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Research in Post-Apartheid South Africa
4 minute read
Last September, I started what was arguably the most challenging and fulfilling journey I have ever experienced. Summarizing my experience working on the Youth Pulse Project, which examines the experiences of HIV-positive adolescents in Eastern Cape, South Africa, in a mere page or two is impossible, but clarifying my reflections on this memorable time in my life is necessary.
Youth Pulse: An ambitious project
When I first arrived in South Africa, I was in awe of the ambitious aims of the Youth Pulse Project. Founded by the Universities of Oxford and Cape Town, with support from the South African government and various international stakeholders, the research endeavor hopes to uncover the lived experiences of HIV-positive adolescents in South Africa's Eastern Cape.
The Eastern Cape is the poorest of the country's nine provinces, considered the slowest progressing region of post-apartheid South Africa with limited resources for health, education, and infrastructure. In this challenging social, cultural, and economic environment, I learned about the ethical dilemmas of conducting international research.
Helping or hindering local staff?
To comprehend the difficulties of working on an international research study, understanding the cultural context in which the project operates is essential. On the one hand, basing the Youth Pulse project in one of South Africa's poorest areas is an excellent way to capture the experiences of the most vulnerable teens in the country. While this is wonderful for finding an interesting research cohort, our operation could inadvertently contribute to the status quo.
For instance, unemployment in the area where I worked, King William's Town, is exceptionally high, allowing for low-paying jobs and minimizing workers' ability to negotiate for better pay or benefits. In a sense, empowering local staff to advocate for themselves goes against the best interest of the research project, given its incredibly limited resources. On the flip side, the presence of this project provides employment for many local Xhosa-speaking Research Assistants (RAs).
The ethical quandary of data collection
Another ethical quandary of international research that I learned is the extractive nature of data collection. To collect data, our RAs sit with adolescents for nearly two hours, asking incredibly personal and possibly triggering questions about their experiences with health, school, home, family, and the greater community. These questions probe into a teen's experience with interpersonal and sexual violence and exploitation, as well as bullying and emotional abuse in a range of contexts. Oftentimes, the teens who have suffered from violence open up to our RAs, hoping for support. At the end of this long and emotionally exhausting process, our RAs must pack up and leave, unable to provide sustainable support or intervention to the teens that need it most.
This is not to say that no help is given to adolescents in need; Youth Pulse offers a range of referrals, including counseling and grant support (for families who are eligible to receive government funding for food or school fees). Nonetheless, it is difficult to say that a few counseling sessions will prevent victimization or heal a broken home. The inability to provide long-term assistance to teens in the project's cohort illustrates the ethical struggle of such research.
Worthwhile strides
In short, my time in South Africa with the Youth Pulse research project allowed me to think critically about the ethics of international work. Generally, research is known for its long-term benefits instead of immediate results. However, we must engage with the process of transforming data and its conclusions to policy and programming that will make its way back to the communities originally burdened through such data collection.
Youth Pulse and its partner projects have helped improve the lives of over two million adolescents across Africa. This feat, a result of evidence-based policy promoting social and economic support of teenagers, has reduced the likelihood of risky sex among adolescents from 11 to just two percent.
While these policy changes may not support the specific teens who opened up to our RAs in the data collection process, we must accept these strides as worthwhile. Moreover, we must focus on affecting positive change in the short- and long-term, while empowering and learning from our local partners in the process.
Neha is currently a Global Health Corps Fellow in Kigali, Rwanda. The InterExchange Foundation Christianson Fellowship supported her 10-month volunteer service with the Youth Pulse Project in South Africa.
Neha volunteered in South Africa with the help of a Christianson Fellowship, from the InterExchange Foundation.
Learn about life abroad
Read about the adventures others have had and get excited for yours.

subset: commoncrawl


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My Obligatory Firefox Extensions Post
Published September 13, 2007
Okay, okay, I know, what you're going to say. Every techie blogger has already spouted off their list of "can't live without" Firefox extensions. To be honest, it's been a while since I last posted and needed something easy to get me back into the swing again.
So here's my list of Firefox extensions that I've just gotta have for web development and life on the Net.
- autoHideStatusbar - Nifty little extension that gives me a little more page viewing area on my little 12" Powerbook.
- Web Developer - Although the Safari 3 equivalent looks promising, this gem will continue to get daily use. Most-used feature: Display Element Information (Command+Shift+F).
- Grease Monkey - Just installed this extension which let's you change the way web pages appear. I'm going to try it with the Better Gmail extension.
- Split Browser Window - We all love tabs, right? I love 'em so much that I refuse to open up extra Firefox windows. When I want to compare web page designs side-by-side or four-at-a-time, this handy extension let's me do it in a single window.
- MeasureIt - Simple, easy to use, a must for any pixel pushing web designer. Very handy for determining column widths and image dimensions.
- Colorzilla -Wondering what hex values you need to add to your style sheet? Grab Colorzilla's eye dropper to whip up a pallette wicked fast.
- del.icio.us - Working on multiple machines? Make your bookmarks available to you, and the world, regardless of location.
- Forecasfox - All I need to do is look to the lower right corner of Firefox to see what it's doing outside.
- StumbleUpon - As if the internet wasn't a big enough time sink, try getting real work done while randomly surfing user recommended web sites. When I'm working on a new site I'll go stumbling for inspiration.
- Gmail Notifier - My Mac's Apple menu is too crowded for the Google Notifier, so I use this instead.
- Ymail Notifier - See above.
What are your "gotta have" Firefox extensions?


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Today's "evidence-based medicine" may be tomorrow's malpractice
Author's note — Readers may find these related articles of interest:
Evidence-based guidelines won't prevent malpractice claims
Germs and the Pseudoscience of Quality Improvement
We hold these truths to be self-evident:
A hospital administrator with a clipboard is in search of a physician who isn't following "evidence-based guidelines".
There are fads in medicine just as there are in fashion—today's "evidence-based medicine" may be tomorrow's malpractice.
Did your hospital, like so many, abruptly switch from povidone-iodine antiseptic solution to ChloraPrep® for cleaning a patient's skin before surgery? If so, I'm sure the staff was told that ChloraPrep would be more effective and cheaper. No doubt, they were also warned of the extra precautions that must be taken with ChloraPrep to prevent operating room fires, since ChloraPrep contains highly flammable 70% isopropyl alcohol in addition to chlorhexidine. Even the fire risk apparently wasn't enough to make hospitals think twice before switching antiseptics.
You (and your hospital's staff) may not have heard this news. The US Department of Justice (DOJ) announced last month that CareFusion Corp. would pay the government a $40.1 million settlement to resolve allegations that the company violated the False Claims Act by paying kickbacks to boost sales of ChloraPrep and promoting it for uses that aren't FDA-approved.
Who received kickbacks? According to the DOJ's press release, the complaint alleged that "CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses, and recommends standardized health care performance measures and practices." Another physician with close ties to CareFusion, Dr. Rabih Darouiche, was the lead investigator on a 2010 NEJM article which concluded (not surprisingly) that Chloraprep was "significantly more protective" than povidone-iodine against surgical site infections.
The Leapfrog Group, launched by the Business Roundtable in 2000, claims that its hospital survey is "the gold standard for comparing hospitals' performance on the national standards of safety, quality, and efficiency." On January 30, Leapfrog announced that it accepted the resignation of Dr. Denham, who had served as chair of Leapfrog's Safe Practices Committee since 2006, amid concerns that Dr. Denham had failed to reveal his "potentially compromising relationship with CareFusion." At the same time, Leapfrog said it would undertake "a thorough scientific review of its full slate of endorsed safe practices."
Are you still feeling good about evidenced-based medicine?
Then you haven't looked closely enough at another quality measure your hospital may track: the use of beta-blockers, a type of blood pressure medicine, around the time that patients undergo surgery. The Surgical Care Improvement Project (SCIP) has defined beta-blocker use as a "core measure" of hospital quality, stating that a patient who has been taking a beta-blocker prior to arrival for surgery must receive a beta-blocker while in the hospital. The medication must be taken, SCIP says, either the day before or the day of surgery, and on either postoperative day 1 or 2.
Is there a controlled study that demonstrates conclusively that the SCIP beta-blocker measure makes surgical patients healthier? Or that they recover better from surgery? No, there isn't. Does the SCIP measure track whether the patient's blood pressure or heart rate are maintained within a normal range? No, it doesn't. All it says is that the patient should receive an unspecified dose of one of a number of drugs in the beta-blocker class. A physician can be "compliant" with the SCIP measure by prescribing only a tiny dose of esmolol, a beta-blocker whose duration of effect can be measured in seconds. You don't have to be a cardiologist to figure out that this is ridiculous.
What's worse is that aggressive beta-blocker use around the time of surgery may be hazardous. A 2013 review and meta-analysis of the medical literature concluded that starting beta-blockers before surgery caused a 27% risk increase in 30-day all-cause mortality. Beta-blockade reduced the incidence of heart attacks, but increased the incidence of strokes and dangerously low blood pressure.
The authors of the SCIP core measure cite scientific evidence to support their recommendations. Unfortunately, much of the science has been discredited. Dr. Don Poldermans, a prolific Dutch researcher, led the DECREASE-IV study referenced by SCIP, which is no longer considered credible. The meta-analysis concluded that in DECREASE-IV, "the key data required to judge outcomes were missing and the adjudication committee was fabricated."
Larry Husten of Forbes.com has been reporting the damage caused by the Poldermans research misconduct with the overwrought headline: "Medicine or Mass Murder? Guideline Based on Discredited Research May Have Caused 800,000 Deaths in Europe Over the Last 5 Years." Even if Husten exaggerates, it would be reasonable to suspend the use of the SCIP beta-blocker measure pending further review. Good control of a patient's blood pressure and heart rate is a doctor's version of common sense, and another medication might be better than a beta-blocker for a specific patient's needs. First-class chefs don't base their success on slavish adherence to a cookbook recipe.
Sadly, the federal government has seized on adherence to "evidence-based guidelines" as a way of demonstrating "quality" in health care. On February 6, key lawmakers unveiled plans to replace the Medicare Sustainable Growth Rate (SGR) formula with a new "Merit-Based Incentive Payment System" for physicians. This system will include payment bonuses or penalties based on a composite performance score. Patients as well as physicians should be frightened at the prospect that the government's version of guidelines for care will forcibly replace physician judgment and experience in caring for patients as individuals.
The good news about the CareFusion settlement is that we may be seeing less of Dr. Denham on the patient safety lecture circuit, playing clips of "Chasing Zero", the video he produced with his new best friend, actor Dennis Quaid. The bad news: hospitals and government agencies hate to admit they're wrong, whether it's about ChloraPrep, beta-blockers, or any other bureaucrat's idea of "quality" in health care.
I have personal experience with standard protocols and core measures as a result of the abdominal surgery I underwent a couple of months ago. From the hospital's point of view, I'm sure I met every one of the "targets" they set for me on my "care pathway". The only glitch is that I developed a superficial wound infection that took more than two weeks to clear up. The hospital's statistics won't reflect that, because it only became apparent after I left for home. Which skin prep solution was used for my case? You guessed it–ChloraPrep. Next time I'll ask for Betadine.
You hit it right as usual Karen. In my mind, there was never any reason to switch from Betadine. The 2-pass system with a foamy scrub followed by a paint destroys all bacteria since the iodine is indiscriminate in its penchant for killing bacteria. On the other hand, it seems that alcohol evaporates, so although Chloraprep may kill initially, it is gone within a few minutes, whereas the iodine remains on the skin.
Show me the data!!
This is a really interesting article, thank you for posting. The hospital that I work at is on the evidence-based practice bandwagon right now and we have seen a lot of changes that just don't make any sense at all to those of us that have been in healthcare for 20+ years. In regards to Betadine versus chlo prep, I remember when I was in college and taking microbiology, we did experiments using alcohol versus Betadine and it was clearly proven that alcohol was pretty ineffective in killing bacteria. Betadine however did the trick in all of our experiments. This is stuck out in my head over the past 24+ years that I have been an RN. Facilities that I have worked at over the years have used many alcohol-based hand sanitizers and skin preps. Although I am compliant because I don't want to get written up, I use what is policy . I doubt if they were to be done again, the results would be any different alcohol is alcohol and it doesn't effectively kill bacteria.
Let's not forget the latest scandal. It seems the CEO of the National Quality Forum has some important conflicts of interest as reported by Pro Publica http://www.propublica.org/article/payments-to-ceo-raise-new-conflicts-at-top-health-quality-group?utm_campaign=bt_twitter&utm_source=twitter&utm_medium=social
Patient safety advocacy is big business.
Well, there has been a long-standing, massive, large-scale misinterpretation of evidence concerning chlorhexidine and its role in skin antisepsis. People in droves were comparing the clinical outcomes from a combination of chlorhexidine and alcohol (i.e. two antiseptics) against povidone-iodine alone (i.e. one antiseptic) and were concluding that "chlorhexidine is better than povidone-iodine." Such a conclusion is obviously incorrect. It has been known for many decades from microbiological studies that alcohols are about 10 times more effective as skin antiseptics than either chlorhexidine or povidone-iodine. So, a better comparison would be chlorhexidine-alcohol combinations versus iodine-alcohol combinations.
We have published about this evidence misinterpretation here:
Maiwald M, Chan ESY (2012) The Forgotten Role of Alcohol: A Systematic Review and Meta-Analysis of the Clinical Efficacy and Perceived Role of Chlorhexidine in Skin Antisepsis. PLoS ONE 7(9): e44277.
[…] Today's "evidence-based medicine" may be tomorrow's malpractice | A Penned Point […]
And then there is all that profiteering without ANY evidence of quality or patient care improvement! Yes, I am talking about the whole MOC and board certification extortion of physicians just to satisfy the administrative needs for documentation of quality. There are no quality outcome based studies that document improvements from any of this and the "bait and switch" transformation of lifelong board certification into a time limited certificate only serves to increase the incomes of the ABMS and affiliate corporations and their executive staffs who earn up to $1.2 million. Christine Cassel MD, Ex CEO of the ABIM switched CEO positions with Dr Baron at the NQF and she is now under the gun for her new role as head of the NQF regarding the Denham fiasco. See:
The ethics of these board members who are simply earning off the backs of working physicians is terrible-so hw does this affect YOUR perception of their programs. The ABIM has amassed a $45 million debt under Cassel as well (see IRS 990 at guidestar.com). I have no faith in an insolvent board led by unethical individuals!
Paul, if I could hug you right now, I surely would! I'm a relatively new physician… Residency trained, board certified and practicing hospital medicine for three years. I have felt so caught up in this web of CME credits, MOC projects? Licensure renewal as well as trying to keep up with my actual doctoring job and life outside of medicine, that I've become overwhelmed and frustrated by the reality of healthcare not being what I thought it was, I've now been strongly considering moving out of clinical medicine. All of the years I worked so hard, now I'm questioning how this is going to affect the rest of my life as well as my family's life. If they just want a big check every 2-3 years, then just say so. Leave the lifelong learning and and to improve quality in medicine up to the people who've already sacrificed their lives to do just that. Thanks for your sentiments… Nice to know I'm not alone.
Thank you for a great piece Dr. Sullivan Sibert.
I humbly propose that medical doctors who have always seen themselves as persons of science and reason do not so easily relinquish the rights to the now-trendy term of "evidence-based medicine" and allow it to be further tainted.
"Evidence-based medicine" is, whether we want to admit it or not, the very thing that distinguishes us from astrologers and alchemists. The observant, rational and most successful among us have been practicing it since prehistorical times and indeed it sits at the heart of good medicine.
So why let it be highjacked by the pencil-pushing suits with the clipboard? To promote skepticism of "EBM" because of some corrupt administrators and bureaucrats is like promoting distrust of "science" because some wacky scientist somewhere is depleting uranium for a dirty bomb.
Instead, I think it's time that clinicians reclaim the term by demanding appropriate representation by other scrub-wearing clinicians at all the levels of administration and in the process of policy making.
"Best evidence is best evidence" but we also know that "always" is rarely used in medicine. This is why EBM must establish *guidelines*, not rules and laws, so as to not interfere with the unique situation between a given patient and her doctor.
Outstanding post and outstanding reply. It is hard for me to get a firm grasp on what the beurocrats are saving us from.
My first chief stated earnestly: "Paul you don't want to be the first one to do something in medicine-but also don't be the last" and there is significant wisdom in that. Particularly since both the English and the US studies have recently embarked on "medical Reversal", where reevaluation of "science" has overturned prior "guidelines" and other evidence based studies:
Disinvestment from low value clinical interventions:
NICEly done? BMJ 2011;343:d4519 doi: 10.1136/bmj.d4519
Over the past 10 years NICE has identified over 800 clinical interventions for potential disinvestment.
But Sarah Garner and Peter Littlejohns report that although disinvestment will increase efficiency
and quality, the opportunity for cash saving is unlikely to meet the necessary targets
Sarah Garner associate director for research and development, Peter Littlejohns clinical and public
health director
NICE, London WC1V 6NA, UK
A Decade of Reversal: An Analysis of 146
Contradicted Medical Practices (found in the NEJMed no less!)
Vinay Prasad, MD; Andrae Vandross, MD; Caitlin Toomey, MD; Michael Cheung, MD;
Results: We reviewed 2044 original articles, 1344 of which concerned a medical practice. Of these, 981
articles (73.0%) examined a new medical practice, whereas 363 (27.0%) tested an established practice. A
total of 947 studies (70.5%) had positive findings, whereas 397 (29.5%) reached a negative conclusion. A
total of 756 articles addressing a medical practice constituted replacement, 165 were back to the drawing
board, 146 were medical reversals, 138 were reaffirmations, and 139 were inconclusive. Of the 363 articles
testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it.
Conclusion: The reversal of established medical practice is common and occurs across all classes of
medical practice. This investigation sheds light on low-value practices and patterns of medical research.
Mayo Clin Proc. 2013;88(8):790-798
The importance of NOT simply believing the newest guideline that conflicts often with many older and other specialty guidelines is important, yet also play a significant role in those trying to "pass the boards" as experienced clinicians at re certification instead of simply going with the only thing you know immediately after residency. YOu know too much to simply believe a new guideline! And of course the questions are never published and right answers put to critical evaluation after the fact. The Boards have complete control and authority-a real problem for any democratic thinkers out there. Then the fact that failure rates as high as 29-33% have occurred in recent years for the primary care specialties IM and FP-no wonder no one wants to go into these shortfall specialties to be castrated by their boards. With over 167 DIFFERENT board certificates, they will NEVER be a standard across the specialties and as an index of Quality (as sold by the ABMS) we there is ABSOLUTELY NO PROOF that this is the case. Thanks Pedsmom for the support.
[…] algo así como "Las evidencias de hoy pueden ser las malas prácticas de mañana" (Today's "evidence-based medicine" may be tomorrow's malpractice) ha sido escrito por una anestesióloga norteamericana, la Dra. Karen Sullivan Silber, en su […]
Very thought provoking. It seems obvious to me that "non-clinicians" will have to learn the hard way that medicine is still an art and not a cookbook. Unfortunately, we may have to endure some bumps before the final product of American medicine regains our status among patients.
As a corollary to the art not science theme, good medicine can only be practiced by very intelligent, thoroughly trained individuals who can put together the varieties of relevant new and old evidence, basic science education, an understanding of statistics, and experience to synthesize the correct path of diagnosis and management. Undertrained individuals with the latest algorithm are no substitute.
Another one for your files Karen. In twenty + years of performing laparoscopic inguinal hernia repairs, I have NEVER seen an infection. (N – approx. 2K) It just doesn't happen, because we're working inside the sterile environs of the abdominal cavity. However, according the SCIP guideline I must give an IV antibiotic to every patient within 30 minutes of making the skin incision. So dutifully a gram of Ancef, or some other equally broad spectrum and totally unnecessary antibiotic, is administered as we head back to the OR. These patients routine go home from the recovery room and I would estimate at least ten percent call within three to five days with unexplained diarrhea. In the last ten years I have seen no fewer than five cases of extremely symptomatic C. diff enterocolitis, which is clearly antibiotic induced. I would defy anyone to provide the logic behind giving a drug that prevents a problem that is virtually never seen yet cause a significant number of patients to suffer a significant, and potentially life-threatening condition they would otherwise not have experienced. Anyone?
The ACCP should be added to the list of evidence-less based medicine. Admittedly, with the 9th edition (2012), considerable effort was put forward to diminish the financial and intellectual based conflicts that dominated the ACCP through the 8th edition. This year, the CMS has mostly caught up with the AAOS recommendations for VTEP from 2007.
However, the decades of evidence-less based guidelines in the field of VTEP have caused great suffering. Thankfully, in 2014 it is again legal to practice good medicine in this small corner of orthopaedics.
In the fast pace ambulatory surgery centers where lap gall bladders are done consistently in 15 minutes skin to skin, anesthesiologists are doing LMA successfully. No problems. Academic programs where most of the papers are manufactured do not address this.
Those administrators with clipboards are not only pushing corporate interests that seem evidenced based, they are the main perpetrators of policy totally unsubstantiated by evidence, but supported by "associations" in literature produced by corporate bias. The American Boards have taken the lifelong certifications attesting attainment of consultant status, used "time limits" to require repeat purchase after 8-10 years and now mandate "continuous MOC" (http://moc2014.abim.org/whats-changing.aspx).
In spite of over 7 decades of existence and many attempts by the ABMS to document that certification makes any difference-they have failed to do so: Certification is at best a slight, or possibly false, promise,recently openly admitted by the ABMS: 'FACT: ABMS recognizes that regardless of the profession – whether it is health care, law enforcement, education or accounting – there is no certification that guarantees performance or positive outcomes'.
It is time for all physicians to simply stop buckling down to clipboards, legislation and corporate propaganda. Quit the recertification extortion NOW before it does become mandatory-change hospital bylaws, state and insurance legislation via all STATE medical societies, as they are not part of the certification industrial complex and all laws are state matters!
The post about the lack of evidence that board certification makes a difference in outcome reinforces what I have observed over a career in medicine. Even worse is the way register physicians are treated. I received my core board certification before they had to be renewed. However, my sub specialty boards must be renewed every 10 years. One year after I retired I found that I wanted to return to work part time. A few weeks after returning to work, my subspecialty board came up for renewal. However I discovered that in order to be "eligible" to take boards I had to have worked 25% for the previous year. So I was not eligible, nor would I ever become eligible because I worked only 20%.
That is nothing more than subtle discrimination against older physicians. Nor is there any evidence that those artificial barriers to recertification lead to better patient care.
Nurses are noticing this too, especially now that reimbursement is tied to compliance with core measure criteria. I have seen blind adherence to the VTE prophylaxis core measure result in a catastrophic SDH that was not amenable to surgical treatment. Core Measures are killing our patients.
I completely agree with you, Diana. These "quality" measures are being applied by rote to patients without individualization or assessment of specific risk factors. It's tragic, and it affects all of us in healthcare who care about our patients. Thank you for writing–
Karen Sibert
Thank you for writing this article and questioning the new status quo.
1. this came out to open public knowledge because of an insider whistleblower. Other wise we all intelligent doctors would be waving our heads and wagging our tails .
2 . we go from extremes of every situation. Doctors in Vienna would do a autopsy on a mother and then not even washing hands with water go do pelvic exam and causes puerperal fever and death.
then came every medical students ritual in operating room " the five minutes " scrub with iodine.
and now surgeons don't even wash there hands before surgery. They are supposed to do scrub before the first case and between case use that hand sanitizer. I rarely see any surgeons at the scrub sink washing hands. The sanitizer is in the room .
I can promise you if somebody does a study of comparing washing the extremity with water and soap and compared to povidone or chloraprep – there will be no difference in incidence of infection .
The minimum expected of surgeons these days is to wash their hand after using the toilet before starting a case. .there are surgeons who are even skimping on that .
3 . how many times I hear from the CRNa asking at time that does the patient need preoperative antibiotics on case of abscess.
The rote following of EBM guidelines. The person has an abscess and he is already infected and on antibiotics for treatment, what are you trying to prevent SSI? .
My favorite is arguing middle of night with pharmacist. Who wants me to stop antibiotics within 24 hours. He wants me to document it is infected to continue antibiotics. My pleas that the would is devitalized and contaminated do not hold any meaning .rules are rules you need to stop the antibiotics .the pharmacist is on the SCIP committee .
4 many cardiologist have told me stories of how patient will come to there office with generalized weakness and dizziness . They had all kind of work up looking for cause.
They recently had a surgery. Somebody followed the guidelines and started them on B- Blockers. And somebody unwittingly discharged with a new prescription to continue at home.
The moment the cardiologist stop the beta blockers ,next visit pt face is lit up happy and full of energy .
There is a reason we have the sympathetic system in our body and designed over million of years and we doctors have found a new way to suppress it and make people feel miserable .
5. Most of these clinical outcome based research and Evidence based guidelines are coming out of VA studies and VA doctors
Are these VA doctors are signing their names to some of this research for the extra money paid by the pharmaceutical industry.
Suddenly the trend of using less antibiotics has been circumvented by using EBM guidelines. ( just one dose preop – 30 million surgeries- 30 million doses to sell )
6. 10.7 million is a lot of money. As they say follow the money.
Never found out how much carefusion paid the doc from VA in Houston for his help in the study ?
Ven Bodavula
St. Louis
This also leads me to question the use of all the SCIP protocoled antibiotics. Does anybody else feel like they have seen an increase of MRSA, VRE, and multiple other super bugs since the government has started requiring doctors to give specific antibiotics for certain surgeries? Why exactly can the physician not choose the medication? And then the whole Foley catheter situation has been brought up. That is a whole other can of worms.
Dear Amanda,
You've raised a good question, but there's another side to it as well. One of the SCIP "rules" is that prophylactic antibiotics have to be discontinued after 24 hours. In other words, if you give an antibiotic to PREVENT infection after surgery, after 24 hours it must be stopped. Many experienced physicians think this rule is based on insufficient evidence. We know that if you're given an antibiotic, you're supposed to finish your prescription–all 7 days worth, or 10 days worth–because otherwise the weaker bacteria may have been killed off but the nastier, tougher ones may still be alive. Could the same thing be happening with surgical antibiotics? Could it be that the weaker bacteria succumb to the 24 hrs of antibiotics, but the tougher ones are surviving? I know experienced surgeons who ignore the SCIP rules and continue antibiotics for 5 days after colorectal surgery, because they know from experience that they work better that way and infection rates are actually lower.
Thank you so much for taking the time to read and comment.
All the best,
Karen Sibert
Karen, you have hit upon the key issue. In a system run by third party payers, chief among them CMS and its army of bureaucrats, there is no place to individual judgement based on experience. Such variables cannot be measures and therefore cannot be managed. Just stick to the "cookbook" to assure payment and keep pushing word like "best practice guidelines", "pay-for-performance initiatives", and "quality metrics" and sooner or later everyone will comply… or retire.
I am not a physician, nor do I claim to have the knowledge or experience of a physician. I am a nurse, and have only been practicing for five years. Evidence based practice was drilled into us in nursing school, and my colleges reacted in one of two ways (primarily). Either they embrace EBP wholeheartedly and adhere to policy and procedure surrounding the EBP without further thought, or they buck EBP, stating there is no need for change just for the sake of change, and medicine is an ancient art and things should be left alone. Dr. Sullivan Seibert, I appreciate your article, and am surprised to, just now, see it as a widely shared article in social media.
Unfortunately, most of the people citing it are on the later of the pendulum for evidence based practice, and presumably haven't read any number of your publications, opinions, or papers.
I want to ask, where do you think practitioners (and yes, I think anesthesiologists are practitioners) hold responsibility in evidence based practice? You cited the Robert Wood Johnson Foundation in one blog post, and their expectation for nurses to "…practice to the full extent of their education and training…[to] achieve higher levels of education and training through an improved education system that promotes seamless academic progression… be full partners, with physicians and other health care professionals, in redesigning health care in the United States…[and to be involved in] effective workforce planning and policy making require[ing a] better data collection and information infrastructure." As you stated, physicians should be held to practice at the full extent of their license. The IOM quoted the statistic that physicians make up 22.61% of institution and hospital boards, and nurses make up 2.3%. Certainly, if more practitioners (regardless of level) were personally involved in and responsible for research and review, issues like CholraPrep wouldn't be passed based on one study.
Unlike the former group of colleagues, I tend not to take things at face value. I read, investigate, speak collaboratively with physicians about reasons for treatment, and their coinciding opinions. I have furthered my education and am currently working on a MSN/MBA, having started as an ADN. I pursue clinic certifications in and outside my primary role, and subscribe to several professional organizations.
My question, I suppose, is how we, as practitioners held to the standards of policy and procedure, discern between effective EBP and bureaucratic garbage? Certainly you aren't practicing in the same way you were in 1985. Although many things, I'm sure, are similar, evidence based practice has affected your practice.
I look forward to your response, and congratulations on your resignation and new position.
Dear Ms. Koenig,
Thank you for your thoughtful reply. It is very difficult indeed to discern between effective EBP and nonsense. A couple of basic bits of advice:
1. If a study's results seem very dramatic and different from prior knowledge, be suspicious. Look to see if the study was based on a small number of patients. If so, subsequent larger studies are unlikely to produce the same statistical results.
2. In so far as you are able, do not dramatically change common sense practices that have stood the test of time on the basis of one new headline.
3. Look at studies to see if they are actually process studies or outcome studies. For example, there are a number of infection control studies based on bacterial counts on scrubs washed at home or in the hospital laundry. Yet no one (to my knowledge) has done a common sense look at bacterial counts on scrubs at 3 pm after the wearer has made several trips to the bathroom, or looked at actual wound infection rates in patients who were looked after by staff wearing scrubs washed at home compared to scrubs washed in the hospital. I am not advocating home laundry specifically; just making the point that it is important to look at the quality of the science.
I do have other articles on this topic on my blog–have a look at "Germs and the Pseudoscience of Quality Improvement", and "The Dark Side of Quality", both of which are more thorough looks at the subject.
All best wishes, and thank you again for taking the time to read and comment.
Karen Sibert
Your mistake is disparaging evidence based medicine when the issue is those who bias the evidence. Further, you use your personal n=1 to support a statement that fits your bias. You have committed the very fraud you disparage.
Illuminating the bias is criticial, but so is getting the conclusion right.
Dear Dr. Schroeter,
Thank you for taking the time to write. I am not convinced that the problem is bias; that is too general a term. Specifically, there are three issues that contaminate "evidence-based medicine":
1. Study results, though initially promising, can't be reproduced. This is often due to small sample size. As a general rule, if results seem too dramatic or too good to be true, they probably won't be reproducible in larger studies.
2. The conclusion drawn from the evidence is based on flawed logic, such as the "post hoc ergo propter hoc" fallacy. You may remember the early theory that AIDS was caused by inhaled nitrites, simply because a number of AIDS patients had used them recreationally.
3. The evidence itself is based on fraud. I think this is what irritated me the most about beta-blockade and about ChloraPrep. Once the study results turn into policy, "pay for performance", and enforced use, it is painfully hard to turn the process around.
My personal n = 1 story is an anecdote, obviously, and nothing more. For further reading, and more dubious "evidence", please have a look at two other, more complete articles on this site: "Germs and the Pseudoscience of Quality Improvement", and "The Dark Side of Quality".
All the best, and thank you again for taking the time to comment,
Karen Sibert
Thank you for this article. In the face of contemporaneous disclosures about psychiatric practices vis-a-vis the DSM and conflicts of interest between industry and mental health researchers, I feel strongly that we need continue to discuss this issue.
Of late, as an RN Patient Advocate, I have spent considerable time debunking the evidence of evidence-based medicine. E-B was actually endorsed to prevent this type of scam with the providone-iodine substitute. But instead often becomes a rigorous enforced standard of care (read "Super Markeying"). Take mammograms (pkease). The current US Prevention Taskforce recommendations are every other year beginning at 50 until age 74. This is a far cry, and a great financial loss, from original mammogram company recommendations. This new standard is evidebce-based, but so, too, claims the American Cancer Society (and it's financial backrrs) is theirs that the test ve annually from age 45 ad infinitum. Need evidence? Take your pick, then institutionalize ut, require it, incentives it, badger with it, profit from it. By the wsy: I recently had three patients with severe allergies to iodine, who were asked by their surgeons, "You're not allergic to iodine on your skin though, are you?" (At least they asked). One said, "Yes, I AM allergic to betadine, and us healing fine. The other two, who shrugged, not knowing as the DOCTOR shold that if you are allergic to iodine, you are allergic to betadine, are now struggling with itchy red rashes and excoriated and infected incisions.we do need an alternative to betadine, that is truly evidence based. Of greater concern in my practice is the arrogant assumption (and scientific mortal sin) that Absence of Evidence is Evidence of Absence. gor exsmple: My patients who come to the hospital and report, "I have a really bad reaction to narcotics. They cause more pain." If one more anesthesiologist say, "No you don't" and gives narcotics anyway, I will call the police for assault. Another example of Absence of Evidence assimptions: As a nursing student I was sure from my readings that I had reactive hypoglycemia. Yes, we thought we had every symptom we learned about. But this one made sense. I went to my doctor who said it is a very rare malady, and a current fad illness, and he refused to test me for it. Over the next 5 yearrs, 3 other doctors would not test me. Yhen, when I was pregnsnt, my doctor insisted on a 3 hour GTT. Voila! Clear evidence of Reactive Hypoglycemia! But, he said, These results don't make any sense." Or is that "cents". Thankfully I was already on the right diet. So, if you don't test for a disorder because it is rsre, guess what? The diagnosis stays rare! I have little faith in current evidence-based practice. We need W I SDOM-BASED care. And to value common sense and what patient's know to be true. I ask, "Who benefits from this medical intervention?" It better be the patient.
Very interesting article. Can't disagree but let's not villain-ize hospitals and people who work in Quality Departments. Hospitals are held hostage to following standards that are promoted by these quality agencies (and therefore the government) to stay alive for their communities! As a nurse for 30+ years and a Quality Department representative for 12+ years, I cringe when my clinical colleagues think of me as a "clipboard". I'd like to think I bring more to the table than that!
In addition, and as long as we're promoting individuality, let's not portray all providers as having the ultimate "wisdom" – I think we all know better than that!
[…] it was well known that the data underlying the rules were seriously flawed. My counterargument, "Today's evidence-based medicine may be tomorrow's malpractice", generated more than 17,000 hits in one day, and has been viewed nearly 83,000 times. It was […]
So glad to see the title and the contents.Change is life but every change must be for good to those for whom it is meant .In Medicine therapies' efficacy is affected by environment, life style, food habits and so on.So must work with real concern for the Patient in front rather than this had evidence. Of course life is too short for doing everything yourself .So others experience matters , But must think analyse and then take steps.


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Want to know more about the author of The Painted Veil? W. Somerset Maugham (1874-1965) one of the most prolific writers of the the 20th century, kept his personal life private. His most famous works include Of Human Bondage and The Razor's Edge. He lived a fascinating life- publicly living the high society life in England and the US and privately suffered anguish from keeping many dark secrets. Bibliographer Shelia Hastings is the first to have permission to quote from his private papers. The Secret Lives of Somerset Maugham is a must read for bibliophiles.
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Kathy Corey
I'm an expert amateur or maybe an amateur expert.
May 2021


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De Blasio making "temporary" move to Gracie Mansion
Despite earlier concerns about his son's high school commute, Mayor-elect Bill de Blasio has committed to moving into Hizzoner's official residence, Gracie Mansion.
He and his family will make a temporary move to the five-bedroom estate overlooking the East River at East End Avenue and 88th Street, he said on his website today. The move will occur over the next few months, he said.
"It's a practical choice but one that we make with respect and gratitude for the people of New York City," de Blasio said in a statement, also citing logistical and security reasons prompting the decision.
While campaigning, de Blasio vowed to move to the home, which features a new $1.25 million kitchen and 14 acres of parkland. But then he said he might stay at his non-renovated Park Slope row house, which he does not plan to sell.
Sofia Song of StreetEasy has estimated Gracie Mansion is worth between $100 million and $150 million. [Transition 2013] — Mark Maurer


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July 22, 2012 marks what would have been the 100th birthday of Lynn Colbert Williamson. He was the middle child of Dr. Sam Williamson and Frankie Jones. Lynn's younger sister was my grandmother.
I only met him 2 or 3 times that I can remember. The first time was when I was 4 and the second time was when I was 19, and then maybe another. He and his wife lived in Texas most of my life, while I was in California.
Lynn grew up in Duncan, Oklahoma. He married the girl across the street. They had one son.
Lynn and his son, about 1940
Lynn was in the oil business. As with many people in that industry, he and his family moved often and all over the place.
Lynn, his mother, his sister (my grandmother), his nephew (my dad)
Lynn looking sharp during his oil days.
Lynn retired in the 1970's and moved to Houston. He played a lot of golf and was an active member of the community.
This looks like Pebble Beach to me, but I can't confirm it.
In the 1980's, Lynn was struck with Guillain–Barré syndrome and essentially paralyzed. He eventually walked again with the aid of a walker but never fully recovered physically. Mentally, he was sharp as a tack. When his legs quit working, he took to writing on his typewriter.
Lynn wrote about his life and his family. I am lucky to have copies of many of these pages, as he is one of the only people in my family to record history. I have few papers.
What I remember most about Lynn was his positive attitude. It was more than just being happy. It resonated from him. He wasted no time feeling sorry or sad. He was truly grateful for life.
When I talk on this blog about living each day and building memories with your family, it is because of the writing Lynn left behind. Life really is short, and you must treasure it. If you spend all your time dwelling on the negative things, you'll completely miss out on what's important.
Happy birthday, Lynn. Hope this crew is throwing a party for you:
The Fearsome Foursome:
My grandparents, Lynn and his wife Imogene


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Men and women aren't that different: investing app Stash
When it comes to investing, the overwhelming narrative is that men have more of an appetite for risk than women. But, men and women are equally risk-taking with their portfolios, according to a new report from financial investment app Stash.
Stash, which lets users invest in ETFs and individual stocks, analyzed self-reported data from 640,000 of its 2.5 million users. Ninety percent of female users identified as having a low or medium risk tolerance.
Though the vast majority of women don't believe they are risk takers, their behavior indicates otherwise. In reality, when it comes to investing, men and women act practically the same, according to the report.
Both men and women hold an average of five different investments in their portfolio. About 50% of women have invested in higher-risk investments like stocks or 'aggressive' ETFs, just like men.
The specific breakdown of portfolios looks very similar for both men and women. Females have, on average, 87% of their Stash investments in ETFs and 13% in individual stocks. Males have, on average, 84% and 16% of their portfolio in ETFs and individual stocks, respectively.
"Society has long maintained that money is a 'man's issue,' oftentimes leaving women on the sidelines, without proper financial access or education. We've certainly made strides recently, but the historical trend likely speaks to why women err on the side of caution when it comes to labeling their own risk tolerance," said Alexandra Phelan, Stash data scientist.
The gender pay (and investing) gap
While portfolios of men and women may look similar on a percentage basis, women invest less of their assets overall.
Women keep 71% of their wealth in cash, according to a BlackRock survey, compared to men who keep 60%. This deeper disparity partially stems from the fact that women have less wealth overall.
In 2017, women earned 77.9 cents for every dollar earned by men, which is only slightly more than a year earlier — when women earned 76.3 cents for every dollar earned by men, according to PayScale, which provides compensation data.
"It's crucial to take the gender pay gap into account when thinking about how much money men and women are investing, or could invest. It's absolutely possible that female users simply have less money to invest than men do," said Phelan.
However, she pointed out that the app sees men and women making consistent contributions — whether weekly, bi-weekly or monthly — in roughly the same amounts.
Where behavior diverges
While men may not be more exposed to riskier investments on Stash, they are more impulsive, especially on down days in the market.
Stash analyzed two volatile days in February to see what trading on the app looked like. The S&P 500 dropped 113.19 points on February 5. Later in the week on February 8, the S&P fell into correction territory after plunging 100.66 points.
On the day of and day after the market dropped, on average, men were 87% more likely than women to sell an investment. In the two weeks following the market declines, on average, men were 50% more likely than women to make a withdrawal from their account.
Men and women may be just as likely to expose themselves to risky bets, but women are more tolerant of the highs and lows that come with being an investor.
Melody Hahm is a senior writer at Yahoo Finance, covering entrepreneurship, technology and real estate. Follow her on Twitter @melodyhahm.
Read more:
Highly unusual investment: Own part of this world-class bar
RVs and recliners are back thanks to millennials
Homebuyers are demanding one amenity right now
Anaheim wants to be the Disneyland of beer
What it's like to glamp on New York City's Rockaway peninsula
Inside the exclusive supper club in a 1-bedroom NYC apartment
Women's-only club The Wing opens its doors for a special occasion


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Guitar Walk at Cavenaugh Park
What to know
A 115-ft-long by 40-ft-wide guitar, based on an Epiphone Casino played by John Lennon, honors the musicians that played along the nearby Rock 'N Roll Highway 67. It features nine plaques dedicated to some of the country's musical legends, including Conway Twitty, Johnny Cash, Elvis Presley, Jerry Lee Lewis, Sonny Burgess and Billy Lee Riley. Others added periodically.
SW Front Street
Walnut Ridge, AR 72476


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Presenter Dr. Giles Yeo will interview and research the ideas and the gurus behind the increasingly popular the "clean eating" trend, the gluten-free fad, and other ideas surrounding food.
Ella Mills is one of the most influential figures of clean eating; she created her popular blog Deliciously Ella after suffering from postural tachycardia syndrome. After feeling let down by modern medicine, Mills turned to a plant-based diet in order to control the symptoms of her rare disease.
Giles discusses gluten-free baking with the Manna Dew Bakery owner Mohamed Aboughazala and describes the methods and beliefs of the Hemsley sisters who recently released their own cookbook.
Cardiologist Dr. Alessio Fasano and Giles discuss the work Fasano has done in the grey area of heart disease regarding the effects of the gliadin protein. Fasano focuses primarily on treating celiac disease and has written several books on the subject.
Bill Davis advocates for not only a gluten-free diet but an entirely grain-free diet arguing all grains greatly contribute to autoimmune disease. However, no studies have been conducted proving his assertions; gluten only causes an issue if a person has a genetic predisposition, a leaky gut, a faulty immune system, and imbalanced gut microbes.
Alkaline eating is a food trend popularized by Honestly Healthy the work of Natasha Corrett who drew inspiration from Robert Young. The medical consensus is nothing a person can eat has the ability to change the alkaline pH of the blood.
Mills was strongly influenced by the book "The China Study" which was written by Colin Campbell who conducted a human study about the incident of disease in rural China which he believes to be connected directly to diet. Mills states more natural foods and vegetables can have powerful effects.
Mills has woven her personal life with her branding online, and this has greatly influenced her success as a food blogger and restaurant owner. Clean eating promises to make people healthier, but Giles worries it has led some people to a lifestyle of disordered eating.
Young believes his alkaline eating method can treat and reverse many different diseases including cancer; the California Medical Board conducted an investigation into Young's methods after a woman died while under his care from congestive heart failure. Young now faces a sentence of up to three years in prison.
After interviewing the world's modern clean eating gurus, Giles describes his concerns about what this pseudoscience is making people believe about food. The internet and food blogs have transformed how people interact with food.
Credits: Clean Eating
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Imagine if the food you choose to eat could "clean" your body and make you feel healthier. This film separates fact from pseudo-scientific fiction to unravel the diet conspiracy gripping the West: clean eating. Meet the biggest names behind this phenomena—people whose philosophies about food have influenced a generation, redefining what we think about the food we eat. In the world of clean eating, not everything is as it seems. Rather than improving physical and psychological wellbeing, is it actually doing the opposite?
Length: 53 minutes
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Chp6 Page 24
well, yeah, didn't you see the mug?
well, yeah, didn't you see the mug?
I like how the zombie assistant's expression is just like "Man this is an awkward conversation".
Oh, yes, Robert turned out VERY well adjusted xD Just ignore the bit about him killing himself. Opa, you..
Actually he was murdered, Schiten only thought he committed suicide.
Hmm…. I don't remember that being explicitly stated or even implied anywhere.
Where'd you get that from? (genuine curiosity)
I thought that was because Schtein tried to kill her. It was implied at the time of that flash back that Schtein's mother drove the father to suicide. She didn't deny it.
I also got the feeling from this page:
that James knows that Robert's death was not suicide. I bet a kid or a group of kids with telekinetic powers could make or help make a very convincing-looking suicide scene.
It's just struck me now how much Grandpa Orville bares a passing resemblance to Hunter Thompson.
He even has the sunglasses. I'm really glad you pointed this out.
What a cute Grinch like smile Opa gives. Adorable.
Is that a wedding band on Orville's hand? Nice!
What a charming smile! :D
I actually really like Schtein's Oppa. He's a nice, enthusiastic, pleasant man, and he holds tight to his morals. (Bearing in mind that his morals aren't the same as everybody else's morals.)
Actually, he reminds me a lot of my Grampa. Of course, my Grampa is a social justice activist, but he's also an eccentric physicist, and those expressions are JUST like what his would be if he was talking about work.
Oppa clearly is a fan of Nietzsche. (Fred, not Jack)
"Whoever has overthrown an existing law of custom has always first been accounted a bad man: but when, as did happen, the law could not afterwards be reinstated and this fact was accepted, the predicate gradually changed; – history treats almost exclusively of these bad men who subsequently became good men!"
giggles oh man that last expression opa makes seems like a tf2 expression
Opa is such a cute mad scientist.
Opa Schtein = what I imagine Medic might look like when he's 103 years old.
I'm diggin' the Opa. I think they need to make a screwball buddy film together while dominating the world. Somehow I don't think it'll work out quite that way, though.
Is that the Fan-Girl Zombie?
I like how Opa shows sadness at remembering his son. It looks like he really was proud of him and how he turned out, even if he seems to think he didn't do a very good job at raising him.
I like him. He's a lot more believable than other… "bad guys".
Don't feel like all your smarts are to belong to Opa, Doc. You could have just as easily 'wasted' all that improved intelligence by being coming a back ally junky or something similar. Unless he found away to genetically compel you to become a scientist, you are what you are because you chose to be. Opa just gave you the ability to choose.
^This. You have a very good point!
Thinking about it is the treatment what gave schiten the hipper-sensitive hands. Cus those gloves were injecting something into his arms and maybe his hands. Just saying
As always the German is great, though instead of "ein klein wenig" "ein bisschen" would be more grammatically correct :D
Every update is worth the wait. The facial expressions, the background details. Just beautiful. Even when it's fungus zombies. XD
Only after reading this a few times did I notice that Opa is in the process of removing his clothing. Here's hoping he's just taking off his jacket and gloves.
I really wish you would put translations of the german at the bottom of the page or something. It really makes it difficult to read. I always feel like I am missing something when I don't understand what is being said.
With all due respect, Tessie – if you're reading this on the intahtubes like the rest of us, and context isn't enough, you can always use http://translate.google.com (I actually have that as one of my search engine choices, so when I come across foreign language content that looks interesting, I just paste the phrase (or the actual url if the text is sourced, and not an image like with this comic) in the search slip and let google do the heavy lifting.
Stripping Orville. My prayers have been answered :D
I saw a guy that looked EXACTLY like Schtein, no joke. The resemblance was uncanny. I wanted to go up to him and ask to take a picture, but that would have been weird huh?
Speaking of
I take that the Gregory Jessup mentioned a few pages ago is the guy under the question mark?
And the new character here:
(commenter calls her "Ronnie"?) is the kid in the middle of the group photo?


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Saving the world is a big priority to the Avengers. They made sure that they are fully equipped and skilled before fighting Thanos. At the end, these superheroes managed to overcome the circumstances and knocked down Thanos. But do you know that these superheroes value education? I did some background check on them and it is very surprising that most of the Avengers have a high level of education. They know that education is power and is the passport for the future. So, check out the Avengers' biography and their education together with the list of universities recommendations in Malaysia if you are interested to pursue the same course with your superheroes.
Iron Man
Name: Iron Man
Real Name: Anthony Edward 'Tony' Stark
Height: 6'1, in armors 6'6
Eyes: Blue
Hair: Black
Those who are interested to study like this genius and billionaire, you can start with a bachelor degree in electrical engineering at this university.
University of Nottingham Malaysia
Bachelor of Electrical and Electronic Engineering
3 years
Entry Requirements
English: IELTS 6.0
A-Level/ STPM: BBB – including Mathematics & Physics
UEC: 2As in Mathematics and Physics & 3Bs excluding Bahasa Malaysia and Chinese
Annual Indicative Fees
Malaysian students: RM47,500
International students: RM55,500
For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
Spider Man
Name: Spiderman
Real Name: Peter Benjamin Parker
Height: 5'10"
Eyes: Hazel
Hair: Brown
Although in the Endgame movie Spiderman was still a highschool student, in the comic, he will grow up and earn a degree in Physics and doctoral studies in biochemistry. If you are wondering where you can learn more about in depth on Science subjects, I have prepared you a recommended university so you too can start learning like Spiderman!
Swinburne University of Technology
Bachelor of Science (Biotechnology)
3 years
March & September
Entry Requirements
English: IELTS 6.0
A-Level: 8
STPM: 2 passes
Prerequisite: Mathematics & Physics/Biology/Chemistry
Indicative Fees
Malaysian students: RM 31,888
International students: RM 40,664
For more information on the program and other enquiries on entry requirements, contact us 😃
Black Widow
Name: Black Widow
Real Name: Natasha Romanoff
Height: 5' 7"
Eyes: Blue
Hair: Red-auburn
Do you know that before Natasha became Black Widow, she was a ballet dancer? Apparently she has artistic skills and if you have the desire to pursue your passion in performing arts, go for it! The recommended university to pursue performing arts in Malaysia is:
Taylors' University
Bachelor of Performing Arts (Hons)
3 years
March & August
Entry Requirements
English: IELTS 5.0
A-Level: 2Es
UEC: 5Bs including English
Annual Indicative Fees
Malaysian students: RM 28,300
International students: USD$ 8,085
This course also requires you to go for an audition or interviews and submission of portfolio. But do not worry, we can help you! For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
Captain America
Name: Captain America
Real Name: Steven Rogers
Height: 6'2"
Eyes: Blue
Hair: Blond
This patriotic superhero, surprisingly, used to be an art student for one year before he got frozen. And according to Screen Rant, Steven Rogers was a fine arts student. If you are interested in unleashing your creativity through designing, the recommended university is below.
Lim Kok Wing
Bachelor of Design (Hons) in Professional Design (Visual Communication)
3 years
Ask us 😃
Entry Requirements
English: IELTS 5.0
A-Level/ STPM: GPA 2.0
Annual Indicative Fees
Malaysian & International students: Enquiry with us 😃
For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
Name: Thor
Real Name: Thor Odinson
Height: 6'6"
Eyes: Blue
Hair: Blond
Here's a thing, in the comic, Thor was very arrogant and selfish. His father, Odin, was angry at Thor and banished him to Earth as a lesson in humility in the form of Dr. Donald Blake. Shocking isn't it? The mighty Thor used to be a doctor. So, if you want to learn medicine and become a doctor like Dr. Donald Blake, the recommended university is below.
MAHSA University
Bachelor of Medicine & Bachelor of Surgery (MBBS)
Program Duration
5 years
Entry Requirements
English: IELTS 6.0
A-Level/ STPM: BBB, ABC or AAC in Biology & Chemistry & Physics/ Mathematics
UEC: B4 in Biology, Chemistry, Physics & Mathematics
Total Indicative Fees
For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
Pepper Pots
Pepper Pots may not be a superhero but she is no stranger in Marvel's world. She was a secretary to Tony Stark. Even the genius Iron Man knew that Pepper Pots is really good at her job and let her run his company, Stark Industries. Of course she is great at her work, she has a degree in Business. To be as competent as her, you can take a business course in the recommended university.
Taylor's University
Bachelor of Business (Hons)
Program Duration
3 years
March & August
Entry Requirements
English: IELTS 5.0
UEC: 5Bs in Mathematics & English
Total Indicative Fees
Malaysian students: RM 102,500
International students: USD$ 29,867
For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
Name: Groot
Height: I am Groot (Translation: 23',depends on the situation)
Eyes: I am Groot (Translation:Yellow)
Hair: I am Groot (Translation:None)
Allegedly, Groot was educated by tutors in his home planet, Planet X. But one thing for sure, Groot was protecting the ecosystem on his planet before he left it. So, if you desire to know more about our environment and help to protect our planet Earth just like Groot protecting his own planet, below is the university where you can study Environmental Science
University of Nottingham Malaysia
Bachelor of Environmental Science
3 years
Entry Requirements
English: IELTS 6.0
A-Level: BBC including 2 science subjects
STPM: BBB including 2 science subjects
UEC: 1A and 4 B3s including 2 science subjects
Annual Indicative Fees
Malaysian students: RM 39,500
International students: RM 46,000
For enquiries on other equivalent entry requirements that are not listed above, contact us 😃
If you have further enquiries on the mentioned universities or courses, do not hesitate to contact us. We would be more than happy to guide you into your dream universities because we love you 3000.
Did you find this helpful? If so Give us some Feedback! We are always finding news ways to improve. If you want to know more or ask us a question, please feel free to contact us any time!
Contact us to find out more
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Email: firstname.lastname@example.com
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Stephanie Calamba
Part time ACCA student, part time content writer but full time child of God.


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Remember the Fast Ferry connecting Rochester and Toronto? Although the idea failed in execution, connecting with the vibrant "Golden Horseshoe" economy made sense then—and still does today. When we compare Rochester to, say, Charlotte or Atlanta or Austin, we can always blame the snow. But that doesn't work when we look across the lake. What's their "secret sauce?"
We may be separated only by a bit of water and a line on a map, but it is clear that Canada's Golden Horseshoe Region, powered by Toronto, has prospered while Upstate New York (defined here as Rochester, Buffalo and Syracuse) has just held its own. Although these neighboring regions share much—that climate, access to markets, and transportation infrastructure—since 1996 the Golden Horseshoe added more than a third to its employment base and a quarter to its population.
Upstate has increased neither. Among the many explanatory variables, two policy differences stand out: Immigration and business taxes.
Give us your smart, your skilled . . .
Canadian voters and politicians understand that immigration is good for their economy. Adjusted for population, immigration to Canada in 2011 was more than twice that of the United States.
As the endless debate over immigration reform in Washington makes abundantly clear, we're much more ambivalent about the subject here in the U.S. Immigration, even if it was a formative force in the creation of our nation and culture, is still a mixed blessing. Yet economists largely agree that immigrants contribute more than they take. And some immigrants contribute much more.
The Canadians admit relatively more immigrants overall, but they also give preferential treatment to "economic immigrants," individuals who bring skill and education to their adopted workplace. Although the United States also grants preference to the skilled and educated, the quota is far smaller. In fact, in 2011 Canada admitted nearly 17,000 more immigrants on economic grounds than the United States, despite the tenfold difference in population. The rate of economic immigration to Canada was 4.5 per thousand residents v. 0.4 in the United States.
The Rochester region attracts many foreign nationals to our large and respected higher education community. Not only is this good for our higher education marketplace—which is a major industry in the Finger Lakes—but it also brings talent from around the globe to our community. Let's make it easier for them to stay after they've gotten an advanced degree from the University of Rochester or Rochester Institute of Technology. These bright, ambitious people have much to contribute.
Tax burden matters
Canada also boasts a favorable tax climate for business. The burden of taxation on business is not the only factor driving a firm's decision to locate in one locale or another, but it can be an important tipping factor. According to a study released by consultancy KPMG in 2012[*], the best tax climate for business overall was India. Ranked second was Canada, just ahead of China. Surprised? I've long assumed that the tax burden in Ontario was more onerous than it is here in New York.
Yet in a head-to-head competition between Buffalo and Toronto (Rochester wasn't included in the study), KPMG reports that business taxes in Toronto are two-thirds of Buffalo's. Taxation isn't the only factor influencing business location—if it were, New York City would be a ghost town. Nonetheless, the tax burden can tip the business location decision, assuming all other factors are comparable. KPMG's study tells us that from a business location perspective, Toronto has a better story to tell. Remember, too, that businesses in Ontario don't provide health care insurance, as do most big businesses here in New York.
What can we learn from Toronto?
Although many other factors are at work here, the Golden Horseshoe's formula includes a welcoming immigration policy and a favorable tax climate. And from the perspective of Upstate New York, it appears to be working.
What are the lessons for New York and the United States?
First, our ability to tax business is limited. The rhetorical battle over tax policy often focuses on what individuals and firms can afford to pay. As much as this may appeal to our sense of fairness, experience tells us that taxes affect behavior. Individuals and business firms are willing and able to take action to avoid or reduce taxation, including relocation.
Second, immigrants revitalize our economy; they don't threaten it. The stars are aligned for immigration reform. As Congress struggles with reform of the nation's immigration laws, it should expand access to the best and brightest of other nations. The colleges and universities of the United States, including the many highly respected institutions located in Upstate New York, are the world's most powerful magnet for smart young people from foreign lands. Some have suggested that a graduate diploma should automatically come with the right to work, that valuable "green card." Not only would this improve the nation's economy, it would help Upstate New York emulate the success of its neighbor to the north.


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|The Beauties, 2012, 33" by 46"
I remember when making it, I complained a lot since art quilts never come easy to me. By the time it was done, I totally hated it and thought OMG why did I bother? Still, it was chosen to represent the
And when Fall comes I hate to put them away.
The particulars for those that are into that kind of thing is that is that its made with commercial fabric, hand dyed and painted fabric by the artist. Rough edged appliqued and thread painted with wool, cotton, rayon and polyester thread. Its an original designed inspired by a wood block print. Here is the whole arduous journey.
I would also like to invite all you would be art quilters to share your journey on my weekly blog link up - Off the Wall Friday. Its a drop in easy going group and all are welcome.


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A Pilgrimage to Fatima, Lourdes & Spain with Fr. Lucien | Oct 16, 2023
Join Fr. Lucien on a Pilgrimage to Fatima, Lourdes & Spain, with Fr. Lucien starting at $3998 from Miami, Fl, on October 16, 2023. You will see St. Jerome's Monastery, Belem Tower, Basilica of the Star, April 25 Bridge, and the Marquee of Pombal Square, St. Stephens Church, Fatima, Plaza Mayor, the Cathedral de Avila, La Basilica de San Vicente, Lourdes, and more!
Celebrate Mass Daily when a Priest Travels
What's Included
- All Inclusive Pricing
- First Class Hotels
- Deluxe A/C Motor Coaches
- Fuel Surcharges and Gov't Taxes
- International Airfare
- Entrance and Program Fees
- Guided Tours
- Overseas Airport Transfers
- Domestic Airfare
- Gratuities
- Select Meals on Itinerary
Daily Itinerary
Day 1 October 16 - Depart USA
Depart on your international overnight flight to Lisbon, Portugal.
Day 2 October 17 - Arrive Lisbon
Upon landing at Lisbon airport, you will be met by your tour guide and driver. Enjoy a panoramic tour of Lisbon, which will include St. Jerome's Monastery, built to give thanks to the Virgin Mary. Drive by the Belem Tower and many landmarks, like; the Basilica of the Star, the 25th of April Bridge, and the Marquee of Pombal Square. Visit St. Anthony's Church. The patron saint of lost things is best known as St. Anthony of Padua (Italy), but he was born and baptized here in Lisbon, Portugal. Celebrate Mass in the Church built on the site of St. Anthony's birth. Check in to your hotel in Lisbon for dinner and overnight. Overnight: Lisbon
Day 3 October 18 - Lisbon - Santarem - Fatima
Journey to Fatima. On the way, stop at St. Stephens Church in the town of Santarem to celebrate Mass and revere the 13th-century Eucharistic Miracle. On the way to Fatima, visit the hamlet of Aljustrel, the birthplace, and home of the three shepherd children. Check in to your hotel in Fatima for dinner and overnight. Overnight: Fatima
Day 4 October 19 - Fatima
Have a memorable experience as you pray and meditate at one of Our Blessed Mother's apparition sites. Our Lady appeared to three shepherd children; Lucia (age 10), Jacinta (age 7), and Francisco (age 9). These apparitions occurred monthly from May until October 1917. The most important message from Our Lady of Fatima was to pray for world peace. Our reflective day begins with a visit to the Little Chapel of the Apparitions, simple yet modern, which is the site where the Virgin Mary first appeared on May 13, 1917. Follow with a visit to the stunning Basilica of Our Lady of the Rosary. This Sacred space contains the tombs of St. Francisco, St. Jacinta, and Sister Lucia. View the monument that commemorates the Sacred Heart of Jesus in the square. Our Lady's messages included consistent reminders to pray the Rosary - the Basilica honors this by featuring fifteen altars dedicated to the fifteen mysteries of the Rosary. Visit the Holy Trinity Basilica. After free time for lunch, experience Christ's unconditional love by participating in the Stations of the Cross along the Via Sacra. "The Sacred Way" marks the path of the shepherd children. End your day with a visit to Valinhos, the site of Our Lady's August 19, 1917 Apparition, which was also the first and third apparition of the Angel. Spend time this evening in private devotions and a candlelight procession. Return to your hotel in Fatima for dinner and overnight. Overnight: Fatima
Day 5 October 20 - Fatima - Salamanca
Travel to Salamanca, a city in the Castilla y Leon region known for its large university, the oldest in Spain, that is still active along with its prominent culture. Your walking tour will bring pass by the grand Plaza Mayor, an iconic square filled with food, shopping, and city events. La Clerecia, a church and college of the Jesuit Order constructed in the seventeenth century. La Casa de las Conchas is currently a public library and monument decorated with shells that symbolize the famous pilgrimage to Santiago (El Camino). The Roman Bridge is a national monument that extends along the River Tormes and is among Salamanca's sturdiest bridges. La Iglesia de San Marcos, constructed in the Romanesque style, contains breathtaking paintings that portray many scenes of Our Lady's life. La Iglesia de San Martin is a Church devoted to St. Martin de Porres, the patron saint of mixed-race people and all those seeking interracial harmony. Visit the inside of the two joint Salamanca Cathedrals (old and new), one Romanesque style and the other Gothic style. Check in to your hotel in Salamanca for dinner and overnight. Overnight: Salamanca
Day 6 October 21 - Salamanca - Alba de Tormes - Avila - Burgos
Board the bus this morning and enjoy a short transfer to the village of Alba de Tormes. This town is home to the Carmelite Monastery that Saint Teresa founded in 1571. Upon arrival in Alba de Tormes, celebrate Mass at the Monastery where she died and was buried. Following Mass, you will have the opportunity to visit the museum dedicated to St. Teresa of Avila, which also holds her incorrupt heart and left arm. Enjoy free time for lunch on your own before continuing to the medieval city of Avila. In Avila, you will immediately notice the perfectly preserved eleventh-century walls surrounding the old town. The Cathedral de Avila encompasses the Romanesque, Gothic, and Renaissance styles of its time with its artwork and architecture. La Basilica de San Vicente in Avila stands on the site of the martyrdom of St. Vincent. Visit the Incarnation Convent, where St. Teresa became a nun. Saint Teresa convinced Saint John of the Cross to reform the male Carmelite order, the reform she started when she met Saint John in Medina del Campo. After walking in the footsteps of St. Teresa, continue your journey to Burgos. Upon arrival in the historic capital of Old Castile, enjoy dinner. Following dinner, you will have the opportunity to explore the city of Burgos and admire its magnificent limestone gothic-style Cathedral. Check in to your hotel in Burgos and enjoy some rest. Overnight: Burgos
Day 7 October 22 - Loyola - Lourdes
Following breakfast, transfer from Burgos to Loyola to visit the birthplace of St. Ignatius, founder of the Jesuit Order. St. Ignatius dedicated himself to becoming a soldier of the Christian faith, and as a result of many tribulations, he wrote the ever-famous Spiritual Exercises. In Loyola, you will see the 17th-century Basilica dedicated to this remarkable saint - the Basilica is part of a series of buildings surrounding the "Holy House," or birthplace of St. Ignatius. When you visit these Holy places, you will also have the opportunity to pray in the most venerated room, where St. Ignatius prayed and began his conversion. After meditating on the life of this founder of the Jesuit Order, enjoy free time for lunch. We will continue to Lourdes for a spectacular view of the Pyrenees Mountains. Upon arrival in Lourdes, check in to your hotel for dinner and overnight. Overnight: Lourdes
Day 8 October 23 - Lourdes
Over the next two days, you will stay in a small town nestled within the Pyrenees Mountains. During your time in Lourdes, you will pray and meditate in yet another site of Our Lady's apparitions. Our Lady first appeared to Bernadette in 1858 and announced herself as "The Immaculate Conception" near the Grotto of Massabielle. During the first two apparitions, little Bernadette prayed the Rosary with Our Lady. She left without exchanging any words. During the following apparitions, Our Lady emphasized God's love for us and the necessity of performing acts of penance for sinners. Throughout your time in Lourdes, you will have the opportunity to attend Mass at the Grotto, where Our Lady appeared to Bernadette.
Day 9 October 24 - Lourdes
You have opportunities to watch a video presentation explaining Lourdes's story; drink water from the miraculous spring that has healed many, or submerge yourself in the healing baths. You will have the opportunity to experience Christ's unconditional love as you meditate upon the "life-size" Stations of the Cross that overlook the Grotto of Massabielle. You will walk in and meditate upon the footsteps of St. Bernadette. You will have the opportunity to see Boly Mill, the birthplace of St. Bernadette, and the "Cachot," an abandoned prison where Bernadette's impoverished family lived. Each evening following dinner, you will have an opportunity to attend the candlelight procession and the Rosary before a restful overnight. Overnight: Lourdes
Day 10 October 25 - Return to USA
Return home with memories of the people and places of our Pilgrimage to Fatima & Lourdes.
Departure Dates
Monday, October 16, 2023From $3998 Sold Out!


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I haven't had a chance to be there but my guides Ben, Steve, Adam, Troy and Mary Ann have been a lot lately and all are reporting very good caddis hatches, mixed with some PMD and PED's and the occasional Hopper take. It may be the best dry fly summer ever in the WS to TC area.
Nymph fishing with Girdle Bugs and Sparkle Pupa's has been stellar. We are also getting a lot of trout on Jigs, 2 Bit Hookers and Micro Mayflies. A Wired Stone and a Rusty Magic Fly is a great combo in the riffles in the AM.
I've been watching water temps at WS and at the Mouth. The last couple of days the Mouth has been well under 70 and that is great news for the small steelhead run coming in. It appears the cold water release has begun…
In any event, the water is 2 or 3 degrees cooler and that is great, especially from Mack's to the Mouth.


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The Wildfong Family
We'd like to take this opportunity to introduce our family, Steve, Anne, Stephanie, Tyler and Jakob. We have always enjoyed nature and the simple things in life. For over 17 summers when the kids were growing up, we have traveled extensively throughout North America with our family in a pop up tent trailer. Our love of the great outdoors led us to the purchase of Lake Edge Cottages in 2019 where we have the ability to share our love of nature with others.
Steve was born in London, ON and raised in Leamington, ON. Anne was born in Trinidad & Tobago and was raised in Preston (now Cambridge) ON. We both attended Wilfrid Laurier University which is where we met. We lived in Waterloo, and later moved to Toronto where we raised our family.
Providing guests of Lake Edge Cottages with fun, rests and relaxation while getting away from it all is important to us. We look forward to your visit where you can experience a memorable and enjoyable stay at Lake Edge.
The Wildfongs