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Ebriefings
Ilott v Mitson – What does it mean for Charity legatees?
Covered initially in our article of 29 July.
[media id=540]
In the case at hand, Mrs Jackson had chosen to leave her estate between a number of charities, including the Blue Cross, the Royal Society for the Protection of Birds and the Royal Society for the Prevention of Cruelty to Animals. This was to the complete exclusion of her daughter, Mrs Ilott, due in no small part to the estrangement between the two which – crucially – was seen to have predominantly been the fault of Mrs Jackson.
As was mentioned in our July article, these were charities with which the testator had enjoyed no significant connection in her lifetime. Nothing was raised in the course of proceedings to indicate why she might have seen fit to benefit these charities in her Will, other than to avoid anything passing to Mrs Ilott. This is significant when considering the legal framework of Mrs Ilott's claim – a claim pursuant to the Inheritance (Provision for Family & Dependants) Act 1975 ("the 1975 Act").
Claims pursuant to the 1975 Act are often said to be "balancing acts", in that the competing claims to the estate from those beneficiaries entitled to inherit under the Will or the rules governing intestacy are weighed up in comparison against arguments of "disinherited" claimants to the estate, taking into account a huge variety of considerations, including the wishes of the deceased. Anyone making a claim pursuant to the 1975 Act must demonstrate to the Court that it would have been reasonable for the deceased to have made greater provision for them. In turn, when considering the competing claims for the estate, the Court must consider the reasonableness of the dispositions made by the deceased.
So we see in Mrs Jackson's case one of the key issues – that it was considered unreasonable of her to favour charities with which she had no connection to the detriment of her (albeit estranged) daughter[1].
Many charity sector readers of this article will have enjoyed long and fruitful relationships with donors who will leave them something in their Will. While this does not in any way mean that a claimant to the estate will not succeed in securing an award from the Court, it does mean that they will be able to argue that the decision made by the deceased to benefit them was reasonable and they may as a consequence be able to preserve some or all of their legacy.
But can charities take any more proactive steps to protect their position? The Institute of Fundraising Code of Legacy Fundraising ("the Code") comments on the position following the making of a legacy at section 18.4. It states:
After a Legacy Has Been Made
18.4.1 Ongoing Contact with Legators
a) Organisations MUST* respect the wishes of the legator if they want no further marketing communications (which would include any fundraising requests) from the organisation or, wherever possible, if they request a certain level of contact.
b) If a legator or potential legator asks the benefitting organisation to explain to disinherited family members why they are being disinherited, the organisation MUST decline or otherwise only explain why the organisation needs the legacy.
The associated guidance also says that charities should:
respect, in all cases, the fact that the decision is the potential legator's and his/hers only
treat all personal information as strictly confidential, unless explicitly agreed otherwise
respect the sensitivity of the family and friends of the potential legator
pay particular attention when communicating with vulnerable people, who could include, but are not limited to, the following: service users and client groups; the terminally ill; bereaved relatives or friends; and people with learning difficulties and/or disabilities
not denigrate another charity in any way, for example, by talking negatively of another organisation
This clearly makes it a little difficult for a charity to proactively protect the legacy made for them while the testator is still alive, at the very least.
Section 18.4.1(b) of the Code does raise an interesting point, however, which charities may find to be of use. It is quite right that charitable legatees – indeed, any legatees – should be relieved of any obligation or requirement to explain to disenchanted family members why they, the legatee, are to inherit and not the family member. It is not the responsibility of that legatee to take on that difficult duty. This explanation will, however, be a key issue in settling any dispute, hopefully before the Court is even involved.
Charities should not only encourage their supporters to make provision for them in their Wills, but should strongly encourage those supporters to seek independent legal advice at the same time as drawing up those Wills. A good solicitor will make enquiries into the background of their testator client, to establish why they are making the provision that they are and, in the event that any party is excluded who might notionally be expected to benefit, can get to the bottom of the reason for their disinheritance.
Per Ilott v Mitson, it may be that the reason for the disinheritance and the charitable provision could be seen as unreasonable. In this case the solicitor can guide their client accordingly and warn them of the risks inherent in what they are choosing to do.
In the absence of such unreasonableness, however, the explanation for the favouring of charitable beneficiaries – and the explanation for the disinheriting of expectant family members or other persons – can be recorded appropriately, most likely in a Letter of Wishes that will remain confidential and for the eyes of the Executors only, unless it is appropriate to reveal the terms – perhaps to help resolve any potential claim[2].
Solicitors may also in such cases advise on other measures that their client may wish to consider to benefit the charities to whom they want their estate to pass. Wealthy clients may be in a position to set up a charitable trust in their lifetime. While such lifetime actions are also potentially open to claims – particularly if there are doubts over the mental capacity of the donor, or suggestions that the lifetime actions were taken simply to avoid future claims rather than to actually benefit the charities for reasonable reasons – such a charitable trust would allow the donor to see their money working for good causes while they are alive.
[1] As an aside, which should always be borne in mind, had Mrs Ilott been a wealthy individual then her claim may have not succeeded. A claim by a child of the deceased pursuant to the 1975 Act also requires that child to demonstrate that they need financial provision for their maintenance.
[2] Mrs Jackson did leave a Letter of Wishes, although it was of little help. It was found to feature factual inaccuracies, particularly over the reasons for her estrangement from Mrs Ilott, and did not satisfactorily explain why she wanted to leave her estate to charities.
Contact James Hall.
Latest news and ebriefings
What's in a name? Reputation and crisis management – part 1 of 2 Wednesday 15 January 2020
Would you know how to manage an escalating social media storm? Are you confident in your plans and policies for responding to, and managing, a prominent 'scandal' in your charity?
Civil Partnerships for Opposite-Sex Couples Tuesday 14 January 2020
The Civil Partnership (Opposite-Sex Couples) Regulations 2019 were made on 5 November 2019 and came into force on 2 December 2019.
National Minimum Wage - is your organisation compliant? Friday 10 January 2020
HMRC's approach to underpayment of the National Minimum Wage (NMW) is getting tougher and shows no sign of abating.
Section 1 statements – preparing for April 2020 Wednesday 8 January 2020
Now 2020 is here and we have welcomed in the new decade, it's time to welcome in changes regards the contents of employee's statement of particulars.
Prosecutions of local authorities by the Care Quality Commission Monday 6 January 2020
In December 2019, the Care Quality Commission brought its first prosecution against a local authority
Community Levy Infrastructure Reforms – Practical points for developing registered providers Wednesday 18 December 2019
The CIL was introduced under the Planning Act 2008 and the CIL Regulations 2010, which came into force in April 2010. CIL is a non-negotiable tax charged by local authorities on new developments.
Taxi licensing schemes are not intended to be self-financing or cross-subsidising Wednesday 18 December 2019
The Court of Appeal's recent decision is likely to be unwelcome news for any cash-strapped councils seeking to fund the costs of taxi enforcement through licence fees.
Transgender and charities Tuesday 17 December 2019
It is important that trustees are aware of the law relating to people who are transgender and those who identify as non-binary so that they can ensure compliance.
Oxfam inquiry report – an aftermath of uncertainty Tuesday 17 December 2019
Earlier this year, the Charity Commission published its inquiry report into Oxfam GB, following allegations about events in Haiti in 2010 involving its staff members.
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Question: Is the ability to view external mode (Shift+8) while replaying a save flight broken? I have XP 11.32 and IXEG 1.21. with only the following two Plug-ins installed; BetterPuchBack and xEnviro 1.9.
As I never, ever use the (Shift+8) while flying, Today for the first time I tried to use this option to evaluate a save flight and view externally my landing, but whenever I press (Shift+8) from the saved replay flight mode nothing happens and during the save flight playback the flight deck is in the cold and dark state, even while taxing and in flight, but there is taxing, and in-flight sounds. (regular sounds, minus the aircraft animations.
Anyone experiencing this issue? If there is a known fix, kindly point me in the direction. (Side note: this is only in a replay mode in the IXEG.
I am not aware of the Shift-8 view mode - the regular external view mode is shift-4. Can you try that?
This one leaves me scratching my head; I have tried all the available View+Change(External) Shift 1-8 options, nothing works.
really weird. The defaults are shift-2 for flyby, shift-3 for nearest runway, shift-4 for chase view, shift-5 for tower,...and so on!
They don´t work for you for default planes, either?
Do you have the SHIFT-LOCK key activated, accidentially?
Do you have a third-party plugin running that may interfere (fly with lua, easyview, etc)?
Did you change the key assignments in a custom key-binding profile?
1. On a saved flight, the command (shift+ 1-8 ) external views works fine on the Cessna default.
2. No, Shift Lock isn't on.
4. No key profile assignments changes made. I have the x52 joystick/throttle set, I've also tried it without the x52 plugged in.
Hope this experience and solution can help others, and add this one to your respective "hat's of knowledge". Thanks Jon for your suggestions.
Thanks Ben for reporting back on that!
I knew Windows Defender would cause some problems while entering a modified route into the FMS...but your problem was new!
I too have encountered that problem in the past while modifying the FMS route in flight, and did exclude my XPX folders, so I never through that was the issue this time around, with Windows Defender.


"However, my birth was more secret, as I was born (sic) underground in Borgo Canale. You had to go down along a cellar staircase, where no light had ever entered. And I took flight, just like an owl…" reads a marble plaque located in Gaetano Donizetti Birthplace.
With these words, one of the 5 most famous music composers of all times described his family's first house, in a letter he wrote to Simone Mayr.
Donizetti's birthplace, a national historic site, is here in Bergamo, in via Borgo Canale, where buildings used to be extremely poor and crumbling.
His family lived in the basement of a building whose ground floor can also be visited today, where you entered by means of a narrow staircase. It was a very humble house, consisting of two rooms - kitchen and bedroom - along with a well and an icehouse.
It seems that Donizetti's destiny was written in the stars: over his life, he interlaced music notes creating immortal compositions, just like his parents used to intertwine fabrics. In fact, the Master's parents were both tailors and were part of that humble people earning their living by working for the noblemen of the Upper Town. Donizetti managed to redeem its humble beginnings becoming famous all over the world and bringing prestige to his city.
For some time now, it is possible to spend a day in Donizetti's house, thanks to the project called Impronte Sonore – Talking Tracks: a multimedia route recreating the life of a typical XVIII Century family from Bergamo by means of remarkable audio tracks. An amazing and surprising immersive experience.


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Book of Heaven – October 8
Fatima Center Increases Presence in Rome
BOOK OF HEAVEN
10/9/32 – Vol. 31
God Created man in an Ecstasy of Love. Creation, Garment of man. The sweet sound of the little bell. Ecstasies in turn of the Creator and of the creature. Prodigy of the Conception of the Virgin.
My abandonment in the Fiat continues, and however more abandoned in It I am, so much more I feel Its Strength that fortifies me, Its Life that animates me, Its Light that comforts me, Illuminates me and, making Itself Revealer, Reveals to me He in whose Arms I am all abandoned, and with Powerful Attraction makes me go around in His Works. He Loves and wants that His little daughter be spectator of what He has done for Love of creatures.
So while I was going around, my Divine and Sovereign Jesus, stopping me in the Act of the Creation of Man, told me: "My daughter (Luisa), what sweet Memory is the Creation of Man. He was Created in an Ecstasy of Our Love. So much was Our Love, that We remained Enraptured before Our own Work that We put forth to the Light. The Beauty with which We had invested him Enraptured Us. The Sanctity with which We had filled him Enraptured Us. The Form, the Harmony with which We had formed him, Enraptured Us. His Prerogatives, each Quality of his, was an Ecstasy of Love that We felt, and it Enraptured Us to Love him.
"So Our Love remained shaken, overcome, and putting Us in Ecstasy, made arise in Us the Operating and Immortal Love toward man. And in this Ecstasy of Love, Enraptured as We were, nothing bothered Us, We placed no limits, We displayed so much in Loving him and in Enriching him with all Goods, that no void remained, so his Love would be Full for Us, and so be able to Enrapture Us to Love him continuously. Therefore, just remembering how man was Created repeats Our Loving Ecstasies to him.
"Now, one who goes around in Our Will, as she (Luisa) finds Our Works that were prepared in order to then Create man, she (Luisa) sounds the little bell to call all creatures to recognize this Love of God toward man. And its sweet sound calls Our Attention, Our Love reawakens, and makes arise again in Us Our Ecstasies of Love toward her. Ecstasies mean total Re-Pouring toward whom one Loves, and one who comes into Our Will has the strength to make Us undergo Our Ecstasy of Love so that We pour Ourselves out again in her. And with Our Power, We put the creature into Ecstasies for Us, so that nothing remains for her, and everything Re-pours into Our Supreme Being.
"A mutual Re-pouring occurs, the one into the other, because there is nothing that pleases Us more, then seeing the creature in that same Will in which she was Created. To contemplate Our Works, know them, and feel the Pulsations of Our Love that each created thing possesses, was the Garment that We prepared and gave to man in Creating so many things and the whole of Creation. Now, who receives the Life of the Good that created things contain? One (Luisa and the souls linked to Luisa) who makes use of this Garment so splendid, and with Right knows them. Knowing them she finds Our Palpitating Love, Our Operating Will, and she loves them and loves in them that Supreme Being who Loves her so much. Therefore be attentive and constant in going around in Our Works, so that We give each other a hand in Loving each other, take turns placing ourselves in Ecstasy, and with utility you (Luisa) will make use of the great Garment that with so much Love your Creator has given you (Luisa)."
After this my little mind wandered in the Acts done by the Divine Will, and passing from one to another, I arrived at the Conception of the Most Holy Virgin. O God! the Heavens remained mute before this Completed Act of the Divine Will. The Angels seemed stammering, and for however much they say, it seems that they do not know how to say everything about this Prodigy so Great. Ah! only God can speak of It, because He is the Author of the Prodigy of what was worked in this Conception.
And while I remained amazed, my Lovable Jesus, surprising me, told me: "My daughter (Luisa), the Conception of the Immaculate Virgin was a New Act of Our Will; New in the Way, New in time, and New in Grace. The whole of Creation was Renewed in Her. In Our All-Seeingness and Immensity We called all creatures, all their good acts present, past, and future, as if they were one alone, so that this Conception would be formed over everything and everyone to give the Right to everyone, and give them the Right not with words, but with deeds over everything.
"When Our Will does an Act that must serve for the Universal Good of everyone, It puts no one aside. And making use of Its Omnipotence It Reunites everything together, creatures and their acts—except for sin, because evil cannot enter into Our Acts—and completes the Act that It wants to do. See, all your acts also contributed. You put forth your part, therefore by Right you are Her Daughter, and the Virgin Queen with Right is your Mama. But do you know why We had this way of bringing this Holy Creature forth to the Light? In order to Renew the whole of Creation, to Love it again with New Love, and to place everyone and everything in safety, as though under the Wings of this Creature and Celestial Mother. We never do Our Works isolated, but We always start from Our One and Only Act, that while it is One, it Unites everything and does everything as if they were one alone. This is Our Omnipotence, Our Creative Strength, in One Single Act to do everything, to find everything, and to do Good to everyone."
Permanent link to this article: https://bookofheaven.org/2013/10/08/book-of-heaven-october-9/

redpajama_set_name: RedPajamaCommonCrawl


What does "Out of Print" mean? It means that the publisher has decided to not make additional copies available for sale. These books are not gone and forgotten, they may very well be alive and checked out from school and public libraries. Copies sometimes can be found on places like EBay. It's an unfortunate part of publishing, but they were written and enjoyed with as much love as the books that are currently in print.
Who's Afraid of Granny Wolf?


text:
Stories from Thursday, April 8, 2010
Incumbents re-elected (Local News ~ 04/08/10)
City council and school board members will retain seats; Seligman approves tax
Funding cuts deepen for area districts (Local News ~ 04/08/10)
Local school districts have been forced to review their budgets this week after the Missouri General Assembly cut another $43 million from the state budget for schools in a supplemental funding bill it passed last week. State lawmakers' recent decision has placed on extra burden on many school districts in the southwest Missouri area, because legislators opted to exclude 152 "hold harmless" districts from the cuts...
Baby's first egg hunt (Local News ~ 04/08/10)
Plan to attend Barry County Pioneer Days (Editorial ~ 04/08/10)
On April 17, Barry County's New Harmonies Committee will host Barry County Pioneer Days at the Crowder College Cassville Campus auditorium. The event, which will be held from 5 to 8 p.m., will offer a performance by the Possum Holler Fiddlers, a talented group of young fiddlers from southwest Missouri and northwest Arkansas who receive training through the Ozark Heritage Camp in Branson. ...
County Calendar (Calendar ~ 04/08/10)
MEETING: Meth to Miracles outreach group will meet at 7 p.m. in the upstairs of the Family Life Center in Cassville. All interested persons are invited to attend. SUPPORT GROUP: The Alcoholics Anonymous (AA) group of Cassville meets at 8 p.m. at 1308 Harold St. in Cassville. For more informa-tion, call 846-4044...
Rhea's complete game leads 'Cats past Seneca (High School Sports ~ 04/08/10)
By Lee Stubblefield The Cassville Wildcats were one shy of a dozen runs in defeating the Seneca Indians on Thursday afternoon by a score of 11-1. Kyle Rhea pitched all five innings of the rule-shortened contest at Wildcat Field and faced only 19 batters in collecting the win. Eric Esposito took the loss for Seneca...
MONA FERN MCMANUS (Obituary ~ 04/08/10)
Mona Fern Dent McManus, 88, of Seligman, passed away Sunday, April 4, 2010, in New Hope Health and Rehabilitation, Rogers, Ark. She was born Jan. 19, 1922, at Gann Ridge in Benton County, Ark., the daughter of Silas and Bessie E. (Gann) Webb. On Dec. ...
LORETTA MOORE (Obituary ~ 04/08/10)
Loretta Moore, 86, of Shell Knob, passed away Tuesday, April 6, 2010, in St. John's Regional Health Center, Springfield. Services are pending and will be announced by Fohn Funeral Home, Shell Knob. A complete obituary will be in next week's paper. Visit www.fohnfuneralhome.com for online obituaries, guestbook and private condolences...
JEAN MELTON (Obituary ~ 04/08/10)
Jean Sanders Melton, 85, passed away Tuesday morning, March 30, 2010, at her home near Cassville. She was born at Shell Knob on Dec. 16, 1924, the daughter of John Perry Sanders and Hattie (Blythe) Sanders. A graduate of Cassville High School, class of 1942, she entered the University of Missouri and graduated with a bachelor of science degree in vocational home economics, which she taught for three years in the Carrollton High School, northeast of Kansas City. ...
LAVERNE KINCAID (Obituary ~ 04/08/10)
Laverne V. Kincaid, 95, of Cassville, passed away Thursday, April 1, 2010, in Red Rose Health and Rehabilitation Center, Cassville. She was born April 22, 1914, in Neosho, the daughter of D.E. and Lula (White) Brown. On Feb. 24, 1947, she was united in marriage to Perry L. Kincaid, who preceded her in death on April 27, 1988. Also preceding her in death were her parents; and two brothers...
JAMES IRA "J.I." SMITH (Obituary ~ 04/08/10)
James Ira "J.I." Smith, 69, of Exeter, passed away Saturday, April 3, 2010, at his home. He was born April 30, 1940, in Barry County, the son of John Smith and Twila (England) Smith. On June 26, 1960, he was united in marriage to his wife, Shirley Faye Plouch, who survives...
MARY JEWELL THOMAS (Obituary ~ 04/08/10)
Mary Jewell Thomas, 75, of Cassville, passed away Monday, April 5, 2010, in Red Rose Health and Rehabilitation Center, Cassville. Funeral services will be held at 10 a.m. Friday in Fohn Funeral Home, Cassville. Rev. David Eaton and Pastor Bobby Harrison will conduct the services. Burial will be at Maplewood Cemetery, Exeter...
HELEN MARIE BROWN (Obituary ~ 04/08/10)
Helen Marie (Lundy) Brown, 86, of Cassville, died Friday, April 2, 2010, at St. John's Hospital in Springfield. She was born Aug. 24, 1924, in Marion County, Iowa, the daughter of Clarence and Rosa (McAllister) Lundy. She received her education in Dallas, Iowa...
TERRY LEE TALBERT (Obituary ~ 04/08/10)
Terry Lee Talbert, 63, of Butterfield, passed away on April 4, 2010, after a sudden stroke. He was born April 6, 1946, in Kewanee, Ill., son of Hartford and Dotty (Crawford). He served in the Navy aboard the USS Yancey from 1965 to 1968. Survivors include: his wife, Kathy (Clark), of 40 years; one son, Ted and his wife, Colleen, of St. ...
MARK MCMULLIN (Obituary ~ 04/08/10)
Mark Fredrick McMullin, 56, of Cassville, died Wednesday, March 31, 2010, at St. John's Hospital, Springfield, after a brief illness. He was born June 7, 1953, in Des Moines, Iowa, the eldest of five sons of Eugene Baker and Delores JoAn Lark McMullin. ...
CARL ROY (Obituary ~ 04/08/10)
Carl Roy, 90, of Exeter, passed away April 1, 2010, in McKinney, Texas. Carl was born Sept. 23, 1919, in Wakita, Okla.,, to Henry and Flora (Armour) Roy. On Oct. 23, 1945, he married Vermo Sampler, in Wichita, Kan. She preceded him in death on Sept. 8, 2009, after 63 years of marriage...
Honored students (Honor Roll ~ 04/08/10)


The 20th edition of the XTERRA World Championship on Sunday garnered an unprecedented amount of media attention – from a BBC preview on Lesley Paterson to an associated press wire report documenting the incredible string of 20 straight Maui races for three locals and even an opening segment ESPN SportsCenter shout-out for men's winner Josiah Middaugh.
Have a look at the highlights video, photo gallery, and only-in-XTERRA dance video to get a feel for the excitement and passion emanating from off-road triathlon's greatest day.
November 1, 2015 (Kapalua, Maui, Hawaii) – Josiah Middaugh, 37, from Eagle-Vail, Colorado and Flora Duffy, 28, from Devonshire, Bermuda won the 20th XTERRA World Championship off-road triathlon elite titles on an incredibly scenic day in Kapalua, Maui.
It's the first XTERRA World Title for Middaugh after 15 attempts, and he becomes the first American to win Worlds since Michael Tobin back in 2000. For Duffy, the win marks a perfect season with five straight wins, her second XTERRA World Championship in a row, and 12th XTERRA major victory in her last 13 attempts since the start of 2014.
Middaugh and Duffy each received $20,000 for their respective victories. The total purse was $100,000, and the event was filmed for international television distribution.
More than 800 endurance athletes from 43 countries participated in the event, which started in the relatively calm waters of the Pacific Ocean at D.T. Fleming Beach, continued with a 20-mile mountain bike that traversed the West Maui Mountains, and finished with a grueling 6.5-mile trail run. There was more than 4,000-feet of combined climbing on the bike and run courses.
After 15 years of trying Josiah Middaugh has his world title.
"15th time's a charm," Middaugh said to the crowd as he crossed the line, barefoot, holding the finish tape and an American flag with his son Porter and daughter Larsen by his side (his oldest son Sullivan and wife Ingrid were watching in admiration).
The men's race started out as expected with all the fast swimmers getting an early jump … Courtney Atkinson, Ben Allen, Jens Roth, Mauricio Mendez and Sam Osborne were the first to hit the 20-mile bike course.
What wasn't expected was how well Middaugh would swim. He was still two minutes behind the swim leaders, but more importantly he was side-by-side with Ruzafa. Last year he was 1:41 down on Ruzafa coming out of the water.
"You never know how you are going to feel, you always feel sluggish the morning of the race. I felt good in the water though and I was psyched to come out with Ruben," said Middaugh.
Those two worked their way to the front of the pack on the bike in no time but after a crash set Middaugh back, Ruzafa pounced.
Ruzafa did indeed put some time on the pack, but the effort took its toll.
"At the top of the climb I passed Josiah and I put some time into him and arrived 1:45 at T2, but my body was not the same and I exploded on the run," he explained.
Braden Currie and Francisco Serrano also had their share of misfortune. For Currie, it was a false alarm.
For Serrano, it was a broken seat that went flying off halfway through the ride.
Indeed he was, finishing 6th just 30 seconds behind Atkinson who ran his way into 5th.
Back to the front of the race, Middaugh was 1:40 down and then went to work.
Middaugh said he also felt inspired.
While Middaugh didn't post the fastest run – that honor went to Mauricio Mendez and his 40:51 split which propelled him from 8th at T2 to 4th at the finish line – he did have the biggest dream come true.
Braden Currie, who had been battling with Middaugh all year on the American Tour, turned on the jets in the run and finished runner-up, his best showing yet in Maui.
"I wasn't expecting it at all. The last split I got was three minutes down towards the top, and I thought that was that and I was happy with third but then all of a sudden I saw Ruben halfway down the downhill and he was sort of in a box and I think he maybe overheated," said Currie.
As for Ruzafa, who had his 15-race win streak broken and his chance to become the only elite man to win three in a row disappear, he was just happy to finish.
Duffy had the fastest women's swim split (5th overall) and was 3:45 up on two-time XTERRA World Champion Lesley Paterson out of the water. Paterson posted the best bike split to pull back a couple of minutes and was seemingly in striking distance heading out on the run.
Paterson was in a similar spot in second place.
In the end Duffy took the tape in 2:54:17, five minutes in front of Paterson.
Emma Garrard had a great race of her own to finish in third position, yet another step forward in her amazing progression through the years (she was 5th two years ago, and 4th last year). Garrard was once again the top American finisher.
Myriam Guillot-Boisset used a great run to move into fourth and Lizzie Orchard had the best race of her XTERRA career to finish in 5th.
Also: Elisabetta Curridori, Maia Ignatz, Kara LaPoint, Verena Eisenbarth, Alena Stevens, Fabiola Corona, Debby Sullivan, Christine Jeffrey, Laurel Dudley.
Christophe Betard from France was the top amateur finisher and placed 20th overall, just 23-seconds ahead of Martin Kostelnicak of Slovakia.
It's the second straight-year Kostelnicak (pictured above) has won the 25-29 title, and he was the third amateur overall last year.
Martin Flinta (who was fourth amateur last year) was third amateur this year and won the 40-44 division for the second time. Benoit Lalevee also won Worlds for the second time (50-54) while Bruce Wacker won the 65-69 division (his third title) and Ed Fattoumy won the physically challenged division for the 10th time in 11 years.
Julie Baker won the overall amateur XTERRA World Championship women's title and finished 13th overall, less than one-minute ahead of Liz Grubber. Those two were the top two amateurs (and 4th/5th overall at the USA Championship in September as well).
It's the third-time Gruber has won her division (25-29) in Maui, and Mimi Stockton (40-44) also picked up her third title. Carol Rasmussen (50-54) and Libby Harrow (65-69) won their second, Cindi Toepel won her sixth, and Wendy Minor won her eighth.
Ben Hoffman won the 2015 Outrigger Resorts elite men's double award and $2,500 prime today and finished 10th overall. His combined time was 11:55:18 (9:05:22 IM + 2:49:56 XTERRA).
Arnaud Bouvier from France won the men's amateur double in 13:28:52, just over five minutes faster than Jorg Schneider of Germany; while Nicole Valentine of Maryland won the women's double for the second straight year despite racing through an injury. Each earned a six-night stay at an Outrigger Resort in Maui for their efforts.
TEAM Unlimited is a Hawaii-based television events and marketing company, founded in 1988. It owns and produces XTERRA and in 2015 offered more than 300 XTERRA off-road triathlon and trail running races in 30 countries worldwide. In addition, TEAM TV has produced more than 400 adventure television shows resulting in three Emmy's and 42 Telly Awards for production excellence since 1990. Learn more at www.xterramaui.com, xterraplanet.com, xterratrailrun.com, xterraeurope.com, and xterraasia.com.


Happy Anniversary to my wonderful man, Reece Bowling!!
I've been thinking about Mary, Jesus' mom, and how she had a pretty tough road to walk, being pregnant out of wedlock in a culture that strongly frowned on "that type of thing". If you think about Mary's situation, she went through a pretty tricky season.


South Carolina State Police have released dashcam footage from Officer Michael Slager's car, captured moments before he shot an unarmed black man named Walter Scott. The video shows Scott running away after being pulled over.
Made public Thursday by the South Carolina State Law Enforcement Division (SLED), the footage does not reveal any details about the moment unarmed man Walter Scott was killed by officer Michael Slager.
The video begins with 33-year-old Slager, a North Charleston police officer, pulling over Walter Scott, 50, for a busted tail light. Slager tells Scott why he pulled him over after asking for his license and registration, and a brief conversation ensues over whether Scott has car insurance.
After Slager returns to his police car, Scott can be seen opening his door. Slager tells Scott to go back inside his vehicle, which he does. A few moments later, Scott opens his door again and runs away. Slager gives chase, but the encounter then moves beyond the dashcam's range.
Release of the footage comes as law enforcement's account of the incident continues to face serious scrutiny from the public and the media. Earlier this week, the New York Times published a video recording of the actual shooting, which was recorded by a third party. In that video, Officer Slager can be seen shooting Scott eight times in the back as he runs away.
Slager was charged with murder on Tuesday. He was fired from the force on Wednesday.
According to the police report on the incident, Slager said that at some point during the incident Scott took his Taser. Neither video shows such a struggle occurring, but the witness who filmed the incident on his own, Feidin Santana told NBC that he saw the two struggling on the ground before he started recording.
"I remember the police (officer) had control of the situation. He had control of Scott," Santana said. He also said he never saw Scott take the officer's Taser.
Before Slager shoots Scott, a dark object can be seen falling to the ground. Whether it is the Taser is unknown. After shooting Scott, Slager walks towards him and drops a dark object. It is also unknown if this is the Taser.
Slager may also have picked up the dark object and placed it near Scott's body.
On #WalterScott dash cam video, retired #CMPD tells me Slager prob touched car to leave his fingerprint. It's (pre-dash cam) tactical move.
— Molly Grantham WBTV (@MollyGrantham) April 9, 2015.
Police reports also stated that officers attempted to revive Scott via CPR, though Santana told MSNBC that, if true, he didn't see it.
Speaking with MSNBC, Scott's relatives said they planned on bringing a lawsuit against Slager, the police and the city.


text:
Candace Cameron Bure defends representation in Hallmark movies and says the network has 'definitely' improved after being criticized for a lack of diversity
Esme Mazzeo
American actress, producer, author, and talk show panelist, as well as star on Full House
Candace Cameron Bure told Insider Hallmark Channel has improved diversity its in holiday films.
The "Fuller House" star said "it's important to represent all people."
"The Christmas Contest" airs on the Hallmark Channel on Sunday, November 28 at 8 p.m. ET/PT.
Hallmark Channel's original movies are a staple in many households over the holidays but have faced criticism in recent years for a lack of Black leads, exclusion of the queer community, and a lack of religious diversity.
When speaking to Insider about her new Hallmark holiday film "The Christmas Contest," Candace Cameron Bure reflected on the network's recent steps toward more inclusivity.
Candace Cameron Bure in "The Christmas Contest."Crown Media
"Hallmark has definitely made changes in that direction, which we are all very, very happy to see," the "Fuller House" star told Insider.
"It's very important to me in all the casting that we do for the films, and it's important to represent all people and all of their journeys and their family dynamics," she continued, noting that everyone's family looks "so different."
In 2020, Hallmark premiered its first holiday movie featuring queer characters, "The Christmas House." A sequel will air in 2021.
"The Christmas Contest" is Bure's 10th holiday film with Hallmark Channel, and her 30th overall.
"I've been with this brand for a very long time and I understand what it's all about and who the audience is and what they're looking for, because as a producer, as well as an actress, it's what I'm looking for in the films. So I have taken that very seriously," she said.
Bure plays businesswoman Lara in her latest Christmas film. She is unexpectedly reunited with an ex then they compete in a televised contest to raise money for charities of their choice. Lara's love interest, Ben (played Bure's "Fuller House" costar John Brotherton), is a famous athlete competing for his foundation while Lara is hoping to raise money for her mom's senior center, which needs repairs.
There's plenty of funny banter in the film, but Bure is partial to its more serious, quiet moments. "Those are the moments where you get to be still and have real emotion and feelings, and that's where you hope to grab the audience," she told Insider.
"The Christmas Contest," also starring Barbara Niven and BJ Harrison, premieres on the Hallmark Channel on Sunday, November 28 at 8 p.m. ET.
AccuWeather: Cold but calmer
U.S. to give written response to Moscow's demands as part of efforts to deescalate Russia-Ukraine tensions
Hector Manley Sentenced
WFTX - Fort Myers Scripps
Meat Loaf sang for Motown, got start in Detroit before 'Bat Out of Hell' fame
Cleveland weather
WEWS-Cleveland Videos
Bloomingdale council: City 'not open for business' for warehouse, apartment development
New bill allows Iowan adoptees access to their original birth certificate
Kremlin says it wants to avoid raising tensions over Ukraine breakaway regions
Voices: I was told off for changing my baby's diaper on a plane. Then the bizarre phone calls started
Hoops 8 January 21
WMTW - Portland ME


Create beautiful tile maps in Unity.
5 tile presets included to start right away.
Paint and modify maps directly in the Unity scene editor.
Create random worlds at runtime. PC and Mobile.
Merge your tiles into clusters for occlusion culling.
Create beautiful islands or awesome dungeons.
Needs only 5 tiles to create beautiful and production ready worlds.
Works with 3rd party pathfinding solutions.
5 additional tile presets with 1k - 2k textures included.
Scatter objects like trees, stones or decals onto your world.
Automatically set a start and end position on a map (player, portals).
Editor / runtime generation of maps.
Paint maps directly in the scene editor.
Runtime generation works on mobile iOS and Android.
Use layers to add heights.
Maps can be merged to clusters for occlusion culling and drawcall reduction.
Create stunning islands or dungeons for your game or quickly build a level for your prototype. Add the TileWorldCreator prefab to an empty scene, setup your tile presets, click on generate and you're done. You can modify your map directly in the scene. Place objects like trees, stones and decals onto your world with the TileWorldObjectScatterer.


> the file. No extra codec 'knowledge' has been added to this file.
> In any case, mp3_read_probe is the routine rejecting the said files.
> One way or another this has to change to accommodate the files.
> +	// handle these files.


In an article published in the Blue Line a few days ago, I reported incorrect results from citizen sampling for plutonium in soil in the area at Rocky Flats proposed for construction of the Jefferson Parkway. The sampling effort was initiated by Rocky Flats Nuclear Guardianship, a project of the Rocky Mountain Peace and Justice Center. We wanted to determine whether highway construction would be likely to stir up a cloud of highly toxic plutonium-laden dust that would endanger workers, nearby residents and others.
In the referenced Blue Line article, I stated that the scientists we hired to do the sampling, Marco Katofen and Strongbear, a colleague from the Boston Chemical Data Corp., had found plutonium concentrations at lower levels than had previously been found in the area intended for the highway construction. I was mistaken. In fact, according to Kaltofen, their samples collected along the eastern, downwind edge of the Rocky Flats site showed plutonium concentrations that closely correspond with results from earlier sampling by others in the same area. Kaltofen and Strongbear found plutonium in 6 samples along Indiana St., the eastern edge of the Rocky Flats site. Two of these samples contained concentrations of plutonium well above what government agencies regard as average background plutonium deposits from global fallout. One came in at about 7 times background, the other at almost 40 times background.
Kaltofen is now doing additional analysis with a focus specifically on the breathable plutonium particles present within the samples he and Strongbear collected, since inhaling such particles is the most dangerous way of being exposed to plutonium. This analysis, he says, will help us see more clearly the actual danger that can result from highway construction proposed for the parkway. By early January we should have information that will help us better understand next steps.
Previous Topic: Slate | Bah, humbug.


text:
Posted in Florida, Health, State & National News
Coronavirus 'panic' could affect state budget; lobbyist says 'it's much ado about nothing'
News Service of Florida March 9, 2020
BY Dara Kam and Jim Saunders, The News Service of Florida
TALLAHASSEE — As the stock marketed plummeted Monday, House Speaker Jose Oliva, R-Miami Lakes, indicated that fears about the novel coronavirus could affect the ongoing negotiations about a new state budget.
"We may be facing a real challenge here," Oliva told House members as they started what is the final scheduled week of the 2020 legislative session.
Oliva pointed to "panic" surrounding the spread of the virus, saying it is "having a real effect." Oliva was not specific about steps that lawmakers might take to address the issue.
House and Senate negotiators are in the midst of trying to hammer out a roughly $92 billion budget for the fiscal year that starts July 1. The legislative session is scheduled to end Friday but already faces an extension because of delays in negotiating the budget.
The economic troubles caused by the coronavirus, known as COVID-19, could play out in some of Florida's key industries — such as tourism — that account for major chunks of tax revenue.
Uncertainty about the economic impact on Florida adds a new level of complication to the budget negotiations, lobbyist Mark Delegal, a partner with the Holland & Knight law firm, told The News Service of Florida following Oliva's remarks.
"There's a lot of uncertainty about the future of sales tax revenues related to tourism and general commerce," Delegal said.
Not only are people reconsidering vacations in the Sunshine State, Floridians "may be thinking they can do a few less outings and a few more in-home activities while this plays out," he added.
"The hope is the virus runs its course in the next couple of weeks and we're back to business as usual," said Delegal, whose clients range from safety-net hospitals that serve large numbers of Medicaid and uninsured patients to the Florida Chamber of Commerce.
Lawmakers use estimates of tax revenues that are produced periodically by a panel of state economists. But the most-recent estimates of general revenue — the most important source of tax dollars for the state — were released Jan. 15, the day after the legislative session started.
The coronavirus, however, had not spread across the globe in mid-January or been found in Florida and other parts of the United States. Florida on Friday night reported its first two deaths from the disease, which started in China.
Though the virus is pummeling the stock market and causing fears across the country, it remains unclear how widespread it will be in Florida.
Delegal said he was unconcerned about the virus itself.
"I'm no epidemiologist," he said, "but I think it's much ado about nothing."
Tagged Coronavirus, Jose Oliva, Mark Delegal
← Nearly 19K votes cast for primaries
FDOH issues international travel advisory →


text:
UAE signs for two more GlobalEye AEW&C
The Globaleye AEW&C is based on the Bombardier Global 6000 business jet. (SAAB)
The UAE has awarded Saab a contract for options it was holding for two GlobalEye airborne early warning and control (AEW&C) aircraft to add to the three aircraft it already has in service or on order.
Based on the Bombardier Global 6000 business jet airframe, the GlobalEye adds mission systems and control stations in the fuselage, and a large Erieye radar antenna and other sensors. The Global 6000 can fly at altitudes up to 50,000 feet giving the radar a large field of regard, and remain on station for up to 14 hours.
"We are proud that the United Arab Emirates continues to show great trust in Saab and our solutions," President and CEO of Saab, Micael Johansson said in a December 30 statement. "It shows that Saab remains on the cutting edge regarding advanced technology. The GlobalEye program is running according to plan and we have an efficient cooperation with the customer."
The order is a follow-on to one placed in 2015 for the UAE's first three GlobalEyes plus the two options, and the first aircraft was delivered in early 2020.
(SAAB)
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Dubai Tuner Marks 10 Years Of Lamborghini Aventador With Sinister Supercar
It was February 2011 when Lamborghini made a noise at the Geneva Motor Show by unveiling a new model, the Aventador. It effectively replaced...


text:
Q: Trigger existing fancybox with a href So I'm really stuck at this point.
In my case I've got an gallery with pictures.
On the main image is a a href to  trigger the fancybox with his child-pictures.
This works, np.
Now I've got a footer with an a href and text..
When I click this link it has to open the Fancybox from the main-image with the child-pictures.
Yes this is possible with a simple a href.. yes you'll get a duplicate picture in your gallery. I don't need redundancy.
Help me and I'll promise to help in our war against Apple.
Code snippet:
echo '
';
       $query = "  SELECT
            *
           FROM
            fotos AS f
           WHERE f.id = '29'
           ";

       #echo $query;
       $result = mysql_query($query) or die(mysql_error());
       $count = 0;
       while($row = mysql_fetch_array($result))
       { $count++;
        echo '
<a style="text-decoration:none;color:black;" rel="gal_'.$row['id'].'"  href="'.$row['fotos'].'"
        title="Navigeren met de pijltoetsen door het album">

        ';
        if($count == 1)

';

        $result2 = mysql_query("SELECT * FROM fotos WHERE type ='".$row['id']."'") or die(mysql_error());
        while ($row2 = mysql_fetch_array($result2))
        {
         echo '';
        }
       }

 echo '
';

So this is my gallery.
Now i got an a href.. with the link below from here I want to trigger the fancybox above.
echo '
 <a style="color:white;text-decoration:none;" title="Navigeren met de pijltoetsen door het album" id="openalbum" >Bekijk de diashow

A: You can trigger clicking on other link, e.g,
$("#second_link").click(function() {
    $(#first_link").trigger("click");
});

Or you can create array of items un use it multiple times -
var items = [
    '1.jpg',
    '1.jpg',
    {
        'href'  : '3.jpg',
        'title' : 'Lorem ipsum'
    }
];

var opts = {
    'padding'   : 0,
    'type'      : 'image'
};

$(".open_manually").click(function() {
    $.fancybox(items, opts);
});

redpajama_set_name: RedPajamaStackExchange


1. FYA has this rumination on the amazing time that we sometimes call the YA years.
2. And over at Argh Ink, there is a post on how sometimes when you're not looking, the Reality Truck will get you.
3. And since in the DC area it is still mitten weather, this story about how the internet found someone's mitten.


...Meh, anyway. Hope you like it.
Ouroboros coming up soon. Red soil was dissapoiting and english ASOM was just...the hell, he still can't pronounce it right>.< But I still have high hopes.
awwww their album wasnt all that bad D: i loved alot of the songs!
luckkkkyyyyy you went to a LIVE!!! D8 theycane here but i missed them cuz my parents were all like "its way to screamy and eeeeemooooo" > darn it all!!!!
This is... disturbing. I like it.
I like what you did with the snake's eye, really interesting abstract tweak in a relatively realistic art-style.
I was looking at this album on iTunes recently, is it any good...?
some songs are expectional, some are same o'l satanic scremo.
I love new intro, but nothing will beat GDS.
old intro from saku single, i think.
nothing will beat the feeling when GDS starts playing and the band is going on stage. and when the percussion starts POW kyo is suddenly in front of you (if you have guts to be in front row of course).
did you, by chance, reference the snake from a book called 'Verdi'?
I just browsed through net an found it somewhere, but It may be from this 'verdi' thing. I'm not sure, but you got me interested. What is ;verdi'?
it's a children's book by Janell Cannon, who also wrote Stellaluna, which was popular a few years ago.
Trust me, the CD is GREAT! I got it from the concert and I love it, I can't stop listening to it! And actually (not trying to be mean!!! DX) it's called Uroboros.
and yeah wacoms pens are @_@ to damn much. i'm lucky to have once lost my pen and a few months later found it again...i also have an ancient tablet from 2000 i believe?
I really like the detailing around her knees, for some reason. Anyway, loving the design~ Blue/Green palette is awesome.
Very nice. I especially love the eye design on the snake.
I agree with Raffy4. At first, Red Soil is disappointing. But after the 4th time, it really started growing on me. Now I can't stop listening to it.
Didn't Scully get that snake as a tattoo in an X-Files episode?
Yeah, in the episode "Never Again"


NextOpposing Chiropractic: Persecution or Justified Criticism?
Before I get into the study, let's first review some of the key concepts behind screening asymptomatic individuals for disease. (If you're familiar with these concepts, you can skip to the next section.) The act of screening for disease is based on a concept that makes intuitive sense to most people, including physicians, but might not be correct for many diseases. That concept is that early intervention is more likely to successfully prevent complications and death than later intervention. This concept is particularly strong in cancer, for obvious reasons. Compare, for example, a stage I breast cancer (less than 2 cm in diameter, no involvement of the lymph nodes under the arm, known as axillary lymph nodes) with a stage III cancer (e.g., a tumor measuring greater than 5 cm and/or having lots of axillary lymph nodes involved). Five year survival is much higher for treated stage I than for treated stage III, and, depending on the molecular characteristics, the stage I cancer might not even require chemotherapy and can be treated with breast conserving surgery ("lumpectomy" or partial mastectomy) far more frequently than the stage III cancer. So it seems intuitively true that it would be better to catch a breast cancer when it's stage I rather than when it's stage III.
Lead time bias, in other words, can give the appearance of longer survival even when treatment has no effect whatsoever on the progress of the disease. Patients are simply diagnosed earlier in the disease time course and only appear to live longer when in reality they simply carry the diagnosis screened for longer.
The second concept is length bias. In general, we can't continually screen for disease so an interval has to be chosen. This introduces a bias. Length bias refers to comparisons that are not adjusted for rate of progression of the disease. The probability of detecting a cancer before it becomes clinically detectable is directly proportional to the length of its preclinical phase, which is inversely proportional to its rate of progression. In other words, slower-progressing tumors have a longer preclinical phase and a better chance of being detected by a screening test before reaching clinical detectability, leading to the disproportionate identification of slowly-progressing tumors by screening with newer, more sensitive tests, with the faster-growing tumors becoming symptomatic "between screenings." Thus, survival due to the early detection of cancer is a complicated issue.
In this chart, which shows growth rates of four hypothetical tumors (A, B, C, and D), tumor D would not be detected because it was growing too fast, while tumor A is growing so slowly that it would likely be overdiagnosed when it reaches the threshold of detectability. Only tumors B and C could potentially benefit from being detected while still confined to the organ. This sort of graph explains why ever-more-sensitive tests that detect disease earlier and earlier have the potential to result in more overdiagnosis.
Finally, overdiagnosis almost inevitably results in overtreatment. Once physicians have detected a disease, be it a cancer, an asymptomatic abdominal aortic aneurysm, or whatever, the onus is on them to treat it.
Now, on to Ioannidis' review.
Does the screening test result in a decrease in mortality due to the disease being screened for (known as disease-specific mortality)?
Does the screening test result in a decrease in mortality due to all causes?
Screening for disease is a key component of modern health care. The rationale is simple and attractive—to detect diseases early in asymptomatic individuals and to treat them in order to reduce morbidity, mortality and the associated costs. However, the role of screening often comes into question. Some high-profile controversies have appeared lately in this regard. For example, for breast cancer, the United States Preventive Services Task Force (USPSTF) currently recommends against routine mammographic screening for women aged 40–49 years after retracting its previous recommendation in favour of mammography, as the data failed to show that benefit outweighed harm. The decision against screening drew sharp criticism from various interest groups including patients who overestimate the benefit of screening. Similarly, USPSTF now recommends against screening for prostate cancer in healthy men because harms from prostate specific antigen (PSA) screening exceed the benefit, trials do not show improvement in long-term survival and screening carries a high risk of over-diagnosis with adverse consequences. Again, heated debates have been generated around this change of recommendation, both in the scientific and the popular press.
Some screening tests were entrenched in clinical and public health practice before randomized controlled trials (RCTs) became widely used. As the screening agenda encompasses a large number of tests, and new ones are continuously proposed, it is useful to reassess the evidence supporting their use. Our research question is whether recommended screening tests, among asymptomatic adults, have evidence from RCTs on mortality for diseases where death is a common outcome. In particular, is there evidence of mortality reduction, either disease-specific or all-cause, from screening? To this end, we have compiled and examined systematically the evidence from individual RCTs and meta-analyses thereof for screening tests that have been proposed for detecting major diseases in adults who have no symptoms.
You can examine the data in Tables 1 and 2 yourselves, in which Saquib et al. examined meta-analyses and individual trials for 39 screening tests for 19 diseases in asymptomatic adults. What is very clear is that there is little strong RCT evidence of benefit for disease-specific mortality for many of these modalities. Indeed, The Gupta Guide notes that, for the six diseases/conditions for which the USPSTF recommends screening, only five of them have strong RCT evidence for a reduction in disease-specific mortality: breast, cervical, and colorectal cancer; abdominal aortic aneurysm (AAA); and type 2 diabetes. There were no randomized trials for screening for hypertension.
Basically, in the individual RCTs examined, the risk of disease-specific mortality was reduced in 16 out of 54 tests (30%), while all-cause mortality was reportedly reduced in 4 of 36 RCTs (11%). Examples of tests for which disease-specific mortality was reduced included ultrasound for AAA (42%-73% risk reduction), mammography for breast cancer (0% to 27% risk reduction), and screening for cervical cancer (11% to 48% risk reduction). For the meta-analyses examined, the risk of disease-specific mortality was reduced in analyses of four of eleven tests, but none for all-cause mortality. Examples of screening tests for which disease-specific mortality was reduced included ultrasound for AAA (again, risk reduction of 45%) and mammography (10% to 25% risk reduction). However, none of the meta-analyses showed an all-cause mortality benefit, while all-cause mortality was reduced only by 3%-13% in the RCTs examined. Basically, the findings were disappointing.
There are many potential underlying reasons for the overall poor performance of screening in reducing mortality: the screening test may lack sufficient sensitivity and specificity to capture the disease early in its process; there are no markedly effective treatment options for the disease; treatments are available but the risk-benefit ratio of the whole screening and treatment process is unfavourable; or competing causes of death do not allow us to see a net benefit. Often, these reasons may coexist. Whether screening saves lives can only be reliably proven with RCTs. However, even for newly proposed tests, we suspect that their adoption in practice may evade RCT testing. A very large number of tests continuously become available due to technological advancement. One may be tempted to claim a survival benefit of screening based on observational cohorts showing improved survival rates, but these are prone to lead-time and other types of bias. Even RCTs can be biased sometimes, as has been discussed and hotly debated in the controversy over mammography.
The authors also note that they did not examine evidence from other trial designs, such as cohort and case-control studies, which could be a potential weakness. Of course, they also make the obvious defense that these studies are generally less robust than RCTs and more prone to biases. The other concession they make is that it can be incredibly difficult to detect reductions in all-cause mortality for the simple reason that the disease being screened for almost always represents only a fraction of causes of death. This means that even a large drop in mortality due to screening for one disease would, even under ideal conditions, result in only a much smaller drop in all-cause mortality. Such a drop is very difficult to detect in an RCT because of the enormous numbers involved.
What is the proper metric to evaluate a screening test?
This point leads us naturally into the discussions of this study. Presented with the study were commentaries by Peter C. Gøtzsche of the Nordic Cochrane Center and Paul Taylor of the Institute of Health Informatics, University College London, entitled "Screening: a seductive paradigm that has generally failed us" and "Tempering expectations of screening: what is the most authoritative advice we can give, given the data that we have?", respectively. Basically, Gøtzsche, as one might expect based on his previous criticisms of mammography, argues that total mortality should be the primary outcome in screening trials of mortality and that the main focus of screening trials should be to "quantify the harm." Taylor, on the other hand, argues that in reality the results of Saquib et al. are not so bad, given that 30% of trials showed a disease-specific benefit and even proponents of screening would expect more trials to fail than not. He also points out the difficulties of using all-cause mortality as the primary outcome.
Screening proponents often say that disease-specific mortality is the right outcome, arguing that in order to show an effect on total mortality, trials would become unrealistically large. I believe this argument is invalid, for both scientific and ethical reasons. We do randomized trials in order to avoid bias, and our primary outcome should therefore not be a biased one. Drug interventions are usually more common in a screened group, and they tend to increase mortality for a variety of non-disease related reasons.
While it is true that overtreatment could potentially increase mortality for reasons other than disease, I believe that Gøtzsche is holding screening to an unrealistically high standard. Using his standard, it would be pointless to screen for virtually anything. Why? I like to use breast cancer as an example to illustrate the difficulties of using all-cause mortality as the be-all and end-all for screening. I know the numbers are rough and the analysis simplistic, but the magnitude is illustrative and close enough to give you an idea of the issues involved. This argument takes the form of a simple thought experiment. Consider first that approximately 40,000 women a year die of breast cancer in the US. However, there are approximately 2.5 million total deaths per year, which means that approximately 1.25 million women die every year (estimated to be 1.26 million in 2011). Thus, breast cancer is the cause of approximately 3.2% of female deaths every year. Consequently, if we could prevent 100% of breast cancer deaths (an unrealistic goal), at most we would expect to see a reduction in all-cause mortality of 3.2%.
So let's say mammography, as an upper estimate, results in a 27% decrease in breast cancer-specific mortality in women over 40. Under ideal circumstances, that would translate into a less than 0.9% decrease in all-cause mortality. The numbers of subjects and years of follow-up in an RCT needed to detect such a small number would be prohibitively expensive. Obviously, for diseases that cause a higher percentage of overall deaths, it will be easier to detect a reduction in all-cause mortality, but for most diseases it's very difficult indeed to tease out an all-cause mortality except using clinical trials so huge as to be impractical. Of course, this cuts both ways. If you see a decrease in overall mortality due to screening reported that's bigger than the proportion of deaths expected to be caused by the disease in the age group studied, then something odd is going on, possibly bias.
In any case, I realize my "back of the envelope" calculations are simplistic. They don't, for example, rigorously consider the trial period and how many deaths would be expected during, for example, one, two, three, or four decades or adjust for age other than in the crudest manner. My point in having done them isn't to give exact numbers, but rather to illustrate that the question of whether to use disease-specific mortality or all-cause mortality as a primary endpoint in trials screening for diseases that can result in death is not as straightforward a question as Prof. Gøtzsche argues, although he is correct to note that screening is not without harm and that the harms of screening for some diseases can outweigh the benefits. In an ideal world, he'd be correct about all-cause mortality as an endpoint, too, but our world is not ideal, and detecting such small differences in all-cause mortality is often beyond what is feasible and our resources can support.
But there's the rub. If breast cancer deaths are reduced, but all-cause mortality is unaffected, is this because detecting the latter requires that more statistical power be deployed? Or is it, as Gøtzsche has suggested, because the harms of screening increase deaths from other causes? The most serious cause of harm is overdiagnosis. The independent UK panel took the view that the best estimate of overdiagnosis could be provided by comparing the rates of cancer detection in the screened and the unscreened groups of randomized controlled trials. The problem is that when most trials ended, screening was offered to the women in the control groups, creating overdiagnosis in the follow-up period. The panel therefore restricted their attention to three trials in which no screening was offered to the control group during follow-up. This is a very limited set of data. Saquib, Saquib and Ioannidis ignore the question of harms presumably because there simply are not enough RCT data to review.
In other words, even in these studies, it's hard to tease out the sorts of data we are interested in so many decades later. Gøtzsche concludes, without presenting concrete evidence to that effect, that the harms of screening negate the benefits, thus resulting in no detectable decline in all-cause mortality. Advocates assume, without proving, that it is a matter of lack of statistical power, as I discussed above, and that bigger trials with more power would detect all-cause mortality decreases. Chances are, it's both, the relative proportion of each contribution varying according to the specific disease and screening test under study. One thing is certain, though. All screening results in some degree of overdiagnosis. As I've said time and time again, whenever you screen for a condition, you will always find a lot more of it. Always. Just consider the 16-fold increase in the incidence of ductal carcinoma in situ since the mammography era began.
We argue that for diseases where short- and medium-term mortality are a relatively common outcomes, RCT should be the default evaluation tool and disease-specific and all-cause mortality should be routinely considered as main outcomes. Our overview suggests that even then, all-cause mortality may hardly ever be improved. One may argue that a reduction in disease-specific mortality may sometimes be beneficial even in the absence of a reduction in all-cause mortality. Such an inference would have to consider the relative perception of different types of death by patients (e.g. death by cancer vs death by other cause), and it may entail also some subjectivity. For diseases where mortality outcomes are potentially important but only in the very long term, one has to consider whether the use of other, intermediate outcomes and/or other quasi-experimental designs that may be performed relatively quickly with very large sample sizes (e.g. before and after the introduction of a test) are meaningful alternatives to very long-term RCTs or may add more bias and confusion in a field that has already seen many hot debates. Screening may still be highly effective (and thus justifiable) for a variety of other clinical outcomes, besides mortality. However, our overview suggests that expectations of major benefits in mortality from screening need to be cautiously tempered.
In other words, the science of screening is messy, and we need to be careful not to be too optimistic. Personally, I tend to agree with Taylor, that better risk stratification will be necessary. Screening tends to benefit most populations at high risk for the disease being screened for. Such stratification could allow for—dare I say it?—personalized screening based on individual risk factors.
One wonders how much of that sort of research will be funded in President Obama's Precision Medicine Initiative, should it be funded. I might have to look into that for a future topic.
Opposing Chiropractic: Persecution or Justified Criticism?


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size up: to look at critically or searchingly, or in minute detail; "he scrutinized his likeness in the mirror"
audit: examine carefully for accuracy with the intent of verification; "audit accounts and tax returns"
(Scrutiny (magazine)) Scrutiny: A Quarterly Review was a literature periodical founded in 1932 by F. R. Leavis, who remained its principal editor until the final issue in 1953. Other editors include Lionel Charles Knights and Harold Andrew Mason.
(Scrutiny) The checking and counting of ballot papers to ascertain the result of an election.
(Scrutiny) The process following the close of polling. Acceptability of votes is determined and the votes are sorted and counted to determine the outcome of the election.
(Scrutiny) searching study or inquiry; judicial investigation into the constitutionality of a statutory classification of persons under the equal protection clause of the U.S. Constitution.