Stormy weather floods roadways, knocks out power for thousands

The Bay Area enjoyed a brief respite from the rain Friday afternoon after the latest storm battered the region in the early morning hours, knocking out power, tying up traffic and flooding some stretches of highway.

The heaviest rainfall has been recorded in the North Bay, according to a National Weather Service forecaster.

The storm system moved southeast through the Bay Area late Friday morning and is expected to soak the entire region for the rest of the day, forecaster Diana Henderson said.

In the past 24 hours, parts of Sonoma County saw more than 7.5 inches of rain while the Santa Cruz Mountains were deluged with 7 inches.

Areas in Napa County received nearly 6 inches, according to Henderson. Rainfall in the past day was recorded at 4.33 inches in Calistoga.

"It's not a superstorm by any measure, but this is pretty significant," Henderson said. "We should see periods of moderate to heavy rains."

With rain expected all weekend long, Tony Negro, a contractor from Penngrove, Calif., in Sonoma County, said Friday that he is worried about more flooding seeping inside his workshop.

"I'm on my way to get some sand bags," he said.

In downtown San Francisco, 1.44 inches of rain was recorded with an additional half inch measured at San Francisco International Airport, Henderson said.

Parts of the Peninsula and the South Bay received more rain, with 3.67 inches falling at Pescadero Creek, 4.88 inches in Loma Prieta and a 7.48 inches of measured rainfall at Mt. Umunhum.

Henderson said more severe weather is expected to affect the region's more mountainous areas and some areas along the coast.

Just before 11:30 a.m., an urban and small stream flood advisory was issued for all Bay Area counties until 2:30 p.m. because of many reports of flooded streets, highways, underpasses and small creeks.

A flash flood warning is in effect for the Monterey Bay area, while the rest of the Bay Area is under a flash flood watch through the weekend, Henderson said.

"It's a heads up basically that conditions are ripe," she said.

A wind advisory expired at 2 p.m. Friday afternoon for the San Francisco and Monterey Bay areas, with strongest winds expected along the coast.

Henderson said wind was more prevalent overnight. Gusts became more benign late Friday morning at about 10 mph, she said.

Because of the storm, the California Highway Patrol has reported an abundance of flooded roadways throughout the region Friday morning.

The National Weather Service issued a flash flood warning for Sonoma County where Highway 121 was closed by flooding near the Sonoma Creek. A sig-alert issued indicated the highway would remain closed due to flooding between CA-116 and Arnold Drive and 8th Street until at least 4:30 p.m. Friday afternoon.

Interstate Highway 580 in and around Livermore was particularly impacted by the storm.

Several lanes of eastbound I-580 were blocked for several hours starting at 11:13 p.m. after a collision between two tractor-trailers near Greenville Road that caught fire.

Later, a major big-rig accident on westbound I-580 in Pleasanton shut down traffic completely.

The big-rig driver lost control of his vehicle after hitting a puddle at around 2 a.m., skidding across all lanes and colliding with the center freeway barrier.

The CHP said the driver was uninjured, but the accident closed all westbound lanes for hours. The proximity to the 580/680 interchange allowed the CHP to detour drivers around the blockage, but coupled with the inclement weather traffic was backed up significantly.

Crews were in the final stages of cleaning up after the accident at 5:30 a.m. Lanes reopened at around 6:15 a.m.

However, a third trailer-rig crash in Livermore on westbound I-580 that left one of the vehicle's two trailers flipped on its back and blocking all but one lane of traffic shortly after 6 a.m. It was several hours before traffic returned to normal after lanes were reopened.

Elsewhere, three left lanes of southbound U.S. Highway 101 in San Francisco were blocked for nearly two hours by an injury accident near the Cesar Chavez Street off-ramp in San Francisco at about 2:49 a.m.

In the North Bay, a vehicle got stuck this morning at Ross Station Road at Ross Branch Road near Sebastopol, while other flooded roadways have been reported at Rohnert Park Expressway at Stony Point near Santa Rosa.

In Hayward, heavy flooding was reported along A Street this morning, while in Fairfield the westbound Interstate Highway 80 Air Base Parkway off-ramp was reportedly completely flooded.

Near Woodside, there was a foot of water reported on Interstate Highway 280 at Woodside Road.

In Sacramento, Interstate 5 south of downtown was blocked in both directions before 9 a.m. Friday after an empty big-rig jackknifed in the southbound lanes and struck the median divider, the CHP said.

"I would definitely say it's weather-related. The reports came in that he hit a water puddle and hydroplaned and couldn't correct," CHP Officer Mike Bradley said. "A lot of high-profile vehicles, especially the lighter ones, are getting windblown and having some problems maintaining their lane."

No one was injured in the crash on I-5, California's main north-south highway. But a second vehicle also was damaged and had to be towed, while workers contained and cleaned up diesel fuel spilled from the tractor-trailer.

In West Sacramento, police say wet conditions may have been a factor when a PG&E worker died after he lost control of his vehicle and slammed into a traffic pole shortly before 2 a.m. Friday.

PG&E workers at the scene tell KCRA-TV that the driver had been working overtime and was returning from Clarksburg in southern Sacramento County.

The weather also caused power outages throughout the region.

About 2,800 PG&E customers in the Bay Area are still without power Friday evening because of storm-related outages, a utility spokesman said.

The affected customers include 1,500 in the North Bay, 400 along the Peninsula, 800 in the East Bay, 50 in the South Bay and 50 in San Francisco, PG&E spokesman Fiona Chan said.

An additional 1,200 customers are without power in the Santa Cruz Mountains as well as just over 1,200 others in Santa Cruz and Monterey counties, Chan said.

The storm had caused outages to nearly 16,000 Bay Area PG&E customers at its peak overnight, according to PG&E.

At San Francisco International Airport, 60 flights -- 30 arrivals and 30 departures -- have been canceled this morning, airport duty manager Joe Walsh said.

The cancellations, which started early this morning, will continue to affect flights until about noon, Walsh said.

A delay program is in place at the airport until the end of the day, Walsh said.

He advised passengers check with their airlines before arriving at the airport.

In the East Bay, there has been only one flight canceled Friday morning out of Oakland International Airport, an airport operations employee said.

No flight delays have been reported there.

Mineta San Jose International Airport has no cancellations or delays because of the weather, airport spokeswoman Rosemary Barnes said.

The forecaster Henderson said steady rain is expected to fall through the end of the weekend.

Source: http://www.ktvu.com/news/news/local/storm-raises-havoc-morning-commute/nTJ54/

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Vampire on the loose in Serbia?

In this Nov. 30, 2012 photo Milka Prokic is seen at twilight with a garland of garlic and a wooden stake, in the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

In this Nov. 30, 2012 photo Milka Prokic is seen at twilight with a garland of garlic and a wooden stake, in the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

In this Nov. 30, 2012 photo villager Mico Matic, displays garlic that he carries in his pockets, in the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

In this Nov. 30, 2012 photo is a church seen at twilight in the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

In this Nov. 30, 2012 photo a billboard showing an impression of the legendary ghost Sava Savanovic. The poster reads "First Serbian vampire", near the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

In this Nov. 30, 2012 photo a woman walks on the road, in the village of Zarozje, near the Serbian town of Bajina Basta. Get your garlic, wooden crosses and stakes ready: a bloodsucking vampire is on the loose. Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between the lush green mountain slopes and spooky thick forests. Rumors that a legendary vampire ghost has returned are spreading panic throughout the town. An official warning telling villagers to put garlic in their pockets and place wooden crosses in each of their rooms, the tools that should keep away the vampires did nothing but fuel the fear. (AP Photo/Darko Vojinovic)

(AP) ? Get your garlic, crosses and stakes ready: a bloodsucking vampire is on the loose.

Or so say villagers in the tiny western Serbian hamlet of Zarozje, nestled between lush green mountain slopes and spooky thick forests. They say that rumors that a legendary vampire ghost has awakened are spreading fear ? and a potential tourist opportunity ? through the remote village.

A local council warned villagers to put garlic in their pockets and place wooden crosses in their rooms to ward off vampires, although it appeared designed more to attract visitors to the impoverished region bordering Bosnia.

Many of the villagers are aware that Sava Savanovic, Serbia's most famous vampire, is a fairy tale. Still, they say, better to take it seriously than risk succumbing to the vampire's fangs.

"The story of Sava Savanovic is a legend, but strange things did occur in these parts back in the old days," said 55-year-old housewife Milka Prokic, holding a string of garlic in one hand and a large wooden stake in another, as an appropriately moody mist rose above the surrounding hills. "We have inherited this legend from our ancestors, and we keep it alive for the younger generations."

Vampire legends have played a prominent part in the Balkans for centuries ? most prominently Dracula from Romania's Transylvania region. In the 18th century, the legends sometimes triggered mass hysteria and even public executions of those accused of being vampires.

Sava Savanovic, described by the Zarozje villagers as Serbia's first vampire, reputedly drank the blood of those who came to the small shack in the dense oak tree forest to mill their grain on the clear mountain Rogatica river.

The wooden mill collapsed a few months ago ? allegedly angering the vampire, who is now looking for a new place to hang his cape.

Some locals claim they can hear steps cracking dry forest leaves and strange sounds coming from the rocky mountain peaks where the vampire was purportedly killed with a sharp stake that pierced his heart ? but managed to survive in spirit as a butterfly.

"One should always remain calm, it's important not to frighten him, you shouldn't make fun of him," said villager Mico Matic, 56, whose house is not far from the collapsed mill.

"He is just one of the neighbors, you do your best to be on friendly terms with him," he said with a wry smile, displaying garlic from both of his trouser pockets.

Some locals say it's easy for strangers to laugh at them, but they truly believe.

"Five people have recently died one after another in our small community, one hanging himself," said Miodrag Vujetic, a local municipal council member. "This is not by accident."

Vujetic, however, said that "whatever is true about Sava," locals should use the legend to promote tourism.

"If Romanians could profit on the Dracula legend with the tourists visiting Transylvania, why can't we do the same with Sava?"

Richard Sugg, a lecturer in Renaissance Studies at the U.K.'s University of Durham and an expert on the vampire legends, said the fear could be very real. Stress can bring on nightmares, which makes people's feelings of dread even worse.

"The tourists think it is fun ? and the Serbian locals think it's terrifying," he said.

Associated Press

Source: http://hosted2.ap.org/APDEFAULT/3d281c11a96b4ad082fe88aa0db04305/Article_2012-12-01-Serbia-Vampire%20On%20The%20Loose/id-1870db98510544f2890d4b4d37a231ea

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Verizon best, AT&T worst in Consumer Reports carrier survey

1 day

Consumer Reports' annual ratings of wireless providers, released Thursday, shows that the major cellphone companies still have a lot of work to do to boost customer satisfaction.

In fact, none of the big four national carriers had an overall satisfaction score above 72 percent, across the board lower than their overall scores from just two years ago. Consumer Reports says cellphone companies remain among the lowest-rated service providers it evaluates.

We pay a lot for our cellphones and wireless services and we expect a lot in return: rock-solid voice connections, seamless data downloads and world-class customer service. But apparently we don?t always feel that we?get it.

Verizon topped the list of major carriers in this year?s subscriber survey, followed by Sprint, T-Mobile and AT&T. The rankings are based on responses from 63,000 readers.

?Verizon stands out from the pack if you are a heavy-duty data user,? said Mike Gikas, senior electronics editor at Consumer Reports. ?They?re the Cadillac network. They?re pricey in some respects, but in terms of overall quality of service and availability of service, they are the overall leader.?

This confirms what J.D. Power and Associates found in its 2012 Wireless Network Quality Performance Study released in August: Verizon is consistently better than the average wireless carrier and much better than most of its competitors.

But your satisfaction can depend on where you live. The Consumer Reports survey looked at 23 metropolitan areas. It found the quality of cell service can vary from place to place. For example, Sprint is virtually tied with Verizon in St. Louis, but in last place (significantly below AT&T) in Chicago.

It?s interesting to note that three smaller companies had the highest marks for customer satisfaction in the Consumer Reports survey: Consumer Cellular, U.S. Cellular and Credo Mobile. U.S. Cellular, the biggest of this group (with service in 24 mostly Midwestern states), earned a reader score of 88 percent.

?They also offer an excellent experience for consumers and an affordable one, especially if you?re looking for a family plan,? Gikas said.

One group that was happier than most: AT&T, Sprint and T-Mobile subscribers who have smartphones that connect to 4G networks. They were consistently more satisfied than customers with 3G service. In fact, when it comes to 4G service, AT&T had the fewest problems of any carrier.

?AT&T has been a basement dweller for several years now. A lot of people are unhappy with the service, except 4G customers. They seem to like the service from AT&T,? Gikas told me.

A tough bunch to please
People?s expectation of good service is much higher than it was just a few years ago.

??They expect their smartphone to do whatever it?s supposed to do every time,? said Kirk Parsons, senior director of wireless services at J.D. Power and Associates.

Smartphone users practically live with the device in their hands. They notice the difference between a connection that takes a second and a fraction of a second. And when something goes wrong, they?re likely to hold a grudge against the company.

The ads promise more and we assume our cellphone company to deliver. For example, subscribers with 4G phones expect those high-speed connections everywhere they go. But 4G service isn?t available everywhere.?

?If you travel, there are still a lot of open patches where 4G is not available,? Parsons noted. ?That frustrates people who want the service wherever they go.?

The potential downside of higher speeds
Consumer Reports cautions that faster phones can result in higher bills. It?s fun to use your phone to play online games and watch streaming video, but if you?re not careful you can really burn through the megabytes.

?Your monthly bill will double with a smartphone,? Gikas said.

And just as more people are upgrading to smartphones, Verizon and AT&T, the country?s two biggest wireless companies, no longer offer unlimited data plans to new customers.

As these ?all-you-can-eat? data plans disappear, some heavy users may find that they go through their monthly allowance a lot sooner than expected.

A cheaper way to go
If you?re looking to spend less on cellphone service, consider a prepaid plan with no monthly service contract. The rates are lower, the phones have gotten better ? you now have a greater choice of smartphones ? and Consumer Reports survey shows that customer satisfaction is relatively high.?

You will pay more for the phone because there is no subsidy from the carrier. With the typical 2-year contract, the cost of that phone is rolled into your monthly rate. With prepaid service, you buy the phone upfront, so your monthly rate is lower.

?Over the course of about two years, you?ll end up paying less,? Gikas noted.

Consumer Reports? top-rated prepaid carrier is TracFone. It offers inexpensive plans for people who don?t use their cell phone very often.

The editors say Straight Talk and Virgin Mobile are standouts for budget smartphones. They offer low-cost, unlimited plans for voice, text and data.

Herb Weisbaum is The ConsumerMan. Follow him on Facebook and Twitter?or visit The ConsumerMan website.

Source: http://www.nbcnews.com/technology/technolog/verizon-best-att-worst-consumer-reports-carrier-survey-1C7319906

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Ukraine fights spreading HIV epidemic

BUCHA, Ukraine (AP) ? Andrei Mandrykin, an inmate at Prison No. 85 outside Kiev, has HIV. He looks ghostly and much older than his 35 years. But Mandrykin is better off than tens of thousands of his countrymen, because is he receiving treatment amid what the World Health Organization says is the worst AIDS epidemic in Europe.

Ahead of World AIDS Day on Saturday, international organizations have urged the Ukrainian government to increase funding for treatment and do more to prevent HIV from spreading from high-risk groups into the mainstream population, where it is even harder to manage and control.

An estimated 230,000 Ukrainians, or about 0.8 percent of people aged 15 to 49, are living with HIV, the virus that causes AIDS. Some 120,000 are in urgent need of anti-retroviral therapy, which can greatly prolong and improve the quality of their lives. But due to a lack of funds, fewer than a quarter are receiving the drugs ? one of the lowest levels in the world.

Ukraine's AIDS epidemic is still concentrated among high-risk groups such as intravenous drug users, sex workers, homosexuals and prisoners. But nearly half of new cases registered last year were traced to unprotected heterosexual contact.

"Slowly but surely the epidemic is moving from the most-at-risk, vulnerable population to the general population," said Nicolas Cantau of The Global Fund to Fight AIDS, Tuberculosis and Malaria, who manages work in Eastern Europe and Central Asia. "For the moment there is not enough treatment in Ukraine."

Stigma is also a big problem for those with HIV in Ukraine. Liliya, a 65-year-old woman who would give only her first name, recently attended a class on how to tell her 9-year-old great-granddaughter that she has HIV. The girl, who contacted HIV at birth from her drug-abusing mother, has been denied a place in preschool because of her diagnosis.

"People are like wolves, they don't understand," said Liliya. "If any of the parents found out, they would eat the child alive."

While the AIDS epidemic has plateaued elsewhere in the world, it is still progressing in Eastern Europe and Central Asia, according to Cantau. Nearly 21,200 new cases were reported in Ukraine in 2011, the highest number since the former Soviet republic registered its first case in 1987, and a 3 percent increase over 2010. As a result of limited and often delayed treatment, the number of AIDS-related deaths grew 17 percent last year to about 3,800.

Two years ago, Mandrykin, the prisoner, was on the verge of becoming part of that statistic, with his level of crucial CD4 immune cells ? a way to measure the strength of the immune system ? dropping to 11. In a healthy person, the CD4 count is usually over 600.

"I was lying in the hospital, I was dying," said Mandrykin, who is serving seven years for robbery, his fourth stint in jail. "It's a scary disease."

After two years of treatment in a small prison clinic, his CD4 count has risen to 159 and he feels much better, although he looks exhausted and is still too weak to work in the workshop of the medium-security prison.

The Ukrainian government currently focuses on testing and treating standard cases among the general population. The anti-retroviral treatment of more than 1,000 inmates, as well as some 10,000 HIV patients across Ukraine who also require treatment for tuberculosis and other complications and all prevention and support activities, are paid for by foreign donors, mainly the Global Fund.

The Global Fund is committed to spending $640 million through 2016 to fight AIDS and tuberculosis in Ukraine and then hopes to hand over most of its programs to the Ukrainian government.

Advocacy groups charge that corruption and indifference by government officials help fuel the epidemic.

During the past two years, Ukrainian authorities have seized vital AIDS drugs at the border due to technicalities, sent prosecutors to investigate AIDS support groups sponsored by the Global Fund and harassed patients on methadone substitution therapy, prompting the Global Fund to threaten to freeze its prevention grant.

Most recently, Ukraine's parliament gave initial approval to a bill that would impose jail terms of up to five years for any positive public depiction of homosexuality. Western organizations say it would make the work of AIDS prevention organizations that distribute condoms and teach safe homosexual sex illegal and further fuel the epidemic. It is unclear when the bill will come up for a final vote.

AIDS drug procurement is another headache, with Ukrainian health authorities greatly overpaying for AIDS drugs. Advocacy groups accuse health officials of embezzling funds by purchasing drugs at inflated prices and then pocketing kickbacks.

Officials deny those allegations, saying their tender procedures are transparent.

Much also remains to be done in Ukraine to educate people about AIDS.

Oksana Golubova, a 40-year-old former drug user, infected her daughter, now 8, with HIV and lost her first husband to AIDS. But she still has unprotected sex with her new husband, saying his health is in God's hands.

"Those who are afraid get infected," Golubova said.

Source: http://news.yahoo.com/ukraine-fights-spreading-hiv-epidemic-112653647.html

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The Consulting Sales Strategy That Works: Book Review | Business ...

There are many books written on the topic of sales. Yet few are quite like this one.

In The Art of the Sale: Learning from the Masters About the Business in Life (published by the Penguin Press), Philip Delves Broughton takes an approach unlike most.

His goal is not to provide the reader with a specific strategy or method for sales.

In fact, from his interviews with top sales people around the world you get the sense that there is no single sales method that works.

Instead, sales is about mindset, determination, and knowing how to satisfy the needs of the customer.

Delves Broughton has hit a homerun with this book.

Good sales people know how to recover from a setback.

It?s an enjoyable read. Filled with stories and interviews. Here you get to access the inner workings of top salespeople from the US, Japan, Europe and more.

As a reader of this blog, I encourage you to get a copy of this book (available on Amazon here).

Here are a few of my favorite points and quotes from the book:

  • Listening is selling?s golden rule.
  • The way to develop excellent habits is through constant repetition of thought and action.
  • Optimism can be learned.
  • Good sales people know how to recover from a setback.
  • Focus on a small market first and win them over before going to a larger market.
  • To make the sale you must really understand what drives your customer.
  • The sales process cannot be rushed. If it is, you most often lose the sale.

My copy of the book is now officially marked up with notes, ideas and bent pages.

This is probably one of the best books on sales I?ve read?and I?ve read many. I hope you?ll enjoy it as much as I did.

Check out our fully updated Consulting Success System! Learn More and Buy Now.

Source: http://www.consulting-business.com/the-consulting-sales-strategy-that-works-book-review.html

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Kerosene lamps identified as big source of black carbon

ScienceDaily (Nov. 28, 2012) ? The primary source of light for more than a billion people in developing nations is also churning out black carbon at levels previously overlooked in greenhouse gas estimates, according to a new study led by researchers at UC Berkeley and the University of Illinois.

Results from field and lab tests found that 7 to 9 percent of the kerosene in wick lamps -- used for light in 250-300 million households without electricity -- is converted to black carbon when burned. In comparison, only half of 1 percent of the emissions from burning wood is converted to black carbon.

Factoring in the new study results leads to a twenty-fold increase in estimates of black carbon emissions from kerosene-fueled lighting. The previous estimates come from established databases used by the Intergovernmental Panel on Climate Change and others. One kilogram of black carbon, a byproduct of incomplete combustion and an important greenhouse gas, produces as much warming in a month as 700 kilograms of carbon dioxide does over 100 years, the authors said.

"The orange glow in flames comes from black carbon, so the brighter the glow, the more black carbon is being made," said study principal investigator Tami Bond, associate professor of civil and environmental engineering at the University of Illinois at Urbana-Champaign. "If it's not burned away, it goes into the atmosphere."

The findings, published online this month in the journal Environmental Science & Technology, are coming out at the same time that the United Nations Climate Change Conference kicks off in Doha, Qatar. While officials from around the world are seeking effective policies and guidelines for cutting greenhouse gas emissions, the study authors note that the simple act of replacing kerosene lamps could pack a wallop toward that effort.

"There are no magic bullets that will solve all of our greenhouse gas problems, but replacing kerosene lamps is low-hanging fruit, and we don't have many examples of that in the climate world," said study co-author Kirk Smith, professor at UC Berkeley's School of Public Health and director of the Global Health and Environment Program. "There are many inexpensive, cleaner alternatives to kerosene lamps that are available now, and few if any barriers to switching to them."

Smith pointed to lanterns with light-emitting diodes that can be powered by solar cells or even advanced cookstoves that generate electricity from the heat produced. Such technology, said Smith, is already available in developing countries.

The researchers used kerosene lamps purchased in Uganda and Peru and conducted field experiments there to measure the emissions. They repeated the tests in the lab using wicks of varying heights and materials, and kerosene purchased in the United States as well as in Uganda.

The study authors noted that converting to cleaner light sources would not only benefit the planet, it would help improve people's health. A recent epidemiological study in Nepal led by Smith and other researchers at UC Berkeley's School of Public Health, for example, found that women who reported use of kerosene lamps in the home had 9.4 times the rate of tuberculosis compared with those who did not use such lamps.

"Getting rid of kerosene lamps may seem like a small, inconsequential step to take, but when considering the collective impact of hundreds of millions of households, it's a simple move that affects the planet," said study lead author Nicholas Lam, a UC Berkeley graduate student in environmental health sciences.

The Centers for Disease Control and Prevention, National Institute of Environmental Health Sciences, U.S. Agency for International Development and Environmental Protection Agency helped support this research.

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Story Source:

The above story is reprinted from materials provided by University of California - Berkeley.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.


Journal Reference:

  1. Nicholas Lam, Yanju Chen, Cheryl Weyant, Chandra Venkataraman, Pankaj Sadavarte, Michael Johnson, Kirk R. Smith, Benjamin Brem, Joseph Arineitwe, Justin Ellis, Tami Bond. Household Light Makes Global Heat: High Black Carbon Emissions From Kerosene Wick Lamps. Environmental Science & Technology, 2012; : 121119133048006 DOI: 10.1021/es302697h

Note: If no author is given, the source is cited instead.

Disclaimer: Views expressed in this article do not necessarily reflect those of ScienceDaily or its staff.

Source: http://feeds.sciencedaily.com/~r/sciencedaily/top_news/~3/vsJWMHXt52c/121128183055.htm

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Infectious Complications in Head and Neck Cancer Patients Treated with Cetuximab: Propensity Score and Instrumental Variable Analysis

BackgroundTo compare the infection rates between cetuximab-treated patients with head and neck cancers (HNC) and untreated patients.MethodologyA national cohort of 1083 HNC patients identified in 2010 from the Taiwan National Health Insurance Research Database was established. After patients were followed for one year, propensity score analysis and instrumental variable analysis were performed to assess the association between cetuximab therapy and the infection rates.ResultsHNC patients receiving cetuximab (n?=?158) were older, had lower SES, and resided more frequently in rural areas as compared to those without cetuximab therapy. 125 patients, 32 (20.3%) in the group using cetuximab and 93 (10.1%) in the group not using it presented infections. The propensity score analysis revealed a 2.3-fold (adjusted odds ratio [OR]?=?2.27; 95% CI, 1.46?3.54; P?=?0.001) increased risk for infection in HNC patients treated with cetuximab. However, using IVA, the average treatment effect of cetuximab was not statistically associated with increased risk of infection (OR, 0.87; 95% CI, 0.61?1.14).ConclusionsCetuximab therapy was not statistically associated with infection rate in HNC patients. However, older HNC patients using cetuximab may incur up to 33% infection rate during one year. Particular attention should be given to older HNC patients treated with cetuximab.

Ching-Chih Lee1,2,3,6, Hsu-Chueh Ho1,3,6, Shih-Hsuan Hsiao1,3,6, Tza-Ta Huang7, Hon-Yi Lin3,5,6, Szu-Chin Li3,4,6, Pesus Chou2, Yu-Chieh Su3,4,6*

1 Department of Otolaryngology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, 2 Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan, 3 Cancer Center, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, 4 Division of Hematology-Oncology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, 5 Department of Radiation Oncology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, 6 School of Medicine, Tzu Chi University, Hualien, Taiwan, 7 Department of Oral and Maxillofacial Surgery, Changhua Chritian Hospital, You-Lin Branch, You-Lin, Taiwan

Background

To compare the infection rates between cetuximab-treated patients with head and neck cancers (HNC) and untreated patients.

Methodology

A national cohort of 1083 HNC patients identified in 2010 from the Taiwan National Health Insurance Research Database was established. After patients were followed for one year, propensity score analysis and instrumental variable analysis were performed to assess the association between cetuximab therapy and the infection rates.

Results

HNC patients receiving cetuximab (n = 158) were older, had lower SES, and resided more frequently in rural areas as compared to those without cetuximab therapy. 125 patients, 32 (20.3%) in the group using cetuximab and 93 (10.1%) in the group not using it presented infections. The propensity score analysis revealed a 2.3-fold (adjusted odds ratio [OR] = 2.27; 95% CI, 1.46?3.54; P = 0.001) increased risk for infection in HNC patients treated with cetuximab. However, using IVA, the average treatment effect of cetuximab was not statistically associated with increased risk of infection (OR, 0.87; 95% CI, 0.61?1.14).

Conclusions

Cetuximab therapy was not statistically associated with infection rate in HNC patients. However, older HNC patients using cetuximab may incur up to 33% infection rate during one year. Particular attention should be given to older HNC patients treated with cetuximab.

Citation: Lee C-C, Ho H-C, Hsiao S-H, Huang T-T, Lin H-Y, et al. (2012) Infectious Complications in Head and Neck Cancer Patients Treated with Cetuximab: Propensity Score and Instrumental Variable Analysis. PLoS ONE 7(11): e50163. doi:10.1371/journal.pone.0050163

Editor: Gabriele Multhoff, Technische Universitaet Muenchen, Germany

Received: August 1, 2012; Accepted: October 17, 2012; Published: November 28, 2012

Copyright: ? 2012 Lee et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This study was funded in part by the Buddhist Dalin Tzu Chi General Hospital ((CTCRD 10092)-I-12) and no additional external funding was received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

* E-mail: hematcd2@hotmail.com

Introduction?Top

The epidermal growth factor receptor (EGFR)-targeting IgG1 monoclonal antibody, cetuximab, is a breakthrough in targeted therapy for head and neck cancers, especially among patients with recurrent or metastatic disease [1]. In patients with locally advanced head and neck cancer, radiotherapy in combination with cetuximab has prolonged the median overall survival in a statistically significant manner when compared to radiotherapy alone [2]. In head and neck cancer patients with recurrent or metastatic squamous cell carcinoma, cetuximab in combination with platinum-fluorouracil chemotherapy improved overall survival when given as first-line treatment [3]. Recently, cisplatin-based chemoradiation in combination with cetuximab led to a complete response rate of 71% among participants in a phase II study that enrolled advanced head and neck cancer patients [4].

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Table 1. Demographic characteristics for head and cancer patients by treatment modality (n = 1083).

doi:10.1371/journal.pone.0050163.t001

Previous studies reported that the administration of cetuximab does not alter or compromise the delivery of scheduled radiation doses or the pharmacokinetics of chemotherapy [1]. They also concluded that adverse side effects, such as skin reactions, are tolerable, and adverse pulmonary events are not statistically more frequent in patients receiving cetuximab [5], [6]. However, several series revealed an increased risk of infection events, neutropenia, or pulmonary adverse reactions, in patients treated with cetuximab. In a meta-analysis, patients treated with cetuximab incurred an additional 12% risk for developing severe neutropenia [7]. A higher rate of high-grade infections was observed with the use of cetuximab in addition to chemotherapy in a randomized phase III study [8]. Increased dyspnea and respiratory insufficiency were noted in head and neck cancer patients undergoing cetuximab therapy [9]. Death due to pneumonia was observed in patients with locoregionally advanced head and neck cancer who were administered a concurrent cetuximab, cisplatin, and boost radiotherapy regimen that was not recommended outside of the clinical trial setting [10].

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Figure 1. Infectious complications in head and neck cancer patients.

doi:10.1371/journal.pone.0050163.g001

The purpose of this study was to examine the incidence of infection events in head and neck cancer patients identified through the National Health Insurance Research Database (NHIRD) in Taiwan. This allowed for a comparison of the risk of infection events between head and neck cancer patients receiving cetuximab therapy and those who were not treated with this compound. It also provided an opportunity to outline follow-up suggestions for cetuximab-treated head and neck cancer patients. Propensity score analysis and instrumental variable analysis techniques were utilized to minimize the selection bias in observational medical studies, such as our NHIRD [11], [12].

Materials and Methods?Top

Ethics Statement

This study was initiated after approval by the Institutional Review Board of the Buddhist Dalin Tzu Chi General Hospital, Taiwan (IRB B10001018). Since all identifying personal information was stripped from the secondary files before analysis, the review board waived the requirement for written informed consent from the patients involved.

NHIRD Dataset

Since 1995, the National Health Insurance program in Taiwan has enrolled up to 99% of the Taiwanese population and is contracted with 97% of the medical providers [13]. This study utilized the 2010 NHIRD published by Taiwan?s National Health Research Institutes. The NHIRD includes all prescribed medication and chemotherapy regimens. Information on tobacco use, dietary habits, and body mass index were not included in this database.

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Figure 2. Distribution of explanatory variables between patients receiving cetuximab and those not receiving cetuximab for propensity score quintiles ranging from 1 (least likely to receive cetuximab) to 5 (most likely to receive cetxuimab).

doi:10.1371/journal.pone.0050163.g002

Study Sample Inclusion and Exclusion Criteria

According to the NHI treatment guidelines in Taiwan, cetuximab was approved for use in oropharyngeal, hypopharyngeal, and laryngeal cancer in patients who underwent radiotherapy and meeting any of the following criteria: 1) age 70 or more, 2) impaired renal function with creatinine clearance rates less than 50 ml/min, 3) hearing impairment with average pure tone audiometry over 25 dB, or 4) intolerance to platinum-based chemotherapy. The study population consisted of patients with head and neck cancer (identified according to the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes including oropharyngeal cancer [146], hypopharyngeal cancer [148], and laryngeal cancer [161]) who were over 20 years of age and underwent radiotherapy, chemotherapy, or chemo-radiotherapy, with or without surgery, in 2010. A sample of 1083 patients was used based on the registry of catastrophic illness patient database and clinical exclusion criteria.

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Table 2. Infection events in study population (n = 1083).

doi:10.1371/journal.pone.0050163.t002

Measurements

A total of 1083 patients who met the inclusion and exclusion criteria were identified. Each patient was tracked from his or her index ambulatory visit in 2010 to identify outcomes including any type of infectious diseases. To maximize case ascertainment, only patients hospitalized for infection events were included. These patients were then linked to the administrative data to calculate the rate of infection events.

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Table 3. Infection rate head and neck cancer patients treated with different treatment modality.

doi:10.1371/journal.pone.0050163.t003

We compared the outcomes for patients who underwent cetuximab therapy (the cetuximab group): chemotherapy (cisplatin/carboplatin-based), chemoradiotherapy, and surgery with chemoradiotherapy, and for those who did not receive cetuximab therapy (the non-cetuximab group): chemotherapy (cisplatin/carboplatin -based), chemoradiotherapy, and surgery with chemoradiotherapy. The two major groups (cetuximab versus non-cetuximab) were analyzed to explore the possible differences between cetuximab administration and infection events.

Patients were characterized by age, gender, treatment modality, comorbidities, individual socioeconomic status, and tumor site. In each patient, the comorbidities were based on the modified Charlson comorbidity index score, which was widely used in recent years for risk adjustment in administrative claims data sets [14]. The insurance amount from the database was used as a proxy for the individual socioeconomic status. The monthly income was classified into one of three categories: 1) low SES (less than NT$20000 or US$625 per month), and 2) high SES (NT$20001 or US$626 per month or more) [15].

The urbanization level of residence is also associated with cancer outcomes and was therefore included in our analysis [16]. We recorded the level of urbanization as urban and sub-urban (urbanization level 1?3) or rural (urbanization level 4?7).

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Table 4. One-year cumulative risk of infection among the patients with cetuximab and those without (n = 1083)a.

doi:10.1371/journal.pone.0050163.t004

Statistical Analysis

The SAS (version 9.2; SAS Institute, Inc., Cary, NC, USA) and SPSS (version 15, SPSS Inc., Chicago, IL, USA) statistical packages were used to analyze the data. Pearson?s chi-square tests were used to explore the differences between categorical variables in the different treatment groups. Continuous variables were analyzed with one-way ANOVA. Multivariate analysis was conducted with propensity score analysis and instrumental variable analysis.

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Figure 3. Distribution of explanatory variables between patients in high-use and low-use cetuximab hospitals (a) and infection rates (b).

doi:10.1371/journal.pone.0050163.g003
(1) Propensity score.

Propensity score stratification was applied to replace the wide host of confounding factors that may be present in an observational study with a variable of these factors [17], [18], [19]. To derive the propensity score in this study, patient characteristics were entered into a logistic regression model predicting selection for cetuximab therapy. The characteristics included age, gender, the Charlson Comorbidity Index score, urbanization and geographic area of residence, and treatment modality. The effect of cetuximab on the one-year infection rate was analyzed within each quintile. The Mantel-Haenszel odds ratio was calculated, in addition to performing the Cochran-Mantel-Haenszel ?2 test.

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Table 5. Characteristics of head and neck cancer patients in high-cetuximab and low-cetuximab use hospitals (n = 611).

doi:10.1371/journal.pone.0050163.t005
(2) Instrumental variable analysis.

Instrumental variable analysis from the Rubin Causal Model was used to account for both the measured and unmeasured confounding factors [20]. The instrumental variable was constructed by first calculating the proportion of head and neck cancer patients who received cetuximab in each hospital. Hospitals with one or more cases were included. The algorithm produced 36 hospitals. High- and low-use hospitals corresponded to the top and bottom tertiles of cetuximab utilization and were used as the binary instrumental variable for the binary treatment assignment. An instrumental variable must be associated with outcomes through its correlation with treatment status (cetuximab) and not through other covariates. The instrumental variable estimate was calculated by the formula:



where ?Hi? indicates a hospital with a high rate of cetuximab therapy administration and ?Lo? indicates a hospital with a low rate of cetuximab therapy use.

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Table 6. Marginal effect of cetuximab on infection event using instrumental variable analysis for one-year follow-up (n = 611).

doi:10.1371/journal.pone.0050163.t006

We verified this assumption by comparing the baseline characteristics, including age at diagnosis, gender, the Charlson Comorbidity Index Score, and monthly income. The two-stage least squares method was used to estimate the effect of cetuximab by using instrumental variables.

Results?Top

In 1083 head and neck cancer patients, the median duration of follow-up was 6.5 months (interquartile range, 3.7?9 months). The mean age of the entire cohort was 57 years (standard deviation, 11 years). Among the participants, 96% were men and all patients were Asian. Among the patients with head and neck cancer, 158 were treated with cetuximab. Patients treated with cetuximab were older, and were more likely to have a lower socioeconomic status and to live in rural area, as compared to those who did not receive cetuximab therapy (Table 1).

At the end of the follow-up period, 125 patients had infection events, and of these, 32 (20.3%) were in the group using cetuximab and 93 (10.1%) were in the group that did not use it (Figure 1). HNC patients with cetuximab therapy aged 55?64 years incurred the highest infection rate of 33%.Table 2 shows the types of infection events for the two groups. Pneumonia was the most common infectious disease complication in both groups. In subgroup analysis, there was no statistical difference between the infection rate and treatment modality (surgery with adjuvant therapy versus chemotherapy or chemoradiotherpy) in cetuximab group or without cetuximab group (P = 0.581 and 0.261, respectively) (Table 3). Patients using cetuximab had an increased risk of infection events (P<0.001). Table 4 shows the infection rates for patients in each of the two groups after propensity score stratification. In most situations, patients with cetuximab therapy had higher infection rates. Figure 2 shows that most of the prognostic characteristics were well balanced within each propensity quintile. The P-value for Cochran-Mantel-Haenszel statistics comparing infection rates in patients receiving cetuximab therapy with infection rates among those not receiving cetuximab therapy, controlling for propensity scores, was 0.001. Patients treated with cetuximab had higher infection rates. The adjusted infection rates for patients treated with cetuximab were higher than for patients without cetuximab therapy (20.3% vs 10.1%; adjusted odds ratio [OR] = 2.27; 95% CI, 1.46?3.54; P = 0.001).

Propensity score analysis is unable to adjust for unmeasured confounders and selection biases, such as higher-risk patients who may be preferentially selected for cetuximab, thus producing apparently adverse outcomes for these groups. Among the IVA, most of the patients? characteristics in high- and low-use cetuximab hospitals were well-balanced, similarly to the distribution of factors that one might hope for in a randomized trial (Figure 3a and Table 5). Cetuximab utilization varied widely across the different health care providers (3?90%). 87 patients had infection events, 14 (9.6%) in the high-use cetuximab hospitals and 73 (12.3%) in the low-use cetuximab hospitals (Figure 3b). By using IVA and the two-stage least squares analysis, we showed that cetuximab use was not statistically associated with infection events (OR, 0.87; 95% CI, 0.61?1.41; p = 0.319) (Table 6).

Discussion?Top

Limited data exist regarding whether cetuximab increases the rate of infections in patients with head and neck cancer. Most of the little information derived from randomized-controlled trials that were not designed to compare the infection rates among different treatment modalities, and many patients were often excluded from clinical trials. Data from day-by-day medical practices in the real world may reflect the true information. In propensity score analysis with adjusting observable confounding factors, the likelihood of developing infection events among head and neck cancer patients treated with cetuximab was 2.3-fold higher than among patients not receiving cetuximab therapy. Using IVA with adjusting measured and unmeasured confounding factors, the average treatment effect of cetuximab was not statistically associated with an increased risk of infection events in head and neck cancer patients.

The strengths of our analysis are the fact that it is a population-based study (n = 1083) in Taiwan, the nearly complete follow-up of any infectious events among the whole study population, and the regular monitoring of diagnosis accuracy and treatment by the National Health Insurance Bureau of Taiwan. Compared with randomized-controlled series or meta-analyses, the NHIRD is a real medical practice record that reflects the day-by-day medical care. Our series used two statistical methods, propensity score analysis and instrumental variable analysis. The propensity scores were used to stratify patients into five groups with similar propensity scores in order to reduce the effects of selection bias between the different treatment groups [18], [19], [21]. HNC patients treated with cetuximab were found to have increased rates of infection. Using IVA to control both the measured and unmeasured confounding factors, we did not find statistically differences between cetuximab and the rate of infections. The severity of comorbidities, the cancer stage, certain social factors such as employment, and patient preferences were difficult to capture correctly from the dataset. Referral selection may depend on the interactions between the comorbidities and cancer stage. All these unmeasured factors could produce significant bias using traditional approaches. Despite the efforts to simulate the randomization situation, propensity scores only adjusted for observable confounding variables. These observations imply that significant unaccounted residual bias exists among the propensity score methods and that IVA may be superior. The instrumental variable analysis was performed by comparing the baseline characteristics, and found that these factors were similar between the high- and low-use cetuximab institutions. The instrumental variable analysis produced less biased estimates.

There are few data evaluating the association between the infection rate and cetuximab therapy in patients with head and neck cancer. Increased risk for dyspnea and respiratory insufficiency had been reported in head and neck cancer patients treated with cetuximab [22]. Bonner et al. reported a 1.9% increase in the infection rate among HNC patients treated with radiotherapy and cetuximab, as compared to those treated with radiotherapy alone, and Burtness et al. revealed a 5% increase in infection rates in HNC patients treated with cetuximab and cisplatin, as compared to those treated with cisplatin alone [8], [23]. A recent meta-analysis found an additional 12% risk for advanced cancer patients treated with cetuximab and concurrent chemotherapy [24]. In the subgroup analysis, higher risk was observed in colorectal cancer patients (relative risk [RR] = 1.17; 95% CI, 1.04?1.32). This suggested that there are several plausible mechanisms to explain the increased rate of infectious complications in advanced cancer patients treated with cetuximab. EGF and EGF-like protein families, such as heparin-binding EGF-like growth factor (HB-EGF), are essential for cell proliferation, differentiation, and wound healing [25], [26]. Cetuximab may target the bone marrow EGF receptors, which are expressed on he surface of neutrophils and play key roles in their proliferation and differentiation. The suppressed bone marrow may further lead to neutropenia and increase the risk of infection. EGF could enhance reactive oxygen intermediates and IL-8 production by TNF-?-primed neutrophils [27]. This process could be suppressed by EGF receptor-selective tyrosine kinase inhibitors. However, subgroup analysis revealed that cetuximab was not associated with neutropenia in head and neck cancer patients receiving concurrent chemotherapy (RR = 1.22; 95% CI, 0.92?1.62). Besides the propensity score analysis, we tried to simulate a randomized study and balanced both the measured and the unmeasured characteristics in the different treatment groups with IVA. Using IVA and the two-stage least squares analysis, our series revealed that cetuximab was not associated, in a statistically significant way, with infection events.

Randomized-controlled trials cannot be undertaken in all situations where evidence is needed to provide treatment guidelines. Observational studies with adequate statistical analysis that have least bias are necessary to evaluate population effectiveness. Post-marketing surveillance is an important issue that could provide physicians, patients, and pharmaceutical companies with useful information about severe adverse effects. The NHIRD in Taiwan provides the opportunity for outcomes and heath service research. Propensity score analysis simulated the randomization process and tried to eliminate the selection bias for observable factors, and revealed an approximately two-fold increased risk of infection in patients receiving cetuximab. However, functional status and unmeasured factors were not adjusted in propensity score analysis and the association between the cetuximab and infection rate may be overestimated. Instrumental variable analyses could decrease or eliminate the measured and unmeasured biases, and they showed that no statistically significant differences existed between the rate of infections and the average treatment effect of cetuximab.

This study has several limitations. First, the diagnoses of head and neck cancer, infection events, and any other co-morbid conditions are completely dependent on ICD codes. Nonetheless, the National Health Insurance Bureau of Taiwan randomly reviews the charts and interviews patients in order to verify the accuracy of diagnosis. The head and neck cancer patients are further verified by the registry for catastrophic illness patient database. Second, radiotherapy dose and type, cancer stage, and the severity of the infection events cannot be precisely extracted from the NHIRD, which prevented further sub-group analysis. Instrumental variable analysis could eliminate the selection biases from the unmeasured factors. However, it is possible that instrumental variables do not adequately control for unknown confounding factors. Third, chemotherapy that was not approved by the NHI before 2010 but was self-paid by patients, such as taxol (approved on Jan 1st, 2011 by the NHI in Taiwan) cannot be extracted from the dataset. Further research studies linking primary hospitalization or ambulatory settings information, such as infection severity, with detailed risk factors, are worth performing in the future.

This study shows that during a one-year follow-up period, cetuximab was not statistically associated with an increased risk of infection by using an instrumental variable analysis. However, older HNC patients using cetuximab may incur an up to 33% infection rate during one year. Therefore, particular attention should focus on older head and neck cancer patients treated with cetuximab.

Acknowledgments?Top

This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, and managed by the National Health Research Institutes (registered number 99018 and 99321). The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or National Health Research Institutes.

Author Contributions?Top

Conceived and designed the experiments: CCL HCH SHH TTH PC YCS. Analyzed the data: CCL TTH PC. Wrote the paper: CCL HCH SHH TTH HYL SCL PC YCS.

References?Top

  1. Bernier J (2008) Drug Insight: cetuximab in the treatment of recurrent and metastatic squamous cell carcinoma of the head and neck. Nat Clin Prac Oncol 5: 705?713. Find this article online
  2. Bonner JA, Harari PM, Giralt J, Azarnia N, Shin DM, et al. (2006) Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 354: 567?578. Find this article online
  3. Vermorken J, Mesia R, Rivera F, Remenar E, Kawecki A, et al. (2008) Platinum-based chemotherapy plus cetuximab in head and neck cancer. N Engl J Med 359: 1116?1127. Find this article online
  4. Merlano M, Russi E, Benasso M, Corv? R, Colantonio I, et al. (2011) Cisplatin-based chemoradiation plus cetuximab in locally advanced head and neck cancer: a phase II clinical study. Annals of Oncology 22: 712?717. Find this article online
  5. Bonner JA, Harari PM, Giralt J, Cohen RB, Jones CU, et al. (2010) Radiotherapy plus cetuximab for locoregionally advanced head and neck cancer: 5-year survival data from a phase 3 randomised trial, and relation between cetuximab-induced rash and survival. The Lancet Oncology 11: 21?28. Find this article online
  6. Kang HJ, Park JS, Kim DW, Lee J, Jeong YJ, et al. (2012) Adverse pulmonary reactions associated with the use of monoclonal antibodies in cancer patients. Respir Med 106: 443?450. Find this article online
  7. Argiris A, Lee SC, Feinstein T, Thomas S, Branstetter BFt, et al. (2011) Serum biomarkers as potential predictors of antitumor activity of cetuximab-containing therapy for locally advanced head and neck cancer. Oral Oncol 47: 961?966. Find this article online
  8. Burtness B, Goldwasser M, Flood W, Mattar B, Forastiere A (2005) Phase III randomized trial of cisplatin plus placebo compared with cisplatin plus cetuximab in metastatic/recurrent head and neck cancer: an Eastern Cooperative Oncology Group study. J Clin Oncol 23: 8646?8654. Find this article online
  9. Hoag J, Azizi A, Doherty T, Lu J, Willis R, et al. (2009) Association of cetuximab with adverse pulmonary events in cancer patients: a comprehensive review. Journal of Experimental & Clinical Cancer Research 28: 113. Find this article online
  10. Pfister D, Su Y, Kraus D, Wolden S, Lis E, et al. (2006) Concurrent cetuximab, cisplatin, and concomitant boost radiotherapy for locoregionally advanced, squamous cell head and neck cancer: a pilot phase II study of a new combined-modality paradigm. J Clin Oncol 24: 1072?1078. Find this article online
  11. Earle CC, Tsai JS, Gelber RD, Weinstein MC, Neumann PJ, et al. (2001) Effectiveness of Chemotherapy for Advanced Lung Cancer in the Elderly: Instrumental Variable and Propensity Analysis. Journal of Clinical Oncology 19: 1064?1070. Find this article online
  12. Stukel TA, Fisher ES, Wenngerg DE, Alter DA, Gottlieb DJ, et al. (2007) Analysis of observational studies in the presence of treatment selection bias: Effects of invasive cardiac management on ami survival using propensity score and instrumental variable methods. JAMA: The Journal of the American Medical Association 297: 278?285. Find this article online
  13. NHI profile (2008). Available: http://www.nhi.gov.tw/english/webdata.as?p?menu=11&menu_id=290&webdata_id=1884.Acessed 2008 July 31.
  14. Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology 45: 613?619. Find this article online
  15. Chou FHC, Tsai KY, Su CY, Lee CC (2011) The incidence and relative risk factors for developing cancer among patients with schizophrenia: A nine-year follow-up study. Schizophrenia Research 129: 97?103. Find this article online
  16. Liu CY, Huang YT, Chung YL, Chen YJ, Weng WS, et al.. (2006) Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey (in Chinese). J Health Manage: 1?22.
  17. Joffe MM, Rosenbaum PR (1999) Invited Commentary: Propensity Scores. Am J Epidemiol 150: 327?333. Find this article online
  18. Rubin DB (1993) Tasks in statistical inference for studying variation in medicine. Med Care 31: YS103?110. Find this article online
  19. Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127: 757?763. Find this article online
  20. Angrist JD IC, Rubin DB (1996) Identification of causal effects using instrumental variables. J Am Stat Assoc 91: 444?455. Find this article online
  21. DAgostino RB (1998) Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 17: 2265?2281. Find this article online
  22. Hoag JB, Azizi A, Doherty TJ, Lu J, Willis RE, et al. (2009) Association of cetuximab with adverse pulmonary events in cancer patients: a comprehensive review. J Exp Clin Cancer Res 28: 113. Find this article online
  23. Bonner J, Harari P, Giralt J, Azarnia N, Shin D, et al. (2006) Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 354: 567?578. Find this article online
  24. Wang L, Chen YZ, Shi D, Shi XY, Zou Z, et al. (2011) Incidence and risk of severe neutropenia in advanced cancer patients treated with cetuximab: a meta-analysis. Drugs R D 11: 317?326. Find this article online
  25. Argiris A, Karamouzis MV, Smith R, Kotsakis A, Gibson MK, et al. (2011) Phase I trial of pemetrexed in combination with cetuximab and concurrent radiotherapy in patients with head and neck cancer. Ann Oncol 22: 2482?2488. Find this article online
  26. Raab G, Klagsbrun M (1997) Heparin-binding EGF-like growth factor. Biochim Biophys Acta 1333: F179?199. Find this article online
  27. Lewkowicz P, Tch?rzewski H, Dytnerska K, Banasik M, Lewkowicz N (2005) Epidermal growth factor enhances TNF-?-induced priming of human neutrophils. Immunology Letters 96: 203?210. Find this article online

Source: http://feeds.plos.org/~r/plosone/Non-ClinicalMedicine/~3/QAfuK9u_DS4/info%3Adoi/10.1371/journal.pone.0050163

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Dang Gia ? Staying In Charge Of Payday Loans And Borrowing

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Troops debate risks, benefits of women in combat

SAN DIEGO (AP) ? A federal lawsuit filed by four service members Tuesday challenges the Pentagon's longstanding policy barring women from serving in direct combat positions. Here are the issues:

WHAT IS THE CURRENT POLICY REGARDING FEMALE TROOPS?

The 1994 combat exclusion policy bars women from being assigned to ground combat units, which are smaller and considered more dangerous since they are often in the thick of battle for longer periods of time than the other units.

WHAT ARE THE ARGUMENTS FOR LETTING WOMEN FIGHT ON THE FRONT LINES?

Supporters of lifting the ban say women are already being wounded or killed in war, and the policy keeps them from being recognized for their battleground experience, which could lead to promotions and higher pay. They also say the policy hurts the U.S. military by limiting the chances of qualified women to move into more senior leadership ranks.

WHAT DO OPPONENTS SAY?

Opponents include some female troops who question whether women are physically capable of handling the rigors of being assigned to ground combat units. The first two women to volunteer for the Marine Corps' grueling 13-week infantry training course at its base in Quantico, Va., were unable to complete it. The Corps will open the course again to female volunteers in January.

WHAT DOES THE MILITARY'S TOP BRASS SAY?

Military leaders say they want to make sure lifting gender-based barriers would not disrupt the cohesion of the smaller combat ground units and military operations. The Marine Corps' top leader, Gen. James Amos, ordered a survey of 53,000 troops to get their views, including whether they believe women in those units would distract male Marines from doing their jobs. The results have not been released yet.

HOW CLOSE DO WOMEN GET TO THE FRONT LINES?

The blurred front lines of modern warfare, with suicide bombs and sniper attacks, have put more and more women in combat situations. More than 144 female troops have been killed and more than 860 have been wounded in Iraq and Afghanistan since the wars began according to Pentagon statistics.

Source: http://news.yahoo.com/troops-debate-risks-benefits-women-combat-194311921.html

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Oral Health ? Disciplined Dental Habits Hold the Key

As a young mother, it is natural that you are concerned about the oral health of your child, if you have read the recent reports from the Australian Dental Association. This report reveals that over 60% of parents have accepted that their kids will face an oral health problem - tooth decay. This is the most common but preventable condition that kids all over the world face during their growing years.

It is pertinent at this point to say that the onset of oral health diseases is not always due to any inaction on the part of parents or kids. Dental disease is caused due to the accumulation of bacteria within the oral cavity, and is completely preventable.

The good news is that there has been extensive coverage by media like the New York Times and ABC News about this growing phenomenon of preschoolers getting cavities and how with some simple steps, they can be easily prevented. Awareness about the problem, you will agree, is the first step towards preventing its occurrence.

The coverage in the media above also talked about how Medicare patients are not receiving the dental care they require on time, making it clear that health policies in this area have to be reviewed to make sure that there is better understanding of the problem.

So what causes tooth decay and how can it be prevented?

This is caused due to the accumulation of bacteria in the oral cavity. These bacteria, if allowed to prosper, will produce acids that eat away at the tooth structure and cause cavities as well as other problems. It can only be prevented by correct brushing techniques and flossing at least twice a day, along with following a healthy diet.

Now this is where young mothers like you can step in and cultivate this habit of dental care in your kids.

It is a challenge no doubt to make them properly brush even once a day, but if you can make the entire process a fun-filled one, you will be able to impress upon your kids the merits of brushing and flossing regularly.

Other steps you can take to maintain oral health of your kids

? Visit the dentist at least once every year in order to identify any dental disease risk and to take suitable action.
? Start these visits from when your baby is a year old so that any early signs are detected.
? Drink only fluorinated water whenever possible
? Cut down consumption of sugary snacks and soft drinks, particularly before going to bed. Consuming them will give bacteria a greater opportunity to attack your teeth when you are asleep and the acids produced can wreak havoc, especially if you have forgotten to brush or floss.

The important lesson in all this to take away is as parents, we should be setting the right example for our kids. When they see us doing everything we preach, they will automatically follow. In conjunction with other public awareness dental programs, oral health can certainly be safeguarded.
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Source: http://oral.ezinemark.com/oral-health-disciplined-dental-habits-hold-the-key-7d38264712a4.html

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