text:
You Are Here: U.S. Preventive Services Task Force > Methods and Processes > Procedure Manual > Section 4
U.S. Preventive Services Task Force (USPSTF) Procedure Manual (continued)
Procedure Manual
Section 4: Evidence Report Development
4.1 Literature Retrieval and Data Abstraction for Topic Reviews
After literature searches are conducted, the team of evidence reviewers uses a set of a priori inclusion/exclusion criteria as appropriate to each key question to define whether identified literature is relevant to the review. These criteria are applied twice first at the title, or title and abstract review stage, and a second time at the article review stage. This two-stage process is designed to be efficient, to minimize errors, and to be transparent and reproducible.
Titles and abstracts are reviewed by broadly applying the inclusion criteria for the review. When in doubt at the title/abstract review phase as to whether an article might meet the inclusion criteria, reviewers should err on the side of inclusion so that article is retrieved and can be reviewed at the article stage. All citations are coded with at least an excluded or included code, which is managed in a database and used to guide the further literature review steps. This database is the source of the final tables documenting the review process.
Full-text articles are retrieved for all citations included at the title/abstract stage, and are reviewed by a member of the review team, using inclusion/exclusion criteria for relevance and for quality. Included articles receive codes to indicate the key question(s) for which they meet criteria and excluded articles are coded for a reason for exclusion. The reasons for exclusions could be either the primary reason or the first reason encountered in reviewing the article; and thus the distribution of reasons for exclusion do not necessarily represent the state of the excluded literature. Similarly, all the reasons for exclusion of an individual article may not be listed in the final exclusion table. Before they are abstracted, articles are reviewed to ensure that they meet minimal design-specific U.S. Preventive Services Task Force (USPSTF) quality criteria.
The abstract and article review process generally involves a team of reviewers and is conducted using established research methods in order to minimize reviewer drift as well as inter-rater review and coding differences.
4.1.1 Procedures for Abstract and Article Review
Abstracts undergo "dual-review" in that either all abstracts are reviewed separately and reconciled, or at least abstracts excluded by the primary reviewer are re-reviewed by another reviewer to ensure that all appropriate studies are included. Any studies excluded by the first reviewer but included by the second reviewer are included in the next phase.
When the volume of abstracts is very high due to the non-specific nature of searches possible within a specific literature (e.g., alcohol misuse), reviewers may use a sampling scheme for quality assurance as follows. For each key question, all of the searches (ML, CCRCT, PsycINFO) will be considered as one search. Reviewers will dual review a set number (1000) of the most recent abstracts that proportionally represents the key databases searched for that key question, and will then review a random subset of the remainder. All abstracts resulting from the CCRCT are dual-reviewed. The other database searches are proportionally reviewed to get up to a total of 1000 abstracts that are dual reviewed, then a random subset of the remainder, to equal about 20-25% of the total number of articles, will be dual-reviewed. In the case of a sampling approach to dual review, inter-rater reliability is calculated using the kappa statistic.
4.1.2 Database of Abstracts
For each systematic review, the review team establishes a database of all articles located through searches and from other sources (i.e., both those included and those eventually excluded from the final set of articles reviewed). Information captured in the database includes the source of the citation (e.g., search source, outside source), whether the abstract was included or excluded, the key question(s) associated with each included abstract, whether the article was excluded (with reasons for exclusion) or included in the review, and other coding approaches developed to support the specific review. For example, a hierarchical approach to answering a question may be proposed at the work plan stage, specifying that reviewers will consider a type of study design or a clinical setting only if research data are too sparse for the preferred type of study. While reviewing abstracts and articles, these can be coded to allow easy retrieval during the conduct of the review, if warranted.
4.1.3 Documenting Search Results
Search terms used for each key question, along with the yield associated with each term, are documented in a table or set of tables; these appear in the summary of the literature search (early in any topic review project) and in the final evidence synthesis. Follow-up searches to capture newly published data are conducted periodically as the project progresses; the frequency of these searches depends on the individual topic. A final search is conducted close to the time of completion of the draft evidence report, with the exact timing determined by the evidence review team. The final documentation of the search should indicate the most recent time point searched.
To the extent that it suits the review rationale and is feasible, search dates for different key questions should conform to one another.
4.1.4 Data Abstraction Approaches
- Use of forms: Data may be abstracted in forms developed or adapted for the review, or directly into evidence tables.
- Minimal elements to abstract: Although the Task Force has no standard or generic abstraction form, the following broad categories are always abstracted from included articles: key question, study design, study participant description, details of the intervention or screening test being studied, study results with emphasis on health outcomes where appropriate, and individual study quality information, including specific threats to validity. Information relevant to generalizability is consistently abstracted. Each team uses these general categories, and other categories if indicated, to develop an abstraction form specific to the topic at hand. For example, source of funding may be an important variable to abstract for some topics.
- Abstraction of included articles: The evidence review teams abstract only those articles that, after review of the entire article, both meet criteria for quality and focus on the key question at hand. Abstractions are conducted by trained team members, and evidence review teams may, but do not routinely, double abstract all included articles. Key articles are always read and checked by more than one team member. All reviewers are trained in the topic, the analytic framework and key questions, and the use of the abstraction instrument. Initial reliability checks are done for quality control.
- Other quality assurance methods: It is desirable to have more than one evidence review team member check data accuracy for key data elements, including data included in a summary table, a meta-analysis, or in calculations supporting a balance sheet/outcomes table.
4.2 Critical Appraisal
By means of its explicit analytic framework and key questions, the Task Force indicates what issues it must examine to make its recommendation. By setting inclusion and exclusion criteria for the searches for each key question, the Task Force indicates what evidence it will consider admissible. The critical aspect used to determine whether an individual study is admissible is its internal and external validity with respect to the key question posed. This initial examination of the "quality" (i.e., internal and external validity) of individual studies is conducted with established criteria (go to Appendix VII and Appendix VIII) by the evidence review team or USPSTF topic work group. If questions arise in the course of this process, Task Force members are asked to review the articles in question. Studies with fatal flaws (i.e., with "poor" internal or external validity) are not admissible for further consideration. Likewise, studies of interventions that require training or equipment not feasible in even high quality primary care would be judged to have poor external validity for the key questions posed by the Task Force, and would not be admissible evidence.
Once the admissible evidence has been found, and the internal and external validity of individual studies has been assessed, the Task Force must consider the level of evidence that the studies provide to answer the KQs. The Task Force's process for determining the level of evidence over a key question involves answering the following 6 critical appraisal questions about the admissible evidence. The Task Force uses these same 6 critical appraisal questions to determine the overall evidence of certainty of net benefit for the entire preventive service, including all key questions in the analytic framework. (Go to Section 5 for a description of the Task Force's methods for judging the cumulative evidence and arriving at a recommendation.)
4.2.1 Critical Appraisal Questions
4.2.2 Levels of Critical Appraisal
The evidence review process involves assessing the validity and reliability of admissible evidence at 3 levels:
- The individual study;
- The key question (i.e., linkage in the analytic framework); and
- The entire preventive service.
For individual studies, questions 1-3 and 6 are assessed. That is, a single study will be categorized as to study design and whether internal and external validity are "good," "fair," or "poor" to answer the key question. For the key question and entire preventive service levels, all 6 questions must be considered.
For the individual study level, the evidence review team finds admissible evidence and then categorizes the internal validity (i.e., quality—Appendix VII) of each study into "good", "fair", and "poor" categories. For critical or borderline studies, the Task Force leads (and sometimes the entire Task Force) will also consider the individual studies. The EPC also provides the Task Force with descriptions of factors entering into the determination of external validity (i.e., applicability or generalizability—Appendix VIII), as well as descriptions of each study's research design and the number and description of studies relevant to each key question.
For the key question level, the Task Force, using information about the evidence supplied by the EPC, assesses the level of evidence across each key question using all 6 critical appraisal questions. The body of evidence is often categorized as to the highest level of applicable evidence available. The Task Force categorizes the evidence across each key question into one of 3 categories: "convincing," "adequate," or "inadequate."
For the preventive service, the entire body of evidence in the entire analytic framework is synthesized by the Task Force into categories of "certainty" of the overall evidence: high, moderate, and low. Again, the Task Force uses all 6 critical appraisal questions for this determination. (Go to Appendix IV regarding topic workgroup procedures for assessing certainty.)
4.3 Assessing Evidence at the Individual Study Level
4.3.1 Critical Appraisal
All individual articles are critically appraised to determine the validity and reliability of the evidence they provide. This assessment is conducted primarily by the topic team (usually led by the EPC or by AHRQ team leaders), with input from Task Force members for critically important or borderline articles. The assessment of internal (i.e., "quality") and external validity (i.e., applicability or generalizability) are based on explicit criteria, given in Appendix VII and Appendix VIII.
4.3.2 Internal Validity
The Task Force recognizes that research design is an important component of the validity of the information in a study, for the purpose of answering a key question. Although RCTs cannot answer all key questions, they are ideal for questions of the benefits or harms of various interventions. Thus, for these questions, the current Task Force endorses a slightly revised version of the "hierarchy of research design" used by the second Task Force:
I: Properly powered and conducted randomized controlled trial (RCT); well-conducted systematic review or meta-analysis of homogeneous RCTs
II-1: Well-designed controlled trial without randomization
II-2: Well-designed cohort or case-control analytic study
II-3: Multiple time series with or without the intervention; dramatic results from uncontrolled experiments
III: Opinions of respected authorities, based on clinical experience; descriptive studies or case reports; reports of expert committees
In assessing individual studies, all are classified first according to this design code, with additional designations added for other or unconventional designs.
Although research design is an important component of the information provided by an individual study, the Task Force also recognizes that not all studies within a research design have equal internal validity ("quality"). To assess more carefully the internal validity of individual studies within research designs, the Task Force adopted design-specific criteria for assessing the internal validity of individual studies.
These criteria, given in Appendix VII, provide general guidelines for categorizing studies into one of three internal validity categories: "good," "fair," and "poor." These specifications are not meant to be rigid rules; individual exceptions, when explicitly explained and justified, can be made. In general, a "good" study is one that meets all design-specific criteria. A "fair" study is one that does not meet (or does not clearly meet) at least one specified criterion, but has no known "fatal flaw." "Poor" studies have at least one fatal flaw. A fatal flaw is a deficit in design or implementation of the study that calls into serious question the validity of its results for the key question being addressed.
The Task Force views the level of evidence, whether for an individual study, a key question/linkage, or an entire preventive service, as independent of the magnitude of effect. Thus, a study (or a number of studies) could be classified as "good" even if it (they) found no effect of the preventive service.
4.3.3 External Validity (Generalizability) and Applicability
It is necessary not only to assess the external validity (generalizability) of the individual studies that contribute to answering the key questions, but also to assess the body of evidence in order to judge its applicability to the population or populations that are the target for the clinical preventive service, to the settings in which the service will be implemented, and to the providers who will deliver the service. In this document, the term "external validity" will be used when discussing assessment of individual studies, and the term "applicability" will be used when discussing the assessment linkages across key questions and the overall body of evidence, even though the external validity of individual studies is a key element of the applicability judgment. The summative judgment about applicability is more than the sum of the assessment of each of the parts.
For the USPSTF, the study-level assessment of external validity and the assessment of applicability are done separately.
A description of the overall conceptual approach for both components is provided below. Appendix VIII gives detailed information on criteria and process.
18.104.22.168 Assessment of the External Validity of a Study
Judgments about the external validity ("generalizability") of a study pertinent to a preventive interventions address three main questions:
- Considering the subjects in the study, to what degree do the study's results measure the likely clinical results in the asymptomatic people who are the recipients of the preventive service in the United States?
- Considering the setting in which the study was done, to what degree do the study's results measure the likely clinical result in United States primary care situation? and
- Considering the providers who were a part of the study, to what degree do the study's results measure the likely clinical results in providers who would deliver the service in the United States primary care setting?
184.108.40.206 Populations
The subjects that comprise the participants in a study may differ from people receiving primary care in many ways. Such differences may include gender, ethnicity, age, co-morbidities, and other personal characteristics. Some of these differences have a small potential to affect the study's results and/or the outcomes of an intervention. Other differences have the potential to cause large differences between the study's results and what would be reasonably anticipated to occur in asymptomatic individuals or people who are the target of the preventive intervention.
The choice of the study population may affect the magnitude of the benefit observed in the study through exclusion/inclusion criteria that limit the study to people most likely to benefit; other study features may impact the risk level of the subjects recruited to the study. The absolute benefit from a service is often greater for people at increased risk than for people at lower risk.
Because of the presence of certain research design elements, adherence is likely to be greater in research studies than in the usual primary care practice. This may lead to overestimation of the benefit of the intervention when delivered to people who are less selected (i.e., who more closely resemble the general population), and who are not subject to the special study procedures.
126.96.36.199 Situations
Factors related to the study situation relative to the situation in U. S. primary care settings must be assessed when assessing the external validity of a study.
The choice of study setting may lead to an over- or under-estimate of the benefits and harms of the intervention as they would be expected to occur in U.S. primary care settings. For example, results of a study in which items essential for the service to have benefit are provided at no cost to patients may not be attainable when the item must be paid for. Results obtained in a trial situation that ensures immediate access to care if a problem or complication occurs may not be obtainable in a usual care situation, where the same safeguards cannot be ensured, and where as a result the risks of the intervention are greater.
188.8.131.52 Providers
When assessing the external validity of a study, factors related to the experience of providers in the study should be considered in comparison with the experience of providers likely to be encountered in primary care in the U.S. Studies may involve providers selected for their experience or their high skill level. Providers involved in studies may undergo special training that affects their performance of the intervention. For these and other reasons, the effect of the intervention may be overestimated or the harms underestimated compared with the likely experience of unselected providers in the primary care setting.
220.127.116.11 Criteria and Process
The criteria used to rate the external validity of individual studies according to the population, the situation, and the setting are described in detail in Appendix VIII. As with internal validity, this assessment of external validity is usually conducted initially by the EPC or AHRQ topic team leader, with input from Task Force members for critically important or borderline studies. This assessment is then used to give each study a rating using the same 3-tiered grading scheme as for internal validity: good, fair, and poor.
The underlying question answered in the grading the external validity of a study as good, fair or poor is:
If the study had been done with the typical U.S. primary care population, situation, and providers, what is the likelihood that the results would be different in a clinically important way?
4.4 Applicability of the Body of Evidence to the Target Population/Situation/Setting
USPSTF members assess the applicability of the body of evidence to populations/situations/settings as one of the components of the overall process of making recommendations.
Judgment about applicability considers the populations, situations, and providers in each study, but it also involves synthesis of the evidence from the individual studies across the key questions, and for the overall body of evidence.
The overall goal of the assessment is to judge whether there are likely to be clinically important differences between the results observed in studies as a whole and the results expected when the intervention is implemented in the U.S. primary care populations/situations/providers.
The following questions are addressed:
- Can an inference be made from the evidence that the intervention has any effectiveness for the U.S. primary care populations/situations/providers?
- Is the magnitude of benefit observed in individual studies that comprise the body of evidence likely to be the same for the U.S. primary care populations/situations/providers?
- Are the harms observed in individual studies that comprise the body of evidence likely to be the same for the U.S. primary care populations/situations/providers?
- What is the relationship between benefits and harms derived from the evidence likely to be for the U.S. primary care population/situation/providers?
- Is the time and effort required to provide the interventions that comprise the body of evidence attainable in the U.S. primary care situations/providers?
- Can people in U.S. primary care populations/situations be expected reasonably to partake of the interventions that comprise the body of evidence considering their time, effort, and cost?
- Is the extrapolation of data from the body of evidence to large populations of asymptomatic people biologically plausible?
4.4.1 Relative Importance of Efficacy/Effectiveness
The USPSTF seeks to make recommendations based on projections of what would be expected from widespread implementation of the preventive service within the actual world of U.S. medical practice. For this reason, the Task Force considers carefully the applicability to medical practice of "efficacy" studies, which measure the effects of the preventive care service under ideal circumstances. However, the USPSTF ultimately seeks to base its recommendations on "effectiveness," which is what results could be expected with widespread implementation under usual practice circumstances.
Questions arise about whether the USPSTF recommendations consider effectiveness in usual practice or in ideal/excellent practice. The "situation" for practices varies widely within the U.S. Some practices have greater support and more resources than others. The TF attempts to makes recommendations for all of these practice "situations," and may specify what resources are required for implementation.
4.4.2 Definition of Primary Care
To further specify the situation that is the object of its concern, the Task Force has adopted the Institute of Medicine's definition of primary care:
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. This definition acknowledges the importance of the patient clinician relationship as facilitated and augmented by teams and integrated delivery systems. (7)
4.4.3 Primary Care Interventions Addressed by the USPSTF
The USPSTF considers interventions that are delivered in primary care settings or are judged to be feasible for delivery in primary care. To be feasible in primary care, the intervention could target patients seeking care in primary care settings, and the skills to deliver the intervention are or could be present in clinicians and/or related staff in the primary care setting, or the intervention could generally be ordered/initiated by a primary care clinician.
4.5 Other Issues in Assessing Evidence at Individual Study Level
4.5.1 Dealing with Secondary and Aggregate Endpoints
The Task Force adopted a policy of critically appraising all of the endpoints (outcomes) of trials in a similar manner, following the 6 critical appraisal questions listed earlier (Section 4.2.1). In its review, the Task Force takes note of the biological plausibility of a study's finding, the supporting evidence, and whether an outcome is a primary or secondary one. Similarly, the Task Force examines composite (aggregate) outcomes carefully. It generally asks 3 questions of these outcomes: (1) are the component outcomes of similar importance to patients? (2) did the more or less important outcomes occur with similar frequency? And (3) are the component outcomes likely to have similar relative risk reduction (RRR)?
4.5.2 Ecologic Evidence
Because biases may be present in ecologic data, the Task Force is careful in its use of this type of evidence. The Task Force rarely accepts ecologic evidence alone as sufficient to recommend a preventive service. Because this evidence is widely accepted by others, the Task Force developed a policy for when it uses ecologic evidence, and how this evidence is critically appraised.
By ecologic evidence we mean data that are not at the individual level; but rather, that relate to the average exposure and average outcome within a population. The "ecologic fallacy" is the erroneous conclusion that there is an association when exposure occurs in some members of a population and an outcome in other members. In addition, ecologic data sets often do not include other potential confounding factors; thus, one cannot directly assess the ability of these potential confounders to explain apparent associations. Finally, some ecologic studies use data collected in ways that are not accurate or reliable.
Ecologic studies usually make comparisons of outcomes in exposed and unexposed populations in one of two ways: (1) between different populations, some exposed and some not, at one point in time (i.e., cross-sectional ecologic study); or (2) within a single population with changing exposure status over time (i.e., time series ecologic study). In either case the potential for making the ecologic fallacy is a major concern.
As it is not possible to completely avoid the potential for making the ecologic fallacy in these studies, the USPSTF does not usually accept ecologic evidence alone as adequate to establish the causal association of a preventive service and a health outcome. In some unusual situations (e.g., cervical cancer screening) ecologic evidence may play the primary role in the Task Force's evidence review, but this is rare.
More frequently, ecologic evidence is considered by the Task Force in the following situations:
- For background, for an understanding of the context in which the preventive service is being considered;
- When well-known ecologic data are being used as evidence by others to justify either recommending or not recommending the service the Task Force is considering;
- Where other evidence is inadequate but the Task Force thinks that good ecologic evidence could add important information;
- When there are reports of dramatic results of ecologic studies.
In the situations above, the Task Force critically appraises ecologic studies. High quality ecologic evidence meets the following criteria:
- The exposures, outcomes, and potential confounders are measured accurately and reliably.
- Other potential explanations and potential confounders are considered and adjusted for.
- The populations and interventions being compared are comparable.
- The populations and interventions are relevant to a primary care population.
- Multiple ecologic studies are present that are consistent/coherent.
4.5.3 Mortality as Outcome: All-cause Versus Disease-specific Mortality
When a condition is a common cause of mortality, all-cause mortality, instead of cause-specific mortality, is a desirable health outcome measure. Few preventive interventions attain the high standard set by use of this outcome. The fact that there is a discrepancy between the effect of the preventive intervention on all-cause and disease-specific mortality is important to recognize and explore. A discrepancy may arise when (1) there is real benefit of the preventive intervention for a targeted condition or (2) because of methodologic issues that are inherent in the study of all-cause mortality:
184.108.40.206 Real Benefit for the Targeted Condition
Three situations can produce this kind of discrepancy. First, when a preventive intervention increases deaths from causes other than the one targeted by the intervention, all-cause mortality may not be decreased even when cause-specific mortality due to the targeted condition is decreased. This indicates a potential harm of the intervention for a condition other than the one targeted.
Second, when the condition targeted by the preventive intervention is rare and/or the effect of the intervention on cause-specific mortality due to the targeted condition is small, the effect on all-cause mortality may be very small or even non-existent.
Third, when the preventive intervention is applied in a population with strong competing causes of mortality, the effect of the preventive intervention considering all-cause mortality may be very small or even non-existent even though the intervention decreases cause-specific mortality due to the targeted condition. For example, preventing death due to hip fracture by implementing an intervention to decrease falls in 85-year women may not decrease all-cause mortality over reasonable time frames for a study because the force of mortality is so large at this age.
18.104.22.168 Methodologic Issues
Methodologic issues can arise because of difficulties in the assignment of cause of death based on records available to or used by a study. In the absence of detail about the circumstances of death, death may be attributed to a chronic condition known to exist at the time of death but without any true contribution to death. Coding conventions for death certificates also result in deaths from some causes being attributed to chronic conditions present at death routinely. For example, it is conventional to assign people with a mention of cancer on the death certificate to cancer as primary cause of death. The result of these methodologic issues is a biased estimate of cause-specific mortality, which may not reflect the true effect an intervention has on death from the targeted condition.
As indicated above, studies that provide data on all-cause and cause-specific mortality may have low statistical power to detect even large or moderate effects of the preventive intervention on all-cause mortality. This is especially true when the disease targeted by the screening test is not common.
When data are available, the Task Force considers data on both all-cause and cause-specific mortality in making its recommendations, taking into account the real and methodologic contributions to potential discrepancies between apparent and true effect.
4.5.4 Subgroup Analyses
The Task Force is interested in targeting its recommendations to those populations or situations in which there would be maximal benefit for the harms and costs involved. Thus, it often takes into consideration subgroup analyses of large studies. It attaches varying levels of credibility to those analyses, however, depending on such factors as: the size of the subgroup; whether randomization occurred within subgroups; whether a statistical test for interaction was done; whether the results of multiple subgroup analyses are consistent within themselves; whether the subgroup analyses were pre-specified; and whether the results are biologically plausible.
4.5.5 Relative Versus Absolute Risk Reduction
The Task Force is interested in reducing risk both for populations and for individuals. For this reason it takes into account both relative (RRR) and absolute risk reduction (ARR) from intervention studies. It generally prioritizes ARR over RRR. That is, it is less impressed with a large RRR in situations of low ARR; it remains interested in an intervention with a low RRR if its ARR is high.
4.6 Incorporating Other Systematic Reviews in USPSTF Reviews
Existing systematic reviews or meta-analyses that meet quality and relevance criteria can be incorporated into topic reviews done for the USPSTF. Quality criteria for reporting meta-analyses are specified by the QUORUM and MOOSE guidelines published, respectively, by The Lancet and the Journal of the American Medical Association (JAMA) (8, 9). The USPSTF has specified its criteria for critically appraising systematic reviews (go to Appendix VII and Appendix VIII). Relevance is considered at two levels: at the general level of the review or analysis question, and at a more specific level. At the general level, the question would be "Is the review or meta-analysis relevant to one or more of the USPSTF key questions for this review?" The more specific question would be: "Did the review include the desired study designs and relevant population(s), settings, exposure/intervention(s), comparator(s), and outcome(s)?" Recency of the review is also a consideration, and can determine whether a review that meets quality and relevance criteria is recent enough not to require any bridging searches. Finally, existing reviews can be used in several ways in a USPSTF review: (1) to answer one or more key questions wholly or in part; (2) to substitute for conducting a systematic search for a specific time period for a specific key question; or (3) as a source document for cross-checking the results of systematic searches.
4.7 Use of Observational Designs in Questions of the Effectiveness/Efficacy of Interventions
The Task Force prefers large, well-conducted RCTs to determine the benefits and harms of preventive services. In many situations, however, such studies have not been or are not likely to be done. When these studies can be done, and other evidence is insufficient to determine benefits and/or harms, the Task Force advocates that large, well-conducted RCTs be done. It notes that small, poorly-conducted RCTs are often of little use.
In some situations, however, the Task Force does use observational evidence to make recommendations. Multiple, large, well-conducted observational studies with consistent results showing a large effect size that does not change markedly with adjustment for multiple potential confounders may be judged sufficient to determine the magnitude of benefits and harms of a preventive service. Also, large, awell-conducted observational studies often provide essential additional evidence even in situations where there are adequate RCTs. Ideally, RCTs provide evidence that an intervention can work and observational studies provide better understanding of the populations where the benefits would be greatest.
Return to Contents
Proceed to Next Section


text:
Skip to main content
Patent ductus arteriosus (pronounced PAY-tent DUCK-tus are-teer-e-OH-sus) happens when a small blood vessel near the heart fails to close after a baby is born.
The ductus arteriosus is a temporary blood vessel that joins the pulmonary artery to the aorta. It allows blood to bypass the lungs during fetal growth.
This works fine because babies don't breathe on their own until after they're born. So they don't need blood going to their lungs to get oxygen. Prior to birth, the fetus gets oxygen through the placenta.
Normally when a newborn's lungs take over at birth, their body stops making the chemicals that keep the ductus arteriosus open. So the ductus closes within a few days.
If the ductus arteriosus remains patent (open), too much blood may go into the baby's lungs. This could lead to heart failure.
A ductus that doesn't close is common in premature babies but rare in full-term babies.
Doctors diagnose patent ductus arteriosus in about 3,000 babies each year in the United States. Girls are two to three times as likely as boys to have it.
Some babies with patent ductus arteriosus have other heart defects, but not all do.
This condition is more common in babies with Down syndrome and babies whose mother had German measles (rubella) while she was pregnant.
In babies who have a normal ductus that's closing but have other kinds of heart defects (like hypoplastic left heart syndrome, interrupted aortic arch or pulmonary atresia), doctors may give medicine (prostaglandin) to keep the ductus open. This helps blood flow through the baby's heart until their other defects can be treated.
Our heart team has treated many children with patent ductus arteriosus. We have extensive experience with the treatment these patients may require, including medicine, cardiac catheterization and surgery. We also have a pediatric cardiac anesthesia team and a cardiac intensive care unit ready to care for children who undergo heart surgery.
When you come to Children's, a team of people will take care of your child. Along with your child's cardiologist, you are connected with neonatologists, pulmonologists (lung doctors), nurses, child life specialists, social workers and others, if their expertise is needed. We work together to meet all of your child's health needs and help your family through this experience.
Since 1907, Children's has been treating children only. Our team members are trained in their fields and also in meeting the unique needs of children. For example, the doctors who give your child anesthesia are board certified in pediatric anesthesiology. This means they have extra years of training in how to take care of kids. Our child life specialists know how to help children understand their illnesses and treatments in ways that make sense for their age. Our expertise in pediatrics truly makes a difference for our patients and families.
The Adult Congenital Heart Disease Program shared by Children's and the University of Washington can help with care throughout your child's life.
Find out by selecting your child's symptom or health condition in the list below:
Download Summer 2014 (PDF)
Seattle Children's provides healthcare without regard to race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry) or disability. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.
© 1995-2014 Seattle Children's Hospital

subset: commoncrawl


text:
Album: You Can Dance (1987)
Songwriters: Madonna/Stephen Bray
Producer: Stephen Bray
Spotlight resembles Everybody via Stephen Bray's more recent drum machine/synth bass sound - Madonna's roots, but not as flawless as you remember them. It was originally recorded during the sessions for True Blue, though left off the album for obvious reasons. Madonna's innate ability for quality control is a big part of her success - hence why the majority of her many unreleased tracks are so vastly inferior. Spotlight is no exception, with clunky lines like "When you feel the rhythm, I'll be by your side/Now you have the power baby, love is on your side" - and it doesn't help that the melodies are perhaps the most uninspired she'd put to record that entire decade.
The thing is, the Who's That Girl singles may have been a letdown after the sheer strength of True Blue, but at least they approached Madonna's music from a slightly different direction. The entire You Can Dance release, however, is and was redundant beyond belief. It was marketed as an album of remixes - and they're adequate, though heavily dated, not that anyone needed an eight-minute version of Into the Groove in 1987 either. The songs also segue together continuously, but it's a botched job - despite being in totally different keys, Spotlight and Holiday crossfade into each other without any editing, and clash spectacularly. The promise of an unreleased track may have been quite the selling point, too, but Spotlight is on par with the rest of the release - mediocre.
Despite being more of a stopgap than a serious release, Madonna's first compilation still sold over a million copies; similarly, Spotlight was only released as a physical single in Japan, but gained enough circulation to appear on Billboard's Top 40 airplay chart in 1988. They were the last gasp of Madonna the teen idol - by then, an outdated style that she would thankfully never revisit. And good riddance - with Like a Prayer arriving a little over a year later, the music and the self-empowerment message would become vital like never before.
Into the Groove
Albums: Like a Virgin (1985 reissue), You Can Dance (1987), The Immaculate Collection (1990), I'm Going to Tell You a Secret (2007), Celebration (2009)
Songwriters/producers: Madonna/Stephen Bray
It's widely recognised that a song better expressing the pure joy of song and dance simply does not exist. The eponymous groove is just massive - the complex, busy drum machine grounds the song whilst the synth floats in the background; the bassline runs circles around everything else, but never to the detriment of the beat. Madonna herself sounds unrestrainably enthusiastic, her vocals flitting from pure hook to occasional soaring high note via the magic of '80s reverb. Despite coming some five years later, I'd call the Immaculate Collection version definitive - the vocals sound fuller and shorn of some unnecessary repetition, not to mention the totally unexpected keyboard solo that somehow fits perfectly.
The lyrics conjure images of a million Madonna wannabes wearing out vinyl grooves in their bedrooms, singing into hairbrushes, making eyes at boys across dancefloors - this was Madonna the teenage idol in full force, commanding an almost Springsteen-esque empathy in the soundtrack to their lives. But ultimately, teenagers and their popstars grow up - Into the Groove was a fleeting yet glorious moment that Madonna the icon thankfully never tried to prolong. And that, folks, is how you drive a mere '80s pop song with oh-so-unimportant, generic lyrics about dancing and singing and love to near-mythological status. Into the Groove feels like an anecdote of teen life - not unlike where I am in the present day - but from a more innocent time in 1985, before all those kids grew up and renounced pop music and became our teachers and bosses and had their own kids. Is there a word for "nostalgia for a time before your birth"? Oh, I know. Envy.
The songwriting's strong enough that Into the Groove's survived multiple Madonna recontextualisations too - it works with bagpipes on the Re-Invention Tour and hip-hop jump rope on the Sticky & Sweet Tour - even Into the Hollywood Groove, the GAP ad with Missy Elliott, isn't too bad.
(that's Into the Groove's appearance in Desperately Seeking Susan; here's the music video as a montage from the film)
Into the Groove obviously transcends Desperately Seeking Susan, the film it was written for, but since I obviously like to reduce entire decades to transient cultural references, the association's quite strong in my mind. No modern-day parody of '80s excess could possibly contain more amusingly, excessively stereotypically '80s imagery as what's shown here. But yes, Desperately Seeking Susan and The Terminator really do inform my perceptions of the decade - especially regarding really sluggish discos, where Into the Groove makes its appearance. The film is essentially a comedy of errors, with an absurdly convoluted plot (this hilarious Videogum piece is as close as a summary gets to brevity) to match the worst Dan Brown has to offer. And in her first major acting role, yes, Madonna is not only absurdly seductive, but steals the show - though mostly because she's effectively playing herself. Rosanna Arquette admittedly doesn't have much to work with - when not playing a bored suburban housewife/stalker, she plays a foggy-minded recovering amnesiac masquerading as an imitation of Madonna. Oh, and you thought that was confusing. Overall, though, it's not a bad film - the weird approach to its plot makes it infinitely more interesting than any modern Matthew McConaughey movie. The sheer datedness is really part of its appeal - maybe in 2034, people will laugh at how I watched the whole thing on YouTube whilst the Hangover is injected directly into their consciousness.
(the way I feel about Madonna in 1985… times three)
From the album Madonna (1983)
Featured on You Can Dance (1987), Ciao Italia: Live from Italy (1988), The Immaculate Collection (1990), The Girlie Show ~ Live Down Under (1994), Drowned World Tour 2001, I'm Going to Tell You a Secret (2006), Celebration (2009)
Written by Curtis Hudson/Lisa Stevens
Produced by John "Jellybean" Benitez
Madonna's first big hit and breakthrough single - could it be any more obvious why? Holiday's perfect combination of groove (the bassline is truly a work of art) and catchy melody makes it a defining work in the dance-pop genre. It was great enough that the "assembly-line" hit single factory Stock Aitken Waterman would even use near-identical chord progressions in many of their songs four years later, from Kylie Minogue's I Should Be So Lucky (just the first time she'd follow in Madonna's footsteps, hah) to Rick Astley's Never Gonna Give You Up. Holiday's lightweight, breezy feel allows it to spread its universal "let love shine" message of celebration with as much sincerity as the likes of We Are the World, with many times the subtlety. At the same time, this makes it more inherently disposable than ANY other Madonna song, partly due to having been written by outside songwriters. Yet this only seems to have increased its appeal - for the song's significance to her career now extends far beyond the original single. As a near-staple of her live tours, the way she performs it generally reflects her feelings at the time - see the oddly commanding, militaristic Re-Invention Tour version documented on I'm Going to Tell You a Secret. Still, in its disposability, the studio recording says next to nothing about Madonna as an artist, except that she adapted herself rather well to a song intended for/rejected by Mary Wilson of the Supremes. But who cares? - Holiday is an undisputed classic, regardless.
The music video, however, is tragically bad, and never officially released for that reason - Madonna and her backup dancers (including brother Christopher) simply perform rather daggy dance moves through an absurdly exaggerated psychedelic filter. Much more interesting is Madonna's 1983 appearance on American Bandstand - her first ever televised live performance. Though it's lipsynced as usual for such shows at the time, Madonna is genuinely captivating as, alone without choreography, she struts her stuff surrounded by a studio audience. A natural center of attention, her energy is infectious; the resulting cheers actually disproportionately enthusiastic for the kind of performers one would usually get on such shows. The interview afterwards is the source of one of THE classic Madonna quotes, as shown in a slightly edited form at her Rock and Roll Hall of Fame induction:
"We are a couple of weeks into the new year; what do you hope will happen, not only in 1984, but for the rest of your professional life - what are your dreams, what's left?"
"To rule the world."
For a twenty-five-year-old then-one-hit-wonder, that's either an admirably courageous or absurdly egotistic statement, but to actually achieve, maintain and surpass it for another twenty-five years is what makes that moment the stuff of legend. Perhaps, considering all that was to follow, it wasn't so pretentious at all. Many other popstars who followed in Madonna's wake talked the talk, but could they walk the walk?
From the album Madonna (1983)
Featured on You Can Dance (1987), Celebration (2009)
Written by Madonna
Produced by Mark Kamins
As the very first single from one of the most successful artists of all time, Everybody carries surprisingly little clout. And yet, the Madonna creation story tells of her apparent mythological ability to walk into a club, hand the DJ the original demo and instantly drive the unfamiliar crowd wild. And that wasn't all she gave him - that DJ, Mark Kamins, became her boyfriend and produced the single, pre-debut album. However true the story, the drive was there from the beginning.
Musically, though, Everybody is merely serviceable dance-pop, hardly inspired - written solely by Madonna after fronting less successful New York rock bands, it's hooky, if a little amateurish. Thankfully omitted from the Immaculate Collection - it would easily have been the worst song there - Madonna's team had no such qualms with Celebration's tracklist. Still, its legacy should be obvious to any listener: the first of many Madonna singles to command people to the dancefloor, but far from the best.
Truly appreciating Madonna's artistry requires an understanding of her cultural context, but one thing that seems to have been completely lost in translation over the past 26 years is the misconception, early in her career, that Madonna was a black artist. With post-"disco sucks" dance-pop/R&B only just experiencing a post-Thriller resurgence at the time, it was still largely the field of black artists, to the extent that Sire Records tried to downplay Madonna's race to secure radio play (just look at the single cover, or the hideous stock photo originally used for Holiday). But speaking for my generation, born well after her debut, I can't even remotely comprehend how anyone could hear her voice and conclude that she was black - that girlishness was a far cry from the late, great Teena Marie.
Director: Ed Steinberg
There's little to say about the music video, which existed partially to prove that Madonna in fact wasn't black. Naturally, such a small budget led to equally little promo/airplay - but it proved popular in certain nightclubs that played videos.


text:
February 15, 2013
File photo: Gov. Rick Snyder speaks in Lansing, Mich. (AP Photo/Paul Sancya)
Stories this photo appears in:
Tax increases affecting more Michigan residents
Saturday, February 16th, 2013 12:00 p.m.
LANSING, Mich. (AP) — In the height of tax season, don't be surprised if you owe more to the taxman in Lansing.
[ report these comments ]
Comments are welcome, but require a Facebook login. Please be considerate of our rules when posting a comment. We do not allow swearing, name calling, slander or advertisements. We operate under a zero tolerance policy; If a rule is broken once, you will no longer be able to leave a comment. To see a complete list of rules that apply to commenting, see our Terms of Service If you see a user breaking the rules, use the "report these comments" link.


text:
feministdk @feministdk ?active 1 year, 5 months ago
feministdk commented on the blog post Ageism and the magical invisibility cloak 1 year, 5 months ago · View
Beautiful article! It is important for a woman, whether young or old to find a way to be creative and productive , a world outside of the superficial pop-culture, magazines, music-videos. Just like men, women have the desire to accomplish things, sometimes even make a difference. I don't think that you can be too old [...]
feministdk wrote a new blog post: Single women 4 years, 4 months ago · View
"Do you have a boyfriend?" "It's time". "The clock is ticking, tick tock". Are you sick of hearing comments like these? Well, I am! I just want to share my frustration. I am starting to question people's ability to think rationally. When it comes down to women, logic and equal rules don't seem to fit? Why is [...]


text:
Spring Herb Quick Bread
Vegan sweets are great, but don't forget about vegan savory quick breads like this one. It's tender, lively with spring herbs and a cinch to make. Enjoy by itself, or topped with tapenade, hummus or roasted vegetables. Feel free to swap the herbs for your favorites.
11/2 cups unsweetened soy milk
1 tablespoon cider vinegar
2 cups whole wheat flour
1/2 cup toasted wheat germ
1 teaspoon baking powder
1 teaspoon baking soda
2 tablespoons finely chopped fresh dill
2 tablespoons finely chopped fresh chive
2 tablespoons olive oil
1 tablespoon agave or maple syrup
Pinch sea salt
Heat oven to 350 degrees. Lightly oil a 9-inch loaf pan.
In a medium bowl, combine soy milk and cider vinegar. This creates a mildly tangy, slightly curdled, plant-based version of buttermilk. Set aside.
In a large bowl, sift together whole wheat flour, wheat germ, baking powder and baking soda.
Pour wet ingredients into flour mixture, stirring gently to combine. Fold in chopped herbs, olive oil, agave and salt. Pour batter into prepared pan, and bake 45 minutes, until bread puffs and top forms a golden crust. Makes 12 slices.
Per slice: 119 calories (25 percent from fat), 3.4 g fat (0.4 g saturated, 1.7 g monounsaturated), 0 cholesterol, 5 g protein, 18.5 g carbohydrates, 2.8 g fiber, 140 mg sodium.


text:
Music Video! Dr. Dre and Eminem Premiere 'Doctor'
February 24, 2011 Music
Watch rap stars Dr. Dre and Eminem in their new music video, "I Need a Doctor," which premiered Thursday on MTV's "Rap Fix Live."
Tune in to "Extra" on Friday for an exclusive interview with the rappers on their music video set!


text:
Reader Comments (Page 1 of 1)
I can't believe Blizzard doesn't automate testing of this stuff. When we can hit target dummies and see changes, they must be able to automate the same thing... take every class and cookie cutter spec - have them dps against a target dummy for long enough that random crap like crit strings average out. Apply a reasonable set of 5, 10 and 25 man buffs - rinse and repeat. Do some variations on the specs... rinse and repeat. Do some variations on gear (or put people all in T7 and T7.5)... rinse and repeat. This can all be scripted and run in parallel on multiple machines - it's not like they need hundred of live bodies to do this.
It's silly that a player can hit a target dummy and see the difference yet Blizzard actually releases this and then goes... oops, our bad, we missed that.
Its not inefficient, its a common programming problem-solving approach. If you think a number is too high, you reduce it by 50%. If the result seems too low, increase it by 50% of its new value; too high, reduce it by 50%. This approach reduces the probability space of the "right" value by half each step, and is known to be the best way to arrive at an unknown value from an arbitrary starting point.
It's known as a binary search:
Well I am a software architect and I can tell you that using a human-driven binary search with iterations of ??PRODUCTION RELEASES?? for this is the most ridiculous thing I have heard in a while.
Wait...I am in software development. that last bit was a total lie.
Regardless. I agree with other posts on running automated tests of some sort. Hell, I think there is a program/website that does just that already?! (albeit without ALL the numbers - blizzard has the numbers)
@eden... yes... but you don't SHIP like that. You make the change and test. That's what I don't understand about this - testing should have shown that BM dps was too low with these changes... so why weren't more changes made to bring it back up?
No one's saying they should be perfect the first time, but they should iterate until they're close to the goal. If they're just going to make changes and not catch this in test or listen to PTR feedback, then... what's the point?


text:
Skip to content
and found 138 items
Andy Davidson,
17 September 2014 17:00
Knox Orsa leather gloves, £79.99 Time tested: 10 months/4000 miles What's good? These shorty gloves are fantastic for summer. The perforated goat skin gloves use a 'Boa' fastening system instead of Velcro. It takes a couple of seconds longer to secure, but saves you from fraying and scratchy Velcro and provides a tighter, more secure fit. It also comes with ...
Tony Hoare,
10 September 2014 17:00
Alpinestars GPX gloves, £99.99 Time used: Three months/3000 miles What's good? It has all of the hand protection of a full-on race glove, including a bridge between the two smallest fingers and a hard knuckle guard, but doesn't demand the faff of fitting a lengthy cuff either over or under a textile jacket, which is what I wear for the ...
Adam Child,
30 July 2014 10:30
Knox Handroid CE gloves, £169.99 Time tested: North West 200 and TT fortnight (1000 miles) What's good? This is the third time I've worn Knox gloves at the TT, and these are the second generation gloves that are now CE-approved. They have also changed the small venting spoiler on the back of the knuckles to make it sturdier. I actually ...
Tony Hoare,
18 June 2014 08:30
Oxford Voyager gloves, £59.99 Time tested: Three months/1500 miles What's good? The comfort of these waterproof, three-season gloves has impressed me in the three months I've been wearing them. Gloves are often too short in the thumb for me, which means mild discomfort when reaching for the clutch lever, but these are absolutely perfect for my hand size and I ...
Simon Patterson,
04 June 2014 11:00
RST Pro Series CPX-C gloves, £89.99 Time tested: Three miles/500 miles What's good? RST's top-of-the-range gloves are designed for track use, although I've been wearing them for my commute, because they're ridiculously comfortable. Made from soft kangaroo leather, they give really good feel and finger dexterity. The closures are thick, reassuring strips of Velcro that I can easily close when ...
Liam Marsden,
07 May 2014 11:00
Rev'It Oceanus gloves, £99.99 Time tested: Five months/2000 miles What's good? The Gore-Tex certainly works on these gloves – they've kept every drop of water out in the five months I've been wearing them and they don't hold water either, like some waterproof gloves, which means they don't get heavy or become wet to the touch. The tri-fleece liner is ...
Steve Hunt,
30 April 2014 11:30
Bering RX19 gloves, £109.99 Time tested: Four months What's good? These gloves are made from supremely soft goat leather and when combined with the solid feel of the knuckle and finger protection this means that these have fast become my go-to gloves when I get the chance to make a foray onto the track. I've been lucky enough to avoid ...
Tim Thompson,
23 April 2014 13:30
Arc-on Competizione gloves, £140 Time tested: 16 weeks What's good? This is a substantial glove with intimate feel and sensible design. It has a mountain of catalogue-topping spec – kangaroo hide, bomb-proof stingray inserts on the cuffs and palm, titanium and carbon knuckle armour, grippy Kevlar matting on finger tips and other contact points – but, crucially, none of it ...
Steve Hunt,
01 April 2014 12:00
Racer Stratos Gore-Tex X-Trafit, £139.99 Time tested: 4000 miles / eight months What's good? Gloves are an essential piece of riding kit; dare I say that their comfort is even more crucial for me than it is with helmet. I've ridden with uncomfortable helmets before and they're just that - uncomfortable - but if the fit and feel of gloves ...
Save money by comparing quotes. It's quick and easy
With over 18,000 products, MCN shop is the best place to buy your biking kit
Motorcycle Cover | Cheap Motorcycle Insurance | Moped Insurance | Scooter Insurance | 125 Insurance | Work Experience | Complaints Policy
Car Magazine | Empire | FHM | Parkers | LRO | Today's Golfer | Zoo
Bauer Consumer Media Ltd (company number 01176085, 1 Lincoln Court, Lincoln Road, Peterborough, England PE1 2RF)


text:
Trade Paperback
368 Pages
CAD20.00Request Desk Copy Request Exam Copy
What happens to human beings when their brains are constantly assaulted by advertising and corporate messages? With the style and irreverence of Vice magazine and the critique of the corporatocracy that made Naomi Klein's No Logo a global hit, the cult magazine Stay Free!—long considered the Adbusters of the United States—is finally offering a compendium of new and previously published material on the impact of consumer culture on our lives. Most people assert that advertising is easily ignored and doesn't have any effect on them or their decision making, but Ad Nauseam shows that consumer pop culture does take its toll.
In an engaging, accessible, and graphically appealing style, Carrie McLaren and Jason Torchinsky (as well as contributors such as David Cross, The Onion's Joe Garden, The New York Times's Julie Scelfo, and others) discuss everything from why the TV program CSI affects jury selection, to the methods by which market researchers stalk shoppers, to how advertising strategy is like dog training. The result is a humorous and thought-provoking account of the many ways consumer culture continues to pervade and transform American life.
Carrie McLaren founded Stay Free! in 1993. A longtime blogger, she speaks regularly on the topic of advertising and media. Jason Torchinsky is a writer and illustrator based in Los Angeles, who currently writes for the Onion News Network.


text:
Everything went smooth as silk. I got a great airgun at a great price, $40 less than anywhere else I could find the model I wanted. I went looking for ... read more
|Related Products
Co2 Accessories | Airgun Targets | Airgun Maintenance and Cleaning | Extra Magazines | Air Gun Cases - Rifle, Pistol, Bow | Pistol Holsters | Pellet Holders | Rifle Slings | Shooting Glasses | PCP Accessories | Bore Sighters | Airgun Bipods | Trigger Locks | Gun Vises


text:
News from WTOP
News from the AP
Mike Causey
Shows & Panels
Shows & Panels
Shows & Panels
Shows & Panels
- The 2014 Big Picture on Cyber Security
- AFCEA Answers
- Ask the CIO
- Building the Hybrid Cloud
- CDWG/NetApp
- Connected Government: How to Build and Procure Network Services for the Future
- Continuing Diagnostics and Mitigation: Discussion of Progress and Next Steps
- Federal Executive Forum
- Federal Tech Talk
- The Future of Government Data Centers
- The Future of IT: How CIOs Can Enable the Service-Oriented Enterprise
- Government Perspectives on Mobility and the Cloud
- The Intersection: Where Technology Meets Transformation
- Maximizing ROI Through Data Center Consolidation
- Mitigating Insider Threats in Virtual & Cloud Environments
- Modern Mission Critical Series
- Moving to the Cloud. What's the best approach for me
- Navigating Tough Choices in Government Cloud Computing
- The New Generation of Database
- Reimagining the Next Generation of Government
- Satellite Communications: Acquiring SATCOM in Tight Times
- Targeting Advanced Threats: Proven Methods from Detection through Remediation
- Transformative Technology: Desktop Virtualization in Government
- The Truth About IT Opex and Software Defined Networking
- Value of Health IT
- Air Traffic Management Transformation Report
- Cloud First Report
- General Dynamics IT Enterprise Center
- Gov Cloud Minute
- Government in Technology Series
- Homeland Security Cybersecurity Market Report
- National Cybersecurity Awareness Month
- Technology Insights
- The Cyber Security Report
- The Next Generation Cyber Security Experts
Shows & Panels
Wis. gov signs abortion bill requiring ultrasound
Friday - 7/5/2013, 4:51pm EDT
Associated Press
MADISON, Wis. (AP) -- Gov. Scott Walker quietly signed a contentious Republican bill Friday that would require women seeking abortions to undergo an ultrasound and ban doctors who lack admitting privileges at nearby hospitals from performing the procedures.
Opponents contend legislators shouldn't force women to undergo any medical procedure and the bill will force two abortion clinics where providers lack admitting privileges to shut their doors. The law takes effect Monday. Planned Parenthood of Wisconsin and the American Civil Liberties Union filed a federal lawsuit within hours of the signing alleging the bill is unconstitutional and asking for a temporary restraining order blocking the measure.
"What the Legislature has done is to set up a system where the ability to provide abortions is contingent on the decision of a private institution and that's unconstitutional," Planned Parenthood's attorney, Lester Pines, said in an interview.
A spokeswoman for the state Department of Justice, which defends state laws, said agency attorneys would review the lawsuit and respond in court.
The bill is part of a broad GOP push to dramatically curtail abortions nationally.
North Dakota's governor, Republican Jack Dalrymple, signed a law this spring that outlaws abortions as early as six weeks into a pregnancy, making North Dakota the most restrictive state in the nation to get an abortion. The state's lone abortion clinic has filed a federal lawsuit seeking to block the law.
Republicans in Arkansas this spring passed a law that bans most abortions after 12 weeks. The American Civil Liberties Union of Arkansas and the Center for Reproductive Rights. A federal judge has temporarily blocked that law. A trial has been tentatively scheduled for next year.
Alabama passed a law similar to the Wisconsin bill in April requiring abortion providers to have admitting privileges at a local hospital. The ACLU and Planned Parenthood filed a lawsuit contending the law would shut down three clinics because doctors at the clinics haven't been able to get admitting privileges at nearby hospitals. A federal judge temporarily blocked the law in June. Another federal judge has temporarily blocked Mississippi officials from closing down that state's only abortion clinic because providers there lack admitting privileges.
Under the new Wisconsin law, any woman seeking an abortion would have to get an ultrasound. The technician would have to point out the fetus' visible organs and external features. Abortion providers would have to have admitting privileges at a hospital within 30 miles to perform the procedures.
Supporters argue ultrasounds will help the woman bond with the fetus and convince her to save it. The admitting privileges requirement ensures a woman who suffers an abortion-related complication has an advocate who can explain what happened when she reaches a hospital, they say.
Opponents maintain the law authorizes the government to dictate medical procedures. They've blasted the admitting privileges as ridiculous, saying an ambulance would take an ailing woman to the nearest hospital regardless of whether the abortion provider has admitting privileges.
Walker, a Republican, didn't sign the bill in public, instead sending out a statement early Friday afternoon saying the bill was now law.
"This bill improves a woman's ability to make an informed choice that will protect her physical and mental health now and in the future," the statement said.
The fight now shifts to court, just as it has in other states.
Planned Parenthood and the ACLU allege the admitting privileges will force a Planned Parenthood abortion clinic in Appleton to close as well as the Affiliated Medical Services abortion clinic in Milwaukee to close. The physicians in both clinics lack local admitting privileges and don't have time to secure any before the law takes effect, the lawsuit alleges.
Hospitals often grant privileges only to physicians who guarantee a minimum number of annual referrals, a requirement the abortion providers can't meet because abortion problems that require hospitalization are rare, according to the lawsuit. And some hospitals won't grant admitting privileges to abortion providers out of political, ideological or religious reasons, the lawsuit added.
Without a clinic in Appleton northern Wisconsin women will have to travel hundreds of miles to obtain abortions at Planned Parenthood's remaining clinics in Madison and Milwaukee, the lawsuit said.
The case fell to U.S. District Judge William Conley. It was unclear whether he would take any action before Monday.
Barbara Lyons, executive director of Wisconsin Right to Life, praised Walker for following through on promises to sign the bill. She said the law is on solid legal ground, noting eight other states have similar admitting privileges requirements for abortion privileges.
"It's no surprise they'll be challenging," she said of Planned Parenthood. "They see their livelihood threatened, their income threatened. We don't think in the long run they'll be successful."
Copyright 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


text:
10 Songs for Your Labor Playlist
From soft and sweet to fast-paced and powerful, these songs helped get me through the labor process!
Photo Credit: www.countrymusiclove.com
"Lullaby" by The Dixie Chicks
"Lullaby" is such a sweet song. Dedicated to their children, the ballad has lots of beautiful lines, including this one: "Never knew the best was yet to come." Soothing words as you anticipate baby's arrival.
Photo Credit: www.retrojunkie.com
"This Woman's Work" by Kate Bush
"This Woman's Work," by Kate Bush, was written for the movie, "She's Having a Baby," (one of my favorite 80s films, by the way). I loooove this song, and I think the lyrics capture the labor process in the most beautiful way. Peaceful and empowering at the same time.
Photo Credit: www.haveuheard.net
"Run the World (Girls)" by Beyonce
"Run the World (Girls)" comes in handy when you're in need of a pick-me-up. Having a baby can (sometimes) be a long process to endure, so I needed songs like these to keep me feeling motivated and remind myself that, um, what my body was capable of was pretty awesome.
Photo Credit: www.dzephyr.wordpress.com
"Dream" by Priscilla Ahn
"Dream" will bring me to tears on an average day, but during the labor process, I found it to be so sweet and soothing. It's one of those "big picture" songs that answers every question you might have when you realize that on this day, you're becoming someone's mother. And it's a pretty wonderful realization.
Photo Credit: www.similarsong.com
"Gotta Have You" by The Weepies
"Gotta Have You" by The Weepies is one of those songs I came across randomly but quickly became a favorite. And the title is self-explanatory, considering the situation (insert smiley face here).
Photo Credit: www.soulbounce.com
"By Your Side" by Sade
"By Your Side" is a shout out anthem to your partner, the one whose hand you're squeezing or ordering to bring you another pillow. Ha!
Photo Credit: www.entertainment.inquirer.net
"Fighter" by Christina Aguilera
When you're feeling tired and near the end (and could really use a pick-me-up). 'Nuff said.
Photo Credit: www.bluegrasstoday.com
"Baby, Now That I've Found You" by Alison Krauss
My southern roots are showing: I'm a huge Alison Krauss fan, and this song is one of my absolute favorites. A peaceful song to get you through the tougher moments.
Photo Credit: www.urbanislandz.com
"Is This Love" by Bob Marley
Love this song so much, it almost took me away from the labor to a beach somewhere with a daiquiri in my hand. Almost. I give him props for trying, though. Doesn't get much more classic than this reggae tune.
Photo Credit: www.billboard.com
"Glitter in the Air" by Pink
Sure, everyone knows Pink for her fast-paced and fun dance songs, but I love her ballads just as much. "Glitter in the Air" is no exception, and it was a great choice to round out my "ultimate playlist."
8 Ways to Take Charge of ChildbirthAfter feeling out of control with the birth of my first daughter, I've found ways to take charge of the birth of my second daughter. Here are 8 ways to feel in control.view gallery


text:
01Oct, 2014
New Mad Caddies video!
22Sep, 2014
New Lagwagon song! Pre-Order NOW!
19Sep, 2014
CJ RAMONE – Last Chance to Dance 11/25/14
12Sep, 2014
Listen to a new Swingin' Utters song now!
12Sep, 2014
Fat Music For Riot Fest People
05Sep, 2014
Chris Cresswell Vinyl out October 14th
02Sep, 2014
29Aug, 2014
Update: Tony Sly Memorial Fund
See a punk show!
From the sunny shores of Southern California come Santa Barbara's Mad Caddies! Combining reggae, dixieland, surf, and ska with punk, the Caddies cover all the musical bases to bring you the rock.
Follow @mad_caddies
FAT WRECK CHORDS | 2196 Palou Ave. | San Francisco, CA 94124
Copyright © Fat Wreck Chords. All rights reserved. | F.A.Q. | Site Contact


text:
Nearby parks include Farrell Marsh Park, Farrell Marsh Park and Washington Park.
2409 Oak Drive has a Walk Score of 23 out of 100. This location is a Car-Dependent neighborhood so almost all errands require a car.
Nearby schools include Cherrydale Elementary School, Lakes High School and Pioneer Middle School.
The closest grocery stores are Grab Your Water, Mercie Foods Inc and Brunson's Market.
Nearby coffee shops include Steilacoom Cafe and Espresso By the Bay. Nearby restaurants include Topside Bar & Grill, La Creme Brulee and Steilacoom Pub & Grill.
Large 3 bedroom 1.5 bath 2 story DUPLEX in Steilacoom. Minutes to the beach, local lakes and military bases. Includes free parking at Sunnyside beach. In Steilacoom school district with Cherrydale Elementrary School right around the corner. full size washer and dryer stove refrigerator garbage disposer and dishwasher. Everything is nice and clean., and 1 car garage. Located in a quiet and peaceful culdesac on both ends of the street. Steilacoom woods at one end of culdesac. Pierce College only a few minutes, military bases, veterans hospital around the corner. To the Lakewood Mall only a few minutes for lots of nice restaurants. Lots of nice big fir trees surround the duplex , which give you a nice cool and shady place in the summer. IN the front entry beautiful boxes for vegetables and flowers, Sun all day. Nice peaceful quiet and friendly neighborhood welcomes you to your new home. Close to American Lake fishing And Solo Point at Puget Sound. Appointment for viewing please call. Screening fee $45. One month deposit, Call for details.


text:
Jesse Elvrom on Saturday became the first Sacramento State javelin thrower to advance to the NCAA Division I Outdoor Track and Field Championships, according to the school's athletics website.
Elvrom placed sixth at the NCAA West Region preliminary meet in Austin, Texas, with a top throw of 235 feet. The top 12 finishers reached the NCAA Championships, June 5-8 in Eugene, Ore.
UC Davis' Ashley Marshall, Lauren Wallace and Katie Fry also advanced to the NCAA Championships from the West Region meet, the school reported.
Marshall became the first Aggies female sprinter to advance to the Division I championships after finishing with the eighth-fastest time in the 100-meter dash, 11.70 seconds. Wallace had the second-fastest time in the 800, 2:04.05, and Fry posted a school-record 9:58.97 in the 3,000 steeplechase.
UC Davis' Ethan Ostrom tied his school record in the pole vault at 17-6 1/2. The mark put him in a four-way tie for the 12th and final qualifying spot, but he was eliminated because of misses and finished 15th.
The Aggies' women's 4x400 relay team of Cekarri Nixon, Tonie Williams, Shanie Landen and Wallace ran a school-record 3:37.56 and just missed advancing, finishing 13th.
Sac State ends baseball season with shutout win
Will Soto drove in three runs with two doubles, and Zach Morgan pitched eight strong innings as Sac State ended its season with a 3-0 win over San Jose State in the Western Athletic Conference tournament in Grand Prairie, Texas, according to the Sac State athletics website.
Soto's doubles in the sixth and eighth innings backed a combined six-hitter by Morgan and Brandon Creel, who picked up the save.
The Hornets finished 34-25 and the Spartans 17-41.
Host UC Davis ended its season with a 5-3 loss to UC Santa Barbara, UCD reported. The Aggies (19-37, 5-22 Big West Conference) were swept in three games by the Gauchos (34-23, 17-10).
Bee Sports staff
© Copyright The Sacramento Bee. All rights reserved.


text:
Despite invoking Ronald Reagan's rhetoric, the public isn't buying Obama's economic renewal.» Read More
WASHINGTON, Sept 12- The United States is planning to push Europe towards new and more aggressive efforts to boost demand and economic growth given a renewed risk of deflation in the euro zone, a senior Treasury official said on Friday.
*Gazprom writes off 71.3 bln roubles over Ukraine debt. MOSCOW, Sept 11- Russia's Gazprom reported a 41 percent fall in first-quarter net profit after cutting prices for gas deliveries to Ukraine, and has lowered projections for exports and gas prices in Europe, its main source of revenue.
SYDNEY, Sept 11- Australian employment surged by the most on record in August and far beyond the most optimistic forecast, on the face of it a stunningly strong report that should calm recent concerns about the health of the economy.
MOSCOW, Sept 8- Russian oil production, a major source of government revenue, may decline slightly next year, having risen steadily since 2009, the Energy Ministry said on Monday. With Russia's $2 trillion economy heavily dependent on crude exports and on the brink of recession, oil production and prices are closely monitored by the Kremlin.
BANGKOK, Aug 27- Thai exports unexpectedly slipped in July, showing that a key pillar of the country's economy remains weak at a time the military government is trying to rev up growth.
BANGKOK, Aug 27- Thai exports unexpectedly slipped in July, showing that a key pillar of the country's economy remains weak at a time the military government is trying to rev up growth.
MOSCOW, Aug 26- Russia's Economy Ministry has ramped up its inflation forecasts and halved its 2015 economic growth forecast, adding to signs that tit-for-tat sanctions over Ukraine are seriously harming its economy. It cited the impact of a ban on Western food imports that Russia introduced in retaliation for Western sanctions.
ROME, Aug 24- The euro zone's growing fears of deflation will be stirred again on Friday when preliminary consumer price data for August is issued, with signs the European Central Bank could be looking at bolder steps to help the region's stagnant economy.
NEW YORK/ LONDON, Aug 22- Gold prices edged up on Friday as U.S. equities slipped, but gains were limited by fears over deflation after Federal Reserve Chair Janet Yellen said U.S. labor markets remain hampered by the effects of the Great Recession. Gold prices continued to hover just above a two-month low reached on Thursday.
NEW YORK, Aug 22- U.S. Treasury prices slid modestly on Friday with investors caught between the cautious message over labor markets from Fed Chair Janet Yellen and geopolitical risks from Ukraine crisis that is hampering euro zone economic growth.
WASHINGTON, Aug 21- U.S. home resales rose to a 10- month high in July and the number of Americans filing new claims for unemployment benefits fell last week, signaling strength in the economy early in the third quarter.
WASHINGTON, Aug 21- The number of Americans filing new claims for unemployment benefits fell slightly more than expected last week, pointing to a sustained improvement in labor market conditions. Initial claims for state unemployment benefits declined 14,000 to a seasonally adjusted 298,000 for the week ended Aug. 16, the Labor Department said on Thursday.
BERLIN, Aug 14- Germany's Chambers of Commerce cut its 2014 estimate for exports from Europe's biggest economy on Thursday due to the Ukraine crisis, but said even its lower forecast would not be achievable if the standoff between Russia and the West worsened.
*Germany surprises by slipping into contraction. BERLIN/ BRUSSELS, Aug 14- The euro zone economy ground to a halt in the second quarter of the year, drained of vigor by contraction in Germany and stagnancy in France.
*Germany surprises by slipping into contraction. BERLIN/ BRUSSELS, Aug 14- The euro zone economy ground to a halt in the second quarter of the year, drained of vigour by surprisingly shrinking growth in Germany and stagnancy in France.
*Outlook for Q3 bleak due to Russia- Ukraine tensions. BERLIN, Aug 14- Europe's largest economy Germany suffered a surprise contraction in the second quarter, raising doubts about whether it can prop up growth across a continent where tougher sanctions against Russia are already fueling business anxiety.
*Germany surprises by slipping into contraction. *France flatlines, government rips up growth forecast. BERLIN/ PARIS, Aug 14- Germany's economy shrank in the second quarter and France again failed to conjure up any growth, snuffing out any signs of a recovery in the euro zone which is now also weighed down by tit-for-tat sanctions with Russia.
MOSCOW, Aug 12- Russia appears for now to have escaped an economic contraction, but recession is still likely in the second half of the year as western sanctions over Ukraine bite, analysts warn.
Craig Botham, emerging market economist at Schroders, discusses the Russian economy and says that consumer purchasing power should continue to diminish as the Western sanctions hit.
KIEV, Aug 8- Ukraine expects that a decision on disbursement of a second $1.4 billion tranche of aid by the International Monetary Fund under a $17 billion loan programme will be adopted on Aug. 29, Central Bank chief Valeria Hontareva said on Friday.


text:
March 25, 2011
TV cast reunions we would love to see
TV cast reunions we would love to see
Some old news got a new wrinkle this week when Elizabeth Berkeley admitted on "The Today Show" that she'd be up for Jimmy Fallon's proposed "Saved by the Bell" reunion -- which had seemingly stalled back in 2009. Mark-Paul Gosselar, Mario Lopez and Dennis Haskins are already on board, meaning it's up to Dustin Diamond (who stayed with the franchise the longest) and Tiffani Amber Thiessen (who put her negative RSVP in the form of a very clever "Funny or Die" video) to make it happen. In the meantime, here are some other mid-90s casts we'd like to see reunite. (Note: we did not include "California Dreamin'" because Fallon already made this happen as part of his "SBTB" campaign).
Related links:


text:
Recent Posts
- RT @NAChristakis: Hilarious quantification of cost of damage caused by Calvin (& Hobbes) on annual basis, compared to real 6 year old: http… 2 weeks ago
- RT @jumpropers: What Will a Liberal Arts Edu Look Like in 50 Years? jro.pe/1ywYzYm via @TheAtlanticVID | @ErikaChristakis @nickdirk… 1 month ago
- Thinking about, and predicting, role of liberal arts education in 50 years, from @aspenideas theatlantic.com/video/index/37… 1 month ago
- @NAChristakis @HopeJahren yeah, we've got enough vanity around here, and we don't need #vanityplate with malapropism risk 1 month ago
- Via @michelledionn & @edwin_lyngar "I was poor, but a GOP die-hard: How I finally left the politics of shame" salon.com/2014/07/16/i_w… 2 months ago
To Want "But LIttle": Reflections From a Second Grade Classroom
Tag Archives: world until yesterday
Constructive Paranoia
I've been reading a new book called The World Until Yesterday, by Jared Diamond (the Guns, Germs, and Steel guy), about what we can learn from 'ancestral' (i.e. hunter-gatherer) societies. He's pretty clear about the things we might not wish to … Continue reading