanamo Bay and serving on several U.S. delegations to international negotiations and conferences. The State Department honored him with four of its prestigious Superior Honor Awards.
People on a Warning Planet
One of the world's leading experts and activists on the issue of climate change Dr. Habiba Gitay is the Senior Environmental Specialist at the World Bank Institute (WBI). An Australian national with a PhD in Ecology from the University of Wales, Gitay has been involved with climate change since 1994. Previously, she was the capacity building coordinator for the Millennium Ecosystem Assessment, and was responsible for bringing young people, especially from developing countries, into international science and assessment. She was also the Vice-Chair of the Scientific and Technical Advisory Panel (STAP) of the Global Environment Facility (GEF).
Teaching a Culture of Peace
Louis Silverstein is a transcendental philosopher and practitioner. Multi-cultural and multi-consciousness educator. Social activist. Earth artist. Areas of special interest: peace and social justice; planetary consciousness; spirituality; psyche-delos; transformative consciousness and alternative realities; ecological harmony; sex, love and relationships; holistic education; parenting; aging; death and dying and living life as an art form.
Striving to Create the Will to Peace
Martin Luther King, Jr. called James Lawson, "the leading theorist and strategist of nonviolence in the world." Reverend Lawson studied the Gandhian movement in India before becoming a leader and the architect of non-violent action in the U.S. civil rights movement, partnering with Martin Luther King, Jr. Reverend Lawson's life has been marked by an abiding faith in non-violence and a willingness to pay the price for those beliefs. He served 13 months of a three-year prison sentence for refusing the draft during the Korean War, and was expelled from Vanderbilt in 1960 because of his work helping to desegregate lunch counters in downtown Nashville, Tennessee.
Peace and Development: Ideas and Practice at the Community Level
Steven Wisman is the Director of Operations for the Millennium Villages Project. Working in collaboration with Millennium Promise's key partners for this sustainable development initiative—Columbia University's Earth Institute (EI) and the United Nations Development Program (UNDP)—his responsibilities include management oversight, operational support, and partnership development services for the project's local management teams responsible for implementing 14 programs, serving over 400,000 individuals in 10 countries in West, East and Southern Africa, and.
¡Si Se Puede! Yes We Can!
Julie Chavez Rodriguez has worked with the Cesar E. Chavez Foundation for the past eight years spearheading their educational and service programs, namely the Educating the Heart School Program and the Chavez After School Service Clubs. Julie has been instrumental in developing and implementing professional development sessions for educators, youth, AmeriCorps memebers, and program coordinators on Chavez values, service-learning, and youth leadership. Through a partnership with the California Department of Education Julie served as lead consultant for the Chavez Foundation on the development of a standards-based K-12 model curriculum on the life, work, and values of Cesar E. Chavez. Julie alsoserves as a service-learning lead trainer in 6 school districts/county offices of education. Julie is a fellow in the National Service-Learning Emerging Leaders Initiative sponsored by the Kellogg Foundation, the National Service-Learning Partnership, and the National Youth Leadership Council. She co-authored, along with Anthony Welch, the Martin Luther King Jr. and Cesar E. Chavez: Legacies of Leadership and Inspiration for Today's Civic Education Issue Paper published by the Education Commission of the States in September 2005. Like her grandfather, Julie believes that the end of all education should surely be service to others.
City Government Approaches to Building the Culture of Peace
Ken Genser is serving in his sixth term on the Santa Monica City Council. He was first elected in November 1988, and is the longest-serving councilmember in the history of the city. He is currently serving a two-year term as Mayor, and was also the city's mayor in 1992 and 2000.
Gender Equality is Essential to Achieving Development and to Building Just Societies
Gender Equality: A Key to Peace and Democracy in the Middle East
Nayereh Tohidi is Professor and Chair of the Gender and Women's Studies Department at California State University, Northridge and a Research Associate at the Center for Near Eastern Studies at UCLA, where she has been coordinating the Bilingual Lecture Series on Iran since 2003.
Climate Change and the Sustainability of Mankind: Overcoming the Inner Limits
An Ethic of Care: Recentering Values, Rights and Needs
The Role of Religion in Building Civil Society
Patrick James is Professor of International Relations and Director of the Center for International Studies at the University of Southern California (PhD, University of Maryland, College Park). James specializes in comparative and international politics. His interests at the international level include the causes, processes and consequences of conflict, crisis and war. With regard to domestic politics, his interests focus on Canada, most notably with respect to the constitutional dilemma. James is the author of fourteen books and over one hundred articles and book chapters. Among his honors and awards are the Louise Dyer Peace Fellowship from the Hoover Institution at Stanford University, the Milton R. Merrill Chair from Political Science at Utah State University, the Lady Davis Professorship of the Hebrew University of Jerusalem, the Thomas Enders Professorship in Canadian Studies at the University of Calgary, the Senior Scholar award from the Canadian Embassy, Washington, DC, the Eaton Lectureship at Queen's University in Belfast, the Quincy Wright Scholar Award from the Midwest International Studies Association and LENNA PROFESSOR AT ST. BONAVENTURE UNIVERSITY. He is a past president of the Midwest International Studies Association and the Iowa Conference of Political Scientists. Jame has been recognized as Distinguished Scholar in Foreign Policy Analysis for the International Studies Association (ISA), 2006-07, AND ETHNICITY, NATIONALISM AND MIGRATION FOR THE ISA, 2009-10. He SERVED AS Vice President, 2005-07, and President, 2007-09, of the Association for Canadian Studies in the United States, and Vice-President (2008-09) of the ISA. James also served a five-year term as Editor of International Studies Quarterly.
2014 Lecture Series Schedule
The Culture of Peace
The SGI-USA Culture of Peace Resource Centers have launched the Culture of Peace Distinguished Speaker Series to engage people in a dialogue on the values, attitudes and behaviors that reject violence and inspire creative energy toward the peaceful resolution of conflicts.
The SGI-USA is involved in non-sectarian, awareness activities to promote the values of peace, culture and education.


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Holidaymakers looking for a beautiful place to stay in the Caribbean should try Little Cayman. This beautiful place is one of the Cayman Islands located 75 miles north east of Grand Cayman and is a great location for many interesting activities. Here visitors will find numerous different places to stay including self catering accommodation, holiday homes, cottages and condos.
The small island of Little Cayman has some lovely sandy beaches that are ideal for relaxing and catching some sun. The waters here are also pleasant for swimming as well as kayaking and sailing. Scuba diving is particularly popular on the north of the island at Bloody Bay and Jackson's Bight.
Holidaymakers can also participate in deep sea and freshwater fishing trips. The island is only 10 square miles in size and can be easily explored by hikers or by bicycle. Other popular activities on the island include beachcombing and bird watching.
There are a handful of bars and restaurants on the island with a mix of Caribbean, American and other international cuisine. Little Cayman has little in the way of large shops but there are a few small gifts stores located around the island. There are places too for self catering holidaymakers to purchase hardware, groceries and supplies.
There are some very pretty places to visit on the island including Booby Pond, which is a haven for birds such as egrets, ducks, herons and the booby. The pond has a visitor centre operated by the National Trust, which has some good exhibits and arts and crafts for sale. The Little Cayman Museum gives visitors an insight into the island's history. Holidaymakers can take a trip to the uninhabited islet of Owen Island, which is just off the south coast of Little Cayman. Boat trips are available to the other Cayman Islands, Grand Cayman and Cayman Brac.
Summer temperatures are generally highest in July and August with daytime highs in the upper 80's to low 90's, whilst at night the lows are still in the in the low 80's. High humidity in the summer months often makes it feel hotter. Rainfall is generally seasonal from May to November, with May, June, September and October usually the wettest months. Rainfall can be heavy during the rainy season. However, the rain often doesn't last very long.
Little Cayman can be reached by flying to Owen Roberts International Airport (GCM) on Grand Cayman, which has flights arriving from London-Heathrow (LHW), Miami (MIA), New York (JFK) and Toronto-Pearson (YYZ) amongst other cities in North America. Passengers can than either travel by boat to Little Cayman or fly via Cayman Airways to Edward Bodden Airfield (LYB). McLaughlin Rentals is the only vehicle rental business on Little Cayman, offering SUVs and mopeds.


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Our KSFY/Taco John's athletes of the week thrived under pressure to win state titles over the past three days.
We'll start in Class AA golf, where Lincoln junior Tommy Vining won his second straight individual state title yesterday at the Brandon Golf Course.
He shot two straight 71's and won in a playoff over O'Gorman's Chris Gaher for the championship.
Meanwhile Aberdeen Roncalli senior Michael Duch won the Class A state championship leading from start to finish at the Central Valley Golf Course in Hartford. Duch is the first Roncalli golfer ever to win a state title.
Besides Vining and Duch, Washingting High School junior Amirah Michaeli's hit a walk off grand slam homerun to give the Warriors a third straight state softball title on Saturday. It was with 2-outs on an 0-2 pitch.
For those performance's we salute Tommy Vining, Michael Duch, and Amirah Michaeli as our KSFY/Taco John's Athletes of the Week.


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Freeze frame
Ayarbe, Heidi.
Teen Fiction AYARBE
Ayarbe, Heidi.
Teen Fiction AYARBE
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kb4444 said:
This is a pretty sad story about a kid who forgets a few crucial minutes of his life. These minutes are the ones in which his friend is shot. He remembers holding the gun, but did he shoot him? This book certainly kept me reading it.
posted Apr 25, 2009 at 11:02AM
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Milwaukee Riverside's size and quickness was too much for Superior in the Division 1 semifinal tonight at the Resch Center as the Lady Tigers won comfortably 69-55. The quickness was delivered by sophomore guard Amani Wilborn and the size of 6-5 senior Breanna Lewis was equally hard to handle as both scored 20 points. After a 1-4 start that included losses to Fox River Classic Conference teams De Pere and Bay Port, Riverside has now reeled off 23 straight victories to reach the state championship game for the first time. Superior finishes the season at 23-4. Riverside will meet Mukwonago for the Division 1 championship in the final game of Championship Saturday at the Resch.
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2006 Chateau Latour Pauillac
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750ml Bottle $7,140.00
Case of 12
750ml Bottle $7,140.00
Case of 12
Item #17268
Size: 750ml
Type: Red Wine
Varietal: Red Bordeaux Blend
Country: France
Region: Bordeaux, Pauillac
"This is a beautifully rich Chateau Latour boasting a dense ruby/purple color, a sweet, smoky, charcoal, cassis, graphite, and forest floor-scented nose, full body, an attractive freshness, and sweet, noble tannins. This layered Latour is one of the vintage's top dozen or so wines." Reviewed by Robert Parker.
Reviewed by: The Wine Advocate - 95pts
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2008 Chateau Mouton Rothschild Pauillac
"The final blend of 83% Cabernet Sauvignon and 17% Merlot exhibits tell-tale black currant liqueur, incense, charcoal and floral-like characteristics. The oak is pushed to the background, one of the major improvements director Philippe Dalhuin has made at this estate. Full-bodied, deep and impressively endowed, it is a deep, rich, less massive effort than either the 2010 or 2009. This gorgeous Mouton will be drinkable in 4-5 years and age effortlessly for three decades." Reviewed by Robert Parker.
$485.00 / 750ml Bottle
$2,910.00 / Case of 6
$2,910.00 / Case of 6
1995 Chateau Mouton Rothschild Pauillac
"It reveals an opaque purple color, and reluctant aromas of cassis, truffles, coffee, licorice, and spice. In the mouth, the wine is "great stuff," with superb density, a full-bodied personality, rich mid-palate, and a layered, profound finish that lasts for 40+ seconds."
$550.00 / 750ml Bottle
$6,270.00 / Case of 12
$6,270.00 / Case of 12
2005 Chateau Mouton Rothschild Pauillac
"The dark purple-hued 2005 exhibits a restrained but promising nose of cedar, tobacco leaf, creme de cassis, and toasty oak. Full-bodied, tannic, and extremely backward, with the vintage's tell-tale acidity, it appears to be even more closed in the bottle than it was from barrel. It does possess a long finish and multilayered mouthfeel. This is an undeniably outstanding, yet restrained, shy wine for a Mouton Rothschild." Reviewed by Robert Parker.
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Posts Tagged 'arrington'
Gadget Rumor: Crunchpad Launching This November, To Cost $400
A bit more news has surfaced about Michael Arrington's Crunchpad computer by way of the The Straits Times, who claims that they've got a sneak preview of the tablet like computer. We already knew about the 4GB of storage and Wi...
Final Prototype Crunchpad Unveiled (video)
I was just wondering what happened to the once fabled then leaked Crunchpad, when low and behold Arrington and crew go and announce a final design for the device. Unfortunately, these are just conceptual drawings, but they say ...


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The Low End Theory Hip-Hop News Report 12.21.12 The End of the World Edition
Posted by
Tony Acero
on 12.21.2012
News and thoughts on Trey Songz being arrested for throwing money around, Starz creating a new hip hop drama, Gunplay blaming the government for Sandy Hook, Glasses Malone's mixtape and more!
It's the end of the world as we know it, and I feel fine! If you're reading this, we've made it...or you should really consider better things to do with the last minutes of your life. In all seriousness, I hope those that truly believe the world will end can take the dose of reality that is to come. And for those of us that think we'll continue on with debts and stupidity on Facebook, Hallelu!! At any rate, there's some interesting things happening in Hip Hop, but I don't want to talk about them. Instead, let's focus on stupidity and how much fun it brings.
Remember, next week will be our end of the year column, and it's going to be great! Let's get to the news!
Video of the Week
Mac Lethal - Freestyle
Our good friend Mac Lethal does it again!
Return of the Miss…
Fat Joe
has pleaded guilty to tax evasion. He was released on a $250,000 bond. Home boy needs to Lean Back.
hopes to be one of the best authors of all time. He's got about as good a chance of being that as I do in having my first quick shot be funny…
has confirmed collabs with Rihanna, Kanye and Drake, proving that times are a changing, and the Future looks…bleak.
Odd Future
have yet to grow up. I mean, in case you were wondering when it was going to happen.
According to some reports, Starz will be creating a series that is based on the rise of Hip Hop. Although the idea is still in its infancy, there are plans to release it and it's already in the development stage. It's said to be a drama and will chronicle the violence of gang life in the Bronx during the 70's to the rise of hip hop as a whole.
Long time readers will know that the history of hip hop is both vital and important to me as well as the column. I've talked many times about where hip hop has come from, and how it got to where it is today. I've written plenty of essays about the topic and have read up quite a bit about it as well. It's probably because of this that I was immediately excited about the prospect of a television show telling this story. I've thought about it for a bit now, and I think that this is a very risky idea. On one hand, you have the very true to life story of hip hop's incarnation, and on the other hand you have the word "drama." If they are going to take the premise of hip hop and create a tv show that is more focused on drama, then I'm not sure I'll be all that interested. The news is fresh both in the world and in this column, so I haven't fully let it register yet, but either way I am pretty enticed to see what comes of it. The Low End Theory will be keeping tabs on it, for sure.
Your Turn:
Will you be checking in on
when it comes out?
Strippers are a funny creature. According to reports,
Trey Songz
had an album release part on August 21st of this year. It was at a strip club (of course, right?) and Trey and his crew stayed till around 4 in the morning. Apparently, an altercation lead to Trey Songz tossing a "sum of United States Currency" that "caused substantial pain" to a stripper's left eye. One month later, and Trey Songz is arrested for misdemeanor assault.
Now, even after reading that, it's obvious that there are some details missing. Was it a box of quarters? A wad of money? A brick of hundreds? And moreover, would it truly matter to someone what it was? This is money and a stripper we're talking about. Past incidents with Trey Songz have shown that he may not be the coolest cucumber, but I can't see this incident being taken too seriously. And this is not, by any means, a defense for Trey Songz. I can imagine the female saying something rude and he pulling the "nigga, I got stacks" card, tossing some sort of heavy amount of money towards her face. If it were a stack, it's gonna hurt. I don't care, personally, but do you really got that kinda money where you can just toss it? If I were rich, I'd hang on to every dollar I had. That's that kinda attitude that gets you in trouble with Murica, yo.
Would it be jumping the gun if I said this was another situation when someone saw a light bulb in the possibility for more money? It's unfortunate, sometimes. See more about this situation below.
Typically, when large-scale events in the world happen, I keep very quiet. I don't make long ranting posts on Facebook, I don't bring it into the column, I don't make YouTube videos on who's to blame and what we can do. There are far too many people in this world who enjoy reading their own text and hearing their own voice. It may shock you, but I have never been that type. We see it everywhere, particularly with social media, and although it's nice to see people interested in world tragedies, and want to do something about it, some people simply talk a bit too much. Want an example?
For those that don't know him, he's not done much for you to know about and interestingly enough has a mixtape dropping just as this "controversial statement" has been made. Just like his tat of a Swastika, it appears he's being outlandish for the sake of being outlandish. Gunplay has been in the news moreso for getting his ass handed to him by G-Unit and an attempted robbery than any particular music that he has released. While I have always appreciate the freedom of speech, there are some people that need a friend that can tell them, "don't tweet that, dawg." According to Gunplay, we are all sheep and the government caused the death of elementary children to "take our guns away." Of course, these tweets were deleted shortly thereafter, but seriously….what the hell?
Listen, readers, if you truly believe that our own government is out to warp our mind and alter everything we believe in, then so be it. That's on you. But I have learned that these are the same people that watch 9 minute YouTube vids dissecting music videos for signs of the Illuminati. The name of the man who was behind this tragedy has been released already, and there's plenty of evidence that points towards mental issues, gun control, lack of protection, and a variety of other "reasons," but one that has always baffled me towards any one situation is that it was the government behind it.
Gunplay, sir, with a name such as the one you have, and the past that you have conducted throughout your years, your opinion is invalid. Please, take the time that you have due to your house arrest and write your thoughts down on paper. Stay away from the keyboard.
The lovely ladies of The Low End Theory have taken a backseat for the past few weeks. Truly, since the crowning of the lovely
as our Hip Hop Hottie of the year, we haven't had a lady grace our column outside of a few choice photos. I don't want you to worry, however, as come the new year we'll have a few new ladies added to the fold as well as a visit or two from the Hip Hop Hottie of the year. Anyways, one of our lovely ladies is in a competition, and she wouldn't mind a bit of our help. She's one of my favorites, and I'm sure one of yours as well…
Our lovely Hip Hop Hottie, Amia Miley, is currently in the running for Orgasm.com's Orgasm Girl, and if you haven't seen Amia in action, then I encourage you to do so (at home, not at work) to see just why she deserves the title. Vote for her
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This Stripper....
- By Joseph Paige Jr.
In today's economy we're all looking for a way to earn a little cash. I know I am with these bills pilling up. So how do you think I felt when I learned that a stripper from Queens, N.Y. was filling a lawsuit against R&B singer Trey Songz for "making it rain" on her? Yes, I repeat he made it rain on the trick and instead of dancing for those bandz she chose to file a police report. Now I know what you're thinking. What's illegal about throwing money in the air for it to only fall back down on naked women? Why there's nothing illegal about the action, but when you throw dollars with such velocity that you result in scratching the cornea of a stripper then you may have some legal issues coming your way.
I myself don't know much about the qualifications of a stripper or what is required on their resume, but I'll go ahead and assume that a stripper is in need of her vision. I mean those clubs do get quite dark and following the reflection of glitter on your co-workers titties can't hardly be enough to guide you through the treacherous crowd of thirsty dudes waiting for the right opportune moment to cop a feel. The most interesting part of this story I find is that the event took place back in August as a celebration for the release of Trey Songz latest lackluster album. However, Trey was not arrested for this incident until just a month ago. Which leaves me to believe that the stripper was in fact not injured the night of the album release party, but after listening to the new tracks for a few weeks she was enlighten to the fact that Trey Songz has been creating the same formula of songs for the past 3 albums and still giving us all a poor man's interpretation of R. Kelly. So she the stripper is taking it into her own two hands (the same hands were the money should have politely handed to her) wants to finally be the one to put an end to Trey's trickery.
I've been a
Glasses Malone
fan for some years now, before he got signed to Cash Money Records alongside Lil Wayne. I was probably one of the dozens of people who ordered his mixtape Watts Towers online back in 2005ish, it came autographed and doesn't even show up on his Wikipedia page as part of his mixtape discography. That being said, G. Malone has come a long way from dealing crack in Watts to having radio singles with Birdman & Akon. A couple years ago I went to a Dogg Pound show at Coheba's in downtown Long Beach and had my first encounter with G. Malone, back in my fan days. That might come off sounding like a bad thing, "back in my fan days"...
To set the record straight, I am still a HUGE fan of his today. I have his personal cell number, have had the pleasure of meeting him as a person, and have plans to work with him in the near future already set in place. His birthday was on December 12th, the same day he released the Glasshouse mixtape. This isn't the typically dark-crack-dealing Glasses tape you would have grown accustom to hearing, which could turn out to help move his career forward from its stale state that it's in.
Glasshouse is a fun tape to party to, or as they say now, FUNCTION to. Just for shits & giggles I'd compare the atmosphere of this mixtape to Ty$ x Joe Moses last mixtape, so if you listened and liked that one, you should have a good time listening to G's. I'd like to give a shout out to the producer
King Dave
who did half of the Glasshouse mixtape. Be on the lookout for a
King Dave x Jay Nari
producing project coming out soon, and if you're wondering what my connection is with these super producers is, we all went to high school together, imagine that.
[Editor's Note: MHS 4 Lyfe! Haha]
Download the #Glasshouse mixtape here:
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That's it for this week, everyone! Join us next week for our End of the Year column!!!!
The Low End Theory Team
Tony Acero
Twitter: @TonyAcero411
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Power Module
Abstract: In this paper, we discuss the upgrade problem of module, and introduce the concepts of the power module, regular power module and uniform power module. We give some results of them.
Key words: power group; power module; regular power module; uniform power module
Key words: power group; power module; regular power module; uniform power module
DOI: http://dx.doi.org/10.3968%2Fj.mse.1913035X20090302.002
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Upstate News
Doretta Royer 315 464-4833
Fifth annual radiothon to benefit pediatric care at University Hospital begins Nov. 1
SYRACUSE, N.Y.— The fifth annual Radiothon for the Golisano Children's Hospital, presented by ClearChannel Radio to benefit pediatric services at University Hospital, will be broadcast live on Newsradio 570 WSYR from University Hospital and Carousel Center Nov. 1 and 2, from 5 a.m. to 7 p.m., and from the Carousel Center on Nov. 3.
Central New Yorkers can make a pledge by calling 315-464-KIDS (5437) during the radiothon or by participating in the radiothon's Change Bandit campaign.
The radiothon will feature live interviews with the families of children who have been treated at University Hospital, members of the hospital's pediatric team and community advocates for children's health.
"University Hospital is a leader in child healthcare, research, advocacy and education," said Toni Gary, director of community relations for the Golisano Children's Hospital at University Hospital, which is set to open in 2009. "Our team of pediatric specialists treat the most complex cases in our region. The radiothon will feature discussions on the most recent advances in medicine and in research into children's disease."
Onondaga County Executive Nicholas Pirro, who has served as honorary chair for the radiothon, will also participate.
Last year's two-day radiothon raised more than $60,000—approximately $54,000 through phone donations.
"In addition to the call-in pledges, we are once again offering Central New Yorkers another fun way to donate by inviting them to become change bandits," said Gary. "Change bandits look for loose change in their own homes, or ask friends, classmates, co-workers, and neighbors for their loose change. It's amazing how the change does add up," said Gary, noting that last year's radiothon raised more than $7,000 through the change bandit effort.
Change bandits receive a special kit that includes a Change Bandit badge, coin collection bag/cannister, drop-off form and posters to display at school or in the office. The names of Change Bandits who collect $50 or more will be eligible to win dinner for two at Carrabba's Italian Grill. To obtain a Change Bandit kit, call 315-464-5748 or e-mail email@example.com.
The Golisano Children's Hospital Radiothon is co-sponsored by the Upstate Medical University Foundation.
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WSYR TV9 Syracuse
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Syracuse Post Standard
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Capital News 9 Albany
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Syracuse Post Standard
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Capital News 9 Albany
- Upstate Medical University researcher awarded $50K grant for medical device: CNY Science
Syracuse Post Standard


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July 1: All Evaluations and Program reports due.


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An up-to-date look at free software and its makers
This month, we examine two Gnome programs: Tomboy gives users Wiki-style notepad management, and Searchparty helps Google users find people with similar interests. We'll also report on WW2D and the Debian-Private mailing list.
Linus Torvalds recently sparked a flame war with his comments on the merits of a certain desktop environment [1]. Although this is just the opinion of one admittedly well-known user, it does put a whole new perspective on the recent overtures of friendship between the KDE and Gnome camps. This month we'll look at two young but ambitious Gnome projects. Tomboy The first of these programs is by Gnome developer Alex Graveley, who recently became a member of the OSDL [2] team dedicated to improving cooperation between Gnome and KDE. The application, titled Tomboy [3], provides a solution for a familiar problem: note management. Of course there are hundreds of programs that aim to help users tackle the chore of organizing notes on their desktops, but Tomboy adopts a new approach. Each "note" is a Wiki-style page. To create a new note, a user just types a heading and enters the body text in a simple text box. The tool supports simple formating with bold, italic, or strike-through typefaces.
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Mozilla Labs Shuts Down
Mozilla's product think tank sinks silently into history.
Internet Giants Launch Collaboration to Improve Open Source
TODO group will focus on open source tools in large-scale environments.
Fedora Announces New Partition Manager App
New tool will look like GParted but support a wider range of storage technologies.
Mozilla Releases a New Firefox
New public key pinning feature will help prevent man-in-the-middle attacks.
Tool Predicts Which Websites Will be Compromised
Carnegie Mellon researchers say 3 million pages could fall down the phishing hole in the next year.
SSH Key Management Guidelines
The US government rolls new best-practice rules for protecting SSH.
Knoppix 7.4 Released
Klaus Knopper announces the latest version of his iconic Live Linux system.
PHP Attack Puts WordPress and Drupal at Risk
All websites that use these popular CMS tools could be vulnerable to denial of service attacks if users don't install the updates.
Heartbleed Bleeds On
According to a report, many potential victims of the Heartbleed attack have patched their systems, but few have cleaned up the crime scene to protect themselves from the effects of a previous intrusion.
Drone Brain Goes Open Source
DARPA and NICTA release the code for the ultra-secure microkernel system used in aerial drones.


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okay, ophelia - jeannine hall gailey
In life, friends come and go. Here are 10 signs that it's time to move on from a friendship:
1. The common ground is gone. Sometimes when whatever brought you together is gone you don't have any reason to stay friends. If you are friends through school and then you graduate you might not be able to sustain a friendship when the common ground is gone.
2. They're a toxic friend. If they're just a bad friend all around, it's time to move on. You shouldn't have to wonder if it's the right choice if they are a toxic person in your life.
3. They're holding you back. If they are holding you back and keeping you from pursuing your goals then it's time to move on. Your friends should help to elevate you in life, not hold you back.
4. You can't relate to each other. If you're not on the same page anymore then it's time to let the friendship go. If you're in different places in life and just can't see where they're coming from, it's ok to move on.
you are allowed to terminate toxic relationships
you are allowed to walk away from people who hurt you
you are allowed to be angry and selfish and unforgiving
you don't owe anyone an explanation for taking care of yourself


text:
Booker T Jones organ, guitar, vocals; Darian Gray drums, vocals; Melvin Brannon Jr bass, vocals and Vernon Black guitar, vocals. Ranked in the 100 greatest songs of all time, the number one, million-selling smash Green Onions celebrates it's very own... find out more Tap to see more
Renowned UK jazz guitarist brings his fiery quartet to Ronnie's for the famed Late Late Show. Femi's Late Late Session is one of the best and most popular so make sure you get there early to avoid disappointment! Click The Video Below For A Taster Of The Late Late Show (actual band on... find out more Tap to see more
Doors open 6pm, closed 3am, Music starts at 9:30 PM (£5 after 8pm, £8 after 11pm) M.U. Free entry PLEASE NOTE THE BAR WILL OPEN TO THE GENERAL PUBLIC AT 8.30pm ON WEDNESDAY 5th June 2013 Until recently, this weekly session was known only to the coolest of jazz heads, but has fast... find out more Tap to see more


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